1 Mar 24, 2026 SEAN F. MCAVOY, CLERK
4 5 UNITED STATES DISTRICT COURT EASTERN DISTRICT OF WASHINGTON 6
7 VICTORIA M.,1 No. 2:25-cv-00291-EFS
8 Plaintiff, ORDER REVERSING THE 9 v. ALJ’S DENIAL OF BENEFITS, AND REMANDING FOR 10 FRANK BISIGNANO, FURTHER PROCEEDINGS Commissioner of Social Security, 11 Defendant. 12 13 14 Due to endometriosis, pelvic floor dysfunction, migraines, post- 15 traumatic stress disorder (PTSD), major depressive disorder, and 16 anxiety, Plaintiff Victoria M. claims that she is unable to work fulltime 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 and applied for disability insurance benefits. She appeals the denial of
2 benefits by the Administrative Law Judge (ALJ) on the grounds that 3 the ALJ improperly analyzed the opinions of the treating medical 4 source, Jessica Long, PsyD; the ALJ erred in imposing a residual
5 functional capacity (RFC) because it did not account for Plaintiff’s 6 physical and mental limitations; and the ALJ failed to properly 7 evaluate Plaintiff’s mental impairments. As is explained below, the
8 ALJ erred; contributing to this error was the ALJ’s failure to recognize 9 Plaintiff’s lengthy participation in an intensive partial hospitalization 10 program. This matter is remanded for further proceedings.
11 I. Background 12 In February 2022, Plaintiff filed an application for benefits under 13 Title 2, claiming disability beginning February 26, 2021, based on the
14 physical and mental impairments noted above.2 Plaintiff’s claim was 15 denied at the initial and reconsideration levels.3 16
18 2 AR 248-249, 289. 19 3 AR 133-138, 140-143. 20 1 After the agency denied Plaintiff benefits, ALJ Palachuk held a
2 telephone hearing in July 2024, at which Plaintiff appeared with her 3 representative.4 Plaintiff and a vocational expert testified.5 After the 4 hearing, ALJ Palachuk issued a decision denying benefits.6
5 The ALJ found Plaintiff’s alleged symptoms were not entirely 6 consistent with the medical evidence and the other evidence.7 As to 7 medical opinions, the ALJ:
8 • Failed to make any finding as to the persuasiveness of state 9 agency physicians Dorothy DeLong, MD, and Diane R., MD. 10 • Found the opinions of state agency psychologist Carol
11 Mahoney, PhD, to be less persuasive. 12 • Failed to articulate a finding of persuasiveness for the 13 opinions of state agency psychologist Kent R., PhD, but
15 4 AR 46-84. 16 5 Id. 17 6 AR 19-38. Per 20 C.F.R. § 404.1520(a)–(g), a five-step evaluation 18 determines whether a claimant is disabled. 19 7 AR 27-29. 20 1 implied that they were more persuasive than those of Dr.
2 Mahoney. 3 • Found the opinions of treating source Jessica Long, PsyD, to 4 be not persuasive.8
5 The ALJ also noted that she considered the third-party function report 6 completed by Plaintiff’s boyfriend but made no finding regarding 7 persuasiveness.9 As to the sequential disability analysis, the ALJ
8 found: 9 • Plaintiff last met the insured status requirements of the 10 Social Security Act on June 30, 2023.
11 • Step one: Plaintiff had not engaged in substantial gainful 12 activity from February 26, 2021, the alleged onset date, 13 through June 30, 2023, her date last insured.
14 • Step two: Plaintiff had the following medically determinable 15 severe impairments: episodic migraines, chronic pelvic pain, 16 anxiety disorder, and major depressive disorder.
18 8 AR 29. 19 9 Id. 20 1 • Step three: Plaintiff did not have an impairment or
2 combination of impairments that met or medically equaled 3 the severity of one of the listed impairments. 4 • RFC: Plaintiff had the RFC to perform a full range of work
5 at all exertional levels with the following nonexertional 6 limitations: 7 Avoid more than moderate exposure to industrial noise, industrial vibration, respiratory irritants and 8 unprotected heights. [Plaintiff] is able to understand, remember and carry out simple, routine tasks. 9 [Plaintiff] is able to maintain concentration, persistence and pace for two-hour intervals between regularly 10 scheduled breaks. [Plaintiff] should have no contact with the public and occasional interaction with 11 coworkers.
12 • Step four: Plaintiff was unable to perform her past relevant 13 work as a hostess, server, and receptionist. 14 • Step five: in the alternative, considering Plaintiff’s RFC, 15 age, education, and work history, Plaintiff could perform 16 work that existed in significant numbers in the national 17 economy, such as a church janitor (DOT 389.667-010), 18 19 20 1 collator operator (DOT 206.685-010), and routing clerk
2 (DOT 222.687-022).10 3 Plaintiff filed a timely request for review of the ALJ decision,11 4 and the Appeals Council denied review on May 28, 2025.12 On July 15,
5 2025,13 and the Appeals Council issued an Order granting an 6 extension.14 Plaintiff timely requested review of the ALJ’s decision by 7 this Court pursuant to the extension granted by the Appeals Council.15
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,”16 and such error
12 10 AR 24-31. 13 11 AR 241. 14 12 AR 6-11. 15 13 AR 4-5. 16 14 AR 1-3. 17 15 ECF No. 1. 18 16 Hill v. Astrue, 698 F.3d 1153, 1158 (9th Cir. 2012). See 42 U.S.C. § 19 405(g). 20 1 impacted the nondisability determination.17 Substantial evidence is
2 “more than a mere scintilla but less than a preponderance; it is such 3 relevant evidence as a reasonable mind might accept as adequate to 4 support a conclusion.”18
5 6 7
8 17 Molina v. Astrue, 674 F.3d 1104, 1115 (9th Cir. 2012) ), superseded 9 on other grounds by 20 C.F.R. § 404.1520(a) (recognizing that the court 10 may not reverse an ALJ decision due to a harmless error—one that “is 11 inconsequential to the ultimate nondisability determination”). 12 18 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 III. Analysis
2 Plaintiff seeks relief from the denial of disability on three 3 grounds. She argues the ALJ erred when evaluating the medical 4 opinion of her treating psychologist, in formulating an RFC that did
5 not account for Plaintiff’s physical and mental limitations, and in 6 failing to properly evaluate Plaintiff’s mental impairments. As is 7 explained below, the Court concludes that the ALJ erred
8 consequentially in her evaluation of the medical opinion evidence and 9 medical records regarding Plaintiff’s mental impairments, and erred in 10 failing to develop the record regarding Plaintiff’s physical impairments.
11 A. Medical Opinions: Plaintiff establishes consequential 12 error 13 Plaintiff argues the ALJ erred in her evaluation of the medical
14 opinions of Dr. Long.19 Specifically, Plaintiff argues that the ALJ erred 15
16 19 An ALJ must consider and articulate how persuasive she found each 17 medical opinion, including whether the medical opinion was consistent 18 with and supported by the record. 20 C.F.R. § 404.1520c(a)–(c); Woods 19 v. Kijakazi, 32 F.4th 785, 792 (9th Cir. 2022). 20 1 in failing to properly articulate any finding as to supportability or
2 consistency.20 The Commissioner counter-argues that the ALJ validly 3 considered the supportability and consistency of the contested medical 4 opinion.21
5 1. Standard 6 The ALJ was required to consider and evaluate the 7 persuasiveness of the medical opinions and prior administrative
8 medical findings.22 The factors for evaluating the persuasiveness of 9 medical opinions and prior administrative medical findings include, 10 but are not limited to, supportability, consistency, relationship with the
11 claimant, and specialization.23 Supportability and consistency are the 12 most important factors,24 and the ALJ must explain how she 13 considered the supportability and consistency factors when reviewing
15 20 ECF No. 14. 16 21 ECF No. 17. 17 22 20 C.F.R. § 404.1520c(a), (b). 18 23 Id. § 404.1520c(c)(1)–(5). 19 24 Id. § 404.1520c(b)(2). 20 1 the medical opinions and support her explanation with substantial
2 evidence.25 When considering the ALJ’s findings, the Court is 3 constrained to the reasons and supporting explanation offered by the 4 ALJ.26
5 2. Dr. Long’s Opinions 6 On January 24, 2023, Dr. Long completed an 8-page form 7 forwarded to her by Plaintiff’s attorney.27 Part of the form was in a
8 check-box format with questions to be answered by checking a box, and 9 part of the form contained blank lines for Dr. Long to write narrative 10
12 25 Id. § 404.1520c(b)(2); Woods, 32 F.4th at 785 (“The agency must 13 articulate . . . how persuasive it finds all of the medical opinions from 14 each doctor or other source and explain how it considered the 15 supportability and consistency factors in reaching these findings.”) 16 (cleaned up). 17 26 See Burrell v. Colvin, 775 F.3d 1133, 1138 (9th Cir. 2014) 18 (recognizing court review is constrained to the reasons the ALJ gave). 19 27 AR 2673-2682. 20 1 answers to questions posed.28 Dr. Long provided long and detailed
2 answers.29 3 Dr. Long wrote that she had seen Plaintiff once or twice weekly 4 since August 12, 2019, through the date the form was completed in
5 2023.30 Dr. Long wrote that Plaintiff was diagnosed with PTSD, panic 6 disorder, major depressive disorder (moderate to severe, recurrent), 7 adjustment disorder with mixed depression and anxiety due to physical
8 illness, and also a rule out diagnosis of bipolar disorder.31 She wrote 9 that secondary diagnoses included migraines, endometriosis, positional 10 orthostatic tachycardia syndrome, pelvic floor dysfunction, and
11 adenomyosis.32 Dr. Long stated that treatments had included surgery, 12 13
15 28 Id. 16 29 Id. 17 30 AR 2674. 18 31 Id. 19 32 Id. 20 1 acupuncture, massage, psychiatric medication, individual counseling
2 and a prior partial hospitalization.33 3 Dr. Long stated that Plaintiff had cooperated with treatment but 4 that her debilitation remained pronounced; that her medications
5 included lithium, cimetidine, Seroquel, gabapentin, diazepam, 6 lorazepam, Mirena, albuterol and fluconazole; and that her 7 medications caused dizziness, drowsiness, brain fog, mood
8 dysregulation, and upset stomach.34 9 Dr. Long stated that during sessions she observed Plaintiff to be 10 in pain, with depressive mood swings with crying, helplessness, brain
11 fog and difficulty staying on topic, dissociation, fidgeting, and wincing, 12 that panic attacks had resulted in her ending the session, and that her 13 symptoms at times prevented her from attending her sessions on
14 time.35 Dr. Long opined that Plaintiff’s prognosis was fair, that her 15 medical and psychiatric conditions are complex, and that without 16
17 33 Id. 18 34 Id. 19 35 AR 2675. 20 1 improvement in her medical conditions it will be difficult for her
2 psychiatric conditions to improve until her physical conditions 3 improve.36 4 Dr. Long opined that Plaintiff’s symptoms lasted for 12 months or
5 more, that she did not suspect exaggeration or malingering, that 6 reduced IQ was not a factor, and that Plaintiff’s psychiatric condition 7 exacerbates her physical pain.37 Dr. Long explained that Plaintiff’s
8 sexual assault trauma likely contributed to her abdominal pain, pelvic 9 pain, and panic attacks.38 10 Dr. Long stated that Plaintiff’s anxiety and PTSD had lasted for
11 at least 2 years, despite treatment, with limited ability to adapt, and 12 that she required a highly structured setting to diminish symptoms.39 13 Dr. Long stated that Plaintiff’s condition deteriorated while in school,
14 that a partial hospitalization was needed to stabilize her after 15
16 36 Id. 17 37 Id. 18 38 Id. 19 39 AR 2676. 20 1 deterioration, and that her deteriorations have resulted in her missing
2 work or school.40 Dr. Long noted that Plaintiff had to miss 3 appointments or leave early due to exacerbations in symptoms.41 4 Dr. Long noted that Plaintiff’s symptoms include the following:
5 diminished interest in activities; appetite disturbance with weight loss; 6 sleep disturbance; feeling of guilt and hopelessness; decreased energy; 7 difficulty concentrating; thoughts of death; distractibility; pressured
8 speech; repetitive behaviors; disorganized speech and thinking; easy 9 fatigability; recurrent aggressive, impulsive outbursts; decreased need 10 for sleep; memory impairment; psychomotor agitation during periods of
11 feeling better; irritability; muscle tension; restlessness; disproportional 12 fear and anxiety; involuntary, time-consuming preoccupation with 13 intrusive, unwanted thoughts; panic attacks; exposure to threats or
14 violence; disturbance in mood or behavior; detachment from social 15 relationships; distrust and suspiciousness of others; excessive emotion 16 and attention-seeking; ability or personal relationships; involuntary re-
18 40 Id. 19 41 Id. 20 1 experiencing of a traumatic event; impaired perception; feelings of
2 inadequacy; avoidance of external reminders of a traumatic event; 3 exaggerated startle response; one or more somatic symptoms; impaired 4 executive functioning; impaired social cognition; and impaired complex
5 attention.42 6 Dr. Long opined that Plaintiff would have a moderate limitation 7 in completing the following: remember work-like procedures; carry out
8 simple, short instructions; make simple work-related decisions; ask 9 simple questions or request assistance; and respond appropriately to 10 routine changes in a work setting.43 Dr. Long opined that Plaintiff
11 would have a marked limitation in completing the following: maintain 12 attention for 2-hour segment; maintain regular attendance and be 13 punctual; sustain an ordinary routine without special supervision;
14 work in proximity to others; complete a normal work week; perform at 15 a consistent pace; accept instruction and respond appropriately to 16
18 42 AR 2677-2678. 19 43 AR 2679. 20 1 criticism; get along with co-workers; and deal with normal work
2 stress.44 3 Dr. Long opined that Plaintiff would have a marked limitation in 4 the following functional areas: understanding, remembering, and
5 applying information; interacting with others; concentrating, 6 persisting, and maintaining pace; and adapting or managing oneself.45 7 She opined that Plaintiff would be on task for less than 80% of the day
8 and would likely miss work or be unable to complete an 8-hour work 9 day on 4 or more days per month.46 Dr. Long opined that the 10 restrictions and limitations noted had existed since February of 2021.47
11 // 12 // 13 //
14 // 15
16 44 Id. 17 45 AR 2680. 18 46 Id. 19 47 AR 2681. 20 1 3. Relevant Medical Records
2 a. Recovery and Wellness Center of Eastern Washington 3 On February 10, 2021, Plaintiff was admitted to a partial 4 hospitalization program48 at the Recovery and Wellness Center of
5 Eastern Washington on the referral of her psychiatrist.49 Plaintiff’s 6 PHQ-9 score was 20, and her GAD-7 score was 21, indicating anxiety 7 and depressive symptoms severe enough to prevent her from
8 performing ADL’s or getting along with others.50 Plaintiff attended 9 10 48 Cleveland Clinic describes partial hospitalization programs as follows: 11 Partial Hospitalization Programs are designed for 12 individuals who require more support than traditional outpatient services but do not need fulltime 13 hospitalization. These programs typically involve structured treatment sessions that include individual therapy, group 14 therapy, and medication management. PHPs are beneficial for those transitioning from inpatient care or those 15 experiencing severe mental health or addiction issues.
16 Partial Hospitalization Programs (PHP) | Cleveland, OH. 17 www.clevelandclinic.org. (last viewed March 19, 2026.) 18 49 AR 514. 19 50 Id. 20 1 group therapy twice that week, missing one day of therapy, and was
2 noted to be prescribed Lithium, Adderall, and Deplin.51 3 Weekly symptom summaries indicated that Plaintiff attended the 4 programs for 5 days per week, with three days of group therapy, and
5 one day of individual therapy and medication management.52 The 6 Court notes that there are no treatment records or progress notes 7 contained in the record, and that the administrative record contains
8 only an abstract of the medical record and is missing the bulk of the 9 treatment records. Distorted thinking was noted at the time of 10 admission and improved in July of 2021.53 On August 24, 2021,
11 Lamictal was added to Plaintiff’s regimen of medications.54 On 12 13
14 51 Deplin is a targeted nutritional supplement designed to increase the 15 effectiveness of anti-depressant medication. www.deplin.com. (last 16 viewed March 19, 2026.) 17 52 AR 484-515. 18 53 AR 508-509, 514. 19 54 AR 489. 20 1 September 1, 2021, Plaintiff’s dosage of Lithium was also adjusted.55
2 On September 24, 2021, Plaintiff’s dosage of Lamictal was increased.56 3 The summary for the week of October 7, 2021, Plaintiff’s week of 4 discharge, indicates that she was found not to be at risk of suicidal or
5 self-harming behaviors.57 Plaintiff reported that her sleep was 6 adequate but not good with 5-7 hours of sleep a night, that she had 7 poor appetite and low energy daily, that she had low energy half the
8 days of the week, and that she continued to address trauma in 9 individual counseling.58 10 b. Jessica Long, PsyD
11 Plaintiff began treatment with Dr. Long on August 12, 2019, after 12 being referred due to diagnosis of post-traumatic stress disorder on 13
14 15
16 55 AR 495 17 56 AR 487. 18 57 AR 484. 19 58 AR 484-485. 20 1 July 11, 2019.59 At the time of intake, Plaintiff was a minor.60 She had
2 not been in counseling prior to this intake but had diagnoses for PTSD, 3 anxiety, and a mood disorder.61 She had been hospitalized twice in the 4 past for suicide attempts.62 Her medications included lithium,
5 Lamictal, trazadone, and Rexulti.63 Bipolar disorder was suspected but 6 needed to be ruled out.64 Plaintiff’s insight was impaired and she was 7 tearful.65
8 In April 2020, it was noted that Plaintiff’s panic attacks were 9 becoming more disabling, and she was somewhat emotionally distant 10 in her session.66 In September 2020, she was experiencing increased
12 59 AR 2778, 2781, 2782. 13 60 AR 2775. 14 61 AR 2777. 15 62 AR 2778. 16 63 AR 2779. 17 64 AR 2790. 18 65 AR 2793. 19 66 AR 2803. 20 1 anxiety and depression.67 In January 2021, it was noted that panic
2 symptoms were on-going and Plaintiff was overwhelmed with distorted 3 thinking.68 In March 2021, Plaintiff had panic attacks, irritability, a 4 depressed mood, and physical pain but had no further suicidal
5 thoughts since starting lithium.69 In May 2021, Dr. Long noted a 6 depressed and irritable mood, difficulty with executive functioning, and 7 distorted thinking, but better motivation and productivity after being
8 prescribed Adderall.70 It was noted at a June 11, 2021 appointment 9 that Plaintiff was tearful and depressed, had tangential thoughts, and 10 was sad and anxious, but reported that her partial hospitalization
11 program was going well.71 Throughout July of 2021, at appointments 12 twice a week, Plaintiff presented as sad, tearful, and anxious and 13
15 67 AR 2807. 16 68 AR 2808. 17 69 AR 289. 18 70 AR 2810. 19 71 AR 2813. 20 1 reported problems maintaining personal relationships.72 In the first
2 week of August 2021, it was noted that Plaintiff’s lithium was 3 decreased due to increased physical pain and Plaintiff became more 4 angry and irritable, and continued to present with sad, tearful, anxious
5 mood.73 In September 2021, Plaintiff had made progress in her 6 treatment and was exploring academic support services to help her 7 with school, but was still positive for weight loss and still displaying
8 sad, tearful, and anxious mood.74 She reported being emotionally 9 distant, and continued to experience panic attacks with irritable 10 mood.75 On October 19, 2021, Plaintiff continued to have irritable sad
11 mood, but had decided to temporarily withdraw from community 12 college in order to deal with her symptoms of feeling overwhelmed and 13 in pain.76
15 72 AR 2813-2817. 16 73 AR 2818. 17 74 AR 2821. 18 75 AR 2822. 19 76 AR 2823. 20 1 In November 2021, Plaintiff reported more energy and was not
2 sad or tearful, but Dr. Long noted the possibility of a manic episode 3 and need to increase the frequency of appointments due to adjustments 4 in medication.77 On December 4, 2021, Dr. Long noted that Plaintiff
5 was again experiencing an increase in irritability, and was sad, tearful, 6 and lethargic.78 7 4. Analysis
8 The Court will address the ALJ’s evaluation of Dr. Long’s 9 opinions, both as to Plaintiff’s allegations that the ALJ failed to 10 adequately articulate her analysis of the supportability and consistency
11 factors, and the Court’s conclusions regarding the need to develop the 12 record. 13 a. The ALJ’s consideration of Dr. Long’s opinions
14 The ALJ articulated the following reasoning as to her 15 consideration of Dr. Long’s opinions: 16 Jessica Long, Psy.D., completed a mental residual functional capacity assessment and opined the claimant’s 17
18 77 AR 2825. 19 78 AR 2828. 20 1 psychiatric condition exacerbated her pain and functioning (Exhibit 16F/3). She opined the claimant had extreme 2 limitations in difficulties with concentrating, persisting or maintaining pace and marked limitations in understanding, 3 remembering or applying information, interacting with others and adapting or managing herself (Exhibit 16F/8; 4 20F/1-3; 22F/14). Moreover, she found the claimant would be absent more than four days per month. These opinions 5 are not persuasive because the findings are not supported with sufficient explanation and is not consistent with the 6 overall medical record showing limited mental health treatment and her release from outpatient therapy due to 7 her ability to properly use independent coping skills.79
8 The ALJ must articulate her findings and cite to supporting 9 evidence in a way that permits the Court to meaningfully review the 10 ALJ’s findings.80 Moreover, while an ALJ need not address every piece 11 12
13 79 AR 29. 14 80 See Nguyen v. Chater, 100 F.3d 1462, 1467 (9th Cir. 1996); Embrey v. 15 Bowen, 849 F.2d 418, 421-22 (9th Cir. 1988) (requiring the ALJ to 16 identify the evidence supporting the found conflict to permit the court 17 to meaningfully review the ALJ’s finding); Blakes v. Barnhart, 331 F.3d 18 565, 569 (7th Cir. 2003) (“We require the ALJ to build an accurate and 19 logical bridge from the evidence to her conclusions so that we may 20 1 of evidence, an ALJ “may not ignore significant probative evidence that
2 bears on the disability analysis.”81 3 The ALJ’s findings regarding Dr. Long’s opinions are cursory. In 4 her summary dismissal of Dr. Long’s opinions on the grounds of
5 supportability, the ALJ fails to acknowledge the lengthy and detailed 6 narrative explanations provided by Dr. Long on the face of the form. 7 Generally, the failure to cite evidence is not a sufficient indication that
8 the ALJ failed to consider it.82 Although an ALJ is not required to 9 discuss every bit of evidence in the record, “it is incumbent upon the 10 ALJ to scrupulously and conscientiously probe into, inquire of, and
11 12 13
15 afford the claimant meaningful review of the SSA’s ultimate 16 findings.”). 17 81 Kilpatrick v. Kijakazi, 35 F.4th 1187, 1193 (9th Cir. 2022). 18 82 Black, 143 F.3d at 386 (“An ALJ’s failure to cite specific evidence 19 does not indicate that such evidence was not considered[.]”). 20 1 explore for all the relevant facts.”83 Here, the ALJ not only failed to
2 address the detailed narrative portions of the opinion form itself, but 3 she failed to mention any actual treatment note in Dr. Long’s records 4 that are inconsistent with her opinions. For this reason, the Court
5 concludes that the ALJ failed to properly consider the supportability 6 factor when evaluating Dr. Long’s opinions. 7 Next, the Court looks to the ALJ’s analysis of the consistency
8 factor, and finds it also to be lacking. The ALJ explains in her analysis 9 that the medical record shows a “limited mental health treatment” and 10 that Dr. Long’s opinions are inconsistent with Plaintiff’s “release from
11 outpatient therapy.”84 12 The Court finds that the ALJ’s conclusory statement that there is 13 a limited treatment record is not supported by the record. The record
14 establishes that during the relevant period, Plaintiff was seen by a 15
16 83 Garcia v. Comm’r of Social Sec., 768 F.3d 925, 930 (9th Cir. 2014) 17 (cleaned up); Vincent v. Heckler, 739 F.2d 1393, 1394–95 (9th Cir. 18 1984). 19 84 AR 29. 20 1 therapist once a week at a minimum and frequently seen more than
2 once a week.85 Additionally, she was seen monthly by a psychiatrist 3 who prescribed medication.86 4 Most striking, is that the record reflects that in February 2021,
5 the time at which Plaintiff alleges onset, her condition was not being 6 managed despite being seen twice a week by her therapist and she was 7 placed into a partial hospitalization program for 10 months.87 While
8 the administrative record contains only the summary reports from 9 Plaintiff’s partial hospitalization, those reports establish that Plaintiff 10 was undergoing treatment 5 days a week.88 Additionally, the records
11 establish that Plaintiff was released back to Dr. Long for care, and that 12 her condition remained so severe that she was required to withdraw 13 from school.89
15 85 AR 2673-2681, 2775-2861, 2348-3369, 3370-3373. 16 86 AR 2674. 17 87 AR 484-518. 18 88 Id. 19 89 AR 484, 2823. 20 1 The ALJ’s misunderstanding as to the context of Plaintiff’s
2 release from treatment was consequential. While the ALJ is correct 3 that Plaintiff was released by Recovery and Wellness Center of Eastern 4 Washington in October 2021, she was not released from “outpatient
5 treatment” but rather was released from an intensive partial 6 hospitalization program, back for weekly outpatient treatment with Dr. 7 Long. Context is crucial as “treatment records must be viewed in light
8 of the overall diagnostic record.”90 9 In addition to the ALJ having taken the medical records from 10 Recovery and Wellness Center of Eastern Washington out of context,
11 the ALJ erred in finding that the medical record was limited. It is 12 clear from the summary reports that several hundred pages of progress 13 notes and treatment records exist but are not a part of the record.
14 Plaintiff attended treatment 5 days a week for a period of 10 months. 15 If one were to assume that each individual and group therapy had even 16 one single page of treatment notes that would indicate more than 200
17 pages of records. 18
19 90 Ghanim, 763 F.3d at 1164. 20 1 “The ALJ always has a special duty to fully and fairly develop the
2 record” to make a fair determination as to disability, even where, as 3 here, “the claimant is represented by counsel.”91 This “affirmative 4 responsibility to develop the record” is necessary to ensure that the
5 ALJ’s decision is based on substantial evidence.92 6 On this record, the Court concludes that the ALJ erred by failing 7 to develop the record as to known treatment notes that were not
8 obtained and then compounded that error by citing to a limited record 9 as a reason for discrediting supportive medical opinion evidence. The 10 Court concludes that remand is warranted for the ALJ to properly
11 develop the record. 12 13
14 15 16
18 91 Celaya v. Halter, 332 F.3d 1177, 1183 (9th Cir. 2003) (cleaned up). 19 92 Id. at 1184. 20 1 5. Summary
2 Because the ALJ did not give good reasons for her evaluation of 3 Dr. Long’s opinions, a remand is warranted. On remand, the ALJ is 4 directed to properly consider the medical evidence and to develop the
5 record further by requesting the full medical record rather than a 6 limited abstract of records regarding Plaintiff’s partial hospitalization. 7 B. Step-Five Findings and Formulated RFC: The Court finds
8 these issues moot. 9 Plaintiff argues the ALJ failed to properly assess her mental and 10 physical limitations. As discussed above, the ALJ failed to develop the
11 record. Because the Court has remanded the case for development of 12 the record, the ALJ is further directed to schedule a consultative 13 examination to determine Plaintiff’s physical limitations, or to call a
14 medical expert to testify regarding the issue, and thereafter to 15 formulate an RFC based on those findings and to make findings at Step 16 Five.
17 C. Remand for Further Proceedings 18 Plaintiff submits a remand for payment of benefits is warranted. 19 The decision whether to remand a case for additional evidence, or
20 1 simply to award benefits, is within the discretion of the court.”93 When
2 the court reverses an ALJ’s decision for error, the court “ordinarily 3 must remand to the agency for further proceedings.”94 4 The Court finds that further development of the record is
5 necessary for a proper disability determination. The ALJ should obtain 6 missing records, schedule a consultative examination regarding 7 Plaintiff’s physical impairments, schedule medical expert testimony if
8 necessary, properly consider the opinion evidence and testimony, and 9 make findings at each of the five steps of the sequential evaluation 10 process.
11 12
13 93 Sprague v. Bowen, 812 F.2d 1226, 1232 (9th Cir. 1987) (citing Stone v. 14 Heckler, 761 F.2d 530 (9th Cir. 1985)). 15 94 Leon v. Berryhill, 880 F.3d 1041, 1045 (9th Cir. 2017); Benecke 379 16 F.3d at 595 (“[T]he proper course, except in rare circumstances, is to 17 remand to the agency for additional investigation or explanation”); 18 Treichler v. Comm’r of Soc. Sec. Admin., 775 F.3d 1090, 1099 (9th Cir. 19 2014). 20 1 IV. Conclusion
2 Accordingly, IT IS HEREBY ORDERED:
3 1. The ALJ’s nondisability decision is REVERSED, and this
4 matter is REMANDED to the Commissioner of Social
5 Security for further proceedings pursuant to sentence four
6 of 42 U.S.C. § 405(g). 7 2. The Clerk’s Office shall TERM the parties’ briefs, ECF
8 Nos. 14 and 17, enter JUDGMENT in favor of Plaintiff, 9 and CLOSE the case.
10 IT IS SO ORDERED. The Clerk’s Office is directed to file this
11 ||order and provide copies to all counsel.
12 DATED this 24* day of March, 2026.
1 Based oe 14 EDWARD F.SHEA | Senior United States District Judge 15 16 17 18 19
DISPOSITIVE ORDER - 32