1 FILED IN THE U.S. DISTRICT COURT EASTERN DISTRICT OF WASHINGTON 2 Aug 04, 2025
3 SEAN F. MCAVOY, CLERK UNITED STATES DISTRICT COURT 4 EASTERN DISTRICT OF WASHINGTON
5 CODY S.,1 No. 1:25-cv-3018-EFS 6 Plaintiff, 7 ORDER REVERSING THE v. ALJ’S DENIAL OF BENEFITS, 8 AND REMANDING FOR FRANK BISIGNANO, MORE PROCEEDINGS 9 Commissioner of Social Security,2
10 Defendant.
11 Plaintiff Cody S. asks the Court to reverse the Administrative 12 Law Judge’s (ALJ) denial of Title 2 and Title 16 benefits, while the 13 14
15 1 For privacy reasons, Plaintiff is referred to by first name and last 16 initial or as “Plaintiff.” See LCivR 5.2(c). 17 2 Frank Bisignano was confirmed as the Commissioner of Social 18 Security on May 6, 2025. Pursuant to Federal Rule of Civil Procedure 19 25(d) and 42 U.S.C. § 405(g), he is substituted as the Defendant. 20 1 Commissioner asks the Court to affirm the ALJ’s denial. As is
2 explained below, because the ALJ 1) failed to consider the required 3 supportability factor for the administrative medical findings and a 4 medical opinion, and 2) did not fully and fairly consider the
5 longitudinal record when evaluating the consistency factor, this matter 6 is remanded for further proceedings. 7 I. Background
8 In 2020, at the age of 24, Plaintiff applied for benefits under 9 Titles 2 and 16, claiming disability, based on autism, anxiety, and 10 depression.3 The at-issue alleged disability period is September 1,
11 2019, to April 1, 2023.4 Plaintiff was placed in special education as a 12 child, and when he attended college at Central Washington University 13 (“Central”), he received accommodation and lived with his father. 5
14 After three years at Central, he dropped out due to stress and mood 15 swings. He then moved to Georgia to live with his mother and worked; 16
17 3 AR 250–62. 18 4 The parties agree this is the alleged closed disability period. 19 5 AR 41, 55–56. 20 1 while there, he experienced panic attacks and attempted suicide in
2 August 2019, which was his third suicide attempt.6 He was placed in 3 inpatient care for about two weeks. 4 Upon release, he returned to Washington, and with the
5 assistance of his family and mental-health care providers, he obtained 6 temporary housing for those with disabilities.7 Plaintiff participated in 7 counseling, behavioral health management, took (and adjusted his)
8 medication, eventually working part-time jobs, although not always 9 successfully.8 On April 4, 2023, he returned to full-time substantial 10 gainful work.9
11 In the interim, the Social Security Administration denied his 12 applications for benefits.10 He requested an administrative hearing, 13 and in March 2022, ALJ Cecilia LaCara held a telephone hearing, at
15 6 AR 257, 398–402, 411, 518. 16 7 AR 46–47, 54, 484. 17 8 AR 725, 929–34, 42–46, 461–62, 500. 18 9 AR 834, 836–37. 19 10 AR 125–51. 20 1 which Plaintiff and a vocational expert testified.11 Plaintiff testified
2 that, for the last seven months, he worked in housekeeping and 3 maintenance at a hotel four days a week between four to six hours a 4 day, which he reported was the most he could tolerate dealing with
5 people.12 He stated that his employers were understanding about his 6 mental-health challenges, allowing him to show up late so long as he 7 gave them a heads up.13 He also discussed his other prior part-time
8 work, one of which he was let go from due to his decline in health and 9 performance.14 He said he was participating in an intermediate 10 housing program to get himself “back on his feet” while trying not to
11 overload himself too much, as that would cause an upheaval to his 12 mental health.15 He acknowledged his ultimate goal was to work full- 13 time, to gain emotional coping mechanisms, to participate in behavioral
15 11 AR 36–64. 16 12 AR 42–43. 17 13 AR 49–50. 18 14 AR 45. 19 15 AR 46–47, 54. 20 1 and cognitive therapy, and to take medications.16 He stated that his
2 medications were being adjusted as necessary.17 He testified that he 3 struggles with depressive phases, which can lead to significant weight 4 loss and behavioral issues where he will either completely shut down or
5 become easily agitated, thereafter leading to decreased job performance 6 and miscommunications at work.18 He said that he can have a 7 depressive episode either once a month or up to four times a month.19
8 He said that his anxiety can be triggered by external events or 9 interactions with others, and causes him to get agitated and fidgety.20 10 After the hearing, the ALJ denied benefits.21 The Appeals Council
11 denied Plaintiff’s requested review, and thereafter, Plaintiff sought 12 13
14 16 AR 47. 15 17 AR 47–48. 16 18 AR 48–49. 17 19 AR 48–49. 18 20 AR 50–51. 19 21 AR 13–35. 20 1 relief in federal district court.22 On review, the district court found the
2 ALJ erred by failing to consider the supportability factor when 3 evaluating Dr. Mashburn’s opinion.23 The matter was remanded back 4 for a new administrative hearing and decision.
5 In August 2024, ALJ LaCara held another telephone hearing.24 6 Plaintiff again testified, stating that he gained full-time work on April 7 4, 2023, working the night-shift at a hotel performing housekeeping
8 and maintenance.25 He talked about his part-time jobs prior thereto, 9 where he had not worked more than 20 hours a week.26 He was fired 10 from one of these jobs after poor performance, lost another due to
11 declining mental health and performance issues, and a third he lost 12
13 22 AR 1–6. See E.D. Wash no. 1:23-cv-3033-WFN (remanding because 14 the ALJ failed to consider the supportability factor as to Dr. 15 Mashburn’s medical opinion). 16 23 AR 885–93. 17 24 AR 830–55. 18 25 AR 836. 19 26 AR 837–38. 20 1 due to the work ceasing. He talked about his involuntary
2 hospitalization in September 2019 and his journey to stabilize his 3 mental health.27 He shared that it took a while for his treating 4 providers to adjust his medications to ensure that he did not have
5 uneven energy levels or brain fog.28 His stated that his medication can 6 cause abnormal sleeping patterns and digestive issues.29 He stated 7 that, although he was a reliable employee as to communicating if he
8 would be running late, he struggled with his prior employment because 9 of his panic and anxiety attacks and chronic depression, which led to 10 low energy and being closed off emotionally.30 He stated that he was
11 able to do his own grocery shopping, cleaning, and cooking.31 12 13
15 27 AR 839–41. 16 28 AR 844–45. 17 29 AR 849. 18 30 AR 841–42. 19 31 AR 843. 20 1 The ALJ again issued a decision denying benefits.32 The ALJ
2 found Plaintiff’s alleged symptoms were “not entirely consistent with 3 the medical evidence and other evidence in the record.”33 The ALJ 4 considered the lay statements from Plaintiff’s dad and sister.34 As to
5 the medical opinions and prior administrative medical findings, the 6 ALJ found: 7 • the administrative medical findings of Richard Borton, PhD,
8 and Leslie Postovoit, PhD, persuasive. 9 • the examining medical opinions of David Mashburn, PhD, and 10 Thomas Genthe, PhD; the reviewing opinions of Michael
11 Jenkins-Guarnieri, PhD, and Holly Petaja, PhD; and the 12 13
14 15
16 32 AR 900–22. Per 20 C.F.R. §§ 404.1520(a)–(g), 416.920(a)–(g), a five- 17 step evaluation determines whether a claimant is disabled. 18 33 AR 908. 19 34 AR 913. 20 1 opined limitations of treating provider Emily Hamilton,
2 LMHCA, not persuasive.35 3 As to the sequential disability analysis, the ALJ found: 4 • Plaintiff met the insured status requirements through
5 December 31, 2027. 6 7
9 35 AR 910–13. Although the ALJ stated that he found Dr. Jenkins- 10 Guarnieri’s opinion persuasive, the Court finds this was a 11 typographical error. The explanation given by the ALJ as to her 12 evaluation of Dr. Jenkins-Guarnieri’s opinion is that his opinion is 13 inconsistent with the longitudinal record, Plaintiff’s activities, and 14 Plaintiff’s own statements; each of these findings indicates that the 15 ALJ found Dr. Jenkins-Guarnieri’s opinion not persuasive, rather than 16 persuasive. As is discussed below, the ALJ must re-evaluate the 17 medical opinions and administrative findings; therefore, if the Court 18 misconstrued the omission of “not” as a typographical error, the ALJ 19 may remedy this on remand. 20 1 • Step one: Plaintiff engaged in substantial gainful activity from
2 April 4, 2023, to the date of the ALJ’s decision, but not during 3 the period from March 6, 2020, to April 4, 2023. 4 • Step two: Plaintiff had the following medically determinable
5 severe impairments: depressive disorder, anxiety disorder, and 6 autism spectrum disorder. 7 • Step three: Plaintiff did not have an impairment or
8 combination of impairments that met or medically equaled the 9 severity of one of the listed impairments. 10 • RFC: Plaintiff had the RFC to perform a full range of work at
11 all exertional levels, but he is limited to occasional brief 12 superficial interaction with the public, routine tasks but not 13 necessarily simple tasks, and only occasional changes in the
14 work setting. 15 • Step four: Plaintiff is unable to perform past relevant work 16 • Step five: Plaintiff can perform work as a hospital cleaner,
17 hand packager, and janitor.36 18
19 36 AR 903–14. 20 1 Plaintiff timely requested review of the ALJ’s denial by this
2 Court.37 3 II. Standard of Review 4 The ALJ’s decision is reversed “only if it is not supported by
5 substantial evidence or is based on legal error” and such error 6 impacted the nondisability determination.38 Substantial evidence is 7 “more than a mere scintilla but less than a preponderance; it is such
8 relevant evidence as a reasonable mind might accept as adequate to 9 support a conclusion.”39 10
11 37 ECF No. 1. 12 38 Hill v. Astrue, 698 F.3d 1153, 1158 (9th Cir. 2012). See 42 U.S.C. § 13 405(g); Molina v. Astrue, 674 F.3d 1104, 1115 (9th Cir. 2012), 14 superseded on other grounds by 20 C.F.R. § 416.920(a) (recognizing that 15 the court may not reverse an ALJ decision due to a harmless error— 16 one that “is inconsequential to the ultimate nondisability 17 determination”). 18 39 Hill, 698 F.3d at 1159 (quoting Sandgathe v. Chater, 108 F.3d 978, 19 980 (9th Cir. 1997)). See also Lingenfelter v. Astrue, 504 F.3d 1028, 20 1 III. Analysis
2 Plaintiff argues the ALJ erred when assessing the medical 3 opinions and Plaintiff’s symptom reports.40 In response, the 4 Commissioner argues the ALJ’s evaluation of the medical opinions and
5 Plaintiff’s symptom reports is supported by substantial evidence. As is 6 explained below, the ALJ failed to consider one of the required 7 factors—supportability—when assessing the administrative medical
8 9
10 1035 (9th Cir. 2007) (The court “must consider the entire record as a 11 whole, weighing both the evidence that supports and the evidence that 12 detracts from the Commissioner's conclusion,” not simply the evidence 13 cited by the ALJ or the parties.) (cleaned up); Black v. Apfel, 143 F.3d 14 383, 386 (8th Cir. 1998) (“An ALJ’s failure to cite specific evidence does 15 not indicate that such evidence was not considered[.]”). 16 40 Plaintiff also raises a step-one issue. This need not be addressed as 17 the parties agree that Plaintiff did not engage in substantial gainful 18 activity during the closed period at issue, September 1, 2019, to April 1, 19 2023. 20 1 findings and a medical opinion, and the ALJ’s evaluation of the
2 inconsistency factor is not supported by substantial evidence. 3 A. Medical Opinions and Prior Administrative Medical 4 Findings: Plaintiff establishes consequential error.
5 Plaintiff argues the ALJ erred when evaluating several of the 6 medical opinions and the prior administrative medical findings; 7 whereas the Commissioner argues the ALJ validly considered the
8 supportability and consistency of the disputed medical opinions and 9 administrative medical findings. The Court finds the ALJ again failed 10 to address the required supportability factor, as well as erred when
11 assessing the consistency factor; these errors are consequential. 12 1. Standard 13 The ALJ must consider and articulate how persuasive she found
14 each medical opinion and prior administrative medical finding.41 The 15 factors for evaluating the persuasiveness include, but are not limited 16 to, supportability, consistency, relationship with the claimant, and
18 41 20 C.F.R. §§ 404.1520c, 416.920c(a)–(c); Woods v. Kijakazi, 32 F.4th 19 785, 792 (9th Cir. 2022). 20 1 specialization.42 Supportability and consistency are the most important
2 factors, as the regulations require the ALJ to consider and explain the 3 supportability and consistency of each medical opinion and prior 4 administrative medical finding:
5 The factors of supportability . . . and consistency . . . are the most important factors we consider when we determine how 6 persuasive we find a medical source’s medical opinions or prior administrative medical findings to be. Therefore, we 7 will explain how we considered the supportability and consistency factors for a medical source’s medical opinions 8 or prior administrative medical findings in your determination or decision.43 9 The regulations define these two required factors as follows: 10 (1) Supportability. The more relevant the objective medical 11 evidence and supporting explanations presented by a medical source are to support his or her medical opinion(s) 12 or prior administrative medical finding(s), the more persuasive the medical opinions or prior administrative 13 medical finding(s) will be.
14 (2) Consistency. The more consistent a medical opinion(s) or prior administrative medical finding(s) is with the evidence 15 from other medical sources and nonmedical sources in the 16 17
18 42 20 C.F.R. §§ 404.1520c, 416.920c(c)(1)–(5). 19 43 Id. §§ 404.1520c, 416.920c(b)(2). 20 1 claim, the more persuasive the medical opinion(s) or prior administrative medical finding(s) will be.44 2 The ALJ may, but is not required to, explain how the other listed 3 factors were considered.45 When considering the ALJ’s findings, the 4 Court is constrained to the reasons and supporting explanation offered 5 by the ALJ.46 6 2. Dr. Borton and Dr. Postovoit 7 Dr. Borton and Dr. Postovoit reviewed the medical records that 8 were available to them at the time they each issued their 9 10 11
12 44 Id. §§ 404.1520c, 416.920c(c)(1)–(2). 13 45 Id. §§ 404.1520c(b)(2), 416.920c(b)(2). When two or more medical 14 opinions or prior administrative findings “about the same issue are 15 both equally well-supported . . . and consistent with the record . . . but 16 are not exactly the same,” the ALJ is required to explain how “the 17 other most persuasive factors in paragraphs (c)(3) through (c)(5)” were 18 considered. Id. §§ 404.1520c(b)(3), 416.920c(b)(3). 19 46 See Burrell v. Colvin, 775 F.3d 1133, 1138 (9th Cir. 2014). 20 1 administrative medical finding: Dr. Borton in January 2021, and
2 Dr. Postovoit in July 2021. They both issued largely the same findings: 3 • that Plaintiff was moderately limited in at least 3 of the B 4 Criteria areas of functioning.
5 • that Plaintiff was moderately limited in the abilities to 6 carry out detailed instructions; perform activities within a 7 schedule, maintain regular attendance, and be punctual
8 within customary tolerances; and complete a normal 9 workday and workweek without interruptions from 10 psychologically based symptoms and perform at a consistent
11 pace without an unreasonable number and length of rest 12 periods. 13 • that Plaintiff is moderately limited in his ability to interact
14 appropriately with the public and thus should not have 15 more than occasional brief, superficial interaction with the 16 public.
17 • that Plaintiff is moderately limited in his abilities to 18 respond to changes in the work setting and set realistic 19 goals or make plans independently of others because of his
20 1 “past diagnosis of [autism spectrum disorder] and current
2 report of being a little put off by changes.”47 3 To support their opined limitations, both doctors wrote: 4 Clmt. likely have some absences with wax and wane of symptoms however not of the frequency to preclude 5 competitive employment. The claimant has worked in the recent past for SGA for two years, and is currently working 6 part time. He would retain the capacity to complete most tasks required of him in a productive manner, without need 7 for excessive breaks and without frequent interruptions.48
8 The ALJ found these opinions persuasive stating: 9 While Drs. Borton and Postovoit did not have an opportunity to examine the claimant or to review the 10 updated record, their opinions are nevertheless generally consistent with the longitudinal record to include, for 11 example, the claimant’s generally intact cognition during routine appointments; his ability to interact at least 12 superficially with providers, who note intermittent poor eye contact, abnormal speech, and irritability but also that he is 13 often polite, engaged, and cooperative; findings on formal mental status testing that have shown full orientation, 14 normal perception, normal memory, a normal fund of knowledge, normal abstract thought, and normal insight 15 and judgment; often intact or otherwise unremarkable cognition during routine appointments with normal 16 attention span and concentration, an unremarkable thought process, full alertness and orientation, and an appropriate 17
18 47 AR 77–80, 93–96, 103–106, 110–13. 19 48 AR 78, 94, 105, 112. 20 1 fund of knowledge; the claimant’s ability to engage in activities such as playing video games and work activity; 2 and the claimant’s statements that he is able to prepare his own meals, complete household chores, and complete his 3 own personal hygiene as well as treatment notes suggesting that he is generally able to maintain his apartment (finding 4 #6).49
5 3. Supportability 6 Plaintiff argues the ALJ failed to address the supportability 7 factor for either of these sources. The Court agrees. Contrary to the 8 Commissioner’s argument otherwise, the ALJ is required to explain 9 how a medical opinion or administrative medical finding is or is not 10 both 1) supported by “more relevant . . . objective medical evidence and 11 supporting explanation presented by [the] medical source,” i.e., the 12 supportability factor; and 2) “consistent with the evidence from other 13 medical sources and nonmedical sources in the claim,” i.e., the
14 consistency factor.50 Here, the ALJ only explained the latter 15 consistency factor and not the supportability factor. The ALJ therefore 16 erred by not explaining whether Dr. Borton’s and Dr. Postovoit’s
18 49 AR 910. 19 50 20 C.F.R. §§ 404.1520c(c)(1)–(2), 416.920c(c)(1)–(2). 20 1 administrative medical findings were supported by relevant objective
2 medical evidence and explanation. 3 The Commissioner’s argument that the ALJ’s mere citation to the 4 exhibits containing Dr. Borton’s and Dr. Postovoit’s administrative
5 medical findings satisfies the supportability factor is not persuasive. 6 The ALJ’s mere citation to the exhibits containing the prior 7 administrative medical findings—the Disability Determination
8 Explanations (hereinafter, “the Determinations”)—and the ALJ’s 9 summary of the administrative medical findings does not satisfy the 10 ALJ’s requirement to “explain how [she] considered” these two
11 administrative medical findings were supported by “relevant . . . 12 objective medical evidence and supporting explanation.”51 The ALJ 13 must do more than cite to the documents containing the administrative
14 medical findings. 15 In addition, the ALJ’s statement that Dr. Borton and 16 Dr. Postovoit did not have an opportunity to review the updated record,
17 i.e., records after January 2021 (Dr. Borton) and July 2021 18
19 51 20 C.F.R. § 404.1520c(b)(2), (c); 416.920c(b)(2), (c). 20 1 (Dr. Postovoit), would indicate a reason to find these administrative
2 findings less persuasive rather than more persuasive. Furthermore, as 3 Plaintiff points out, that Dr. Borton and Dr. Postovoit did not examine 4 Plaintiff goes to the “relationship with the claimant” factor, not
5 necessarily the supportability factor.52 Regardless, the fact that 6 Dr. Borton and Dr. Postovoit did not examine or meet with Plaintiff 7 would typically indicate a reason to find these administrative findings
8 less persuasive rather than more persuasive. 9 Furthermore, even if the Court delves into the content of the 10 Determinations to assess supportability, the Determinations’
11 summaries of some of the underlying treatment records fails to fairly 12 summarize the then-existing treatment records. For instance, the 13 Determination for Dr. Borton’s administrative medical findings fails to
14 highlight some of the abnormal observed symptoms in the summarized 15 medical records; likewise, the Determination does not summarize 16 several medical records containing abnormal findings. For instance,
17 the Determination fails to mention that: 18
19 52 Id. §§ 404.1520c(c)(1), (3); 416.920c(c)(1), (3). 20 1 • During a March 10, 2020 appointment, Plaintiff was observed
2 stammering with somewhat pressured speech and correcting 3 his father’s statements.53 4 • Plaintiff’s mood was labile during the May 13, 2020
5 appointment.54 6 • During a May 20, 2020 appointment, Plaintiff’s mood was still 7 labile.55
8 • During the May 22, 2020 appointment, Plaintiff demonstrated 9 avoidance and had pressured speech.56 10 • Instead of having a normal speech pattern during the August
11 17, 2020 counseling session, Plaintiff presented with pressured 12 speech.57 13
15 53 Compare AR 88 with AR 523. 16 54 Compare AR 88 with AR 517. 17 55 Compare AR 88 with AR 516. 18 56 Compare AR 89 with AR 638. 19 57 Compare AR 89 with AR 468. 20 1 • During the September 1, 2020 counseling session, Plaintiff was
2 hyperverbal at times.58 3 • During the September 28, 2020 counseling session, Plaintiff 4 presented with pressured speech at times.59
5 Although the Determination was merely a summary and need not have 6 included every reviewed medical record or observation, the 7 Determination does not fairly reflect the abnormal mental-health
8 findings in the summarized documents.60 This cherry-picking of 9 summarized findings on the Determination compounds the ALJ’s error 10 of not explaining the supportability of Dr. Borton’s and Dr. Postovoit’s
11 administrative medical findings. 12 13
14 58 Compare AR 89 with AR 474–75. 15 59 AR 479. 16 60 Kilpatrick v. Kijakazi, 35 F.4th 1187, 1193 (9th Cir. 2022); Garrison 17 v. Colvin, 759 F.3d 995, 1018 (9th Cir. 2014) (“While ALJs obviously 18 must rely on examples . . . the data points they choose must in fact 19 constitute examples of a broader development . . . .”). 20 1 The ALJ’s error when considering Dr. Borton’s and Dr. Postovoit’s
2 administrative medical findings is consequential as these are the only 3 administrative medical findings or medical opinions that the ALJ 4 found persuasive.61
5 4. Consistency 6 As to the ALJ’s finding that Dr. Borton’s and Dr. Postovoit’s 7 findings are “generally consistent” with the longitudinal medical
8 record, this finding fails to meaningfully evaluate that Plaintiff had 9 worse mental-health symptoms during the beginning of the relevant 10 period versus latter.
11 12
13 61 As previously noted, although the ALJ stated that she found 14 Dr. Jenkins-Guarnieri’s medical opinion persuasive, it appears the ALJ 15 mistakenly omitted “not,” as the ALJ’s analysis indicates that the ALJ 16 found Dr. Jenkins-Guarnieri’s medical opinion not persuasive. 17 Therefore, other than Dr. Borton’s and Dr. Postovoit’s findings, the 18 ALJ found all other treating, examining, and reviewing opinions, which 19 were largely consistent with each other, not persuasive. 20 1 The Ninth Circuit requires an ALJ to consider how a claimant’s
2 condition changes over time, and whether such changes support a 3 finding of disability for a shorter period even if not for the entire 4 relevant period.62
5 Here, the ALJ did not discuss that the longitudinal treatment 6 record reflects that Plaintiff’s journey toward stabilizing his mental 7 health through counseling and medication management involved more
8 mental-health symptoms at the forefront. For instance, Plaintiff was 9 observed with an impaired affect or mood in the spring and summer 10 2020, i.e., anxious, restricted, tearful, blunted, labile, or irritable.63
11 Then beginning in the fall of 2020 the longitudinal record shows a 12 trend of some waning of symptoms but continued waxing as well, with 13 notes that Plaintiff’s mood or affect was intermittently labile or
14 depressed or mildly anxious, but other times Plaintiff presented as 15 16
17 62 Smith v. Kijakazi, 14 F.4th 1108, 1110 (9th Cir. 2021). 18 63 See, e.g., AR 420, 426, 459, 465, 468, 509, 510, 513, 514, 515, 517, 19 519, 521. 20 1 anxious.64 Consistent with the treatment record notes that reflect
2 waning anxiety and mood symptoms, a treatment note in March 2021 3 states, “He has made remarkable progress this last year securing his 4 independence and his relationships with his family have improved a lot
5 and have more confidence.”65 The counseling and other records 6 thereafter reflect that Plaintiff was not often observed with an 7 impaired affect or mood. Nonetheless, he still experienced depressive
8 episodes and struggled with hygiene and maintaining a clean 9 residence.66 The longitudinal record also reflects that, notwithstanding 10 waning of mood and affect symptoms, Plaintiff routinely struggled with
11 stammering, pressured or elevated speech, and fast speech.67 A full and 12 fair review of the longitudinal record reveals that the ALJ cherry- 13 picked the normal mental-health findings and/or relied on the
14 improvement in Plaintiff’s mental health closer to the end of the 15
16 64 See, e.g., AR 495, 497, 498, 500, 600, 606, 607. 17 65 AR 599. 18 66 See, e.g., AR 578, 585, 797, 803, 815. 19 67 See, e.g., AR 437, 448, 463, 514, 521, 1127, 1133, 1134, 1136. 20 1 relevant period to discount Plaintiff’s observed mental-health
2 symptoms during the earlier part of the relevant period.68 As a result of 3 this cherry-picking of evidence, the ALJ’s finding that Dr. Borton’s and 4 Dr. Postovoit’s findings are generally consistent with the longitudinal
5 medical record is not supported by substantial evidence. 6 In addition, the ALJ’s consistency analysis contains further error. 7 The ALJ’s finding that Dr. Borton’s and Dr. Postovoit’s findings are
8 consistent with Plaintiff’s abilities to “complete household chores and 9 complete his own personal hygiene as well as treatment notes 10 suggesting that he is generally able to maintain his apartment”
11 conflicts with other findings by the ALJ. For instance, as to Plaintiff’s 12 ability to maintain his apartment, the ALJ states in other portions of 13 her decision:
15 68 See Garrison, 759 F.3d at 1017 (“Cycles of improvement and 16 debilitating symptoms are a common occurrence, and in such 17 circumstances, it is error for an ALJ to pick out a few isolated instances 18 of improvement over a period of months or years and to treat them as a 19 basis for concluding a claimant is capable of working.”). 20 1 The claimant was not consistently tidy (Ex. 13F, pg. 12) but at the majority of appointments the claimant remained 2 “cooperative, orientated x3, and pleasant. His mood was euthymic and he appeared to be in good spirits,” (Ex. 13F, 3 pg. 15-24) despite ongoing difficulties keeping his apartment clean. 4 . . . . 5 While the claimant did complaint [sic] of fatigue (for which 6 his dosage was adjusted) and maintained his apartment in a substandard manner, record largely showed the claimant to 7 be pleasant and cooperative, with a euthymic mood and affect the majority of the time (Ex. 10, 11F 13F). 69 8 The ALJ fails to meaningfully explain how Plaintiff’s maintaining of 9 his apartment in a “substandard manner” or his “ongoing difficulties 10 keeping his apartment clean”—difficulties that are reflected in the 11 record, particularly once he began part-time work—is consistent with 12 the ALJ’s decision to find Dr. Borton’s and Dr. Postovoit’s findings 13 persuasive on the basis that they were consistent with Plaintiff’s so- 14 found ability to complete household chores and general ability to 15 16 17 18
19 69 AR 909. 20 1 maintain his apartment.70 Moreover, the records also note at times
2 that Plaintiff had body odor, indicating difficulties maintaining his 3 personal hygiene.71 4 On remand, the ALJ is to reassess Plaintiff’s documented
5 difficulties with hygiene and passing housing inspections, and is to 6 reevaluate whether such are consistent with or inconsistent with the 7 opined limitations in the administrative medical findings and medical
8 opinions. 9 5. Other Medical Opinions 10 The ALJ’s cherry-picking of normal mental-health findings and
11 failure to appreciate that Plaintiff’s mental-health symptoms more 12 consistently waned during the end of the relevant period, permeated 13 the ALJ’s “consistency” evaluation for not only the findings of
14 Dr. Borton and Dr. Postovoit, but for each of the medical opinions. The 15 ALJ used the same “consistency” rationale—either in the positive or 16
17 70 See, e.g., AR 578, 585, 797, 803, 806, 807, 818, 1125, 1128, 1135, 18 1137, 1140, 1166, 1178. 19 71 See, e.g., AR 578, 585, 816. 20 1 the negative—when assessing each prior administrative medical
2 finding or medical opinion.72 3 The ALJ’s cherry-picking of the normal mental-health 4 observations also impacted the ALJ’s supportability analysis for
5 Dr. Genthe’s opinion, as the ALJ did not mention that Dr. Genthe 6 observed Plaintiff with “moderate difficulties following the 7 conversation” and that Plaintiff’s autism symptoms were not well
8 managed.73 This error in turn impacted the ALJ’s supportability 9 analysis for Dr. Petaja’s opinion, as the ALJ incorporated her 10 supportability analysis for Dr. Genthe when evaluating Dr. Petaja’s
11 opinion. 12 Further, like the ALJ failed to do for Dr. Borton and 13 Dr. Postovoit, the ALJ failed to evaluate the supportability factor for
14 Dr. Jenkins-Guarnieri’s opinion.74 15 16
17 72 AR 910, 911, 912, 913. 18 73 AR 725–27. 19 74 AR 911. 20 1 Finally, the record reflects care providers adjusted the type and
2 dosage of medications to stabilize Plaintiff’s mental-health symptoms 3 while also reducing the side-effects of fatigue, nausea, lightheadedness, 4 confusion, and stomach issues.75 For instance, as the ALJ commented,
5 Plaintiff’s treating provider reduced his dosage of Cymbalta in August 6 2022 due to his complaints of fatigue resulting from the prior dosage.76 7 On remand, the ALJ must consider how medication side effects may
8 have impacted Plaintiff’s ability to work during the closed period.77 9 B. Symptom Reports: this issue is moot. 10 Plaintiff argues that the ALJ failed to provide valid reasons for
11 discounting his subjective complaints. Because the Court is remanding 12
13 75 See, e.g., AR 436, 437, 565, 601, 607, 1096, 1104, 1106, 1107. See Soc. 14 Sec. Rlg. 16-3p (allowing the medical source to consider medication 15 side-effects and requiring the ALJ to consider medication side-effects 16 when assessing the claimant’s symptom reports). 17 76 AR 1104–05. 18 77 See Smith, 14 F.4th at 1110; Varney v. Sec’y of Health & Human 19 Servs., 846 F.2d 581, 585 (9th Cir. 1988). 20 1 the case with direction that the ALJ re-evaluate the medical opinions
2 and administrative medical findings, the ALJ must re-evaluate 3 Plaintiff’s symptom reports. When doing so, the ALJ is to fairly 4 consider how Plaintiff’s condition changed over time.
5 C. Remand: further proceedings 6 Plaintiff prefers a remand for payment of benefits, rather than a 7 remand for more proceedings. However, when the court reverses an
8 ALJ’s decision for error, the court “ordinarily must remand to the 9 agency for further proceedings.”78 At this time, remand for further 10 proceedings is appropriate.
11 The record reflects that at the beginning of the relevant period–– 12 September 1, 2019, to April 1, 2023—Plaintiff was not stable enough to 13 sustain full-time work following his inpatient stay after his suicide
14 attempt. However, “over time, [Plaintiff] moved from a state where” he 15 was unable to “engage in meaningful work to a state in which [he] was 16
18 78 Leon v. Berryhill, 880 F.3d 1041, 1045 (9th Cir. 2017); Sprague v. 19 Bowen, 812 F.2d 1226, 1232 (9th Cir. 1987). 20 1 significantly less hindered,”79 and thus he was able to obtain and
2 sustain fulltime employment beginning April 4, 2023. 3 On remand, the ALJ is to fairly and fully consider the 4 longitudinal record, reevaluate the medical opinions and Plaintiff’s
5 symptom reports, and then complete the five-step disability evaluation, 6 assessing whether Plaintiff was disabled for at least a 12-month period 7 during the at-issue closed period.
8 IV. Conclusion 9 Plaintiff establishes the ALJ erred. The ALJ is to reevaluate— 10 with meaningful articulation and evidentiary support—the sequential
11 process. If necessary, the ALJ is to consider calling a medical expert to 12 testify as to when Plaintiff’s mental-health symptoms waned 13 sufficiently to allow him to sustain full-time work.
14 Accordingly, IT IS HEREBY ORDERED: 15 1. The ALJ’s nondisability decision is REVERSED, and this 16 matter is REMANDED to the Commissioner of Social
17 18
19 79 Smith, 14 F.4th at 1114. 20 1 Security for further proceedings pursuant to
2 sentence four of 42 U.S.C. § 405(g). 3 2. Consistent with Social Security Administration policy, a
4 new ALJ is to be assigned to this matter.8° The ALJ is to
5 issue a new decision within 120 days. 6 3. The Clerk’s Office shall TERM the parties’ briefs, ECF
7 Nos. 8 and 10, enter JUDGMENT in favor of Plaintiff, g and CLOSE the case.
9 IT IS SO ORDERED. The Clerk’s Office is directed to file this
10 order and provide copies to all counsel.
11 DATED this 4** day of August 2025.
2 awed I lew. 13 EDWARD F. SHEA Senior United States District Judge 14 15 16 17 18 |} Program Operations Manual System (POMS) HA 01210.055-D 19 (Assignment of Service Area Cases to Administrative Law Judges).
DISPOSITIVE ORDER - 33