Sweeney v. Commissioner of Social Security

• Court: District Court, W.D. Washington
• Decided: January 30, 2024
• Docket: 2:23-cv-01014
• Status: Unknown

Opinion

1 2 3 4 5 UNITED STATES DISTRICT COURT 6 WESTERN DISTRICT OF WASHINGTON AT SEATTLE 7 REBECCA E. S., 8 Plaintiff, Case No. C23-1014 RSM 9 v. ORDER REVERSING DENIAL OF 10 BENEFITS AND REMANDING COMMISSIONER OF SOCIAL SECURITY, FOR FURTHER PROCEEDINGS 11 Defendant. 12

13 Plaintiff seeks review of the denial of her applications for Supplemental Security Income 14 (SSI) and Disability Insurance Benefits (DIB). Plaintiff contends the ALJ erred (1) by rejecting 15 her symptom testimony, (2) rejecting Dr. May’s opinion, and (3) at step four. Dkt. 11.1 As 16 discussed below, the Court REVERSES the Commissioner’s final decision and REMANDS the 17 matter for further administrative proceedings under sentence four of 42 U.S.C. § 405(g). 18 BACKGROUND 19 Plaintiff is 63 years old and has worked as a home attendant and general clerk. Admin. 20 Record (AR) 31. Plaintiff applied for benefits, alleging disability as of July 1, 2018. AR 67, 73, 21 22 1 Plaintiff’s Opening Brief does not entirely comply with the briefing requirements provided in the Court’s Scheduling Order, as Plaintiff did not list the alleged errors on the first page of the brief. See Dkts. 7 at 2; 11 at 1. In 23 the future, counsel shall take care to review and comply with the Court’s briefing requirements.

ORDER REVERSING DENIAL OF 1 83. Plaintiff’s applications were denied initially and on reconsideration. AR 71, 80, 90. The 2 ALJ conducted a hearing in June 2022, where Plaintiff amended her alleged onset date to 3 November 3, 2020. AR 42–65. In July 2022, the ALJ issued a decision finding Plaintiff not 4 disabled. AR 12–41. 5 DISCUSSION 6 The Court may reverse the ALJ’s decision only if it is legally erroneous or not supported 7 by substantial evidence of record. Ford v. Saul, 950 F.3d 1141, 1154 (9th Cir. 2020). The Court 8 must examine the record but cannot reweigh the evidence or substitute its judgment for the 9 ALJ’s. Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002). When evidence is susceptible to 10 more than one interpretation, the Court must uphold the ALJ’s interpretation if rational. Ford,

11 950 F.3d at 1154. Also, the Court “may not reverse an ALJ’s decision on account of an error 12 that is harmless.” Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012). 13 1. Dr. May 14 In a letter dated August 17, 2021, neuro-ophthalmologist Dr. May wrote: “1. [Plaintiff] 15 cannot drive. 2. She can only see clearly up close. 3. She has to be able to wear an eye patch, as 16 needed. 4. She can only work continuously for 30 minutes at a time with 30 to 60-minute breaks 17 in between. 5. Has poor depth perception. 5. Fatigues very easily not because of the visual 18 strain.” AR 746. 19 ALJs must consider every medical opinion in the record and evaluate each opinion’s 20 persuasiveness, with the two most important factors being “supportability” and “consistency.”

21 Woods v. Kijakazi, 32 F.4th 785, 791 (9th Cir. 2022); 20 C.F.R. §§ 404.1520c(a), 416.920c(a). 22 Supportability concerns how a medical source supports a medical opinion with relevant 23 evidence, while consistency concerns how a medical opinion is consistent with other evidence ORDER REVERSING DENIAL OF 1 from medical and nonmedical sources. See id.; 20 C.F.R. §§ 404.1520c(c)(1), (c)(2); 2 416.920c(c)(1), (c)(2). Under the new regulations, “an ALJ cannot reject an examining or 3 treating doctor’s opinion as unsupported or inconsistent without providing an explanation 4 supported by substantial evidence.” Woods, 32 F.4th at 792. 5 Here, the ALJ found Dr. May’s opinion regarding Plaintiff’s limited driving and ability to 6 only see up close unsupported by his own treatment records. AR 29. The ALJ pointed out that 7 after Plaintiff underwent an operation for an aneurysm, Dr. May found her eye exam findings 8 “pretty stable.” AR 728. Dr. May also wrote that he doubted “there has been a significant 9 increase in her esotropia or possible 6th nerve palsy,” and “[it] is reassuring that the pain is less 10 than it had been.” Id. The record also shows Dr. May prescribed plano spectacles for Plaintiff to

11 wear after she reported having double vision. Id. Subsequent treatment notes show that 12 although Plaintiff did not get the spectacles, her findings remained “pretty stable.” AR 838. 13 Given the stability of Plaintiff’s findings, even after she did not follow through with Dr. May’s 14 prescription, the ALJ did not err in rejecting these portions of Dr. May’s opinion. 15 As to the rest of the opinion, the ALJ wrote: 16 [Dr. May’s] opinion that [Plaintiff] could only work continuously for 30 minutes at a time with 30 to 60 minute breaks in between may have been supported by his 17 finding that the claimant[] fatigues easily, but he specifically states that this is not from visual strain. Thus, the cause of this fatigue was not worked up by him and [] 18 outside of his area of his expertise. Therefore it is not supported by his clinical examination findings. 19 AR 29–30. 20 Plaintiff argues the ALJ misread Dr. May’s opinion and that the physician’s 21 finding that Plaintiff is only able to work for only 30 minutes at a time is due to visual 22 strain and therefore within his area of expertise. Dkt. 11 at 8–10 (citing AR 718, 835). 23 Plaintiff’s argument assumes the ALJ was analyzing Dr. May’s treatment notes from ORDER REVERSING DENIAL OF 1 August 16, 2021, which state, in relevant part, “Straining with her eyes makes her very 2 tired, requiring that she can only do work for 30 minutes at a time but then has to take a 3 break for 30 to 60 minutes.” See AR 718, 835. But it was the August 17 letter the ALJ 4 assessed, and the contents of the letter were different from the treatment notes Plaintiff 5 cites to. Compare AR 746 with AR 718, 835. In any case, the ALJ’s reasoning—that Dr. 6 May’s opinion was not within his area of expertise—is erroneous because it is predicated 7 on the assumption that Plaintiff’s 30-minute working limitation is related to Plaintiff’s 8 fatigue (that Dr. May stated as unrelated to visual strain). However, reading the letter, 9 Dr. May did not seem to be basing his opinion on said fatigue. See AR 746. He listed 10 the two proposed limitations separately and made no indication they were related. See id.

11 Because the ALJ’s evaluation is based on a misinterpretation of Dr. May’s opinion, the 12 Court cannot say his reason was supported by substantial evidence. Further, even if 13 fatigue was the basis of this part of Dr. May’s opinion, a medical source’s lack of 14 specialization alone is not the “most important factor” the ALJ must consider when 15 weighing a medical opinion. See 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2). Instead, 16 the ALJ must consider a medical opinion’s supportability and consistency, which the ALJ 17 did not do with this specific part of the Dr. May’s opinion. Therefore, in evaluating Dr. 18 May’s opinion, the ALJ erred. 19 2. Plaintiff’s Symptom Testimony 20 Plaintiff testified to pain in her lower back, hip, knees, left elbow, shoulder, wrists,

21 fingers, and ankles. AR 56. She stated she has dislocations almost daily and her pain lasts for 22 days. AR 56–57. She explained she has difficulties with standing, walking, and she falls and 23 gets lightheaded when she stands up too quickly. AR 57. She stated she spends 30 to 40 ORDER REVERSING DENIAL OF 1 minutes laying down every day at any given time. Id. Plaintiff also testified that she has been 2 diagnosed with major depression and post-traumatic stress disorder. AR 54. She stated she is 3 forgetful and has difficulties focusing. AR 55. In her function report, Plaintiff wrote that her 4 vision is limiting. AR 258. 5 Where, as here, an ALJ determines a claimant has presented objective medical evidence 6 establishing underlying impairments that could cause the symptoms alleged, and there is no 7 affirmative evidence of malingering, the ALJ can only discount the claimant’s testimony as to 8 symptom severity by providing “specific, clear, and convincing” reasons supported by 9 substantial evidence. Trevizo v. Berryhill, 871 F.3d 664, 678 (9th Cir. 2017). “The standard 10 isn’t whether our court is convinced, but instead whether the ALJ’s rationale is clear enough that

11 it has the power to convince.” Smartt v. Kijakazi, 53 F.4th 489, 499 (9th Cir. 2022). 12 In evaluating Plaintiff’s physical symptoms, the ALJ focused on Plaintiff’s aneurysm and 13 records after her aneurysm was obliterated in April 2021, implying Plaintiff’s symptoms were 14 connected to this condition and that Plaintiff’s symptoms improved as a result of her procedure. 15 See AR 24–27. Evidence cited by the ALJ shows that following her procedure, Plaintiff denied 16 focal neurologic deficits, vision loss, weakness in her upper or lower extremities, sensory deficit, 17 or gait instability. AR 667. In another follow-up appointment in October 2021, Plaintiff again 18 reported the same, and her physical examination showed full strength in all muscle groups. AR 19 873. The effectiveness of treatment is relevant to the evaluation of a claimant’s alleged 20 symptoms, 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3), but subsequent treatment notes in the

21 record present some ambiguity regarding Plaintiff’s physical condition. For example, the ALJ 22 pointed out Plaintiff’s physical examination “remained normal,” but the treatment note cited only 23 includes psychiatric and neurological findings. See AR 1025. The ALJ pointed out Plaintiff’s ORDER REVERSING DENIAL OF 1 weight and BMI, but did not explain how this necessarily detracts from Plaintiff’s testimony. 2 AR 26 (citing AR 1025). The ALJ also cited Plaintiff’s physical examination from May 2022 3 and explained it did not corroborate her subjective reports. AR 26 (citing AR 1031). But there 4 were no actual objective findings from that examination that supports the ALJ’s reasoning. 5 Instead, the examination includes notations by Plaintiff’s physician regarding possibly needing 6 “further scanning for aneurysms…” given the increase of Plaintiff’s joint dislocation. See AR 7 1036. 8 The ALJ also noted that because Plaintiff’s therapy records included only subjective 9 reports about Plaintiff’s joints popping, “the degree in which they result in functional limitations 10 is in question.” AR 26. This description of Plaintiff’s therapy records is not entirely accurate,

11 because in addition to Plaintiff’s subjective reports, they include findings regarding Plaintiff’s 12 range of motion and strength. See AR 1114–37. The ALJ pointed to a February 20222 13 appointment but did not explain why the therapy note supports his reasoning as it shows Plaintiff 14 had limited range of motion. See AR 1141. 15 In rejecting Plaintiff’s testimony regarding her mental health, the ALJ pointed out that 16 Plaintiff’s evaluator found her mood, psychomotor, insight, judgment, and abstract thinking 17 impacted by Plaintiff’s aneurysm procedure. AR 30 (citing AR 1076). The ALJ’s reasoning that 18 Plaintiff’s mental symptoms were situational is reasonable given the evaluator’s notes. Tidwell 19 v. Apfel, 161 F.3d 599, 602 (9th Cir. 1998) (finding no error with the ALJ’s rejection of the 20 plaintiff’s testimony because her symptoms were attributed in part to plaintiff’s living situation

21 rather than her mental impairment). The ALJ also pointed to Plaintiff’s other mental 22

23 2 The ALJ mistakenly wrote that the therapy note was from December 2020, but the record shows Plaintiff’s visit date as “02/02/2022.” See AR 1141. ORDER REVERSING DENIAL OF 1 examinations showing normal psychiatric findings. See AR 30 (citing AR 778, 1025). “When 2 objective medical evidence in the record is inconsistent with the claimant’s subjective testimony, 3 the ALJ may indeed weigh it as undercutting such testimony.” Smartt, 53 F.4th at 498. Here, 4 counseling notes show Plaintiff often appeared oriented with neutral, mild, cheerful, or improved 5 affect. See AR 1046, 1054, 1055–57. While Plaintiff did report some lapses in memory, later 6 notes also show she was less distracted and did well. See AR 1046, 1055. Given these records, 7 the ALJ did not err in rejecting Plaintiff’s testimony regarding her mental health. 8 The ALJ also did not err in rejecting Plaintiff’s testimony regarding her vision. The ALJ 9 noted Plaintiff had optic neuropathy in her left eye, but nonetheless found her records indicated 10 improvement. See 20 C.F.R. §§ 404.1529(c)(3) (the effectiveness of medication and treatment

11 are relevant to the evaluation of a claimant’s alleged symptoms), 416.929(c)(3) (same). The 12 ALJ’s reasoning is supported by the record, which shows Dr. May found her findings “stable” 13 following her aneurysm procedure. AR 728. The record also shows Plaintiff reported double 14 vision in her left eye, for which Dr. May suggested getting spectacles with a prism. Id. In a 15 follow-up appointment, Plaintiff reported she did not get the spectacles, but Dr. May again found 16 her findings “pretty stable.” See AR 838. Given the stability of Plaintiff’s symptoms, it was 17 reasonable for the ALJ to find Plaintiff’s testimony regarding her vision inconsistent with her 18 record. 19 In sum, the ALJ did not err in rejecting Plaintiff’s testimony concerning her mental health 20 and vision symptoms, given her normal examinations and improvement. However, because the

21 ALJ disregarded probative records concerning Plaintiff’s physical symptoms, the ALJ erred in 22 rejecting this portion of her testimony. 23 3. Step Four ORDER REVERSING DENIAL OF 1 Plaintiff contends the ALJ erred in finding she is able to perform her past work based on 2 her RFC. Dkt. 11 at 4–7. The Court need not address this argument, as it has found errors with 3 the ALJ’s evaluation of Dr. May’s opinion and Plaintiff’s symptom testimony, and such errors 4 necessitate reassessment of Plaintiff’s RFC. See Social Security Ruling 96-8p (an RFC “must 5 always consider and address medical source opinions”); Valentine v. Comm’r Soc. Sec. Admin., 6 574 F.3d 685, 690 (9th Cir. 2009) (“an RFC that fails to take into account a claimant’s 7 limitations is defective”). 8 CONCLUSION 9 For the foregoing reasons, the Commissioner’s final decision is REVERSED and this 10 case is REMANDED for further administrative proceedings under sentence four of 42 U.S.C. §

11 405(g). On remand, the ALJ shall reevaluate Dr. May’s opinion and Plaintiff’s testimony, and 12 reassess Plaintiff’s RFC and all relevant steps of the disability evaluation process. The ALJ shall 13 conduct all further proceedings necessary to reevaluate the disability determination in light of 14 this opinion. 15 DATED this 30th day of January, 2024.

16 A 17 18 RICARDO S. MARTINEZ UNITED STATES DISTRICT JUDGE 19

21 22 23 ORDER REVERSING DENIAL OF