2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 CENTRAL DISTRICT OF CALIFORNIA 10 11 YOLANDA C. M., Case No. CV 20-1339-RAO
12 Plaintiff,
13 v. MEMORANDUM OPINION AND ORDER 14 ANDREW SAUL, Commissioner of Social Security, 15 Defendant. 16 17 I. INTRODUCTION 18 Plaintiff Yolanda C. M.1 (“Plaintiff”) challenges the Commissioner’s denial of 19 her application for supplemental security income (“SSI”).2 For the reasons stated 20 below, the decision of the Commissioner is REVERSED and the action is 21 REMANDED for further proceedings consistent with this Order. 22 /// 23
24 1 Plaintiff’s name is partially redacted in compliance with Federal Rule of Civil 25 Procedure 5.2(c)(2)(B) and the recommendation of the Committee on Court Administration and Case Management of the Judicial Conference of the United 26 States. 27 2 Plaintiff does not challenge the denial of her application for disability insurance benefits (“DIB”). (Joint Submission (“JS”) at 5.) Accordingly, the Court addresses 28 only Plaintiff’s challenge to the denial of her SSI claims. 1 II. SUMMARY OF PROCEEDINGS 2 On February 10, 2016, Plaintiff filed a Title II application for DIB and, on 3 January 9, 2017, she filed a Title XVI application for SSI, alleging in both 4 applications that she had been disabled since November 30, 2014, due to diabetes, 5 high blood pressure, “thyroid,” carpal tunnel, and “tumor on pituitary.” 6 (Administrative Record (“AR”) 85, 212, 245, 296.) Her DIB claims were denied 7 initially on July 28, 2016, and upon reconsideration on September 26, 2016. (AR 85, 8 202, 212.) On October 3, 2016, Plaintiff filed a written request for hearing, and a 9 hearing on both applications was held on September 26, 2018. (AR 175-92, 222-23, 10 245.) Appearing unrepresented, Plaintiff testified, along with an impartial vocational 11 expert. (AR 175-92.) On December 4, 2018, the Administrative Law Judge (“ALJ”) 12 found that Plaintiff had not been under a disability, pursuant to the Social Security 13 Act,3 from November 30, 2014, through the date of the decision. (AR 93.) The ALJ’s 14 decision became the Commissioner’s final decision when the Appeals Council 15 denied Plaintiff’s request for review. (AR 1-6.) Plaintiff filed this action on July 2, 16 2020. (Dkt. No. 1.) 17 The ALJ followed a five-step sequential evaluation process to assess whether 18 Plaintiff was disabled under the Social Security Act. Lester v. Chater, 81 F.3d 821, 19 828 n.5 (9th Cir. 1995). At step one, the ALJ found that Plaintiff had not engaged 20 in substantial gainful activity since November 30, 2014, the alleged onset date. (AR 21 87.) At step two, the ALJ found that Plaintiff has the severe impairments of diabetes 22 mellitus with distal neuropathy and morbid obesity. (AR 87.) At step three, the ALJ 23 found that Plaintiff “does not have an impairment or combination of impairments that 24 meets or medically equals the severity of one of the listed impairments in 20 CFR 25 Part 404, Subpart P, Appendix 1.” (AR 89.)
26 3 Persons are “disabled” for purposes of receiving Social Security benefits if they are 27 unable to engage in any substantial gainful activity owing to a physical or mental impairment expected to result in death, or which has lasted or is expected to last for 28 a continuous period of at least 12 months. 42 U.S.C. § 423(d)(1)(A). 1 Before proceeding to step four, the ALJ found that Plaintiff has the residual 2 functional capacity (“RFC”) to perform the full range of light work as defined in 20 3 C.F.R. §§ 404.1567(b) and 416.967(b). (AR 89.) At step four, based on Plaintiff’s 4 RFC and the vocational expert (“VE”)’s testimony, the ALJ found that Plaintiff is 5 capable of performing past relevant work as a caregiver as actually performed and as 6 an accounts receivable as actually and generally performed. (AR 92-93.) 7 Accordingly, the ALJ did not proceed to step five, and instead, found that there are 8 jobs that exist in significant numbers in the national economy that Plaintiff can 9 perform. (AR 23-24.) Accordingly, the ALJ found that Plaintiff “has not been under 10 a disability . . . from November 30, 2014, through the date of this decision.” (AR 11 93.) 12 III. STANDARD OF REVIEW 13 Under 42 U.S.C. § 405(g), a district court may review the Commissioner’s 14 decision to deny benefits. A court must affirm an ALJ’s findings of fact if they are 15 supported by substantial evidence, and if the proper legal standards were applied. 16 Mayes v. Massanari, 276 F.3d 453, 458-59 (9th Cir. 2001). “Substantial evidence . 17 . . is ‘more than a mere scintilla[,]’ . . . [which] means—and means only—‘such 18 relevant evidence as a reasonable mind might accept as adequate to support a 19 conclusion.’” Biestek v. Berryhill, —U.S. —, 139 S. Ct. 1148, 1154, 203 L. Ed. 2d 20 504 (2019) (citations omitted); Revels v. Berryhill, 874 F.3d 648, 654 (9th Cir. 2017). 21 An ALJ can satisfy the substantial evidence requirement “by setting out a detailed 22 and thorough summary of the facts and conflicting clinical evidence, stating his 23 interpretation thereof, and making findings.” Reddick v. Chater, 157 F.3d 715, 725 24 (9th Cir. 1998) (citation omitted). 25 “[T]he Commissioner’s decision cannot be affirmed simply by isolating a 26 specific quantum of supporting evidence. Rather, a court must consider the record 27 as a whole, weighing both evidence that supports and evidence that detracts from the 28 Secretary’s conclusion.” Aukland v. Massanari, 257 F.3d 1033, 1035 (9th Cir. 2001) 1 (citations and internal quotations omitted). “‘Where evidence is susceptible to more 2 than one rational interpretation,’ the ALJ’s decision should be upheld.” Ryan v. 3 Comm’r of Soc. Sec., 528 F.3d 1194, 1198 (9th Cir. 2008) (citing Burch v. Barnhart, 4 400 F.3d 676, 679 (9th Cir. 2005)); see also Robbins v. Social Sec. Admin., 466 F.3d 5 880, 882 (9th Cir. 2006) (“If the evidence can support either affirming or reversing 6 the ALJ’s conclusion, we may not substitute our judgment for that of the ALJ.”). The 7 Court may review only “the reasons provided by the ALJ in the disability 8 determination and may not affirm the ALJ on a ground upon which he did not rely.” 9 Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007) (citing Connett v. Barnhart, 340 10 F.3d 871, 874 (9th Cir. 2003)). 11 IV. DISCUSSION 12 Plaintiff presents two issues for review as to her Title XVI claim: (1) whether 13 the ALJ properly considered the relevant medical evidence of record in her 14 determination of severe impairments and in her assessment of Plaintiff’s RFC; and 15 (2) whether the ALJ properly considered Plaintiff’s subjective statements in her 16 assessment of Plaintiff’s RFC. (JS at 4-14, 28-31.) For the reasons below, the Court 17 agrees with Plaintiff that remand is warranted. 18 A. The ALJ’s Consideration of the Relevant Medical Evidence 19 Plaintiff contends that the ALJ failed to properly consider the relevant medical 20 evidence in determining her severe impairments and in assessing her RFC. (JS at 4- 21 14.) 22 1.
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2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 CENTRAL DISTRICT OF CALIFORNIA 10 11 YOLANDA C. M., Case No. CV 20-1339-RAO
12 Plaintiff,
13 v. MEMORANDUM OPINION AND ORDER 14 ANDREW SAUL, Commissioner of Social Security, 15 Defendant. 16 17 I. INTRODUCTION 18 Plaintiff Yolanda C. M.1 (“Plaintiff”) challenges the Commissioner’s denial of 19 her application for supplemental security income (“SSI”).2 For the reasons stated 20 below, the decision of the Commissioner is REVERSED and the action is 21 REMANDED for further proceedings consistent with this Order. 22 /// 23
24 1 Plaintiff’s name is partially redacted in compliance with Federal Rule of Civil 25 Procedure 5.2(c)(2)(B) and the recommendation of the Committee on Court Administration and Case Management of the Judicial Conference of the United 26 States. 27 2 Plaintiff does not challenge the denial of her application for disability insurance benefits (“DIB”). (Joint Submission (“JS”) at 5.) Accordingly, the Court addresses 28 only Plaintiff’s challenge to the denial of her SSI claims. 1 II. SUMMARY OF PROCEEDINGS 2 On February 10, 2016, Plaintiff filed a Title II application for DIB and, on 3 January 9, 2017, she filed a Title XVI application for SSI, alleging in both 4 applications that she had been disabled since November 30, 2014, due to diabetes, 5 high blood pressure, “thyroid,” carpal tunnel, and “tumor on pituitary.” 6 (Administrative Record (“AR”) 85, 212, 245, 296.) Her DIB claims were denied 7 initially on July 28, 2016, and upon reconsideration on September 26, 2016. (AR 85, 8 202, 212.) On October 3, 2016, Plaintiff filed a written request for hearing, and a 9 hearing on both applications was held on September 26, 2018. (AR 175-92, 222-23, 10 245.) Appearing unrepresented, Plaintiff testified, along with an impartial vocational 11 expert. (AR 175-92.) On December 4, 2018, the Administrative Law Judge (“ALJ”) 12 found that Plaintiff had not been under a disability, pursuant to the Social Security 13 Act,3 from November 30, 2014, through the date of the decision. (AR 93.) The ALJ’s 14 decision became the Commissioner’s final decision when the Appeals Council 15 denied Plaintiff’s request for review. (AR 1-6.) Plaintiff filed this action on July 2, 16 2020. (Dkt. No. 1.) 17 The ALJ followed a five-step sequential evaluation process to assess whether 18 Plaintiff was disabled under the Social Security Act. Lester v. Chater, 81 F.3d 821, 19 828 n.5 (9th Cir. 1995). At step one, the ALJ found that Plaintiff had not engaged 20 in substantial gainful activity since November 30, 2014, the alleged onset date. (AR 21 87.) At step two, the ALJ found that Plaintiff has the severe impairments of diabetes 22 mellitus with distal neuropathy and morbid obesity. (AR 87.) At step three, the ALJ 23 found that Plaintiff “does not have an impairment or combination of impairments that 24 meets or medically equals the severity of one of the listed impairments in 20 CFR 25 Part 404, Subpart P, Appendix 1.” (AR 89.)
26 3 Persons are “disabled” for purposes of receiving Social Security benefits if they are 27 unable to engage in any substantial gainful activity owing to a physical or mental impairment expected to result in death, or which has lasted or is expected to last for 28 a continuous period of at least 12 months. 42 U.S.C. § 423(d)(1)(A). 1 Before proceeding to step four, the ALJ found that Plaintiff has the residual 2 functional capacity (“RFC”) to perform the full range of light work as defined in 20 3 C.F.R. §§ 404.1567(b) and 416.967(b). (AR 89.) At step four, based on Plaintiff’s 4 RFC and the vocational expert (“VE”)’s testimony, the ALJ found that Plaintiff is 5 capable of performing past relevant work as a caregiver as actually performed and as 6 an accounts receivable as actually and generally performed. (AR 92-93.) 7 Accordingly, the ALJ did not proceed to step five, and instead, found that there are 8 jobs that exist in significant numbers in the national economy that Plaintiff can 9 perform. (AR 23-24.) Accordingly, the ALJ found that Plaintiff “has not been under 10 a disability . . . from November 30, 2014, through the date of this decision.” (AR 11 93.) 12 III. STANDARD OF REVIEW 13 Under 42 U.S.C. § 405(g), a district court may review the Commissioner’s 14 decision to deny benefits. A court must affirm an ALJ’s findings of fact if they are 15 supported by substantial evidence, and if the proper legal standards were applied. 16 Mayes v. Massanari, 276 F.3d 453, 458-59 (9th Cir. 2001). “Substantial evidence . 17 . . is ‘more than a mere scintilla[,]’ . . . [which] means—and means only—‘such 18 relevant evidence as a reasonable mind might accept as adequate to support a 19 conclusion.’” Biestek v. Berryhill, —U.S. —, 139 S. Ct. 1148, 1154, 203 L. Ed. 2d 20 504 (2019) (citations omitted); Revels v. Berryhill, 874 F.3d 648, 654 (9th Cir. 2017). 21 An ALJ can satisfy the substantial evidence requirement “by setting out a detailed 22 and thorough summary of the facts and conflicting clinical evidence, stating his 23 interpretation thereof, and making findings.” Reddick v. Chater, 157 F.3d 715, 725 24 (9th Cir. 1998) (citation omitted). 25 “[T]he Commissioner’s decision cannot be affirmed simply by isolating a 26 specific quantum of supporting evidence. Rather, a court must consider the record 27 as a whole, weighing both evidence that supports and evidence that detracts from the 28 Secretary’s conclusion.” Aukland v. Massanari, 257 F.3d 1033, 1035 (9th Cir. 2001) 1 (citations and internal quotations omitted). “‘Where evidence is susceptible to more 2 than one rational interpretation,’ the ALJ’s decision should be upheld.” Ryan v. 3 Comm’r of Soc. Sec., 528 F.3d 1194, 1198 (9th Cir. 2008) (citing Burch v. Barnhart, 4 400 F.3d 676, 679 (9th Cir. 2005)); see also Robbins v. Social Sec. Admin., 466 F.3d 5 880, 882 (9th Cir. 2006) (“If the evidence can support either affirming or reversing 6 the ALJ’s conclusion, we may not substitute our judgment for that of the ALJ.”). The 7 Court may review only “the reasons provided by the ALJ in the disability 8 determination and may not affirm the ALJ on a ground upon which he did not rely.” 9 Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007) (citing Connett v. Barnhart, 340 10 F.3d 871, 874 (9th Cir. 2003)). 11 IV. DISCUSSION 12 Plaintiff presents two issues for review as to her Title XVI claim: (1) whether 13 the ALJ properly considered the relevant medical evidence of record in her 14 determination of severe impairments and in her assessment of Plaintiff’s RFC; and 15 (2) whether the ALJ properly considered Plaintiff’s subjective statements in her 16 assessment of Plaintiff’s RFC. (JS at 4-14, 28-31.) For the reasons below, the Court 17 agrees with Plaintiff that remand is warranted. 18 A. The ALJ’s Consideration of the Relevant Medical Evidence 19 Plaintiff contends that the ALJ failed to properly consider the relevant medical 20 evidence in determining her severe impairments and in assessing her RFC. (JS at 4- 21 14.) 22 1. Step Two 23 Plaintiff appears to contend that the ALJ failed to properly consider the 24 severity of the combination of impairments affecting her knees, legs, back, hands, 25 and mental functioning at step two. (JS at 5.) 26 a. Applicable Legal Standards 27 The step two inquiry is meant to be a de minimis screening device. Smolen v. 28 Chater, 80 F.3d 1273, 1290 (9th Cir. 1996) (citing Bowen v. Yuckert, 482 U.S. 137, 1 153–54, 107 S. Ct. 2287, 96 L. Ed. 2d 119 (1987)). At step two, the ALJ identifies 2 a claimant’s severe impairments, i.e., impairments that significantly limit his or her 3 ability to do basic work activities.4 20 C.F.R. § 416.920(a)(4)(ii); Smolen, 80 F.3d at 4 1290. A determination that an impairment is not severe requires evaluation of 5 medical findings describing the impairment, and an informed judgment as to its 6 limiting effects on a claimant’s ability to do basic work activities. Social Security 7 Ruling (“SSR”) 85-28, 1985 WL 56856, at *4 (Jan. 1, 1985).5 8 The ALJ must take into account subjective symptoms in assessing severity, 9 Smolen, 80 F.3d at 1290, but “medical evidence alone is evaluated . . . to assess the 10 effects of the impairment(s) on ability to do basic work activities.” SSR 85-28 at *4. 11 An impairment or combination thereof may properly be found not severe if the 12 clearly established objective medical evidence shows only slight abnormalities that 13 minimally affect a claimant’s ability to do basic work activities. Webb v. Barnhart, 14 433 F.3d 683, 687 (9th Cir. 2005); Smolen, 80 F.3d at 1290. 15 b. The ALJ’s Decision 16 Here, at step two, the ALJ discussed Plaintiff’s bilateral knee pain, lower back 17 pain, carpal tunnel syndrome, and memory disorder and found they were not severe 18 impairments. (AR 87-88.) The ALJ noted that despite diagnostic imaging showing 19 mild degenerative joint disease in the knees, Plaintiff did not complain of significant 20 joint pain and/or weakness; physical examinations revealed the lower extremities 21 were without deformity, clubbing, cyanosis or edema; there was normal muscle tone, 22 strength, and range of motion; and there were no significant neurological changes. 23 (AR 88, 427-28, 439, 472, 502, 555.) Regarding Plaintiff’s lower back pain, the ALJ 24 noted that despite evidence of chronic L5, S1 radiculopathy and an MRI of the lumbar 25 spine showing mild to moderate degenerative changes, physical examinations noted
26 4 Basic work activities are “the abilities and aptitudes necessary to do most jobs[.]” 27 20 C.F.R. § 416.921(b). 5 SSRs do not have the force of law, but a reviewing court generally accords them 28 some deference. Holohan v. Massanari, 246 F.3d 1195, 1202 n.1 (9th Cir. 2001). 1 musculoskeletal structures were near normal with normal symmetry, tone, strength, 2 and range of motion; there was no effusion, instability or tenderness; and there were 3 no significant neurological changes. (AR 88, 397, 428, 439, 472, 523-24.) Regarding 4 Plaintiff’s carpal tunnel syndrome, the ALJ noted that diagnostic testing revealed 5 bilateral median nerve dysfunction at the wrist consistent with carpal tunnel 6 syndrome; Plaintiff denied joint pain, weakness and/or issues with coordination; 7 physical examinations were normal and the upper extremities were without 8 deformities, clubbing, cyanosis or edema; normal muscle tone, strength and range of 9 motion were noted; and there were no significant neurological changes. (AR 87-88, 10 396, 428, 439, 472-74.) Regarding Plaintiff’s mental disorder, the ALJ found that 11 Plaintiff’s memory remained intact on psychiatric examinations. (AR 89, 436.) 12 c. Discussion 13 The overall treatment record supports the ALJ’s finding at step two. Plaintiff 14 presents a different interpretation of the objective medical evidence and diagnoses. 15 (JS at 7-14.) While Plaintiff’s interpretation of the evidence is not unreasonable, 16 neither is the ALJ’s interpretation. See Burch, 400 F.3d at 679 (“Where evidence is 17 susceptible to more than one rational interpretation, it is the ALJ’s conclusion that 18 must be upheld.”). Further, mere diagnosis of an impairment, or even treatment for 19 it, is insufficient to establish severity at step two, especially when the objective 20 medical evidence in the record fails to show any work-related limitations connected 21 to the impairment. See Harvey v. Colvin, 2013 WL 3899282, at *5 (C.D. Cal. July 22 29, 2013) (citing Matthews v. Shalala, 10 F.3d 678, 680 (9th Cir. 1993)). The Court 23 is not persuaded by the additional evidence Plaintiff submitted to the Appeals 24 Council, dated after the ALJ’s decision, which the Appeals Council found did not 25 relate to the period at issue. (JS 10-11; AR 1-81, 100-74.) 26 Even assuming that the ALJ erred in making her step two determination, any 27 error was harmless because she considered all symptoms when determining 28 Plaintiff’s RFC. (AR 89.) See Lewis v. Astrue, 498 F.3d 909, 911 (9th Cir. 2007) 1 (even if the ALJ erred by not including an impairment at step two, any error was 2 harmless because the ALJ considered the limitations posed thereby in later steps of 3 the sequential evaluation process). 4 Accordingly, remand is not warranted at step two. 5 2. Medical Opinion Evidence 6 Plaintiff contends that the ALJ erred in considering the medical opinion 7 evidence in assessing her RFC. (JS at 6.) 8 a. Applicable Legal Standards 9 The ALJ is responsible for assessing a claimant’s RFC “based on all of the 10 relevant medical and other evidence.” 20 C.F.R. § 416.945(a)(3); see Robbins, 466 11 F.3d at 883 (citing SSR 96-8p, 1996 WL 374184, at *5 (July 2, 1996)). In doing so, 12 the ALJ may consider any statements provided by medical sources, including 13 statements that are not based on formal medical examinations. See 20 C.F.R. 14 § 416.927.6 An ALJ’s determination of a claimant’s RFC must be affirmed “if the 15 ALJ applied the proper legal standard and his decision is supported by substantial 16 evidence.” Bayliss v. Barnhart, 427 F.3d 1211, 1217 (9th Cir. 2005); accord Morgan 17 v. Comm’r of Soc. Sec. Admin., 169 F.3d 595, 599 (9th Cir. 1999). 18 Courts give varying degrees of deference to medical opinions based on the 19 provider: (1) treating physicians who examine and treat; (2) examining physicians 20 who examine, but do not treat; and (3) non-examining physicians who do not examine 21 or treat. Valentine v. Comm’r, Soc. Sec. Admin., 574 F.3d 685, 692 (9th Cir. 2009); 22 see also 20 C.F.R. § 416.927. Most often, “[t]he medical opinion of a claimant’s 23 treating physician is given ‘controlling weight’ so long as it ‘is well-supported by
24 6 For all claims filed on or after March 27, 2017, 20 C.F.R. § 416.920c applies, not 25 § 416.927. The new regulations provide that the Social Security Administration “will not defer or give any specific evidentiary weight, including controlling weight, to any 26 medical opinion(s) or prior administrative medical finding(s), including those from 27 your medical sources.” 20 C.F.R. § 416.920c. The claim here, however, was filed before March 27, 2017. Thus, the Court analyzes Plaintiff's claim pursuant to the 28 treating source rule set forth in § 416.927. 1 medically acceptable clinical and laboratory diagnostic techniques and is not 2 inconsistent with the other substantial evidence in [the claimant’s] case record.’” 3 Trevizo v. Berryhill, 871 F.3d 664, 675 (9th Cir. 2017) (quoting 20 C.F.R. 4 § 404.1527(c)(2)). Generally, the opinion of a treating physician is given greater 5 weight than the opinion of a non-treating physician, and the opinion of an examining 6 physician is given greater weight than the opinion of a non-examining physician. See 7 Garrison v. Colvin, 759 F.3d 995, 1012 (9th Cir. 2014). 8 The ALJ must provide “clear and convincing” reasons to reject a treating or 9 examining physician’s uncontradicted opinion. Trevizo, 871 F.3d at 675; Lester, 81 10 F.3d at 830-31. When a treating or examining physician’s opinion is contradicted by 11 another opinion, the ALJ may reject it only by providing specific and legitimate 12 reasons supported by substantial evidence in the record. Orn, 495 F.3d at 633; Lester, 13 81 F.3d at 830; Carmickle v. Comm’r, Soc. Sec. Admin., 533 F.3d 1155, 1164 (9th 14 Cir. 2008). “An ALJ can satisfy the ‘substantial evidence’ requirement by ‘setting 15 out a detailed and thorough summary of the facts and conflicting evidence, stating 16 his interpretation thereof, and making findings.’” Garrison, 759 F.3d at 1012 17 (citation omitted). Although the opinion of a non-examining physician “cannot by 18 itself constitute substantial evidence that justifies the rejection of the opinion of either 19 an examining physician or a treating physician,” such an opinion may serve as 20 substantial evidence when it is consistent with and supported by other independent 21 evidence in the record. Lester, 81 F.3d at 830-31; see also Bray v. Comm’r of Soc. 22 Sec. Admin., 554 F.3d 1219, 1221, 1227 (9th Cir. 2009) (finding ALJ properly relied 23 on non-examining state agency physician’s assessment in determining the claimant’s 24 RFC and in rejecting the treating doctor’s opinion regarding the claimant’s functional 25 limitations). 26 b. The ALJ’s Decision 27 In determining the RFC, the ALJ gave great weight to the opinions of the non- 28 examining State Agency physicians, who found Plaintiff was capable of a full range 1 of light work. (AR 91.) On initial review of Plaintiff’s DIB claim, A. Lizarraras, 2 M.D., evaluated the medical evidence and opined that Plaintiff could perform light 3 work, noting that the longitudinal evidence showed a stable pituitary macroadenoma, 4 hypothyroidism and thyroiditis. (AR 198-99.) In July 2016, Dr. Lizarraras 5 determined that Plaintiff’s condition was not disabling on any date through December 6 31, 2014, when Plaintiff was last insured for disability benefits. (AR 200.) On 7 reconsideration of Plaintiff’s DIB claim in September 2016, M. Amado, M.D. 8 affirmed a light RFC between November 30, 2014 and December 31, 2014, noting 9 that most of the medical evidence of record on file was past the date last insured. 10 (AR 207.) The ALJ found the State Agency opinions consistent with the medical 11 evidence. (AR 91-92.) 12 The ALJ gave less weight to the April 2018 treating opinion of Samuel Wilson, 13 M.D., who opined that Plaintiff could stand or sit for 30 minutes due to neuropathic 14 and right knee pain, could walk 25 feet without stopping, would need to lie down 15 during the day, could rarely handle and finger or reach down, could lift and carry less 16 than five pounds, suffered from anxiety and panic attacks, needed help with her 17 activities of daily living, and could not work. (AR 92, 504-09.) The ALJ discounted 18 Dr. Wilson’s opinion because his assessed limitations were inconsistent with and not 19 supported by his own progress notes and medical evidence, and he did not provide 20 any significant treatment for Plaintiff’s carpal tunnel syndrome. (AR 92.) 21 c. Discussion 22 Plaintiff argues that the ALJ erred in determining her RFC because (1) the 23 State Agency physicians’ opinions cannot form the sole basis for the RFC 24 assessment; and (2) the State Agency physicians’ opinions are from 2016 and only 25 address Plaintiff’s application for Title II benefits, focusing on her condition prior to 26 her date last insured in 2014, because she had not yet filed her Title XVI application. 27 (JS at 6.) 28 /// 1 Here, the ALJ’s decision is not supported by substantial evidence. The record 2 contains medical opinion evidence from the State Agency physicians and Dr. Wilson, 3 a treating source.7 (AR 198-99, 207, 504-09.) The ALJ effectively rejected Dr. 4 Wilson’s opinion. (AR 92.) This left the State Agency physicians’ opinions, which 5 the ALJ found consistent with the medical evidence. (AR 91-92.) The ALJ noted 6 that despite Plaintiff’s morbid obesity, distal polyneuropathy, benign pituitary mass, 7 carpal tunnel syndrome and degeneration, her physical examinations were “largely 8 unremarkable” aside from mild decrease in sensation. (AR 91, 428, 439, 472, 550.) 9 These physical examinations show no deformities, clubbing, cyanosis, or edema in 10 extremities; normal musculoskeletal tone, strength and range of motion; no effusions, 11 instability or tenderness to palpation; no neurological changes; decreased pulse but 12 normal vibration sensation in feet; and gait within normal limits. (AR 428, 439, 472, 13 550.) In general, these findings would permit the State Agency physicians’ opinions 14 to constitute substantial evidence. See Morgan, 169 F.3d at 600 (holding a non- 15 examining physician’s opinion can constitute substantial evidence if it is supported 16 by other evidence in the record and is consistent with it). Here, however, the State 17 Agency physicians’ opinions have limited probative value regarding Plaintiff’s SSI 18 claim because the State Agency physicians considered the medical evidence only as 19 it related to Plaintiff’s DIB claim, i.e., for the period between November 30, 2014 to 20 December 31, 2014. (AR 196, 207.) See Coffman v. Colvin, 2015 WL 5826790, at 21 *4 (C.D. Cal. Sept. 30, 2015) (remanding where ALJ rejected all treating and 22 examining opinions and remaining State Agency opinions addressed the medical 23 evidence only as to plaintiff’s DIB claim). For the later-filed SSI claim, the period 24 between December 31, 2014 and the date of the ALJ’s decision was relevant, and the 25 State Agency physicians’ opinions did not address the medical evidence as it related 26 to that period. Thus, it appears that the RFC assessment for the period after 27 7 The consultative examination by Dr. Liu on January 15, 2019, occurred after the 28 ALJ’s decision and does not relate to the period at issue. (AR 2, 45-49.) 1 December 31, 2014, was mistakenly based on the State Agency opinions. To the 2 extent the RFC assessment post-December 31, 2014 was based solely on the ALJ’s 3 interpretation of the medical evidence, she was not qualified to make a functional 4 assessment as a layperson. Id. (“[A]n ALJ is simply not qualified to interpret raw 5 medical data in functional terms.”) (quoting Padilla v. Astrue, 541 F. Supp. 2d 1102, 6 1106 (C.D. Cal. 2008) (quoting Nguyen v. Chater, 172 F.3d 31, 35 (1st Cir. 1999) 7 (per curiam), and citing Day v. Weinberger, 522 F.2d 1154, 1156 (9th Cir. 1975)). 8 The Commissioner asserts that the ALJ is not precluded from relying on the 9 State Agency physicians’ opinions on the ground that their review was prior to 10 Plaintiff’s Title XVI application, but cites only general statutes relating to what 11 evidence a State Agency physician considers, 20 C.F.R. §§ 404.1513(a)(1), 12 416.913(a)(1). The Commissioner further argues that in addition to the longitudinal 13 record, the ALJ also considered the third-party testimony and Plaintiff’s subjective 14 allegations in determining Plaintiff’s RFC. (JS at 15.) The ALJ, however, essentially 15 rejected the third-party testimony and Plaintiff’s subjective allegations and 16 erroneously relied on the State Agency physicians’ opinions regarding her DIB 17 claim. (AR 90-92.) The Court finds that the ALJ erred by formulating an RFC 18 without a physician’s assessment of Plaintiff’s functional capacity after December 19 31, 2014.8 Perez v. Sec’y of Health and Human Servs., 958 F.2d 445, 446 (1st Cir. 20 1991) (per curiam) (“[W]here an ALJ reaches conclusions about [a] claimant’s 21 physical exertional capacity without any assessment of residual functional capacity 22 by a physician, the ALJ’s conclusions are not supported by substantial evidence and 23 it is necessary to remand for the taking of further functional evidence.”). It was 24 improper for the ALJ to make an RFC determination for Plaintiff’s SSI claim based 25 8 The fact that subsequent evidence was introduced after the State Agency review is 26 not the issue here, but rather that the State Agency physicians’ opinions addressed 27 the medical evidence only as it related to Plaintiff’s DIB claim, and there was no other medical opinion in the record, except for Dr. Wilson’s rejected opinion, that 28 addressed the medical evidence as it related to Plaintiff’s later-filed SSI claim. 1 on the State Agency physicians’ opinions solely regarding Plaintiff’s DIB claim. 2 The Court cannot find the ALJ’s error harmless, as it cannot confidently 3 conclude that the ALJ’s RFC assessment and the non-disability decision would have 4 been the same absent such error. Dr. Wilson’s opinion suggests that Plaintiff’s 5 functional limitations would prevent Plaintiff from performing all work. (AR 504- 6 09.) 7 Accordingly, remand is warranted to reevaluate the medical opinion evidence. 8 B. The Court Declines to Address Plaintiff’s Remaining Issue 9 Having found that remand is warranted, the Court declines to address 10 Plaintiff’s remaining issue. See Hiler v. Astrue, 687 F.3d 1208, 1212 (9th Cir. 2012) 11 (“Because we remand the case to the ALJ for the reasons stated, we decline to reach 12 [plaintiff’s] alternative ground for remand.”); see also Augustine ex rel. Ramirez v. 13 Astrue, 536 F. Supp. 2d 1147, 1153 n.7 (C.D. Cal. 2008) (“[The] Court need not 14 address the other claims plaintiff raises, none of which would provide plaintiff with 15 any further relief than granted, and all of which can be addressed on remand.”). 16 C. Remand for Further Administrative Proceedings 17 Plaintiff contends that the ALJ’s decision should be vacated and the matter 18 remanded for further proceedings. (JS at 38-39.) The Commissioner agrees that 19 should the Court find reversible error, the proper remedy is remand for further 20 proceedings. (JS at 39.) 21 The Court agrees with the parties that remand for further administrative 22 proceedings on Plaintiff’s SSI claim is appropriate, as further administrative review 23 could remedy the ALJ’s errors. See Brown-Hunter v. Colvin, 806 F.3d 487, 495 (9th 24 Cir. 2015) (remanding for an award of benefits is appropriate in rare circumstances).9 25 9 Before ordering remand for an award of benefits, three requirements must be met: 26 (1) the Court must conclude that the ALJ failed to provide legally sufficient reasons 27 for rejecting evidence; (2) the Court must conclude that the record has been fully developed and further administrative proceedings would serve no useful purpose; and 28 (3) the Court must conclude that if the improperly discredited evidence were credited 1 || The Court finds that as to Plaintiff's SSI claim, the ALJ erred in considering the 2 || medical opinion evidence in assessing her RFC. On remand, the ALJ shall solicit the 3 || expertise of a medical advisor to interpret the medical evidence generated after 4 || Plaintiff's date last insured. The ALJ shall then reassess Plaintiff's RFC as to 5 || Plaintiffs SSI claim and proceed to step four and, if necessary, step five. This order 6 || does not preclude the ALJ from considering, on remand, any other arguments raised 7 || by Plaintiff. g | Vv. CONCLUSION 9 IT IS ORDERED that Judgment shall be entered REVERSING the decision of 10 || the Commissioner denying benefits as to Plaintiffs Title XVI SSI claim, and 11 || REMANDING the matter for further proceedings consistent with this Order. 12 IT IS FURTHER ORDERED that the Clerk of the Court serve copies of this 13 || Order and the Judgment on counsel for both parties. 14 . Rayeeis, QA. QC 15 || DATED: July 6, 2021 16 ROZELLA A. OLIVER UNITED STATES MAGISTRATE JUDGE 17 18 19 NOTICE 20 || THIS DECISION IS NOT INTENDED FOR PUBLICATION IN WESTLAW, 5 LEXIS/NEXIS, OR ANY OTHER LEGAL DATABASE.
22 23 24 25 | ———_—————___ oo as true, the ALJ would be required to find the claimant disabled on remand. /d. 26 (citations omitted). Even if all three requirements are met, the Court retains 27 || flexibility to remand for further proceedings “when the record as a whole creates serious doubt as to whether the claimant is, in fact, disabled within the meaning of 28 || the Social Security Act.” /d. (citation omitted). 13