Mendel v. Commissioner of Social Security

• Court: District Court, W.D. Washington
• Decided: May 27, 2025
• Docket: 2:24-cv-01901
• Status: Unknown

Opinion

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5 6 7 UNITED STATES DISTRICT COURT 8 WESTERN DISTRICT OF WASHINGTON AT TACOMA 9 10 JOSEPH E. M., CASE NO. 2:24-CV-1901-DWC 11 Plaintiff, v. ORDER REVERSING AND 12 REMANDING DEFENDANT’S COMMISSIONER OF SOCIAL DECISION TO DENY BENEFITS 13 SECURITY, 14 Defendant.

15 Plaintiff filed this action under 42 U.S.C. § 405(g) seeking judicial review of Defendant’s 16 denial of his application for disability insurance benefits (“DIB”).1 After considering the record, 17 the Court concludes the Administrative Law Judge (“ALJ”) erred in her evaluation of certain 18 medical opinion evidence. Had the ALJ properly considered this evidence, Plaintiff’s residual 19 functional capacity (“RFC”) may have included additional limitations, or the ultimate disability 20 determination may have changed. The ALJ’s error is, therefore, not harmless, and this matter is 21 22 23 1 Pursuant to 28 U.S.C. § 636(c), Federal Rule of Civil Procedure 73, and Local Rule MJR 13, the parties have 24 consented to have this matter heard by the undersigned Magistrate Judge. See Dkt. 2. 1 reversed and remanded pursuant to sentence four of 42 U.S.C. § 405(g) to the Commissioner of 2 Social Security (“Commissioner”) for further proceedings consistent with this order. 3 I. Factual and Procedural History 4 Plaintiff filed a claim for DIB with a protective filing date of December 1, 2021, alleging

5 disability beginning on March 1, 2019. Dkt. 7, Administrative Record (“AR”) 201–02. His 6 application was denied at the initial level and on reconsideration. AR 75–86. He requested a 7 hearing before an ALJ, which took place on October 19, 2023. AR 35–60, 101, 186–87. Plaintiff 8 was represented by counsel at the hearing. See AR 35. On November 20, 2023, the ALJ issued 9 an unfavorable decision denying benefits. AR 14–34. The Appeals Council denied Plaintiff’s 10 request for review, making the ALJ’s decision the final decision of the Commissioner. AR 1–6, 11 197. Plaintiff appealed to this Court. See Dkts. 1, 4. 12 In the final decision, the ALJ found Plaintiff had the severe impairments of lumbar 13 degenerative disc disease and stenosis, obesity, and degenerative joint disease of the knees. AR 14 19. Despite these impairments, the ALJ found Plaintiff had the RFC to perform light work as

15 defined in 20 C.F.R. § 404.1567(b), “except with no climbing ladders, ropes, or scaffolds; 16 occasional crawling, crouching, kneeling, and stooping; frequent climbing ramps or stairs; and 17 no concentrated exposure to extreme cold, vibration or hazards (defined as work at heights).” AR 18 24. 19 II. Standard of Review 20 When reviewing the Commissioner’s final decision under 42 U.S.C. § 405(g), this Court 21 may set aside the denial of social security benefits if the ALJ’s findings are based on legal error 22 or are not supported by substantial evidence in the record. Bayliss v. Barnhart, 427 F.3d 1211, 23 1214 n.1 (9th Cir. 2005) (citing Tidwell v. Apfel, 161 F.3d 599, 601 (9th Cir. 1999)). Substantial

24 1 evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a 2 conclusion.” Biestek v. Berryhill, 587 U.S. 97, 103 (2019) (quoting Consol. Edison Co. v. NLRB, 3 305 U.S. 197, 229 (1938)). “We review only the reasons provided by the ALJ in the disability 4 determination and may not affirm the ALJ on a ground upon which he did not rely.” Garrison v.

5 Colvin, 759 F.3d 995, 1010 (9th Cir. 2014). 6 “[H]armless error principles apply in the Social Security Act context.” Molina v. Astrue, 7 674 F.3d 1104, 1115 (9th Cir. 2012), superseded on other grounds by 20 C.F.R. § 404.1502(a). 8 Generally, an error is harmless if it is not prejudicial to the claimant and is “inconsequential to 9 the ultimate nondisability determination.” Stout v. Comm’r, Soc. Sec. Admin., 454 F.3d 1050, 10 1055 (9th Cir. 2006); see also Molina, 674 F.3d at 1115. 11 III. Discussion 12 Plaintiff contends the ALJ erred in evaluating certain medical opinion evidence and 13 Plaintiff’s testimony about the severity of his symptoms. Dkt. 9 at 1. He states the proper remedy 14 for these errors is remand for an award of benefits or for further proceedings. Id. at 11.

15 A. Medical Opinion Evidence 16 Plaintiff argues the ALJ erred in rejecting medical opinion evidence from consultative 17 examiner Avery Sills, PA-C, and Plaintiff’s primary care physician, Luis Garduno, M.D. Dkt. 9 18 at 8–10. When evaluating medical opinion evidence, ALJs “will not defer or give any specific 19 evidentiary weight, including controlling weight, to any medical opinion(s) or prior 20 administrative medical finding(s). . . .” 20 C.F.R. §§ 404.1520c(a), 416.920c(a).2 Instead, ALJs 21 must consider every medical opinion or prior administrative medical finding in the record and 22 2 The regulations regarding the evaluation of medical opinion evidence have been amended for claims filed on or 23 after March 27, 2017. See Revisions to Rules Regarding the Evaluation of Medical Evidence, 82 Fed. Reg. 5844, 5867–68, 5878–79 (Jan. 18, 2017). Because Plaintiff’s application was filed after that date, the new regulations 24 apply. See 20 C.F.R. §§ 404.1520c, 416.920c. 1 evaluate the persuasiveness of each one using specific factors. Id. §§ 404.1520c(a), 2 416.920c(a). 3 The two most important factors affecting an ALJ’s determination of persuasiveness are 4 the “supportability” and “consistency” of each opinion. Id. §§ 404.1520c(a), 416.920c(a).

5 “Supportability means the extent to which a medical source supports the medical opinion by 6 explaining the ‘relevant . . . objective medical evidence.’” Woods v. Kijakazi, 32 F.4th 785, 791– 7 92 (9th Cir. 2022) (quoting 20 C.F.R. § 404.1520c(c)(1)); see also 20 C.F.R. § 416.920c(c)(1). 8 An opinion is more “supportable,” and thus more persuasive, when the source provides more 9 relevant “objective medical evidence and supporting explanations” for their opinion. 20 C.F.R. 10 §§ 404.1520c(c)(1), 416.920c(c)(1). “Consistency means the extent to which a medical opinion 11 is ‘consistent . . . with the evidence from other medical sources and nonmedical sources in the 12 claim.’” Woods, 32 F.4th at 792 (quoting 20 C.F.R. § 404.1520c(c)(2)); see also 20 C.F.R. § 13 416.920c(c)(2). ALJs must articulate “how [they] considered the supportability and consistency 14 factors for a medical source’s medical opinions” when making their decision. 20 C.F.R. §§

15 404.1520c(b)(2), 416.920c(b)(2). “Even under the new regulations, an ALJ cannot reject an 16 examining or treating doctor's opinion as unsupported or inconsistent without providing an 17 explanation supported by substantial evidence.” Woods, 32 F.4th at 792. 18 Avery Sills, PA-C, evaluated Plaintiff on February 14, 2023. AR 990. Her notes indicate 19 she reviewed “specialty clinic notes” in Plaintiff’s record. Id. She noted Plaintiff’s report of 20 constant low back pain rating seven out of ten at rest and nine to ten out of ten with walking or 21 standing. AR 991. Plaintiff also reported left side radiation down the lateral leg to the foot 22 associated with numbness, tingling, and burning, as well as emerging intermittent numbness and 23

24 1 burning on the right side. Id. He complained of weakness with walking and sometimes stumbled 2 on his feet. Id. 3 On physical examination, PA-C Sills found Plaintiff had a steady gait, was able to rise 4 from his chair and walk to the exam table without assistance, and was able to heel-toe walk

5 without assistance for a brief distance, but she noted he appeared to be in mild pain during the 6 exercise. AR 992. She found no gross deformities and normal muscle bulk in his upper and lower 7 extremities during motor exam but noted mild discomfort with hip flexion. AR 993. She also 8 noted pain on palpation of Plaintiff’s lumbar spine. Id. Plaintiff’s supine straight leg raise was 9 normal on the right side but abnormal on the left at 30 to 50 degrees. Id. On examination, PA-C 10 Sills found reduced range of motion in bilateral shoulder external rotation, and in lumbar spine 11 flexion, extension, lateral flexion, and rotation. AR 995. 12 She listed among Plaintiff’s diagnoses: “Low back pain [with] reduced [range of motion] 13 and paresthesia secondary to lumbar stenosis with neurogenic claudication, left sided lumbar 14 radiculopathy, lumbar facet arthropathy and pars defect.” AR 997. She found Plaintiff’s overall

15 prognosis to be “[f]air, expect some (~50%) improvement in the next 12 months assuming 16 optimal treatment,” but she noted anticipated barriers or limitations to treatment of financial 17 stressors and poor coping skills. Id. 18 PA-C Sills completed a medical source statement regarding Plaintiff’s functional 19 capabilities “based on the claimant’s physical condition only as assessed by the information 20 available today, including objective findings on the claimant’s exam as well as assessment of the 21 natural history of the claimant’s medical/physical conditions.” AR 998 (emphasis in original). 22 Among other opined limitations, PA-C Sills found Plaintiff could stand/walk for 30 minutes to 23 two hours per day and 15 to 45 minutes at a time. Id. She also opined Plaintiff could sit for 30

24 1 minutes to two hours per day and 30 to 60 minutes at a time. Id. She found Plaintiff’s overall 2 function in these areas was poor. Id. PA-C Sills listed her physical examination of Plaintiff and 3 his diagnoses as the bases for these opinions. Id. 4 The ALJ found PA-C Sills’ opinion unpersuasive “because it is based too much on the

5 one-time exam and the claimant’s subjective complaints, rather the rest of the record, which 6 shows stable back deficits on imaging along with conservative treatment, and mild knee deficits 7 on imaging along with limited treatment.” AR 28. 8 Regarding the supportability of PA-C Sills’ opinion, the ALJ first found it was “based too 9 much on the one-time exam[.]” Id. An ALJ may consider the length, purpose, and extent of the 10 treating relationship in considering the persuasiveness of a medical opinion. See 20 C.F.R. § 11 404.1520c(c)(3). However, the fact a provider examined a claimant only once, standing alone, is 12 not a legally sufficient basis for rejecting the provider’s opinion. See Yeakey v. Colvin, No. 13 CV13–05598, 2014 WL 3767410, at *6 (W.D. Wash. July 31, 2014) (“Discrediting an opinion 14 because the examining doctor only saw claimant one time would effectively discredit most, if not

15 all, examining doctor opinions.”); Keri J. v. Comm’r of Soc. Sec., No. 3:20-CV-5779, 2021 WL 16 4026320, at *2 (W.D. Wash. Sept. 3, 2021) (“[T]he fact that [the provider] only examined 17 Plaintiff twice is not, in and of itself, a valid reason for discounting her opinion, especially in 18 light of the revised regulations, which eliminate the regulatory distinction between ‘treating’ and 19 ‘examining’ opinions, and provide that an examining source ‘may have a better understanding’ 20 of an individual's limitations.”). The ALJ erred in discounting PA-C Sills’ opinion on this basis. 21 The ALJ next found PA-C Sills’ opinion was unpersuasive because it was based on 22 Plaintiff’s subjective complaints. AR 28. An ALJ may reject a physician’s opinion “if it is based 23 ‘to a large extent’ on a claimant’s self-reports that have been properly discounted as incredible.”

24 1 Tommasetti v, Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008) (quoting Morgan v. Comm’r. Soc. 2 Sec. Admin., 169 F.3d 595, 602 (9th Cir. 1999)). Although PA-C Sills noted she considered 3 Plaintiff’s subjective reports of pain, she also reviewed some of Plaintiff’s prior medical records 4 and specifically indicated her opinions regarding Plaintiff’s standing, walking, and sitting

5 limitations were based on Plaintiff’s diagnoses and her physical examination, as well as the 6 clinical interview. See AR 998–99. Accordingly, substantial evidence does not support the ALJ’s 7 conclusion that PA-C Sills’ opinion was based to a large extent on Plaintiff’s subjective 8 complaints, and the ALJ erred in finding the opinion unpersuasive on this basis. 9 The ALJ did not make any specific findings regarding consistency but noted “the rest of 10 the record . . . shows stable back deficits on imaging along with conservative treatment, and 11 mild knee deficits on imaging along with limited treatment.” AR 28. The ALJ provided no 12 citations to the record or any additional explanation in support of this statement. Although the 13 ALJ is responsible for resolving conflicts in the evidence, she must explain her reasoning to 14 allow for this Court’s review. See Ford v. Saul, 950 F.3d 1141, 1149 (9th Cir. 2020); Brown-

15 Hunter v. Colvin, 806 F.3d 487, 492 (9th Cir. 2015). Because of the lack of explanation and 16 specific reference to the record, the Court cannot determine whether this finding is supported by 17 substantial evidence. See Blakes v. Barnhart, 331 F.3d 565, 569 (7th Cir. 2003) (“We require the 18 ALJ to build an accurate and logical bridge from the evidence to her conclusions so that we may 19 afford the claimant meaningful review of the SSA’s ultimate findings.”). 20 For the above reasons, the Court concludes the ALJ failed to properly evaluate PA-C 21 Sills’ medical opinion. Accordingly, the ALJ erred. Had the ALJ properly evaluated this 22 evidence, the ultimate disability determination may have changed, or the RFC may have 23 included additional limitations. For example, PA-C Sills opined Plaintiff could sit for only 30

24 1 minutes to 2 hours per day and only 30 to 60 minutes at a time. AR 998. The ALJ did not 2 account for any need to change positions in the RFC.3 See AR 24. Accordingly, the error is not 3 harmless and require reversal. 4 B. Remedy

5 The Court may remand a case “either for additional evidence and findings or to award 6 benefits.” Smolen v. Chater, 80 F.3d 1273, 1292 (9th Cir. 1996). Generally, when the Court 7 reverses an ALJ’s decision, “the proper course, except in rare circumstances, is to remand to the 8 agency for additional investigation or explanation.” Benecke v. Barnhart, 379 F.3d 587, 595 (9th 9 Cir. 2004) (quoting INS v. Ventura, 537 U.S. 12, 16 (2002)). 10 Plaintiff requests the Court reverse and remand the ALJ’s decision either for immediate 11 calculation and payment of benefits or for further proceedings. Dkt. 9 at 11. Plaintiff does not 12 explain why he is entitled to the extraordinary remedy of an immediate award of benefits, nor 13 has he shown that the record is free from important and relevant conflicts or that no issues 14 remain that must be resolved concerning Plaintiff’s functional capabilities. Therefore, remand for

15 further administrative proceedings is appropriate. 16 C. Remaining Issues 17 Plaintiff further contends the ALJ failed to properly evaluate medical opinion evidence 18 from Dr. Luis Garduno, as well as Plaintiff’s testimony about the severity of his symptoms. Dkt. 19 9 at 1. As noted above, the Court concludes the ALJ committed harmful error in assessing the 20 medical opinion evidence of PA-C Sills and remand for further proceedings is appropriate. Due 21 to this error, the ALJ must re-evaluate all the medical evidence on remand. Because Plaintiff 22 3 “[A]n individual [who must alternate periods of sitting and standing] is not functionally capable of doing either the 23 prolonged sitting contemplated in the definition of sedentary work (and for the relatively few light jobs which are performed primarily in a seated position) or the prolonged standing or walking contemplated for most light work.” 24 Social Security Ruling 83-10, 1983 WL 31253, at *4 (Jan. 1, 1983). 1 may be able to present new evidence and new testimony on remand and the ALJ’s 2 reconsideration of the medical evidence may impact the assessment of Dr. Garduno’s opinion 3 and Plaintiff’s testimony, the ALJ must also reconsider this evidence on remand. 4 IV. Conclusion

5 Based on the foregoing reasons, the Court hereby finds the ALJ improperly concluded 6 Plaintiff was not disabled beginning March 1, 2019. Accordingly, Defendant’s decision to deny 7 benefits is reversed and this matter is remanded for further administrative proceedings in 8 accordance with the findings contained herein. 9 Dated this 27th day of May, 2025. 10 A 11 David W. Christel United States Magistrate Judge 12 13 14 15 16 17 18 19 20 21 22 23 24