1 EASTERUN. SD.I SDTIRSITCRTI COTF CWOAUSRHTI NGTON Oct 14, 2025 2 SEAN F. MCAVOY, CLERK 3 UNITED STATES DISTRICT COURT 4 EASTERN DISTRICT OF WASHINGTON 5 TIMOTHY H.,1 No. 2:25-cv-00009-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, 10 Defendant. 11 Plaintiff Christopher R. asks the Court to reverse the 12 Administrative Law Judge’s (ALJ) denial of Title 16 benefits, while the 13 Commissioner asks the Court to affirm the ALJ’s denial. As is 14 explained below, because the ALJ failed to consider the longitudinal 15 record regarding Plaintiff’s varicose veins and lower extremity 16 17 18 1 For privacy reasons, Plaintiff is referred to by first name and last 19 initial or as “Plaintiff.” See LCivR 5.2(c). 20 1 neuropathy when considering the medical opinion and Plaintiff’s
2 subjective complaints and erred in failing to call a medical expert, this 3 matter is remanded for further proceedings. 4 I. Background
5 In March 2019, Plaintiff applied for benefits under Title 16, 6 claiming disability based on chronic post-traumatic stress disorder 7 (PTSD), personality disorder, mood disorder, an abdominal hernia, and
8 bilateral carpal tunnel syndrome.2 Plaintiff amended his claim later in 9 March 2019 to include bilateral venous insufficiency/varicose veins and 10 dyslexia as severe impairments.3
11 When he filed his application, Plaintiff was 50 years old, which 12 made him a person closely approaching advanced age, and in 13 September 2023 he changed category to that of a person of advanced
14 age.4 Plaintiff attended school to the 10th grade, including attending 15 special education classes from 1980–82, and completed a GED in 16
17 2 AR 307-313, 406. 18 3 AR 404. 19 4 20 CFR § 416.963. 20 1 1986.5. The vocational expert testified that Plaintiff’s past relevant
2 work was as a plastic molder, which is light and semi-skilled with an 3 SVP of 3; and as a binding machine operator, which is medium and 4 unskilled with an SVP of 2.6
5 Plaintiff’s claim was denied at the initial and reconsideration 6 levels.7 In November 2019, Plaintiff requested an administrative 7 hearing.8 In May 2023, ALJ Allen Erickson held a video hearing, at
8 which Plaintiff appeared unrepresented, and ALJ Erickson postponed 9 the hearing in order to allow Plaintiff to hire an attorney.9 In 10 September 2023, the ALJ held a second hearing at which Plaintiff
11 12 13
15 5 AR 400. 16 6 AR 51-53. 17 7 AR 128, 135. 18 8 AR 138. 19 9 AR 87-100. 20 1 appeared by video and his counsel and a vocational expert appeared by
2 telephone.10 Plaintiff and the vocational expert testified.11 3 Plaintiff testified that in March 2019 he had just completed his 4 carpal tunnel surgery and been told that he reached maximum
5 improvement.12 Plaintiff’s doctor said he had serious permanent 6 damage.13 He said he understood he could not be paid benefits after his 7 confinement in August 2022.14 He said that his hands would lock up
8 and he would feel like there was an icepick through his wrist, and he 9 would have to un-pry his fingers.15 It was sporadic but he would need 10 to stop using his hands after 20-30 minutes and let them relax.16 He
11 12
13 10 AR 38-86. 14 11 Id. 15 12 AR 54. 16 13 AR 55. 17 14 AR 56. 18 15 AR 58. 19 16 AR 58-59. 20 1 said the left (nondominant) was worse than the right.17 After the
2 surgery, his pain level was a 5-6.18 3 Plaintiff said he also had issues with his legs and varicose veins 4 and that after walking 15 minutes his legs felt like they were on fire.19
5 He said the pain was an 8-9 and he would need to sit.20 He said they 6 were trying to figure where the nerve damage originated.21 Between 7 the first surgery in 2019 and the last one in 2021, Plaintiff said that
8 there are 46-47 varicose veins removed from his legs and that he had 9 both stripping and ablation procedures to remove his varicose veins.22 10 Plaintiff said he had stents put in his arteries going from his knees up
14 17 AR 59. 15 18 Id. 16 19 AR 59-60. 17 20 AR 60. 18 21 Id. 19 22 Id. 20 1 to his groin area to allow blood flow and this caused chronic issues with
2 walking.23 3 Plaintiff said he had PTSD from childhood abuse and that since 4 2019 he has avoided others.24 He said he had worked at jobs that did
5 not require him to work with others, and that for 10 years as a 6 machinist he was able to work solo.25 He had a lot of treatment for his 7 physical impairments with ablation and vein stripping but that when
8 he went for psychiatric treatment he found the side effects of the 9 medication they gave him made things worse.26 He got back together 10 with his ex-wife in late 2019 but she passed away in July 2020.27 From
11 2020 to 2022, he had friends but did not hang out with them and was 12 usually alone.28 He lived in a little office space in his parents’ home 13
14 23 AR 60-61. 15 24 AR 61. 16 25 AR 62. 17 26 AR 62-63. 18 27 AR 63. 19 28 AR 64. 20 1 from mid-2019 to mid-2020 and then was homeless.29 He lived in his
2 car from mid-2020 until the time he was incarcerated.30 When he was 3 in his car he didn’t do much.31 He once drove to TriCities but made no 4 other trips.32 He would eat precooked meals that he defrosted in his
5 car.33 6 Plaintiff testified that he needed to lie down due to the pressure 7 and swelling in his legs and had to elevate his legs above waist level for
8 15 minutes about 3-4 times a day.34 He said that even basic standing 9 and walking caused pressure and swelling and that the longer he was 10 on the feet the longer he would need to elevate them.35 If he stood too
13 29 AR 65. 14 30 AR 66-67. 15 31 AR 69. 16 32 AR 69-70. 17 33 AR 70-71. 18 34 AR 71-72. 19 35 AR 72. 20 1 long, his legs felt like they were burning and the pain was worse than
2 the swelling.36 3 He said that he also needed to stretch his hands for about 15 4 minutes every half hour and that after working continuously on a car
5 with his hands for 2 hours he will need to stretch them every 10 6 minutes.37 He is right-handed and can write for 45 minutes before 7 having to stop for 15-20 minutes before he can write again.38 He also
8 said he has problems with people being physically near him and will at 9 times want to have his back against a wall so no one is behind him.39 10 He sleeps only 3-4 hours a night because of nightmares.40 About 3
11 times a month he has days with flashbacks and needs to stay in bed.41 12 13
14 36 Id. 15 37 AR 73. 16 38 AR 73-74. 17 39 AR 74-75. 18 40 AR 76. 19 41 Id. 20 1 At least 6-7 days a month his pain in his legs was so bad that he didn’t
2 leave his car to get food.42 3 After the hearing, the ALJ denied benefits.43 The ALJ found 4 Plaintiff’s alleged symptoms were “not entirely consistent with the
5 medical evidence and other evidence in the record.”44 As to the medical 6 opinions and prior administrative medical findings, the ALJ found: 7 • the administrative medical findings of JD Fitterer, MD, to be
8 not persuasive; 9 • the examining medial findings of Curtis GG Greenfield, PsyD, 10 to be somewhat persuasive;
11 • the administrative medical findings of Jan Lewis, PhD; 12 Matthew Comrie, PsyD; and Gordon Hale, MD, to be 13 somewhat persuasive.45
15 42 AR 77. 16 43 AR 16-37. Per 20 C.F.R. § 404.1520(a)-(g), a five-step evaluation 17 determines whether a claimant is disabled. 18 44 AR 25-29. 19 45 AR 29-30. 20 1 As to the sequential disability analysis, the ALJ found:
2 • Step one: Plaintiff engaged in substantial gainful activity since 3 March 18, 2019, the application date. 4 • Step two: Plaintiff had the following medically determinable
5 severe impairments: bilateral lower extremity varicose veins, 6 PTSD, and major depressive disorder. The ALJ also found the 7 following impairments to be medically determinable non-
8 severe impairments: bilateral carpal tunnel syndrome with 9 status post surgeries, peripheral neuropathy, right hand 10 laceration, hypertension, GERD, hyperlipidemia, insomnia,
11 and ventral hernia. He also found Plaintiff’s personality 12 disorder to be medically non-determinable. 13 • Step three: Plaintiff did not have an impairment or
14 combination of impairments that met or medically equaled the 15 severity of one of the listed impairments and specifically 16 considered Listings 4.11, 12.04, and 12.15.
17 • RFC: Plaintiff had the RFC to perform a full range of work at 18 the medium exertional level, with the following exceptions: 19 he could occasionally climb ladders, ropes, or scaffolds. He could understand, remember, and apply detailed 20 1 not complex instructions, not in fast-paced production type environment, with exposure to only occasional 2 workplace changes and only occasional interaction with the general public. 3 • Step four: Plaintiff is able to perform past relevant work as a 4 plastic molder and a bonding machine operator.46 5 Thus, he found Plaintiff was not disabled pursuant to the Act.47 6 On November 5, 2024, the Appeals Council denied Plaintiff’s 7 appeal.48 Plaintiff timely requested review by this Court.49 8 II. Standard of Review 9 The ALJ’s decision is reversed “only if it is not supported by 10 substantial evidence or is based on legal error” and such error 11 impacted the nondisability determination.50 Substantial evidence is 12 13
14 46 AR 21–30. 15 47 AR 30-31. 16 48 AR 1-6. 17 49 ECF No. 1. 18 50 Hill v. Astrue, 698 F.3d 1153, 1158 (9th Cir. 2012). See 42 U.S.C. § 19 405(g); Molina v. Astrue, 674 F.3d 1104, 1115 (9th Cir. 2012), 20 1 “more than a mere scintilla but less than a preponderance; it is such
2 relevant evidence as a reasonable mind might accept as adequate to 3 support a conclusion.”51 4 III. Analysis
5 Plaintiff argues the ALJ erred when assessing the medical 6 opinions, erred in his step-two evaluation by rejecting carpal tunnel 7
8 superseded on other grounds by 20 C.F.R. § 416.920(a) (recognizing that 9 the court may not reverse an ALJ decision due to a harmless error— 10 one that “is inconsequential to the ultimate nondisability 11 determination”). 12 51 Hill, 698 F.3d at 1159 (quoting Sandgathe v. Chater, 108 F.3d 978, 13 980 (9th Cir. 1997)). See also Lingenfelter v. Astrue, 504 F.3d 1028, 14 1035 (9th Cir. 2007) (The court “must consider the entire record as a 15 whole, weighing both the evidence that supports and the evidence that 16 detracts from the Commissioner's conclusion,” not simply the evidence 17 cited by the ALJ or the parties.) (cleaned up); Black v. Apfel, 143 F.3d 18 383, 386 (8th Cir. 1998) (“An ALJ’s failure to cite specific evidence does 19 not indicate that such evidence was not considered[.]”). 20 1 syndrome and neuropathy as severe impairments, erred by rejecting
2 Plaintiff’s symptom reports, and erred in his step-four and step-five 3 evaluations.52 In response, the Commissioner argues that there was no 4 error in the ALJ’s evaluation of the medical opinions, that there is no
5 error in the ALJ’s evaluation at steps two, four, or five, and that the 6 ALJ’s rejection of Plaintiff’s symptom reports is supported by 7 substantial evidence.53 As is explained below, the ALJ failed to
8 consider the consistency of Dr. Hale’s opinions with the longitudinal 9 record indicating that for at least a substantial portion of the relevant 10 period Plaintiff suffered chronic venous insufficiency, and therefore the
11 ALJ’s evaluation of the opinion is not supported by substantial 12 evidence. 13 A. Medical Opinions: Plaintiff establishes consequential
14 error. 15 Plaintiff argues the ALJ erred when he ignored the opinion that 16 Plaintiff needed to elevate his legs and avoid prolonged sitting and
18 52 ECF No. 8. 19 53 ECF No. 13. 20 1 standing, by PA-C Leslie Pohl, ARNP Lindsay Waterman, PA-C Chrys
2 Buchanan, and Dr. Nicholas Garcia, and instead found Dr. Gordon 3 Hale’s opinion that Plaintiff could sit, stand, and walk for six hours a 4 day to be “somewhat persuasive.” The Commissioner argues that the
5 statements made by PA-C Pohl, ARNP Waterman, PA-C Buchanan, 6 and Dr. Garcia did not constitute a “medical opinion.” The Court finds 7 that, regardless of whether the statements met the definition of a
8 “medical opinion,” they should have been considered both generally and 9 specifically when evaluating the overall consistency of Dr. Hale’s 10 opinion with the longitudinal record, and these errors are
11 consequential. 12 1. Standard 13 The regulations define a “medical opinion” as follows:
14 A medical opinion is a statement from a medical source about what you can still do despite your impairment(s) and 15 whether you have one or more impairment-related limitations or restrictions in the following abilities: (For 16 claims filed (see § 404.614) before March 27, 2017, see § 404.1527(a) for the definition of medical opinion.) 17 (i) Your ability to perform physical demands of work 18 activities, such as sitting, standing, walking, lifting, carrying, pushing, pulling, or other physical functions 19 (including manipulative or postural functions, such as reaching, handling, stooping, or crouching); 20 1 (ii) Your ability to perform mental demands of work 2 activities, such as understanding; remembering; maintaining concentration, persistence, or pace; 3 carrying out instructions; or responding appropriately to supervision, co-workers, or work pressures in a 4 work setting;
5 (iii) Your ability to perform other demands of work, such as seeing, hearing, or using other senses; and 6 (iv) Your ability to adapt to environmental conditions, 7 such as temperature extremes or fumes.54
8 The ALJ must consider and articulate how persuasive he found 9 each medical opinion and prior administrative medical finding.55 The 10 factors for evaluating the persuasiveness include, but are not limited 11 to, supportability, consistency, relationship with the claimant, and 12 specialization.56 Supportability and consistency are the most important 13 factors, as the regulations require the ALJ to consider and explain the 14 15
16 54 20 C.F.R. § 416.913(2). 17 55 20 C.F.R. § 416.920c(a)–(c); Woods v. Kijakazi, 32 F.4th 785, 792 (9th 18 Cir. 2022). 19 56 20 C.F.R. § 416.920c(1)–(5). 20 1 supportability and consistency of each medical opinion and prior
2 administrative medical finding: 3 The factors of supportability . . . and consistency . . . are the most important factors we consider when we determine how 4 persuasive we find a medical source’s medical opinions or prior administrative medical findings to be. Therefore, we 5 will explain how we considered the supportability and consistency factors for a medical source’s medical opinions 6 or prior administrative medical findings in your determination or decision.57 7 The regulations define these two required factors as follows: 8 (1) Supportability. The more relevant the objective medical 9 evidence and supporting explanations presented by a medical source are to support his or her medical opinion(s) 10 or prior administrative medical finding(s), the more persuasive the medical opinions or prior administrative 11 medical finding(s) will be.
12 (2) Consistency. The more consistent a medical opinion(s) or prior administrative medical finding(s) is with the evidence 13 from other medical sources and nonmedical sources in the claim, the more persuasive the medical opinion(s) or prior 14 administrative medical finding(s) will be.58 15 16 17
18 57 Id. § 404.1520c(b)(2). 19 58 Id. § 404.1520c(c)(1)–(2). 20 1 The ALJ may, but is not required to, explain how the other listed
2 factors were considered.59 When considering the ALJ’s findings, the 3 Court is constrained to the reasons and supporting explanation offered 4 by the ALJ.60
5 2. Relevant Medical Records 6 On April 23, 2019, Plaintiff presented to Nicholas Garcia, MD, of 7 Multicare Vascular Surgery for follow-up for bilateral varicose veins.61
8 Plaintiff reported that he had a 20-year history of varicose veins and 9 began having discomfort in his legs 15 years ago and was scheduled to 10 have a surgery in 2011 but it was cancelled when he was
12 59 Id. § 404.1520c(b)(2). When two or more medical opinions or prior 13 administrative findings “about the same issue are both equally well- 14 supported . . . and consistent with the record . . . but are not exactly the 15 same,” the ALJ is required to explain how “the other most persuasive 16 factors in paragraphs (c)(3) through (c)(5)” were considered. Id. § 17 404.1520c(b)(3). 18 60 See Burrell v. Colvin, 775 F.3d 1133, 1138 (9th Cir. 2014). 19 61 AR 551. 20 1 incarcerated.62 After release from prison, he found that he could only
2 walk 3 blocks due to throbbing in his left leg, only relieved by elevating 3 the leg.63 He recently had a carpal tunnel release surgery and was on 4 pain medication.64 On examination, Dr. Garcia noted right posterior
5 calf with varicose vein clusters, and spider veins of the foot, and the 6 left leg had a large varicose vein cluster in the posterior calf, distal 7 posterior thigh, and medial leg, and spider veins in the left foot and
8 ankle.65 Dr. Garcia assessed varicose veins interfering with activities of 9 daily living and recommended compression stockings and an 10 ultrasound.66
11 On July 30, 2019, Plaintiff presented to Leslie Pohl, PA-C, for 12 follow-up for venous insufficiency after three months of conservative 13
15 62 Id. 16 63 AR 551-552. 17 64 AR 552. 18 65 AR 554. 19 66 AR 555. 20 1 compression treatment failed.67 Plaintiff was experiencing throbbing
2 pain causing difficulty walking and on examination had insufficiency of 3 the left greater saphenous vein, with multiple varicose veins in both 4 legs.68 PA-C Pohl consulted with Dr. Garcia and recommended left stab
5 phlebectomies with 10-20 stabs.69 6 On October 9, 2019, Plaintiff presented to Dr. Garcia for follow- 7 up, at which Dr. Garcia noted numbness of the feet on examination and
8 imaging showing reflux of the left calf greater saphenous vein.70 9 Dr. Garcia performed a 32 stab phlebectomy of the left posterior calf 10 veins.71 On October 29, 2019, Plaintiff returned to Dr. Garcia reporting
11 significant improvement in his left leg since the surgery with healed 12 incisions, but reporting increased pain, itching, and swelling in the 13
15 67 AR 636. 16 68 AR 638-639. 17 69 AR 639. 18 70 AR 959-961. 19 71 AR 962. 20 1 right extremity.72 A doppler study performed on November 1, 2019,
2 indicated deep reflux in the greater saphenous vein of the right leg.73 3 On November 5, 2019, Plaintiff followed up with Lindsay Waterman, 4 ARNP, and reported continued pain, swelling, and itching in the right
5 lower extremity.74 He also reported some residual pain in the left leg.75 6 ARNP Waterman noted that there were varicose veins in both 7 extremities but that there were no spider veins.76 She assessed chronic
8 venous insufficiency manifested by varicose veins and counseled 9 Plaintiff that it was not a life threatening condition.77 10 On January 8, 2020, Plaintiff presented to Dr. Garcia for follow-
11 up for venous insufficiency following conservative therapy for right 12 extremity and endorsed pain, itching, and swelling in his right leg after 13
14 72 AR 948. 15 73 AR 951. 16 74 AR 936. 17 75 Id. 18 76 AR 938. 19 77 Id. 20 1 prolonged standing that required him to sit and raise his leg.78 He
2 reported some relief with compression stockings and residual pain his 3 left leg after vein surgery.79 On examination, Plaintiff had varicose 4 veins bilaterally.80
5 Dr. Garcia noted: 6 IMPRESSION: Right GSV [greater saphenous vein] patent- measures 4.1-6.7 mm in diameter. Competent in the thigh 7 and SFJ but reflux distally, up to 3.5 sec at knee. Varicose veins originating from proximal calf from GSV, largest 8 measures 4.2 mm with 4.6 sec reflux. Deep reflux 1 sec CFV, 2.2 sec femoral vein, and 1.7 sec popliteal vein. There is no 9 evidence of deep venous thrombosis or outflow obstruction of the right lower extremity.81 10 Dr. Garcia planned a right GSV radiofrequency obliteration 11 endovenous catheter-based ablation, as well as stab phlebectomies of 12 the varicose veins on his right leg and residual veins on the left.82 13 14
15 78 AR 925. 16 79 Id. 17 80 AR 928. 18 81 AR 929. 19 82 Id. 20 1 Dr. Garcia performed the procedures the same day.83 On January 13,
2 2020, Plaintiff returned for a post-op doppler which revealed that the 3 GSV was occluded up to the level of the epigastric branch.84 Plaintiff 4 also complained of increased pain and redness, worried about an
5 infection and asked to be seen.85 On examination, there was swelling, 6 blanching erythema, and tenderness on palpation, and PA-C Chrys 7 Buchanan assessed cellulitis.86 On January 19, 2020, Plaintiff
8 presented to the ER of Tacoma General with continued leg pain, and 9 concern that he had a blood clot.87 Plaintiff complained of sharp pain in 10 his right leg radiating up to the groin area.88 Blood tests indicated
11 leukocytosis and a doppler study indicated thrombus in the greater 12 13
14 83 AR 930-931. 15 84 AR 923. 16 85 AR 914. 17 86 Id. 18 87 AR 868. 19 88 Id. 20 1 saphenous vein.89 At a follow-up on February 4, 2020, Plaintiff reported
2 continued right scrotal discomfort.90 3 On October 20, 2020, Plaintiff presented to PA-C Pohl with 4 complaints that he had initially improved after surgery to his left leg
5 but that his condition began worsening several months later and he 6 now had aching and occasionally shooting pain.91 Plaintiff reported 7 continued use of compression stockings with some improvement but
8 continued difficulty with prolonged standing.92 On examination, 9 Plaintiff had multiple healed scars from prior phlebectomies and had a 10 small firm area in the medial calf tender to palpation.93 On October 30,
11 2020, a doppler study indicated that the left great saphenous vein was 12 13
15 89 Id. 16 90 AR 860. 17 91 AR 845. 18 92 Id. 19 93 AR 847. 20 1 not obstructed but there was reflux in the left mid saphenous vein and
2 left proximal saphenous vein.94 3 On November 3, 2020, Plaintiff presented to Dr. Garcia for follow- 4 up following a recent ultrasound noting “GSV reflux 0.9 seconds at
5 saphenofemoral junction and left calf reflux of 3.2s.”95 Plaintiff 6 reported pain with prolonged standing.96 Dr. Garcia requested 7 insurance approval for GSV radiofrequency obliteration and left leg
8 stab phlebectomy.97 On November 18, 2020, Plaintiff was seen by Joni 9 Casteneda, DO, for counseling regarding smoking cessation and 10 reported that he continued to have left lower extremity pain while
11 awaiting treatment and asked for a sleeping medication to help him 12 sleep.98 On December 11, 2020, Dr. Garcia performed a left 13 radiofrequency obliteration of greater saphenous vein, left leg stab
15 94 AR 850. 16 95 AR 827. 17 96 Id. 18 97 AR 831. 19 98 AR 817. 20 1 phlebectomy N-16.99 The pre-procedure and post-procedure diagnosis
2 was left leg symptomatic veins, and Dr. Garcia noted that the left 3 greater saphenous vein was patent prior to procedure and occluded 4 post-procedure.100 Dr. Garcia also performed a left stab phlebectomy
5 with 16 stabs.101 Plaintiff was discharged without complications.102 6 On December 23, 2020, a post-surgical doppler study was 7 performed by Sarah Koch, MD, of the Pulse and Heart Institute.103 The
8 impression was: “Left greater saphenous vein surgically occluded, with 9 acute thrombus extending slightly into the common femoral vein 10 without occlusion or flow limitations.”104 Plaintiff presented to
11 Dr. Garcia on January 12, 2021, and Dr. Garcia opined that other than 12 13
14 99 AR 797-798. 15 100 AR 797. 16 101 AR 798. 17 102 AR 795-796. 18 103 AR 787. 19 104 AR 787. 20 1 numbness in his left leg Plaintiff was recovering well from his
2 surgery.105 3 On April 13, 2023, Plaintiff presented to Bob Lee, MD, of the 4 Multicare Rockwood Physiatry Center with complaints of numbness in
5 his left hand and bilateral numbness and tingling in both legs and 6 feet.106 Plaintiff denied a history of diabetes or alcohol abuse but 7 reported a prior bilateral carpal tunnel release, as well as multiple
8 varicose vein removal procedures bilaterally, a history of 9 thrombophlebitis in his right leg, hypertension and hyperlipidemia.107 10 Plaintiff reported that his exercise consisted of walking several miles
11 daily and working on cars, and Plaintiff sat comfortably in a chair.108 12 On examination, Plaintiff had full strength bilaterally in his 13 upper extremities, grossly intact cranial nerves, a Hoffman test that
14 15
16 105 AR 779-780. 17 106 AR 751. 18 107 AR 751-752 19 108 AR 754. 20 1 was negative bilaterally, and a heel to toe strike gait.109 Dr. Lee noted
2 that Plaintiff’s physical history and examination suggested a nerve 3 entrapment in the upper left extremity and possible peripheral 4 neuropathy in his lower extremities.110 Dr. Lee also noted that
5 electrodiagnostic testing performed on the upper left extremity that 6 day indicated mild left median mononeuropathy and testing performed 7 on the lower extremities indicated “chronic severe axonal sensory and
8 motor peripheral neuropathy.”111 Dr. Lee diagnosed carpal tunnel 9 syndrome of the left wrist, paresthesia, and neuropathy, and 10 recommended use of a hand brace as well as ordering fasting lab tests
11 to determine the etiology of Plaintiff’s neuropathy.112 12 3. Analysis 13 Plaintiff argues the ALJ erred when he failed to address the
14 medical findings by PA-C Pohl, ARNP Waterman, PA-C Buchanan, and 15
16 109 AR 755. 17 110 Id. 18 111 Id. 19 112 AR 751, 755. 20 1 Dr. Garcia that Plaintiff needed to elevate his legs due to chronic
2 venous insufficiency. The Court agrees. The Commissioner admits in 3 his brief that the ALJ failed to address the medical statements from 4 various providers that Plaintiff should elevate his legs but argued that
5 the ALJ was not obligated to consider them because they did not 6 constitute “medical opinions” within the definition of the regulations 7 because they were merely “recommendations.”
8 The Court concludes that the statements about the need to 9 elevate his legs by Plaintiff’s medical providers constituted an opinion 10 and that additionally, absent a finding that they constituted opinion
11 evidence, the statements were medical evidence that the ALJ should 12 have considered when assessing the consistency of the opinion of Dr. 13 Hale with the longitudinal record.
14 The regulations provide: “A medical opinion is a statement from a 15 medical source about what you can still do despite your impairment(s) 16 and whether you have one or more impairment-related limitations or
17 restrictions in the following abilities.”113 18
19 113 20 C.F.R. § 416.913(2) (emphasis added). 20 1 The context of the medical statements makes clear that the
2 statements were not casual “suggestions” as the Commissioner appears 3 to argue. It was the statement of ARNP Waterman, for instance, that 4 “[T]he primary mode of treatment is non-surgical with leg elevation
5 and external compression.”114 This clearly indicates that the need for 6 Plaintiff to elevate his legs was a restriction placed upon him by his 7 treating sources, and was prescribed treatment in the same manner as
8 medication or use of a cane or walker would be expected to be. 9 Moreover, it was the statement of multiple treating sources that 10 Plaintiff was required to elevate his legs to reduce swelling.115
11 While the Ninth Circuit Court of Appeals has not specifically 12 ruled that the need to elevate legs meets the definition of a limitation 13 or restriction as set forth in the regulations, there are several districts
14 15 16
18 114 AR 938. 19 115 AR 914, 917, 925, 929, 949. 20 1 in which this has been held to be a restriction or limitation pursuant to
2 20 C.F.R. § 416.913(2).116 3 Dr. Garcia made clear that he considered that the need for 4 Plaintiff to elevate his legs would be a work restriction, stating: “Leg
5 pain limits his ability to find work as cannot accommodate need for leg 6 7
9 116 See Allen T. v. Comm'r of Soc. Sec., No. 20-1257, 2021 WL 1884956, 10 at *4 (W.D. Wash. May 11, 2021) (finding that a form opinion 11 describing the claimant’s symptoms and limitations constituted 12 medical opinion because the doctor opined the claimant could perform 13 sedentary work and recommended claimant elevate his legs at work, 14 thereby implicating his ability to sit, which is a functional workplace 15 limitation). See also Carrie D. v. Kijakazi, No. 20-3227, 2022 WL 16 2901010, at *6 (E.D. Wash. June 6, 2022) (finding doctor's notes that 17 Plaintiff needs to raise her legs while seated which may have 18 corresponding workplace limitations falls within the definition of 19 medical opinion as it relates to meeting the physical demands of work). 20 1 elevation, interferes with his ability to work, care for himself, clean his
2 living arrangement.117 3 The ALJ made a vague finding regarding Plaintiff’s need to 4 elevate his legs, stating briefly that in October 2020, “[Dr. Garcia]
5 recommended ibuprofen, ice, compression and elevation for a likely 6 superficial phlebitis of his right calf.”118 The statement misquotes the 7 record, however. Dr. Garcia was not recommending elevation of the leg
8 for superficial phlebitis, he was recommending it because Plaintiff had 9 varicose veins in both legs and had developed a new varicose vein in 10 his left leg despite the fact that he had already undergone two separate
11 rounds of stab phlebectomies.119 Aside from the prescribed treatment to 12 elevate his legs, Dr. Gracia ordered an ultrasound to be performed and 13 a follow-up in 2 weeks to discuss the results of the ultrasound.120
16 117 AR 957. 17 118 AR 27, citing AR 848. 18 119 AR 848. 19 120 Id. 20 1 The ALJ did not consider the statements to be medical opinions
2 and also declined to consider the opinion of state agency consultant JD 3 Fitterer, MD, who rendered his opinion prior to Plaintiff’s treatment 4 for varicose veins and at a time when the medical record was relatively
5 sparse.121 As a result, the only medical opinion considered by the ALJ 6 as to Plaintiff’s physical limitations was that of non-examining state 7 agency consultant Gordon Hale, MD.122
8 The ALJ articulated his consideration of Dr. Hale’s opinions as 9 follows: 10 In October 2019, state agency consultant, Gordon Hale, M.D., opined that the claimant could perform work at a 11 light exertional level with lifting and carrying 20 pounds occasionally and 10 pounds frequently and sitting, standing, 12 and walking for six hours in an eight-hour workday (4A). Dr. Hale opined that the claimant could occasionally climb 13 and crawl and frequently balance, kneel, and crouch (4A). Further, Dr. Hale opined that the claimant should avoid 14 concentrated exposure to extreme cold, vibration, fumes, odors, dusts, gases, poor ventilation, and hazards (4A). The 15 undersigned finds Dr. Hale’s opinions somewhat persuasive because they are somewhat consistent with and supported 16 by the medical evidence. The treatment records show that the claimant could perform medium exertional work. 17
18 121 AR 29. 19 122 AR 29-31. 20 1 Examinations revealed varicose veins and corresponding areas of tenderness on his legs (4F/7; 7F/5; 10F/81, 97, 122, 2 164, 188, 199). However, the treatment records show that the claimant experienced symptoms improvement with 3 ablations, phlebectomies, and compression socks.123
4 Initially, the Court notes that, while the ALJ stated that he found 5 Dr. Hale’s opinion to be somewhat persuasive, he discounted Dr. Hale’s 6 finding that Plaintiff was limited to work at the light level of exertion 7 and instead found him capable of performing medium exertion work. 8 In doing so, the ALJ gave little, if any, consideration of the 9 supportability factor when assessing Dr. Hale’s opinion. It is notable 10 that Dr. Hale’s explanation of his findings makes no mention of
11 Plaintiff’s venous insufficiency and addresses only the symptoms of 12 carpal tunnel syndrome.124 The ALJ did not address the fact that 13 Dr. Hale’s opinion was not supported by an explanation.
14 The ALJ failed to consider the consistency of Dr. Hale’s opinion 15 with those of the treating providers that Plaintiff would be expected to 16 need to elevate his legs. It is unclear whether the limitation was
18 123 AR 30. 19 124 AR 120-123. 20 1 expected to change following Plaintiff’s ablation surgery, but regardless
2 of any improvement, there was a period, at a minimum from October 3 2019 through January 2021, in which those restrictions were 4 prescribed by medical sources.
5 The ALJ is required to explain how a medical opinion or 6 administrative medical finding is or is not both 1) supported by “more 7 relevant . . . objective medical evidence and supporting explanation
8 presented by [the] medical source,” i.e., the supportability factor; and 9 2) “consistent with the evidence from other medical sources and 10 nonmedical sources in the claim,” i.e., the consistency factor.125 Here,
11 the ALJ erred when considering the consistency factor and did not 12 consider the supportability factor. 13 On remand, the ALJ is to develop the record as to Plaintiff’s
14 physical impairments and schedule a consultative examination and, if 15 necessary, call a medical expert to testify. The ALJ is to reassess 16 Plaintiff’s ability to use his upper extremities considering his diagnosis
17 of carpal tunnel syndrome, and reassess Plaintiff’s ability to use his 18
19 125 20 C.F.R. § 416.920c(c)(1)–(2). 20 1 lower extremities considering his chronic venous insufficiency and
2 peripheral neuropathy 3 Because the Court has remanded the case for further 4 proceedings, the ALJ is to re-evaluate the medical opinion evidence as
5 a whole and articulate his findings as to both the supportability and 6 consistency of the opinions. 7 B. Symptom Reports and Other Steps of the Evaluation
8 Process: this issue is moot. 9 Plaintiff argues that the ALJ failed to provide valid reasons for 10 discounting his subjective complaints and erred at steps two, four, and
11 five. Because the Court is remanding the case with direction that the 12 ALJ re-evaluate the medical opinions and administrative medical 13 findings, the ALJ must re-evaluate Plaintiff’s symptom reports and
14 conduct the disability evaluation anew. 15 C. Remand: further proceedings 16 Plaintiff prefers a remand for payment of benefits, rather than a
17 remand for more proceedings. However, when the court reverses an 18 ALJ’s decision for error, the court “ordinarily must remand to the 19
20 1 agency for further proceedings.”126 At this time, remand for further
2 proceedings is appropriate. 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 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 call a medical expert to testify as to 12 the combined effects of Plaintiff’s physical impairments and their effect 13 on his ability to perform work at the medium, light, or sedentary
14 exertional level. 15 Accordingly, IT IS HEREBY ORDERED: 16
18 126 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 1. The ALJ’s nondisability decision is REVERSED, and this
2 matter is REMANDED to the Commissioner of Social
3 Security for further proceedings pursuant to
4 sentence four of 42 U.S.C. § 405(g). 5 2. The Clerk’s Office shall TERM the parties’ briefs, ECF
6 Nos. 8 and 13, enter JUDGMENT in favor of Plaintiff, 7 and CLOSE the case.
8 IT IS SO ORDERED. The Clerk’s Office is directed to file this
9 ||order and provide copies to all counsel.
10 DATED this 14* day of October, 2025.
sed I he 12 EDWARD F. SHEA Senior United States District Judge 13 14 15 16 17 18 19
DISPOSITIVE ORDER - 37