Ramon Avila Gonzalez v. Frank Bisignano, Commissioner of Social Security

Opinion

1 2 3 4 5 6 7 UNITED STATES DISTRICT COURT 8 EASTERN DISTRICT OF CALIFORNIA 9 10 RAMON AVILA GONZALEZ, Case No. 1:25-cv-00840-SKO

11 Plaintiff,

12 ORDER ON PLAINTIFF’S SOCIAL v. SECURITY COMPLAINT 13

14 FRANK BISIGNANO, Commissioner of Social Security1 (Doc. 1) 15

16 Defendant. 17 _____________________________________/ 18 I. INTRODUCTION 19 Plaintiff Ramon Avila Gonzalez (“Plaintiff”) seeks judicial review of a final decision of the 20 Commissioner of Social Security (the “Commissioner” or “Defendant”) denying his application for 21 disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under the Social 22 Security Act (the “Act”). (Doc. 1). The matter is currently before the Court on the parties’ briefs, 23 which were submitted, without oral argument, to the Honorable Sheila K. Oberto, United States 24 Magistrate Judge.2 25 II. BACKGROUND 26 1 On May 7, 2025, Frank Bisignano was named Commissioner of the Social Security Administration. See 27 https://www.ssa.gov/history/commissioners.html. He is therefore substituted as the defendant in this action. See 42 U.S.C. § 405(g) (referring to the “Commissioner’s Answer”); 20 C.F.R. § 422.210(d) (“the person holding the Office 28 of the Commissioner shall, in [their] official capacity, be the proper defendant.”). 1 Plaintiff was born in 1997. (Administrative Record (“AR”) 614). He earned a high school 2 diploma. (AR 87−88). Plaintiff filed an application for DIB and SSI, alleging he became disabled 3 on June 4, 2017, after an auto accident that resulted in burns over the majority of his body. (AR 4 570). 5 A. Relevant Evidence of Record3 6 1. Medical Evidence 7 Treatment records establish Plaintiff was obese, (AR 2493); had back, (AR 1945, 2533, 2551, 8 2644–45, 2744, 2761, 2767), neck, (AR 1945, 2047, 2556, 2572–73, 2592, 2596, 2697, 2701, 2747, 9 3134, 3175, 3177, 3181, 3342, 3366), and foot pain, (AR 1575, 1647, 1654, 1679, 1724–26, 1936, 10 1938–39, 2085, 2103, 2129–34, 2538, 2546–47, 2615, 2691, 2922, 3245, 3251, 3277); as well as 11 neurological, (AR 1558, 1786, 1944, 1949, 1951, 1956–58, 1972–73, 2566, 2662, 3256), and 12 psychological impairments, (AR 1589, 1592–97, 2088, 2495–97, 2505–07, 2584, 2587, 2659–60, 13 2710, 2778, 2784–85, 3222–23, 3231, 3254, 3260, 3277). 14 Additionally, imaging studies of Plaintiff’s feet and back yielded results such as “extensive 15 soft tissue swelling” with “staple-like foreign bodies seen in the soft tissue” as to Plaintiff’s feet, 16 (AR 2148; see also AR 2418–19, 2616), and “mild to moderate bilateral neuroforaminal narrowing,” 17 (AR 2644), “[g]rade 1 L5-SI spondylolisthesis,” (AR 2645, see also AR 2551, 2761), “[m]ild 18 degenerative osteophytes of thoracic spine,” (AR 2646, 2761), “[m]inimum to mild bilateral 19 uncovertebral hypertrophy with minimal to mild bilateral neuroforaminal narrowing at C3-C4,” (AR 20 2647), “retrolisthesis of L5 on S1,” (AR 2551), as to Plaintiff’s back. 21 2. Medical Opinions 22 The record reflects that numerous medical professionals evaluated Plaintiff, either directly 23 or through his medical records, and based on those evaluations, formed medical opinions. 24 Dr. Anna M. Franco, Psy.D, evaluated Plaintiff’s psychological records on behalf of the 25 agency on initial review of Plaintiff’s claim, and completed a medical evaluation on October 1, 2018. 26 (See AR 127−28, 143−45, 160−62). Dr. R. Friedman, M.D. also reviewed Plaintiff’s medical 27

28 3 Because the parties are familiar with the medical evidence, it is summarized here only to the extent relevant to the 1 records during that initial review, made several findings, and performed a “Physical Functional 2 Capacity Assessment,” on December 12, 2018. (See AR 124−26, 129−31, 133, 141−43, 146−48, 3 150, 158−160, 163−65, 167). 4 Upon request for reconsideration, Dr. Julie Jennings, PhD, evaluated Plaintiff’s psychiatric 5 records on behalf of the agency, and completed a medical evaluation on April 8, 2019. (See AR 6 184−85, 207−08, 230−31). Dr. Leslie E. Arnold, M.D. also reviewed Plaintiff’s medical records 7 during that reconsideration review, made several findings, and performed a “Physical Functional 8 Capacity Assessment” on April 7, 2019. (See AR 180−84, 87−90, 191−93, 203−07, 210−13, 216, 9 226−30, 233−36, 238−39). 10 During the course of the agency’s reconsideration, two consultative examiners, Dr. Patricia 11 Spivey, Psy.D., and Dr. Satish K. Sharma, M.D., examined Plaintiff in September 2018 and 12 produced reports reflecting the results of their examination and their medical opinions as to Plaintiff. 13 (See AR 1934−37 (reflecting Dr. Spivey’s “Mental Status Disability Report”); 1943−46 (reflecting 14 Dr. Sharma’s “Health Analysis: Internal Medicine Evaluation” report). 15 Finally, Plaintiff’s primary care provider, Nurse Practitioner Stephanie Castillo, who treated 16 Plaintiff over the course of several years, (see, e.g., AR 1561, 1567, 2085, 2088−8937, 3251−60, 17 3260, 3277, 3288), produced a medical source statement on May 30, 2023, in which she opined on 18 Plaintiff’s limitations based on his psychiatric condition, (see AR 3080−81). 19 B. Administrative Proceedings 20 The Commissioner denied Plaintiff’s application for benefits initially on December 12, 2018, 21 and again on reconsideration on April 7, 2019. (AR 117–242). Consequently, Plaintiff requested a 22 hearing before an Administrative Law Judge (“ALJ”). (AR 303–17). The ALJ conducted a hearing 23 on August 23, 2023. (AR 19–46). Plaintiff appeared at the hearing with his attorney and testified 24 as to his alleged disabling conditions and work history. (AR 55–71). 25 A Vocational Expert (“VE”) also testified at the hearing. (AR 65–75). The VE testified that 26 an individual with a high school education and no relevant work experience with a hypothetical 27 residual functional capacity (“RFC”) matching the RFC ultimately assessed by the ALJ would be 28 able to be a price marker or routing clerk. (AR 67–68). 1 C. The ALJ’s Decision 2 In a decision dated October 24, 2023, the ALJ found that Plaintiff was not disabled. (AR 3 22–38). The ALJ conducted the five-step disability analysis set forth in 20 C.F.R. § 404.1520. (AR 4 23–37). The ALJ decided that Plaintiff had not engaged in substantial gainful activity since 5 November 15, 2015. (AR 26). At step two, the ALJ found Plaintiff’s following impairments to be 6 severe: burns to bilateral feet status-post grafting and surgical release of bilateral toe contractures, 7 lumbar degenerative disc disease, and obesity. (Id.). The ALJ then determined that Plaintiff did not 8 have an impairment or combination of impairments that met or medically equaled one of the listed 9 impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (“the Listings”) (step three). (AR 26– 10 29). 11 The ALJ assessed Plaintiff’s RFC4 and applied the assessment at steps four and five. See 20 12 C.F.R. § 404.1520(a)(4) (“Before we go from step three to step four, we assess your residual 13 functional capacity . . . . We use this residual functional capacity assessment at both step four and 14 step five when we evaluate your claim at these steps.”). The ALJ determined that Plaintiff had the 15 RFC: 16 to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except the claimant can lift and carry 20 pounds occasionally and 10 pounds frequently. The 17 claimant can stand or walk about six hours and sit about six hours. He can never 18 climb ladders, ropes or scaffolds, but he can occasionally climb stairs or ramps. The claimant can frequently balance, kneel, crouch, and crawl and occasionally stoop. 19 He will be required to avoid all exposure to hazards such as unprotected heights and machinery with unguarded moving mechanical parts. The claimant can perform 20 simple tasks that involve occasional interaction with the general public, co-workers, and supervisors and can adapt to occasional workplace changes. 21 22 (AR 29; see also id. 29–36). Although the ALJ recognized that Plaintiff’s impairments “could 23 reasonably be expected to cause the alleged symptoms,” the ALJ rejected Plaintiff’s subjective 24

25 4 RFC is an assessment of an individual’s ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis of eight hours a day, for five days a week, or an equivalent work schedule. 26 TITLES II & XVI: ASSESSING RESIDUAL FUNCTIONAL CAPACITY IN INITIAL CLAIMS, Social Security Ruling (“SSR”) 96-8P (S.S.A. July 2, 1996). The RFC assessment considers only functional limitations and restrictions that result 27 from an individual’s medically determinable impairment or combination of impairments. Id. “In determining a claimant’s RFC, an ALJ must consider all relevant evidence in the record, including, inter alia, medical records, lay 28 evidence, and ‘the effects of symptoms, including pain, that are reasonably attributed to a medically determinable 1 testimony as to “the intensity, persistence and limiting effects of these symptoms” as being “not 2 entirely consistent with the medical evidence and other evidence in the record.” (AR 30). 3 The ALJ then determined Plaintiff had no relevant work (step four) but that, given his RFC, 4 he could perform a significant number of jobs in the national economy (step five). (AR 36–37). 5 In making this determination, the ALJ relied on the VE’s answers to a series of hypothetical 6 questions the ALJ posed to the VE during the hearing. (AR 37). The VE testified that a person 7 with the RFC specified above could perform the jobs of price marker or routing clerk. (AR 67−68). 8 The ALJ ultimately concluded Plaintiff was not disabled at any time after June 4, 2017, the alleged 9 onset date. (AR 37). 10 Plaintiff sought review of this decision before the Appeals Council, which denied review on 11 February 12, 2024. (AR 6–8). Therefore, the ALJ’s decision became the final decision of the 12 Commissioner. 20 C.F.R. § 404.981. 13 III. LEGAL STANDARD 14 A. Applicable Law 15 An individual is considered “disabled” for purposes of disability benefits if [they are] unable 16 “to engage in any substantial gainful activity by reason of any medically determinable physical or 17 mental impairment which can be expected to result in death or which has lasted or can be expected 18 to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). However, 19 “[a]n individual shall be determined to be under a disability only if [their] physical or mental 20 impairment or impairments are of such severity that [they are] not only unable to do [their] previous 21 work but cannot, considering [their] age, education, and work experience, engage in any other kind 22 of substantial gainful work which exists in the national economy.” Id. § 423(d)(2)(A). 23 “The Social Security Regulations set out a five-step sequential process for determining 24 whether a claimant is disabled within the meaning of the Social Security Act.” Tackett v. Apfel, 180 25 F.3d 1094, 1098 (9th Cir. 1999) (citing 20 C.F.R. § 404.1520). The Ninth Circuit has provided the 26 following description of the sequential evaluation analysis: 27 In step one, the ALJ determines whether a claimant is currently engaged in substantial gainful activity. If so, the claimant is not disabled. If not, the ALJ 28 proceeds to step two and evaluates whether the claimant has a medically severe 1 so, the ALJ proceeds to step three and considers whether the impairment or 2 combination of impairments meets or equals a listed impairment under 20 C.F.R. pt. 404, subpt. P, [a]pp. 1. If so, the claimant is automatically presumed disabled. If 3 not, the ALJ proceeds to step four and assesses whether the claimant is capable of performing [their] past relevant work. If so, the claimant is not disabled. If not, the 4 ALJ proceeds to step five and examines whether the claimant has the [RFC] . . . to perform any other substantial gainful activity in the national economy. If so, the 5 claimant is not disabled. If not, the claimant is disabled. 6 Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005). “If a claimant is found to be ‘disabled’ or 7 ‘not disabled’ at any step in the sequence, there is no need to consider subsequent steps.” Tackett, 8 180 F.3d at 1098 (citing 20 C.F.R. § 404.1520). 9 “The claimant carries the initial burden of proving a disability in steps one through four of 10 the analysis.” Burch, 400 F.3d at 679 (citing Swenson v. Sullivan, 876 F.2d 683, 687 (9th Cir. 1989)). 11 “However, if a claimant establishes an inability to continue [their] past work, the burden shifts to 12 the Commissioner in step five to show that the claimant can perform other substantial gainful work.” 13 Id. (citing Swenson, 876 F.2d at 687). 14 B. Scope of Review 15 “This court may set aside the Commissioner’s denial of [social security] benefits [only] when 16 the ALJ’s findings are based on legal error or are not supported by substantial evidence in the record 17 as a whole.” Tackett, 180 F.3d at 1097 (citation omitted). “Substantial evidence . . . is ‘more than 18 a mere scintilla,’” and means only “such relevant evidence as a reasonable mind might accept as 19 adequate to support a conclusion.” Biestek v. Berryhill, 587 U.S. 97, 103 (2019) (quoting Consol. 20 Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)); see also Ford v. Saul, 950 F.3d 1141, 1154 (9th 21 Cir. 2020). 22 “This is a highly deferential standard of review.” Valentine v. Comm’r of Soc. Sec. Admin., 23 574 F.3d 685, 690 (9th Cir. 2009). “The ALJ’s findings will be upheld if supported by inferences 24 reasonably drawn from the record.” Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 2008) 25 (citation omitted). Additionally, “[t]he court will uphold the ALJ’s conclusion when the evidence 26 is susceptible to more than one rational interpretation.” Id.; see, e.g., Edlund v. Massanari, 253 F.3d 27 1152, 1156 (9th Cir. 2001) (“If the evidence is susceptible to more than one rational interpretation, 28 the court may not substitute its judgment for that of the Commissioner.” (citations omitted)). 1 Nonetheless, “the Commissioner’s decision ‘cannot be affirmed simply by isolating a 2 specific quantum of supporting evidence.’” Tackett, 180 F.3d at 1098 (quoting Sousa v. Callahan, 3 143 F.3d 1240, 1243 (9th Cir. 1998)). “Rather, a court must ‘consider the record as a whole, 4 weighing both evidence that supports and evidence that detracts from the [Commissioner’s] 5 conclusion.’” Id. (quoting Penny v. Sullivan, 2 F.3d 953, 956 (9th Cir. 1993)). 6 Finally, courts “may not reverse an ALJ’s decision on account of an error that is harmless.” 7 Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012) (citing Stout v. Comm’r, Soc. Sec. Admin., 8 454 F.3d 1050, 1055–56 (9th Cir. 2006)). Harmless error “exists when it is clear from the record 9 that ‘the ALJ’s error was inconsequential to the ultimate nondisability determination.’” Tommasetti, 10 533 F.3d at 1038 (quoting Robbins v. Soc. Sec. Admin., 466 F.3d 880, 885 (9th Cir. 2006)). “[T]he 11 burden of showing that an error is harmful normally falls upon the party attacking the agency’s 12 determination.” Shinseki v. Sanders, 556 U.S. 396, 409 (2009) (citations omitted). 13 IV. DISCUSSION 14 Plaintiff asserts three claims of error: (1) the ALJ’s RFC is not based on substantial evidence, 15 (2) the ALJ failed to give legally adequate reasons for discounting the medical opinions of Dr. 16 Sharma and Nurse Practitioner Castillo, and (3) the ALJ failed to give legally adequate reasons for 17 discounting Plaintiff’s reported subjective symptoms. (See Doc. 16 at 23–45). The Commissioner 18 counters that the ALJ properly assessed the RFC and the medical opinions of record, and reasonably 19 discounted Plaintiff’s symptom allegations. (Doc. 18 at 3–13). The Court agrees that the RFC is 20 not supported by substantial evidence in light of the ALJ’s formulation of an RFC based on 21 ambiguous evidence without relying on any credited medical opinion in the record.5 22 23

24 5 Because further proceedings will necessitate the re-evaluation of the record and the medical opinions provided, see infra, the Court does not reach the issue of the ALJ’s treatment Dr. Sharma and Nurse Practitioner Castillo’s medical 25 opinions or Plaintiff’s subjective symptom complaints—which were discounted in part because they were inconsistent with and/or unsupported by that undeveloped record. See Hiler v. Astrue, 687 F.3d 1208, 1212 (9th Cir. 2012) 26 (“Because we remand the case to the ALJ for the reasons stated, we decline to reach [plaintiff’s] alternative ground for remand.”); see also Rendon G. v. Berryhill, No. EDCV 18-0592-JPR, 2019 WL 2006688, at *8 (C.D. Cal. May 7, 27 2019); Harris v. Colvin, No. 13-cv-05865 RBL, 2014 WL 4092256, at *4 (W.D. Wash. Aug. 11, 2014); Augustine ex rel. Ramirez v. Astrue, 536 F. Supp. 2d 1147, 1153 n.7 (C.D. Cal. 2008) (“[The] Court need not address the other 28 claims plaintiff raises, none of which would provide plaintiff with any further relief than granted, and all of which can 1 A. Analysis 2 Plaintiff claims that the ALJ erred in formulating an RFC after rejecting each of the medical 3 opinions in the record as unpersuasive. (Doc. 18 at 36–37). In defense of the ALJ’s decision as to 4 this assertion of error, the Commissioner contends that because ALJs, who are not medical 5 professionals, are responsible for determining a claimant’s RFC, the ALJ’s conclusion must be 6 upheld. (Doc. 18 at 7–8). 7 An RFC is the most a claimant can do despite their limitations and is based upon all relevant 8 evidence in the record, including medical records, medical source statements, and symptom 9 testimony. 20 C.F.R. § 404.1545(a)(1)−(3); Shafer v. Barnhart, 120 F. Appx. 688, 698 (9th Cir. 10 2005). As the Commissioner contends, it is true that a determination of residual functional capacity 11 is not a medical opinion, but a legal decision that is expressly reserved for the Commissioner. 12 See (Doc. 13 at 2); 20 C.F.R. §§ 414.927(d)(2) (RFC is not a medical opinion), 414.946(c) 13 (identifying the ALJ as responsible for determining RFC). And that legal determination necessarily 14 involves engaging in credibility determinations, resolving conflicts in medical testimony, and 15 resolving evidentiary ambiguities, see Andrews v. Shalala, 53 F.3d 1035, 1039–40 (9th Cir. 1995)— 16 such that an ALJ’s RFC determination need not mirror any particular provider’s opinion, see, e.g., 17 Petrini v. Berryhill, 705 F. App’x. 511, 512 (9th Cir. 2017). 18 In light of this legal framework, the Court is mindful that the ALJ, not this Court, is 19 responsible for resolving conflicts in the evidence. However, the Court also takes note of the fact 20 that ALJs are obliged to exercise caution in formulating an RFC that leads to a finding of non- 21 disability in cases where “no doctor or other medical expert opined, on the basis of a full review of 22 all relevant records,” that Plaintiff could perform work during the relevant time period. See Garrison 23 v. Colvin, 759 F.3d 995, 1018 (9th Cir. 2014) (holding that ALJ should have exercised caution 24 because “no doctor or other medical expert . . . opined, on the basis of a full review of all relevant 25 records, that [Plaintiff] is capable of working or is prepared to return to work’”). For the following 26 reasons, the Court finds that such caution was warranted here. 27 Here, the ALJ considered and evaluated several medical opinions regarding the effects of 28 Plaintiff’s impairments, specifically from State Agency medical consultants, Drs. Franco, (AR 1 127−28, 143−45, 160−62), and Friedman, (AR 124−26, 129−31, 133, 141−43, 146−48, 150, 2 158−160, 163−65, 167), on initial review, and Drs. Jennings, (see AR 184−85, 207−08, 230−31), 3 and Arnold, (see AR 180−84, 87−90, 191−93, 203−07, 210−13, 216, 226−30, 233−36, 238−39), on 4 reconsideration—two consultative examiners—Drs. Spivey, (see AR 1934−37), and Sharma, (see 5 AR 1943−46)—and Plaintiff’s primary care provider, Nurse Practitioner Castillo, (see AR 6 3080−81). See also 20 C.F.R. § 404.1527(a)(2), 416.927(a)(2) (defining medical opinions as 7 statements that “reflect judgments about the nature and severity of your impairment(s), including 8 your symptoms, diagnosis and prognosis, what you can still do despite your impairment(s), and your 9 physical or mental restrictions.”). The ALJ found each of these medical opinions “unpersuasive,” 10 finding that (1) agency medical consultants Drs. Franco and Jennings’ opinions “were not consistent 11 with the medical record;” (2) consultative examiner Dr. Spivey’s opinion was “not consistent with 12 the medical record;” (3) primary care provider Nurse Practitioner Castillo’s opinion “was essentially 13 a checkbox form” that “endorsed the most significant limits in many areas without citation to the 14 objective evidence and without support in the treatment notes,” “was not consistent with the medical 15 record,” and impermissibly opined on an issue “reserved to the Commissioner”; (4) agency medical 16 consultants Drs. Friedman and Arnold’s opinions “were not consistent with the medical record”: and 17 (5) consultative examiner Dr. Sharma’s opinion “was not consistent with the medical record.” (AR 18 34−36). In other words, the ALJ found each and every medical opinion in the record concerning 19 Plaintiff’s impairments not credible or otherwise impermissible. While the absence of a medical 20 opinion is not necessarily fatal, the RFC determination still must be supported by substantial 21 evidence. See Bradford v. Comm’r of Soc. Sec. Admin., No. CV-21-00232-TUC-SHR (JR), 2022 22 WL 4538569, at *5 (D. Ariz. Aug. 18, 2022). 23 Turning to whether the ALJ’s assessed RFC is supported by substantial evidence, the Court 24 observes that it is well-settled that an ALJ may not render their own medical opinion and is not 25 empowered to independently assess clinical findings “when there is ambiguous evidence or when 26 the record is inadequate to allow for proper evaluation of the evidence.” Mayes v. Massanari, 276 27 F.3d 453, 459–60 (9th Cir. 2001); see also Tackett, 180 F.3d at 1102–03 (holding an ALJ erred in 28 rejecting physicians’ opinions and rendering his own medical opinion); Miller v. Astrue, 695 F. 1 Supp. 2d 1042, 1048 (C.D. Cal. 2010) (reasoning that it is improper for the ALJ to act as the medical 2 expert); Banks v. Barnhart, 434 F. Supp. 2d 800, 805 (C.D. Cal. 2006) (“An ‘ALJ cannot arbitrarily 3 substitute his own judgment for competent medical opinion . . . and he ‘must not succumb to the 4 temptation to play doctor and make his own independent medical findings’” (quoting Balsamo v. 5 Chater, 142 F.3d 75, 81 (2d Cir. 1998)). 6 Applying this rule to the present case, the Court finds that the ALJ did not simply synthesize 7 the medical evidence and opinions to reach an RFC determination. Instead, without relying on any 8 medical opinion regarding what work-related restrictions would be appropriate, the ALJ based the 9 RFC determination on its own interpretation of Plaintiff’s testimony and the medical evidence— 10 formulating limitations to the RFC out of whole cloth and concluding that those limitations were 11 sufficient to address Plaintiff’s impairments. 12 For example, while the treatment records establish Plaintiff was obese, (AR 2493), and had 13 back, (AR 1945, 2533, 2551, 2644–45, 2744, 2761, 2767), neck, (AR 1945, 2047, 2556, 2572–73, 14 2592, 2596, 2697, 2701, 2747, 3134, 3175, 3177, 3181, 3342, 3366), and foot pain, (AR 1575, 1647, 15 1654, 1679, 1724–26, 1936, 1938–39, 2085, 2103, 2129–34, 2538, 2546–47, 2615, 2691, 2922, 16 3245, 3251, 3277); in addition to neurological, (AR 1558, 1786, 1944, 1949, 1951, 1956–58, 1972– 17 73, 2566, 2662, 3256), and psychological impairments, (AR 1589, 1592–97, 2088, 2495–97, 2505– 18 07, 2584, 2587, 2659–60, 2710, 2778, 2784–85, 3222–23, 3231, 3254, 3260, 3277); excluding the 19 discounted medical opinions, the records do not indicate the functional limitations caused by such 20 pain and impairments. See Hurt v. Kijakazi, No. 3:20-CV-00481-CSD, 2022 WL 444355, at *9–10 21 (D. Nev. Feb. 14, 2022) (“When the ‘medical findings in the record merely diagnose [the] claimant’s 22 exertional impairments and do not relate those diagnoses to specific residual functional capabilities 23 . . . [the] bare medical findings are unintelligible to a lay person in terms of residual functional 24 capacity.’”) (quoting Rosado v. Sec’y of Health & Human Servs., 807 F.2d 292, 293 (1st Cir. 1986))). 25 Moreover, while the imaging studies of Plaintiff’s feet and back yielded results such as “extensive 26 soft tissue swelling” with “staple-like foreign bodies seen in the soft tissue,” (AR 2148; see also AR 27 2418–19, 2616), as to Plaintiff’s feet, and “mild to moderate bilateral neuroforaminal narrowing,” 28 (AR 2644), “[g]rade 1 L5-SI spondylolisthesis,” (AR 2645, see also AR 2551, 2761), “[m]ild 1 degenerative osteophytes of thoracic spine,” (AR 2646, 2761), “[m]inimum to mild bilateral 2 uncovertebral hypertrophy with minimal to mild bilateral neuroforaminal narrowing at C3-C4,” (AR 3 2647), and “retrolisthesis of L5 on S1,” (AR 2551), as to Plaintiff’s back—it is not clear what 4 functional limitations result from those clinical findings. See Howell v. Kijakazi, No. 20-CV-2517- 5 BLM, 2022 WL 2759090, at *7 (S.D. Cal. July 14, 2022) (MRIs, radiological studies, and X-rays 6 “generally reflect only the findings, impressions, and medical diagnoses, which are difficult for a 7 lay person to interpret.”). 8 Therefore, the Court finds that the underlying treatment and imaging records are the kinds of 9 “raw,” Shipp v. Colvin, No. CV 13-9468 JC, 2014 WL 4829035, at *7 (C.D. Cal. Sept. 26, 2014), 10 and “ambiguous” evidence that themselves do not provide sufficient indications of Plaintiff’s 11 physical functional limitations and thus, the ALJ was not qualified to the translate evidence into 12 functional limitations and engage in its “own exploration and assessment” of a Plaintiff’s 13 impairments taken together. McAnally v. Berryhill, Case No.: 3:18-cv-02272-GPC-RNB, 2020 WL 14 1443734, at *7 (S.D. Cal. Mar. 25, 2020) (quoting Day v. Weinberger, 522 F.2d 1154, 1156 (9th 15 Cir. 1975)). It then follows that, under these circumstances, the ALJ had a duty to develop the record 16 further, see Ford, 950 F.3d at 1156. See Warren v. Comm'r of Soc. Sec., No. 1:24-CV-00751-SAB, 17 2025 WL 2473120, at *10 (E.D. Cal. Aug. 28, 2025) (finding the ALJ erred in formulating an RFC 18 where the record was void of a “medical finding that ‘mild spondylosis at C3-4 and C4-5’ and 19 ‘[s]mall anterior endplate osteophytes noted at C4 and C5,’ in consideration of Plaintiff's other 20 assessed physical limitations, translates to modified light work.”); Heskett v. Bisignano, No. 1:25- 21 CV-00274-SKO, 2025 WL 1993698, at *6 (E.D. Cal. July 17, 2025) (noting that although imaging 22 studies yielded predominately mild findings, “it is not clear what functional limitations result from 23 those clinical findings” and thus the imaging records are the kinds of raw and ambiguous evidence 24 that itself does not provide sufficient indications of Plaintiff's physical functional limitations). 25 Indeed, Ninth Circuit courts have found that “[b]arring a few exceptions, an ALJ must have 26 a doctor’s opinion of a claimant’s functional capacity in order for there to be substantial evidence 27 supporting the decisions.” Bradford, 2022 WL 4538569, at *5 (quoting Howell, 2022 WL 2759090, 28 at *7); Walker v. Comm’r of Soc. Sec., Case No. 2:22-cv-01871-EJY, 2024 WL 64784, at *6 (D. 1 Nev. Jan. 4, 2024) (“While the ALJ ‘can pick and choose between opinions expressed by the 2 experts,’ when an ALJ decides severity or residual functional capacity ‘without the support of any 3 of the medical opinion evidence,’ this is error.” (quoting Holtan v. Kijakazi, 2:22-cv-01222-VCF, 4 2023 WL 2424648, at *3 (D. Nev. Mar. 9, 2023))). Or, put another way, without a persuasive 5 medical opinion to support the conclusion that Plaintiff can 6 perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except the claimant can lift and carry 20 pounds occasionally and 10 pounds frequently. The 7 claimant can stand or walk about six hours and sit about six hours. He can never climb ladders, ropes or scaffolds, but he can occasionally climb stairs or ramps. The 8 claimant can frequently balance, kneel, crouch, and crawl and occasionally stoop. He will be required to avoid all exposure to hazards such as unprotected heights and 9 machinery with unguarded moving mechanical parts. The claimant can perform simple tasks that involve occasional interaction with the general public, co-workers, 10 and supervisors and can adapt to occasional workplace changes, 11 the ALJ’s RFC lacks the support of substantial evidence. See Holtan, 2023 WL 2424648, at *3 12 (finding that the ALJ erred primarily by simply summarizing the medical evidence without making 13 it clear how the ALJ then translated that evidence into an RFC, noting that it was “particularly 14 concerning because the ALJ did not rely on any of the medical opinions, finding all of the medical 15 opinions of record unpersuasive.”); De Gutierrez v. Saul, No. 1:19-cv-00463-BAM, 2020 WL 16 5701019, at *6 (E.D. Cal. Sept. 24, 2020) (“Without a medical opinion to support the conclusion 17 that Plaintiff was able to perform” a certain level of work, lift and carry certain weight, or sit, stand 18 or walk for certain periods of time, “the ALJ’s RFC lacks the support of substantial evidence.”) 19 (citing Perez v. Sec’y of Health & Human Servs., 958 F.2d 445, 446 (1st Cir. 1991) (“where an ALJ 20 reaches conclusions about claimant’s . . . capacity without any assessment of residual functional 21 capacity by a physician, the ALJ’s conclusions are not supported by substantial evidence”)); Goolsby 22 v. Berryhill, Case No. 1:15–cv–00615–JLT, 2017 WL 1090162, at *8 (E.D. Cal. Mar. 22, 2017) 23 (finding that an ALJ erred in including “simple routine tasks” in RFC when the record did not contain 24 medical opinions supporting this limitation); Shipp, 2014 WL 4829035, at *7 (“Since . . . the record 25 contains no assessment by a treating or examining doctor regarding the effect of plaintiff’s physical 26 impairments on her ability to function, it appears that the ALJ’s physical residual functional capacity 27 assessment was erroneously based solely on the ALJ’s own, lay interpretation of plaintiff’s 28 testimony and other raw medical evidence in the record.”). Accordingly, the Court finds that the 1 ALJ erred in evaluating Plaintiff’s RFC. 2 B. Harmlessness Review 3 The Court must now consider whether the ALJ’s error was harmless. Molina, 674 F.3d at 4 1115. Courts look to the record as a whole to determine whether the error alters the outcome of the 5 case. Id.; March v. Colvin, 792 F.3d 1170, 1172 (9th Cir. 2015). An error is harmless “where it is 6 inconsequential to the ultimate nondisability determination.” Molina, 674 F.3d at 1115 (citations 7 omitted) (first quoting Balsamo v. Chater, 142 F.3d 75, 81 (2d Cir. 1998), and then quoting Rohan 8 v. Chater, 98 F.3d 966, 970 (7th Cir. 1996)). 9 This Court finds this was harmful error necessitating remand. Tommasetti, 533 F.3d at 1038 10 (ALJ error is harmless if it is “inconsequential to the ultimate nondisability determination.”). While 11 the ALJ assigned physical limitations restricting Plaintiff to light work with additional limitations, 12 the RFC is still without supporting evidence. Had the ALJ included different limitations in the RFC 13 based upon a proper review of the evidence and an adequate record, the ultimate disability 14 determination may have been different.6 See Clarenda A. S. v. O’Malley, No. 1:24-CV-00127-DKG, 15 2024 WL 4851214, at *5 (D. Idaho Nov. 21, 2024) (finding harmful error where the ALJ relied on 16 her own interpretation of the medical records without any medical opinion of Plaintiff's physical 17 functioning in formulating the RFC). In particular, because the record “[did] not support the 18 assumptions in the hypothetical[s]” posed to the VE, the hypotheticals were incomplete and 19 therefore, the “vocational expert's opinion [had] no evidentiary value.” Lewis v. Apfel, 236 F.3d 503, 20 517 (9th Cir. 2001). 21 C. Remand 22 In a case where the ALJ’s determination is not supported by substantial evidence or is tainted 23 by legal error, the court may remand the matter for additional proceedings or an immediate award 24 of benefits. Remand for additional proceedings is proper where (1) outstanding issues must be 25 resolved, and (2) it is not clear from the record before the court that a claimant is disabled. See 26 Benecke v. Barnhart, 379 F.3d 587, 593 (9th Cir. 2004). 27

28 6 This is not to say that the disability determination will or should be different regarding the period at issue--only that 1 Here, the Court finds that remand for further proceedings is warranted. See, e.g., Bunnell v. 2 Sullivan, 947 F.2d 341, 348 (9th Cir. 1991) (affirming a remand for further proceedings where the 3 ALJ failed to explain with sufficient specificity the basis for rejecting the claimant's testimony); 4 Byrnes v. Shalala, 60 F.3d 639, 642 (9th Cir. 1995) (remanding the case “for further findings 5 evaluating the credibility of [the claimant’s] subjective complaints”). On remand, the Commissioner 6 shall further develop the record, as outlined above, to allow for proper consideration of the medical 7 evidence related to the time period at issue. 8 V. CONCLUSION AND ORDER 9 Based on the foregoing, the Court finds that the ALJ’s decision is not supported by 10 substantial evidence and is therefore VACATED, and the case is REMANDED to the ALJ for 11 further proceedings consistent with this Order. The Clerk of this Court is DIRECTED to enter 12 judgment in favor of Plaintiff Ramon Avila Gonzalez and against Defendant Frank Bisignano, 13 Commissioner of Social Security. 14 IT IS SO ORDERED. 15

16 Dated: February 17, 2026 /s/ Sheila K. Oberto . UNITED STATES MAGISTRATE JUDGE 17

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