Rolando Jose G. v. Commissioner of Social Security

Opinion

1 2 3 4 UNITED STATES DISTRICT COURT 5 NORTHERN DISTRICT OF CALIFORNIA 6 7 ROLANDO JOSE G.,1 Case No. 25-cv-04141-JST

8 Plaintiff, ORDER ON SOCIAL SECURITY 9 v. APPEAL

10 COMMISSIONER OF SOCIAL Re: ECF Nos. 13, 14 SECURITY, 11 Defendant.

13 Before the Court is Plaintiff’s request for judicial review, under 42 U.S.C. § 405(g), of the 14 Social Security Commissioner’s denial of his application for disability insurance benefits. The 15 Court will reverse the Commissioner’s decision and remand for further proceedings. 16 I. BACKGROUND 17 Plaintiff filed a claim for disability benefits with an alleged onset date of December 31, 18 2019, his undisputed last-insured date, and subsequently amended his claimed onset date to 19 August 31, 2019. He claimed disability based on the following conditions: “severe spinal issues; 20 and neck problems; back and neck spasms; left knee; right ankle (gout); swollen finger; anxiety- 21 stressed out; after COVID systems-memory-loss of taste etc[.]; high cholesterol; [and] high blood 22 pressure.” AR 79 (citation modified). His claim was denied, denied on reconsideration, and 23 denied following a hearing by an administrative law judge (“ALJ”). The Appeals Council denied 24 review, and Plaintiff timely filed this lawsuit challenging the denial of benefits. 25 At the hearing before the ALJ, Plaintiff testified that he was in a car accident in August 26

27 1 The Court partially redacts Plaintiff’s name to mitigate privacy concerns, as suggested by the 1 2019, after which his neck and back pain “got worse.” AR 52. He further testified that, since the 2 accident, he thought the most weight he could lift would be 10 or 15 pounds; that he had difficulty 3 standing, walking, or sitting for long periods of time; and that he did not think he could stand for 4 more than 20 minutes without taking a break, walk for more than 20 to 30 minutes before needing 5 to rest, or sit for more than 15 or 20 minutes before needing to get up or change positions. Id. He 6 also said that he could drive for about half an hour. AR 52–53. He testified that he had no 7 problems going grocery shopping and that he was “independent in terms of [his] personal care, 8 dressing, feeding, [and] bathing.” AR 54. He takes prescription pain medication three to five 9 times a week, AR 53, and has acupuncture treatments and physical therapy approximately twice a 10 month, AR 55. 11 The ALJ determined that Plaintiff “had the following medically determinable impairments: 12 degenerative disc disease of the lumbar and cervical spines, and obesity.” AR 23. The ALJ 13 denied benefits after concluding that Plaintiff “did not have an impairment or combination of 14 impairments that significantly limited the ability to perform basic work-related activities for 12 15 consecutive months; therefore, [he] did not have a severe impairment or combination of 16 impairments,” as required for an award of benefits. Id. 17 The ALJ concluded the following:

18 The claimant alleges that, after a motor vehicle accident, he experienced neck pain. Ex. B2F at 13. However, the claimant did 19 not seek medical treatment for some four days after the accident. Id. Radiological study of the cervical spine performed prior to the date 20 last insured showed only mild degenerative changes. Ex. B2F at 10. A January 2020, magnetic resonance imaging study of the cervical 21 spine showed mostly mild degenerative changes, but there was [sic] “moderately severe” degenerative changes at the level of the sixth 22 and seventh cervical vertebrae, and moderate degenerative changes at the level of the fourth and fifth cervical vertebrae. Ex. B7F at 23. 23 The claimant denied weakness or numbness in the upper extremities and he was diagnosed with a sprain and given ibuprofen with 24 Flexeril to take “as needed.” Ex. B2F at 13, 15.

25 The claimant complained of lumbar radiculopathy in June 2019. Ex. B3F at 35. The claimant also had a body mass index of 35 during 26 the relevant period. Ex. B2F at 14. However, the claimant declined an injection in favor of oral medication. Ex. B3F at 37. In March 27 2020, after the date last insured, the claimant presented with a gait recurrent back pain from the age of 5, supporting an inference the 1 severity of the condition has not significantly interfered with work. Ex. B7F at 18. 2 After considering the evidence of record, the undersigned finds that 3 the claimant’s medically determinable impairments could have reasonably been expected to produce the alleged symptoms; 4 however, the claimant’s statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely 5 consistent for the reasons explained in this decision.

6 There is scant evidence of extensive treatment during the four months under consideration. The claimant was treated for his motor 7 vehicle accident but there is little evidence of any significant physical limitation during the period under consideration. Without 8 speculating from later evidence, there is scant support for a finding of severity. 9 Based on the foregoing, the claimant’s physical and mental 10 impairments, considered singly and in combination, do not significantly limit the claimant’s ability to perform basic work 11 activities. Thus, the claimant does not have a severe impairment or combination of impairments. 12 This conclusion is consistent with the opinions of agency 13 consultants who reviewed the record. In June 2022, A. Dipsia, M.D., concluded the claimant did not have a severe impairment 14 prior to the date last insured. Ex. B2A at 6. Also in June of 2022, M. Lin, M.D., concluded there was insufficient evidence from which 15 to draw a conclusion about mental impairments prior to the date last insured. Ex. B2A at 7. In December 2022, J. Pham concluded there 16 was insufficient evidence from prior to the date last insured from which to draw conclusions about the claimant’s physical capacities. 17 Ex. B4A at 10. This was also the conclusion of Joshua Boyd, Psy.D., writing in January 2023, regarding mental impairments. Ex. 18 B4A at 11. A statement from a consultant that there is insufficient evidence is not a medical opinion. The opinion of A. Dipsia, M.D., 19 was persuasive as to the period between the amended onset date and the date last insured. The opinion is supported by the doctor’s 20 written analysis and expertise in the assessment of physical impairments. 21 AR 24–25. 22 II. LEGAL STANDARD 23 As the Ninth Circuit has summarized: 24 The Social Security Regulations set out a five-step sequential 25 process for determining whether a claimant is disabled within the meaning of the Social Security Act. The burden of proof is on the 26 claimant as to steps one to four. As to step five, the burden shifts to the Commissioner. If a claimant is found to be disabled or not 27 disabled at any step in the sequence, there is no need to consider 1 Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999) (citation modified).

2 The five-step process requires the ALJ to determine: (1) whether the claimant is presently working in a substantially gainful activity; 3 (2) whether the claimant’s impairment is severe; (3) whether the impairment meets or equals one of a list of specific impairments 4 described in the Social Security Regulations; (4) whether the claimant is able to do any work that he or she has done in the past; 5 and (5) whether the claimant is able to do any other work. 6 Maxwell v. Saul, 971 F.3d 1128, 1130 n.2 (9th Cir. 2020) (citation modified). 7 Courts “may set aside the Commissioner’s denial of disability insurance benefits when the 8 ALJ’s findings are based on legal error or are not supported by substantial evidence in the record 9 as a whole.” Tackett, 180 F.3d at 1097. “Even when the ALJ commits legal error, [courts] uphold 10 the decision where that error is harmless,” meaning that “it is inconsequential to the ultimate 11 nondisability determination, or [that] the agency’s path may reasonably be discerned, even if the 12 agency explains its decision with less than ideal clarity.” Treichler v. Comm'r of Soc. Sec. Admin., 13 775 F.3d 1090, 1099 (9th Cir. 2014) (citation modified). 14 When considering whether substantial evidence supports the ALJ’s decision, courts 15 “review the administrative record in its entire[ty] . . ., weighing evidence that supports and 16 evidence that detracts from the ALJ’s determination,” Drouin v. Sullivan, 966 F.2d 1255, 1257 17 (9th Cir. 1992), and “leav[ing] it to the ALJ to determine credibility, resolve conflicts in the 18 testimony, and resolve ambiguities in the record,” Treichler, 775 F.3d at 1098. “Substantial 19 evidence is ‘more than a mere scintilla. It means such relevant evidence as a reasonable mind 20 might accept as adequate to support a conclusion.’” Drouin, 966 F.2d at 1257 (quoting 21 Richardson v. Perales, 402 U.S. 389, 401 (1971)). “Where evidence exists to support more than 22 one rational interpretation, the Court must defer to the decision of the ALJ.” Id. at 1258. 23 Courts may not “affirm the denial of benefits on a ground not invoked by the 24 Commissioner in denying the benefits originally.” Pinto v. Massanari, 249 F.3d 840, 847–48 25 (9th Cir. 2001). 26 III. DISCUSSION 27 The ALJ rejected Plaintiff’s claims at step two of the five-step process. Plaintiff contends 1 reasons for rejecting his subjective symptom testimony. The Court agrees. 2 The ALJ concluded that Plaintiff’s “medically determinable impairments could have 3 reasonably been expected to produce the alleged symptoms” but determined that Plaintiff’s 4 “statements concerning the intensity, persistence and limiting effects of these symptoms [was] not 5 entirely consistent.” AR 25. She did not cite any “affirmative evidence that [Plaintiff was] 6 malingering,” so she “must provide clear and convincing reasons for rejecting [Plaintiff’s] 7 testimony regarding the severity of symptoms.” Rollins v. Massanari, 261 F.3d 853, 857 (9th Cir. 8 2001). “The clear and convincing standard is the most demanding required in Social Security 9 cases.” Moore v. Comm’r of Soc. Sec. Admin., 278 F.3d 920, 924 (9th Cir. 2002). “[T]he ALJ 10 must specifically identify the testimony she or he finds not to be credible and must explain what 11 evidence undermines the testimony.” Holohan v. Massanari, 246 F.3d 1195, 1208 (9th Cir. 2001) 12 The ALJ’s decision does not meet that standard here. While she correctly described the 13 medical evidence on which Plaintiff relies, AR 24–25; ECF No. 13 at 7–8, she did not address 14 Plaintiff’s testimony regarding his physical limitations—e.g., that he could not walk, stand, or sit 15 for long periods of time—or explain why such testimony would not support a finding of severity. 16 To the contrary, she listed “[p]hysical functions such as walking, standing, sitting, lifting, pushing, 17 pulling, reaching, carrying, or handling” as examples of “the abilities and aptitudes necessary to 18 do most jobs.” AR 24. Although she noted that “there is little evidence of any significant 19 physical limitation during the period under consideration,” AR 25, “general findings are an 20 insufficient basis to support an adverse credibility determination,” Holohan, 246 F.3d at 1208. 21 She failed to mention Plaintiff’s testimony at all, let alone provide “specific, clear and convincing 22 reasons” for rejecting it. Smolen v. Chater, 80 F.3d 1273, 1281 (9th Cir. 1996). “[P]roviding a 23 summary of medical evidence . . . is not the same as providing clear and convincing reasons for 24 finding the claimant’s symptom testimony not credible.” Brown-Hunter v. Colvin, 806 F.3d 487, 25 494 (9th Cir. 2015) (emphasis in original). The Court “cannot review whether the ALJ provided 26 specific, clear, and convincing reasons for rejecting” Plaintiff’s testimony when she “never 27 identified which testimony she found not credible, and never explained which evidence 1 reason or reasons upon which her adverse determination is based.” Jd. at 494-95 (citation 2 || modified) (emphasis in original). Without such reasoning, the Court is unable “to meaningfully 3 determine whether the ALJ’s conclusions were supported by substantial evidence.” Treichler, 775 4 |} F.3dat 1103. Accordingly, the Court reverses the Commissioner’s decision to deny benefits. 5 The Court will remand the matter for further proceedings. “Usually, if additional 6 || proceedings can remedy defects in the original administrative proceeding, a social security case 7 || should be remanded.” Garrison v. Colvin, 759 F.3d 995, 1019 (9th Cir. 2014) (citation modified). 8 This is not a case in which “it is clear from the record that a claimant is entitled to benefits” such 9 || that it would be appropriate to remand “with instructions to calculate and award benefits.” Jd. 10 CONCLUSION 11 For the reasons discussed above, the Court reverses the Commissioner’s decision denying 12 || Plaintiffs claim for disability benefits and remands the case for further proceedings. The Clerk 13 shall enter judgment and close the file. IT IS SO ORDERED. 3 15 || Dated: May 11, 2026 . 16 . JON S. TIGA! 17 United States District Judge 18 19 20 21 22 23 24 25 26 27 28