Sophy N. v. Commissioner of Social Security

Opinion

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5 6 7 UNITED STATES DISTRICT COURT 8 WESTERN DISTRICT OF WASHINGTON AT TACOMA 9 10 SOPHY N., CASE NO. 2:25-CV-02389-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 pursuant to 42 U.S.C. § 405(g), seeking judicial review of 16 Defendant’s denial of his application for supplemental security income (“SSI”).1 Had the post- 17 hearing submission of the medical opinion been considered, the residual functional capacity 18 (“RFC”) may have included additional limitations, or the ultimate determination of disability 19 may have changed. This error is, therefore, not harmless, and this matter is reversed and 20 remanded pursuant to sentence four of 42 U.S.C. § 405(g) to the Commissioner of the Social 21 Security Administration for further proceedings consistent with this order. 22 23 1 Pursuant to 28 U.S.C. § 636(c), Federal Rule of Civil Procedure 73, and Local Rule MJR 13, the parties 24 have consented to have this matter heard by the undersigned Magistrate Judge. See Dkt. 2. 1 I. Procedural History 2 Plaintiff filed his application for SSI on September 30, 2019. AR 194. His claim was 3 denied initially on February 26, 2021, and upon reconsideration on October 7, 2021. AR 194, 4 199. A hearing was held before ALJ Virginia Robinson on September 13, 2022, and on March

5 31, 2023, ALJ Cecilia LaCara2 (“the ALJ”) issued a decision denying Plaintiff’s claim. AR 140, 6 209–27. That decision was remanded by the Appeals Council on January 12, 2024. AR 233. 7 The matter came on for a second hearing on September 9, 2024, and by decision entered 8 December 5, 2024, the ALJ again concluded that Plaintiff was not disabled. AR 17–30. From 9 this decision, Plaintiff filed a complaint with this Court on December 2, 2025, seeking judicial 10 review of the ALJ’s decision denying benefits. Dkt. 5. 11 II. Standard of Review 12 Pursuant to 42 U.S.C. § 405(g), this Court may set aside the Commissioner’s denial of 13 social security benefits if the ALJ’s findings are based on legal error or are not supported by 14 substantial evidence in the record as a whole. Bayliss v. Barnhart, 427 F.3d 1211, 1214 n.1 (9th

15 Cir. 2005) (citing Tidwell v. Apfel, 161 F.3d 599, 601 (9th Cir. 1999)). Substantial evidence is 16 “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” 17 Biestek v. Berryhill, 587 U.S. 97, 103 (2019) (citation omitted). “We review only the reasons 18 provided by the ALJ in the disability determination and may not affirm the ALJ on a ground 19 upon which [they] did not rely.” Garrison v. Colvin, 759 F.3d 995, 1010 (9th Cir. 2014). 20 “[H]armless error principles apply in the Social Security Act context.” Molina v. Astrue, 21 674 F.3d 1104, 1115 (9th Cir. 2012), superseded on other grounds by 20 C.F.R. § 404.1502(a). 22

23 2 ALJ Virginia Robinson was “unavailable due to an extended absence of 20 or more days” and the case was “reassigned to be decided by the undersigned, Administrative Law Judge Cecilia LaCara” pursuant to “HALLEX I- 24 2-1-55(F)(2).” AR 212. 1 Generally, an error is harmless if it is not prejudicial to the claimant and is “inconsequential to 2 the ultimate nondisability determination.” Stout v. Comm’r, Soc. Sec. Admin., 454 F.3d 1050, 3 1055 (9th Cir. 2006); see also Molina, 674 F.3d at 1115. 4 III. Discussion

5 In his Opening Brief, Plaintiff argues that “[t]he ‘new and material’ evidence submitted 6 to the Appeals Council undermines the ALJ’s determination[,] warranting a remand in order for 7 the ALJ to consider the evidence.” Dkt. 10 at 3. Specifically, Plaintiff alleges that “[t]here is a 8 reasonable probability that[,] had the ALJ had an opportunity to review” the medical opinion of 9 Dr. Melisa Mulick (“Dr. Mulick”), “it would have changed the outcome of the case because the 10 opinion includes greater limitations than those accounted for in the RFC.” Id. at 5. 11 For SSI applications filed after March 27, 2017, in evaluating medical opinion evidence, 12 ALJs “will not defer or give any specific evidentiary weight, including controlling weight, to any 13 medical opinion(s) or prior administrative medical finding(s).” 20 C.F.R. §§ 404.1520c(a), 14 416.920c(a). Rather, the ALJ must consider every medical opinion or prior administrative

15 medical finding in the record and evaluate the persuasiveness of each opinion using specific 16 factors. Id. The critical factors in an ALJ’s determination of persuasiveness are the 17 “supportability” and “consistency” of each opinion. Id. §§ 404.1520c(b)(2), 416.920c(b)(2). 18 “Supportability means the extent to which a medical source supports the medical opinion 19 by explaining the ‘relevant . . . objective medical evidence.’” Woods v. Kijakazi, 32 F.4th 785, 20 791–92 (9th Cir. 2022) (quoting 20 C.F.R. § 404.1520c(c)(1)); see also 20 C.F.R. § 21 416.920c(c)(1). A medical opinion is more “supportable,” and therefore, more persuasive, when 22 the sources provide ample relevant “objective medical evidence and supporting explanations” for 23 the medical opinion. Woods, 32 F.4th at 793 n.4. “Consistency means the extent to which a

24 1 medical opinion is ‘consistent . . . with the evidence from other medical sources and nonmedical 2 sources in the claim.’” Id. at 792 (quoting 20 C.F.R. § 404.1520c(c)(2)); see also 20 C.F.R. § 3 416.920c(c)(2). An ALJ must articulate “how [they] considered the supportability and 4 consistency factors for a medical source’s opinion” when making their decision. 20 C.F.R. §§

5 404.1520c(b)(2), 416.920c(b)(2). “Even under the new regulations, an ALJ cannot reject an 6 examining or treating doctor’s opinion as unsupported or inconsistent without providing an 7 explanation supported by substantial evidence.” Woods, 32 F.4th at 792. 8 On June 14, 2024, Dr. Mulick submitted a “Psychological/Psychiatric Evaluation” in 9 support of Plaintiff’s claim for SSI. AR 37. In her evaluation, Dr. Mulick conducted “[t]he Beck 10 Depression Inventory, 2nd Edition (BDI-2) and the Beck Anxiety Inventory (BAI) . . . in order to 11 assess [Plaintiff]’s levels of depression and anxiety and achieve more diagnostic clarity.” AR 38. 12 Following these tests, Dr. Mulick observed that Plaintiff’s BDI-2 was “indicative of ‘severe 13 depression’” and his BAI was “indicative of ‘severe anxiety[.]’” Id. Furthermore, Dr. Mulick 14 opined that Plaintiff had severe depression, anxiety, trauma, paranoia, and panic that impacted

15 him “daily.” AR 38–39.3 16 When considering Plaintiff’s “ability to sustain the activity over a normal workday and 17 workweek on an ongoing, appropriate, and independent basis[,]” Dr. Mulick observed that 18 Plaintiff had “severe” limitations in every enumerated activity. AR 39. Dr. Mulick ultimately 19 diagnosed Plaintiff with posttraumatic stress disorder (“PTSD”); major depressive disorder, 20 “recurrent episode, [w]ith psychotic features, [w]ith mood-congruent psychotic features[;]” and 21 agoraphobia. Id. 22 23 3 Dr. Mulick also opined that Plaintiff experienced “moderate” hallucinations with a “daily” frequency. AR 24 39. 1 The Appeals Council denied Plaintiff’s request for review of the ALJ’s December 5, 2 2024, decision. AR 1–3. As to the medical opinion of Dr. Mulick, the Appeals Council found 3 that “this evidence does not show a reasonable probability that it would change the outcome of 4 the decision. We did not exhibit this evidence.” AR 2. The Appeals Council gave no further

5 explanation as to how it evaluated the new medical opinion evidence. Id. “[W]hen the Appeals 6 Council considers new evidence in deciding whether to review a decision of the ALJ, that 7 evidence becomes part of the administrative record, which the district court must consider when 8 reviewing the Commissioner’s final decision for substantial evidence.” Brewes v. Comm’r of 9 Soc. Sec. Admin., 682 F.3d 1157, 1163 (9th Cir. 2012). 10 As discussed, supra, Dr. Mulick diagnosed Plaintiff with PTSD, depression, and 11 agoraphobia. AR 39. She opined that Plaintiff suffered “severe” limitations in his ability to 12 “[u]nderstand, remember, and persist in tasks by following very short and simple instructions[,]” 13 whereas the ALJ found Plaintiff only had a “moderate limitation” in this area. AR 20, 39. Dr. 14 Mulick found Plaintiff would have severe limitations in his ability to “[p]erform activities within

15 a schedule, maintain regular attendance, and be punctual within customary tolerances without 16 special supervision[,]” while the ALJ determined Plaintiff would not be limited in this area in 17 Plaintiff’s RFC. AR 22, 39. 18 Dr. Mulick also opined that Plaintiff would have severe limitations in his ability to 19 “[c]ommunicate and perform effectively in a work setting[,]” while the ALJ determined that 20 Plaintiff only had a “moderate” limitation in his ability to interact with others. AR 20, 39. Dr. 21 Mulick observed “severe” limitations in Plaintiff’s ability to “[c]omplete a normal work day and 22 work week without interruptions from psychologically based symptoms[,]” while the ALJ did 23 not include any limitations in this area of functioning in Plaintiff’s RFC. AR 22, 39.

24 1 Upon review, there are conflicts between the medical opinion of Dr. Mulick and the 2 ALJ’s assessment of limitations as set forth in Plaintiff’s RFC. AR 20–22, 37–42. Therefore, this 3 matter must be remanded to the Administration for consideration of Dr. Mulick’s opinion, 4 because consideration of her opinion may have changed Plaintiff’s RFC, or the ultimate

5 determination of disability may have changed. See Doubt K. v. Comm’r, Soc. Sec. Admin., No. 6 6:23-CV-00120-YY, 2024 WL 1740023, at *3 (D. Or. Apr. 23, 2024) (observing that “courts 7 have remanded cases wherein new medical opinion evidence expressed greater limitations than 8 those determined by the ALJ” after the Appeals Council declined the Plaintiff’s request for 9 review) (citing Javier V. R. v. Kijakazi, No. 1:23-CV-3015-WFN, 2023 WL 6326562, at *3 (E.D. 10 Wash. Sep. 28, 2023)). The ALJ must have an opportunity to review the conflicts between the 11 limitations opined by Dr. Mulick and those in the ALJ’s decision. See Andrews v. Shalala, 53 12 F.3d 1035, 1039 (9th Cir. 1995) (the ALJ is responsible for “resolving conflicts in medical” 13 evidence). 14 IV. Conclusion

15 Based on the foregoing reason and the relevant record, the Court ORDERS that this 16 matter be REVERSED and REMANDED for further administrative proceedings, consistent 17 with this order. 18 Dated this 15th day of April, 2026. 19 A 20 David W. Christel United States Magistrate Judge 21 22 23 24