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5 6 7 UNITED STATES DISTRICT COURT 8 WESTERN DISTRICT OF WASHINGTON AT TACOMA 9 10 RACHEL A., CASE NO. 3:25-cv-05315-DGE 11 Plaintiff, ORDER REVERSING AND 12 v. REMANDING FOR FURTHER PROCEEDINGS 13 COMMISSIONER OF SOCIAL SECURITY, 14 Defendant. 15 16 Plaintiff seeks review of the denial of the Commissioner of Social Security’s denial of her 17 application for Disability Insurance Benefits (“DIB”). As discussed below, the Court 18 REVERSES and REMANDS the Commissioner’s decision for further proceedings. 19 I. FACTUAL AND PROCEDURAL BACKGROUND 20 Plaintiff was 53 years old when she applied for disability benefits. Administrative 21 Record (“AR”) 70. Plaintiff attended community college for two years, and previously worked 22 as an admitting clerk, a customer service representative, and a janitor. AR 282–283. Plaintiff 23 filed her application for DIB on October 26, 2022, alleging a disability onset date of September 24 1 21, 2020. AR 22, 212–213. Plaintiff’s application was denied initially and on reconsideration. 2 AR 22, 95–99, 109–112. Plaintiff’s requested hearing was held before Administrative Law 3 Judge (“ALJ”) Howard Prinsloo on June 13, 2024. AR 37–68. On September 27, 2024, ALJ 4 Prinsloo issued an order finding Plaintiff was not disabled pursuant to the Social Security Act.
5 AR 19–36. On November 19, 2024, the Appeals Council denied Plaintiff’s request for review. 6 AR 6–11. On April 14, 2025, Plaintiff filed a complaint in this Court. (Dkt. No. 1.) 7 II. LEGAL STANDARD
8 The Court may reverse the ALJ’s decision only if it is legally erroneous or not supported 9 by substantial evidence of record. Ford v. Saul, 950 F.3d 1141, 1154 (9th Cir. 2020). The Court 10 must examine the record but cannot reweigh the evidence or substitute its judgment for the 11 ALJ’s. Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002). When evidence is susceptible to 12 more than one interpretation, the Court must uphold the ALJ’s interpretation if rational. Ford, 13 950 F.3d at 1154. Also, the Court “may not reverse an ALJ’s decision on account of an error 14 that is harmless.” Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012). 15 III. DISCUSSION
16 In Plaintiff’s opening brief, Plaintiff raises the following issues: (1) whether the ALJ 17 properly evaluated the opinion of Michelle Maciel, Psy.D,; (2) whether the ALJ properly 18 evaluated Plaintiff’s subjective symptom testimony; and (3) whether the ALJ erred by not 19 resolving an alleged inconsistency between the testimony of the vocational expert (“VE”) and 20 the Dictionary of Occupational Titles (“DOT”). (Dkt. No. 7.) Plaintiff asks the Court to remand 21 this case for further proceedings “at the very least.” (Id. at 14.) 22
24 1 A. Medical Opinion Evidence
2 Plaintiff contends the ALJ erred in evaluating the opinion of psychologist Dr. Michelle 3 Maciel. (Dkt. No. 7 at 4–8.) 4 ALJs must consider every medical opinion in the record and evaluate each opinion’s 5 persuasiveness, with the two most important factors being “supportability” and “consistency.” 6 Woods v. Kijakazi, 32 F.4th 785, 791 (9th Cir. 2022); 20 C.F.R. § 404.1520c(a). Supportability 7 concerns how a medical source supports a medical opinion with relevant evidence, while 8 consistency concerns how a medical opinion is consistent with other evidence from medical and 9 nonmedical sources. See id.; 20 C.F.R. § 404.1520c(c)(1), (c)(2). 10 Dr. Maciel examined Plaintiff on June 3, 2023. AR 768–771. Dr. Maciel’s examination 11 consisted of a clinical interview, a review of the medical records, a test of intellectual 12 functioning, and a mental status examination. AR 768–770. Based on the results of her 13 examination, Dr. Maciel found Plaintiff would not have difficulty performing either simple and 14 repetitive tasks or detailed and complex tasks. AR 770. Dr. Maciel further opined Plaintiff
15 would not have difficulty accepting instructions from supervisors or performing work 16 activities on a consistent basis without special or additional instructions. AR 770. Dr. Maciel 17 stated Plaintiff would not have difficulty dealing with usual stress encountered in the workplace. 18 AR 771. 19 Dr. Maciel opined Plaintiff would have difficulty interacting with co-workers and the 20 public due to hypervigilance and possible pharmaceutical/alcohol sedation. AR 770. Dr. Maciel 21 further opined Plaintiff would have difficulty maintaining regular attendance and completing a 22 normal workday/workweek without interruptions from a psychiatric condition due to 23 hypervigilance and possible pharmaceutical/alcohol sedation. AR 771.
24 1 The ALJ found Dr. Maciel’s opinion partially persuasive, reasoning that: (1) the opinion 2 did not assess the degree to which Plaintiff was limited; (2) the limitations assessed by Dr. 3 Maciel were not supported by Dr. Maciel’s own examination findings; and (3) the attendance 4 limitations assessed by Dr. Maciel are not consistent with Plaintiff’s ability to regularly attend
5 appointments or with the largely normal mental status evaluations in the record. AR 30. The 6 ALJ found the limitations included in Plaintiff’s residual functional capacity (“RFC”), which 7 restricted Plaintiff to understanding, remembering, and carrying out simple instructions, no more 8 than occasional interaction with the public and co-workers, and no collaborative tasks, were 9 sufficient to accommodate Plaintiff’s subjective complaints. AR 26, 30. 10 With respect to the ALJ’s first reason, the ALJ appears to assert he was unable to include 11 limitations related to Plaintiff’s hypervigilance and possible pharmaceutical/alcohol sedation in 12 Plaintiff’s RFC because Dr. Maciel’s opinion was insufficiently specific concerning the degree 13 of limitation this issue would cause. Dr. Maciel’s opinion does not assess the degree of 14 limitation Plaintiff would have with respect to maintaining regular attendance and completing a
15 normal workday/workweek, for example by using words typically used in such opinions, such as 16 “mild,” “moderate,” “marked,” or “severe.” Nevertheless, the RFC does not appear to 17 incorporate this aspect of Dr. Maciel’s opinion at all, for example, by including a limitation 18 concerning time Plaintiff would be off-task, or the number of days per month Plaintiff would 19 miss work due to her impairments. See AR 26–30. 20 The ALJ’s reasoning is problematic because an individual whose impairments created 21 significant attendance issues would likely be unable to perform any work. During the hearing, 22 the ALJ asked the VE whether the VE could identify any jobs that an individual, who was unable 23 to complete a normal work week or work month without interruption from psychologically based
24 1 symptoms to the extent that the individual would be absent more than two days a month, could 2 perform. AR 66. The VE testified he could not identify a job such an individual could sustain in 3 a competitive labor market. AR 66. 4 As for the ALJ’s second reason, the ALJ stated the limitations assessed by Dr. Maciel
5 were inconsistent with her own examination findings, which revealed Plaintiff to be cooperative, 6 fully oriented, with fair memory and concentration, and of average intelligence. AR 30.
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5 6 7 UNITED STATES DISTRICT COURT 8 WESTERN DISTRICT OF WASHINGTON AT TACOMA 9 10 RACHEL A., CASE NO. 3:25-cv-05315-DGE 11 Plaintiff, ORDER REVERSING AND 12 v. REMANDING FOR FURTHER PROCEEDINGS 13 COMMISSIONER OF SOCIAL SECURITY, 14 Defendant. 15 16 Plaintiff seeks review of the denial of the Commissioner of Social Security’s denial of her 17 application for Disability Insurance Benefits (“DIB”). As discussed below, the Court 18 REVERSES and REMANDS the Commissioner’s decision for further proceedings. 19 I. FACTUAL AND PROCEDURAL BACKGROUND 20 Plaintiff was 53 years old when she applied for disability benefits. Administrative 21 Record (“AR”) 70. Plaintiff attended community college for two years, and previously worked 22 as an admitting clerk, a customer service representative, and a janitor. AR 282–283. Plaintiff 23 filed her application for DIB on October 26, 2022, alleging a disability onset date of September 24 1 21, 2020. AR 22, 212–213. Plaintiff’s application was denied initially and on reconsideration. 2 AR 22, 95–99, 109–112. Plaintiff’s requested hearing was held before Administrative Law 3 Judge (“ALJ”) Howard Prinsloo on June 13, 2024. AR 37–68. On September 27, 2024, ALJ 4 Prinsloo issued an order finding Plaintiff was not disabled pursuant to the Social Security Act.
5 AR 19–36. On November 19, 2024, the Appeals Council denied Plaintiff’s request for review. 6 AR 6–11. On April 14, 2025, Plaintiff filed a complaint in this Court. (Dkt. No. 1.) 7 II. LEGAL STANDARD
8 The Court may reverse the ALJ’s decision only if it is legally erroneous or not supported 9 by substantial evidence of record. Ford v. Saul, 950 F.3d 1141, 1154 (9th Cir. 2020). The Court 10 must examine the record but cannot reweigh the evidence or substitute its judgment for the 11 ALJ’s. Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002). When evidence is susceptible to 12 more than one interpretation, the Court must uphold the ALJ’s interpretation if rational. Ford, 13 950 F.3d at 1154. Also, the Court “may not reverse an ALJ’s decision on account of an error 14 that is harmless.” Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012). 15 III. DISCUSSION
16 In Plaintiff’s opening brief, Plaintiff raises the following issues: (1) whether the ALJ 17 properly evaluated the opinion of Michelle Maciel, Psy.D,; (2) whether the ALJ properly 18 evaluated Plaintiff’s subjective symptom testimony; and (3) whether the ALJ erred by not 19 resolving an alleged inconsistency between the testimony of the vocational expert (“VE”) and 20 the Dictionary of Occupational Titles (“DOT”). (Dkt. No. 7.) Plaintiff asks the Court to remand 21 this case for further proceedings “at the very least.” (Id. at 14.) 22
24 1 A. Medical Opinion Evidence
2 Plaintiff contends the ALJ erred in evaluating the opinion of psychologist Dr. Michelle 3 Maciel. (Dkt. No. 7 at 4–8.) 4 ALJs must consider every medical opinion in the record and evaluate each opinion’s 5 persuasiveness, with the two most important factors being “supportability” and “consistency.” 6 Woods v. Kijakazi, 32 F.4th 785, 791 (9th Cir. 2022); 20 C.F.R. § 404.1520c(a). Supportability 7 concerns how a medical source supports a medical opinion with relevant evidence, while 8 consistency concerns how a medical opinion is consistent with other evidence from medical and 9 nonmedical sources. See id.; 20 C.F.R. § 404.1520c(c)(1), (c)(2). 10 Dr. Maciel examined Plaintiff on June 3, 2023. AR 768–771. Dr. Maciel’s examination 11 consisted of a clinical interview, a review of the medical records, a test of intellectual 12 functioning, and a mental status examination. AR 768–770. Based on the results of her 13 examination, Dr. Maciel found Plaintiff would not have difficulty performing either simple and 14 repetitive tasks or detailed and complex tasks. AR 770. Dr. Maciel further opined Plaintiff
15 would not have difficulty accepting instructions from supervisors or performing work 16 activities on a consistent basis without special or additional instructions. AR 770. Dr. Maciel 17 stated Plaintiff would not have difficulty dealing with usual stress encountered in the workplace. 18 AR 771. 19 Dr. Maciel opined Plaintiff would have difficulty interacting with co-workers and the 20 public due to hypervigilance and possible pharmaceutical/alcohol sedation. AR 770. Dr. Maciel 21 further opined Plaintiff would have difficulty maintaining regular attendance and completing a 22 normal workday/workweek without interruptions from a psychiatric condition due to 23 hypervigilance and possible pharmaceutical/alcohol sedation. AR 771.
24 1 The ALJ found Dr. Maciel’s opinion partially persuasive, reasoning that: (1) the opinion 2 did not assess the degree to which Plaintiff was limited; (2) the limitations assessed by Dr. 3 Maciel were not supported by Dr. Maciel’s own examination findings; and (3) the attendance 4 limitations assessed by Dr. Maciel are not consistent with Plaintiff’s ability to regularly attend
5 appointments or with the largely normal mental status evaluations in the record. AR 30. The 6 ALJ found the limitations included in Plaintiff’s residual functional capacity (“RFC”), which 7 restricted Plaintiff to understanding, remembering, and carrying out simple instructions, no more 8 than occasional interaction with the public and co-workers, and no collaborative tasks, were 9 sufficient to accommodate Plaintiff’s subjective complaints. AR 26, 30. 10 With respect to the ALJ’s first reason, the ALJ appears to assert he was unable to include 11 limitations related to Plaintiff’s hypervigilance and possible pharmaceutical/alcohol sedation in 12 Plaintiff’s RFC because Dr. Maciel’s opinion was insufficiently specific concerning the degree 13 of limitation this issue would cause. Dr. Maciel’s opinion does not assess the degree of 14 limitation Plaintiff would have with respect to maintaining regular attendance and completing a
15 normal workday/workweek, for example by using words typically used in such opinions, such as 16 “mild,” “moderate,” “marked,” or “severe.” Nevertheless, the RFC does not appear to 17 incorporate this aspect of Dr. Maciel’s opinion at all, for example, by including a limitation 18 concerning time Plaintiff would be off-task, or the number of days per month Plaintiff would 19 miss work due to her impairments. See AR 26–30. 20 The ALJ’s reasoning is problematic because an individual whose impairments created 21 significant attendance issues would likely be unable to perform any work. During the hearing, 22 the ALJ asked the VE whether the VE could identify any jobs that an individual, who was unable 23 to complete a normal work week or work month without interruption from psychologically based
24 1 symptoms to the extent that the individual would be absent more than two days a month, could 2 perform. AR 66. The VE testified he could not identify a job such an individual could sustain in 3 a competitive labor market. AR 66. 4 As for the ALJ’s second reason, the ALJ stated the limitations assessed by Dr. Maciel
5 were inconsistent with her own examination findings, which revealed Plaintiff to be cooperative, 6 fully oriented, with fair memory and concentration, and of average intelligence. AR 30. A 7 finding that a medical opinion contains internal inconsistencies can serve as a valid reason for 8 discounting it. See Morgan v. Comm'r of Soc. Sec. Admin., 169 F.3d 595, 603 (9th Cir. 1999); 9 see also Rollins v. Massanari, 261 F.3d 853, 856 (9th Cir. 2001) (upholding ALJ's rejection of 10 internally inconsistent medical opinion). Here, Dr. Maciel’s findings concerning Plaintiff’s 11 hypervigilance and possible pharmaceutical/alcohol sedation are supported by the results of Dr. 12 Maciel’s clinical interview, during which Plaintiff asserted she drinks alcohol “excessively” 13 beginning at noon every day, and also consumes marijuana edibles to the point where her 14 tolerance has increased. AR 769. Dr. Maciel’s opinion is also consistent with Plaintiff’s
15 blunted, sedated affect during the mental status examination. AR 770. 16 With respect to the ALJ’s third reason, the ALJ found the attendance limitations assessed 17 by Dr. Maciel were not consistent with her ability to regularly attend appointments or with the 18 largely normal mental status evaluations in the record. AR 30. Plaintiff’s ability to attend 19 doctor’s appointments is not a valid reason for discounting Dr. Maciel’s opinion concerning 20 Plaintiff’s ability to maintain regular attendance and complete a normal workday/workweek 21 without interruptions; the ALJ has not explained how Plaintiff's ability to periodically attend 22 doctor's appointments demonstrates Plaintiff's capacity to maintain regular attendance and be 23 punctual in a competitive working setting. See Mulanax v. Comm'r of Soc. Sec. Admin., 293 Fed.
24 1 Appx. 522, 523 (9th Cir. 2008) (citing SSR 96-8p) (“Generally, in order to be eligible for 2 disability benefits under the Social Security Act, the person must be unable to sustain full-time 3 work – eight hours per day, five days per week.”). Moreover, disability claimants “should not be 4 penalized for attempting to lead normal lives in the face of their limitations.” Reddick v. Chater,
5 157 F.3d 715, 722 (9th Cir. 1998). Finally, the ALJ cites the “largely normal” mental status 6 examinations in the record, but does not cite any records in particular. See Robbins v. Soc. Sec. 7 Admin., 466 F.3d 880, 884 n.2 (9th Cir. 2006) (noting that without a “reference to the record” the 8 court was left to speculate as to the ALJ's reasoning). 9 Accordingly, the Court finds the ALJ erred in evaluating Dr. Maciel’s opinion. 10 B. Other Issues
11 Plaintiff also contends the ALJ erred in evaluating her symptom testimony and by not 12 resolving an alleged inconsistency between the VE’s testimony and the DOT. (Dkt. No. 7 at 3– 13 4, 8–14.) Because Plaintiff will be able to present new evidence and testimony on remand, and 14 because the ALJ's evaluation of Dr. Maciel’s opinion may impact his evaluation of the remaining 15 record, the ALJ shall re-evaluate this evidence on remand. 16 IV. REMEDY
17 Plaintiff asks the Court to remand this case for further proceedings “at the very least.” 18 (Dkt. No. 7 at 14.) The Court interprets this as a request to remand this case for an award of 19 benefits. 20 “The decision whether to remand a case for additional evidence, or simply to award 21 benefits[,] is within the discretion of the court.” Trevizo v. Berryhill, 871 F.3d 664, 682 (9th Cir. 22 2017) (quoting Sprague v. Bowen, 812 F.2d 1226, 1232 (9th Cir. 1987)). “When the ALJ denies 23 benefits and the court finds error, the court ordinarily must remand to the agency for further 24 1 proceedings before directing an award of benefits.” Leon v. Berryhill, 880 F.3d 1041, 1045 (9th 2 Cir. 2017). The Ninth Circuit has developed a three-step analysis for determining when to 3 remand for a direct award of benefits. Such remand is generally proper only where: 4 (1) the record has been fully developed and further administrative proceedings would serve no useful purpose; (2) the ALJ has failed to 5 provide legally sufficient reasons for rejecting evidence, whether claimant testimony or medical opinion; and (3) if the improperly discredited 6 evidence were credited as true, the ALJ would be required to find the claimant disabled on remand. 7 8 Trevizo, 871 F.3d at 682–683 (quoting Garrison v. Colvin, 759 F.3d 995, 1020 (9th Cir. 2014)). 9 “Even if [the Court] reach[es] the third step and credits [the improperly rejected evidence] as 10 true, it is within the court’s discretion either to make a direct award of benefits or to remand for 11 further proceedings.” Leon, 880 F.3d at 1045 (citing Treichler, v. Comm’r of Soc. Sec. Admin., 12 775 F.3d 1090, 1101 (9th Cir. 2014). 13 Here, the Court finds the ALJ must re-evaluate the opinion of Dr. Maciel. Accordingly, 14 remand for further proceedings is appropriate. 15 V. ORDER
16 Based on the foregoing reasons, the Court finds the ALJ improperly discounted the 17 opinion of Dr. Maciel. Accordingly, Defendant's decision to deny benefits is REVERSED and 18 this matter is REMANDED for further administrative proceedings. 19 20 Dated this 20th day of October, 2025. 21 A 22 David G. Estudillo 23 United States District Judge