Langfield v. Commissioner of Social Security Administration ( 2021 )

1 WO 2 3 4 5 6 IN THE UNITED STATES DISTRICT COURT 7 FOR THE DISTRICT OF ARIZONA 8 9 Lynda Michelle Langfield, No. CV-20-00579-PHX-JJT 10 Plaintiff, ORDER 11 v. 12 Commissioner of Social Security Administration, 13 Defendant. 14 15 16 At issue is the denial of Plaintiff Lynda Michelle Langfield’s Application for 17 Disability Insurance benefits by the Social Security Administration (“SSA”) under the 18 Social Security Act. Plaintiff filed a Complaint (Doc. 1) with this Court seeking judicial 19 review of that denial, and the Court now addresses Plaintiff’s Opening Brief (Doc. 20, “Pl. 20 Br.”), Defendant SSA Commissioner’s Response Brief (Doc. 24, “Def. Br.”), and 21 Plaintiff’s Reply Brief (Doc. 28, “Reply”). The Court has reviewed the briefs and 22 Administrative Record (Doc. 15, “R.”) and now reverses and remands for computation and 23 award of benefits. 24 I. BACKGROUND 25 Plaintiff filed an Application for Disability Insurance benefits on April 24, 2013, for 26 a period of disability beginning on September 9, 2010. (R. at 18.) Her claim was denied 27 initially on September 17, 2013, and upon reconsideration on March 27, 2014. (R. at 18.) 28 Plaintiff appeared before the ALJ for a hearing regarding her claim on April 10, 2015, 1 which the ALJ denied on May 21, 2015. (R. at 18, 32.) On November 8, 2016, the Appeals 2 Council denied Plaintiff’s Request for Review and adopted the ALJ’s decision as the 3 agency’s final decision. (R. at 1–3.) 4 This Court then vacated and remanded the case for further proceedings on 5 March 23, 2018. (R. at 916–29.) Langfield v. Comm’r of Soc. Sec. Admin., No. CV-17- 6 00056-PHX-JZB, 2018 WL 1456311, at *1–8 (D. Ariz. Mar. 23, 2018). Plaintiff appeared 7 and testified at a hearing regarding her claim held on November 5, 2018, which the ALJ 8 denied on January 8, 2019. (R. at 831, 843.) On January 21, 2020, once again, the Appeals 9 Council denied Plaintiff’s Request for Review and adopted the ALJ’s decision as the 10 agency’s final decision. (R. at 811–14.) 11 The Court has reviewed the medical evidence in its entirety and will discuss the 12 pertinent medical evidence in addressing the issues raised by the parties. Upon considering 13 the medical records and opinions, the ALJ evaluated Plaintiff’s disability based on the 14 severe impairment: degenerative disc disease with stenosis. (R. at 835.) 15 Ultimately, the ALJ evaluated the medical evidence and testimony and concluded 16 that Plaintiff was not disabled from the alleged disability onset-date through the date of the 17 decision. (R. at 843.) The ALJ found that Plaintiff “does not have an impairment or 18 combination of impairments that meets or medically equals the severity of one of the listed 19 impairments in 20 CFR Part 404, Subpart P, Appendix 1.” (R. at 837.) Next, the ALJ 20 calculated Plaintiff’s residual functional capacity (“RFC”): 21 [Plaintiff] has the [RFC] to perform light work as defined in 20 CFR 404.1567(b), except she could frequently operate foot 22 controls with the bilateral lower extremities. She could never climb ladders, ropes, or scaffolds. She could frequently climb 23 ramps or stairs. She could frequently balance, kneel, and crawl. She could occasionally stoop and crouch. She could 24 occasionally reach overhead with the bilateral upper extremities. She could occasionally tolerate exposure to 25 dangerous machinery with moving mechanical parts and unprotected heights. 26 27 (R. at 838.) Accordingly, the ALJ found that Plaintiff can perform jobs that exist in 28 significant numbers in the national economy. (R. at 842.) 1 II. LEGAL STANDARD 2 In determining whether to reverse an ALJ’s decision, the district court reviews only 3 those issues raised by the party challenging the decision. See Lewis v. Apfel, 236 F.3d 503, 4 517 n.13 (9th Cir. 2001). The Court may set aside the Commissioner’s disability 5 determination only if it is not supported by substantial evidence or is based on legal error. 6 Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007). Substantial evidence is relevant evidence 7 that a reasonable person might accept as adequate to support a conclusion considering the 8 record as a whole. Id. To determine whether substantial evidence supports a decision, the 9 Court must consider the record as a whole and may not affirm simply by isolating a 10 “specific quantum of supporting evidence.” Id. Generally, “[w]here the evidence is 11 susceptible to more than one rational interpretation, one of which supports the ALJ’s 12 decision, the ALJ’s conclusion must be upheld.” Thomas v. Barnhart, 278 F.3d 947, 954 13 (9th Cir. 2002) (citations omitted). 14 To determine whether a claimant is disabled for purposes of the Act, the ALJ 15 follows a five-step process. 20 C.F.R. § 404.1520(a). The claimant bears the burden of 16 proof on the first four steps, but the burden shifts to the Commissioner at step five. Tackett 17 v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). At the first step, the ALJ determines whether 18 the claimant is presently engaging in substantial gainful activity. 20 C.F.R. 19 § 404.1520(a)(4)(i). At step two, the ALJ determines whether the claimant has a “severe” 20 medically determinable physical or mental impairment. 20 C.F.R. § 404.1520(a)(4)(ii). At 21 step three, the ALJ considers whether the claimant’s impairment or combination of 22 impairments meets or medically equals an impairment listed in Appendix 1 to Subpart P 23 of 20 C.F.R. Part 404. 20 C.F.R. § 404.1520(a)(4)(iii). If so, the claimant is automatically 24 found to be disabled. Id. At step four, the ALJ assesses the claimant’s RFC and determines 25 whether the claimant is still capable of performing past relevant work. 20 C.F.R. 26 § 404.1520(a)(4)(iv). If not, the ALJ proceeds to the fifth and final step, where she 27 determines whether the claimant can perform any other work in the national economy 28 1 based on the claimant’s RFC, age, education, and work experience. 20 C.F.R. 2 § 404.1520(a)(4)(v). If not, the claimant is disabled. Id. 3 III. ANAYSIS 4 Plaintiff raises two issues for the Court’s consideration, which are the same issues 5 that were raised the last time this Court reviewed this case. First, Plaintiff argues the ALJ 6 erred in rejecting her symptom testimony. (Pl. Br. at 12–19.) Second, Plaintiff argues the 7 ALJ erred in rejecting the opinion of Dr. John Peachy, who performed one medical 8 examination of Plaintiff. (Pl. Br. at 20–24.) 9 The Court finds that the ALJ erred in rejecting Plaintiff’s symptom testimony 10 because the ALJ’s only potential valid reason for rejecting the symptom testimony was 11 inconsistencies with the medical evidence. Since this reason cannot stand on its own, the 12 ALJ erred. Second, the ALJ erred in rejecting Dr. Peachy’s medical opinion by not making 13 clear arguments about how other medical evidence contradicted Dr. Peachy’s opinion. For 14 the following reasons, the Court reverses and remands for computation and award of 15 benefits 16 A. The ALJ erred in rejecting Plaintiff’s symptom testimony. 17 Plaintiff argues the ALJ erred in rejecting her symptom testimony. (Pl. Br. at 12– 18 19.) An ALJ performs a two-step analysis to evaluate a claimant’s testimony regarding 19 pain and symptoms. Garrison v. Colvin, 759 F.3d 995, 1014 (9th Cir. 2014). First, the ALJ 20 evaluates whether the claimant has presented objective medical evidence of an impairment 21 “which could reasonably be expected to produce the pain or symptoms alleged.” 22 Lingenfelter v. Astrue, 504 F.3d 1028, 1035–36 (9th Cir. 2007) (quoting Bunnell v. 23 Sullivan, 947 F.2d 341, 344 (9th Cir. 1991) (en banc) (internal quotation marks omitted)). 24 If the claimant presents such evidence then “the ALJ can reject the claimant’s testimony 25 about the severity of her symptoms only by offering specific, clear and convincing reasons 26 for doing so.” Garrison, 759 F.3d at 1014–15 (citing Smolen v. Chater, 80 F.3d 1273, 1281 27 (9th Cir. 1996)). This is the most demanding standard in Social Security cases. Id. at 1015. 28 “In evaluating the credibility of pain testimony after a claimant produces objective medical 1 evidence of an underlying impairment, an ALJ may not reject a claimant’s subjective 2 complaints based solely on a lack of medical evidence to fully corroborate the alleged 3 severity of pain.” Burch v. Barnhart, 400 F.3d 676, 682 (9th Cir. 2005). 4 Here, the ALJ found “[Plaintiff’s] medically determinable impairments could 5 reasonably be expected to cause the alleged symptoms; however, [Plaintiff’s] statements 6 concerning the alleged intensity, persistence and limiting effects of these symptoms are not 7 entirely consistent with the medical evidence and other evidence in the record for the 8 reasons explained in this decision.” (R. at 838.) 9 First, the ALJ opined that Plaintiff improved or remained stable with treatment. 10 (R. at 839.) The ALJ pointed out that Plaintiff reported 60% to 70% relief with steroid 11 injections. (R. at 325, 577, 839.) Plaintiff also reported her medications were effective in 12 managing her pain. (R. at 325, 839, 389, 475, 485, 577, 631, 633, 668, 670, 678, 722, 737, 13 741, 769, 970, 1172, 1178, 1332, 1337, 1342, 1434, 1513.) The ALJ also noted that 14 Plaintiff’s treating providers consistently noted she was in no acute distress. (R. at 273– 15 417, 423, 433, 647, 804, 839.) In the 2018 opinion, this Court noted that Plaintiff takes 16 prescribed medications but indicated that nothing takes her pain away completely. (R. at 17 925, 47.) Langfield, No. CV-17-00056-PHX-JZB, 2018 WL 1456311, at *6. Plaintiff’s 18 relief from radiofrequency ablation and epidural injections was only short term. (R. at 925– 19 26, 56.) Id. Plaintiff correctly points out that the Court found that this reason was 20 insufficient in rejecting Plaintiffs’ symptom testimony in 2018. The Court now finds that 21 is once again true. (Pl. Br. at 17; R. at 926–27.) Id. at 7. 22 Additionally, the ALJ noted that Plaintiff did not stop working because of her 23 medical impairments. (R. at 567, 839.) However, the Court noted in the 2018 opinion that 24 Plaintiff indicated she did not know if her employment was terminated due to her medical 25 problems. (R. at 925, 55.) Id. at 6. Additionally, the Court indicated that Plaintiff 26 considered applying for “some type of secretarial type work” but decided not to because 27 she did not think she would be able to work on a computer with her neck and back pain. 28 (R. at 925, 46.) Id. 1 Next, the ALJ explained that Plaintiff’s symptom testimony was inconsistent with 2 Plaintiff’s ADLs. (R. at 840.) Specifically, the ALJ pointed out that Plaintiff cares for her 3 young grandchildren and recently adopted her two-year-old grandchild. (R. at 211, 840, 860, 4 969–70.) The ALJ found that Plaintiff’s ability to care for her young grandchildren, even 5 considering the help she has from family, is inconsistent with Plaintiff’s symptom testimony. 6 (R. at 840, 860.) This explanation provides no more detail than the ALJ’s 2015 opinion, 7 which this Court found was insufficient. Id. at 6–7. This Court also explained in 2018 that 8 though Plaintiff cared for her young grandchildren, she had to make modifications to 9 accommodate her physical limitations. (R. at 926.) Id. at 6. For example, this Court pointed 10 out that Plaintiff makes meals for her grandchildren, but instead of cooking things, she will 11 heat things up in the microwave because it is easier. (R. at 926.) Id. at 6. 12 Finally, the ALJ found that Plaintiff’s symptom testimony was not consistent with 13 the medical record. (R. at 839.) Specifically, the ALJ found that diagnostic imaging reports 14 showed that Plaintiff has severe musculoskeletal disorders, but that the findings in those 15 reports “fall short of substantiating her assertions of debilitating exertional restrictions.” 16 (R. at 839.) The ALJ noted that Plaintiff was diagnosed with degenerative disc disease in 17 her neck and back and that diagnostic images showed mild to moderate findings including: 18 central disc protrusion, anterior disc protrusion, broad-based disc protrusion, moderate 19 bilateral neural foraminal narrowing, and disc bulge. (R. at 723, 839.) The ALJ noted that 20 there was no objective evidence of severe stenosis or nerve root impingement and that 21 diagnostic images of Plaintiff’s spine were stable. (R. at 723, 839.) The ALJ also found 22 that Plaintiff did not experience numbness or weakness. (R. at 439, 839.) Additionally, the 23 ALJ explained that Plaintiff consistently had normal gait, normal strength and sensation in 24 her upper extremities, and normal sensation in her lower extremities. (R. at 321, 327, 333, 25 351, 355, 359, 371, 423, 433, 439, 444, 495, 533–43, 549, 559–60, 657, , 672, 724, 729, 26 757–58, 771, 839, 1173, 1205, 1313, 1329–30, 1339, 1435–46.) Plaintiff’s providers 27 frequently noted she had tenderness to palpation in the paraspinous cervical muscles, 28 trapezius muscles, mid para thoracic muscles, and lumbar paraspinal muscles. (R. at 327, 1 333, 339, 440, 444–45, 460, 576–77, 608, 662, 672, 839, 1436.) Plaintiff had positive leg 2 raises and slightly reduced strength in her lower extremities, but the ALJ noted that there 3 was no evidence that Plaintiff had difficulty standing or walking, and Plaintiff denied that 4 she had difficulty walking or unsteadiness. (R. at 439–40, 444, 459, 514, 576, 582, 688– 5 89, 703, 724, 729, 738–39, 839, 1172–73, 1179, 1204–05, 1330, 1339, 1436, 1514–15.) 6 The ALJ’s only potential valid reason for rejecting Plaintiff’s symptom testimony—that it 7 was purportedly inconsistent with the objective medical evidence—also fails because, even 8 if true, it cannot form the sole basis for rejecting a claimant’s testimony. See Burch, 400 9 F.3d at 682. Since the Court rejects the ALJ’s other bases for rejecting Plaintiff’s testimony, 10 the ALJ’s reliance on the objective medical evidence stands alone, and therefore, is 11 inadequate. As such, the ALJ erred in rejecting Plaintiff’s symptom testimony. 12 B. The ALJ erred in assigning little weight to Dr. Peachy’s medical opinion. 13 Plaintiff argues the ALJ erred in assigning little weight to the opinion of Dr. Peachy. 14 (Pl. Br. at 20–24.) While “[t]he ALJ must consider all medical opinion evidence,” there is 15 a hierarchy among the sources of medical opinions. Tommasetti v. Astrue, 533 F.3d 1035, 16 1041 (9th Cir. 2008). Those who have treated a claimant are treating physicians, those who 17 examined but did not treat the claimant are examining physicians, and those who neither 18 examined nor treated the claimant are nonexamining physicians. Lester v. Chater, 81 F.3d 19 821, 830 (9th Cir. 1995). “As a general rule, more weight should be given to the opinion 20 of a treating source than to the opinion of doctors who did not treat the claimant.” Id. This 21 is so because treating physicians have the advantage of in-person interaction and typically 22 a longer history of treatment than a claimant’s other doctors, and their “subjective 23 judgments . . . are important, and properly play a part in their medical evaluations.” Embrey 24 v. Bowen, 849 F.2d 418, 422 (9th Cir. 1988). 25 An ALJ “may only reject a treating or examining physician’s uncontradicted 26 medical opinion based on ‘clear and convincing reasons.’” Carmickle v. Comm’r of Soc. 27 Sec., 533 F.3d 1155, 1164 (9th Cir. 2008) (citing Lester, 81 F.3d at 830–31). “Where such 28 an opinion is contradicted, however, it may be rejected for specific and legitimate reasons 1 that are supported by substantial evidence in the record.” Id. An ALJ meets this standard 2 by “setting out a detailed and thorough summary of the facts and conflicting medical 3 evidence, stating his interpretation thereof, and making findings.” Magallanes v. Bowen, 4 881 F.2d 747, 751 (9th Cir. 1989). 5 Dr. Peachy examined Plaintiff in April 2015. (R. at 802–10, 840.) He concluded that 6 Plaintiff had a “complete form of disability.” (R. at 806, 840.) The ALJ assigned little 7 weight to Dr. Peachy’s opinion because it was not consistent with the medical evidence in 8 the record. (R. at 841.) For example, Plaintiff’s treating providers noted Plaintiff had 9 normal strength and sensation in her bilateral upper extremities and she has normal gait. 10 (R. at 321, 327, 333, 351, 355, 359, 371, 423, 433, 439, 444, 495, 533–43, 549, 559–60, 11 657, 672, 724, 729, 757–58, 771, 841, 1173, 1205, 1313, 1329–30, 1339, 1435–46.) 12 However, the ALJ noted that Dr. Peachy opined that Plaintiff could lift and/or carry more 13 than 15 pounds but less than 20 pounds, Plaintiff could only sit for 2 hours in an eight-hour 14 workday and stand or walk for 2 hours in an eight-hour workday, and Plaintiff would need 15 to switch between sitting, standing, and walking every 46 to 60 minutes with a 10 to 15 16 minute rest between changing positions. (R. at 807, 841.) The ALJ thus found that 17 Dr. Peachy’s opinion was not consistent with the treating providers’ opinions. (R. at 841.) 18 The ALJ also found that medical evidence in the record did not support Dr. Peachy’s 19 opinion that Plaintiff would need to miss 4 to 5 days of work a month because Plaintiff’s 20 treating providers consistently noted that Plaintiff was in no acute distress. (R. at 273–417, 21 423, 433, 647, 804, 808, 841.) Finally, the ALJ noted that Dr. Peachy’s opinion should be 22 awarded little weight because Plaintiff reported her medication was effective for pain and 23 had no side effects. (R. at 325, 389, 475, 481, 485, 577, 631, 633, 668, 670, 678, 722, 737, 24 741, 769, 1172, 1178, 1332, 1337, 1342, 1434, 1513.) 25 In 2018, the Court determined the ALJ had not provided specific and legitimate reasons 26 for assigning little weight to Dr. Peachy’s opinion. (R. at 921–25.) Id. at 3–5. Specifically, this 27 Court found that the ALJ did not identify specific medical evidence that was inconsistent or 28 contrary to Dr. Peachy’s findings. (R. at 922.) Id. at 4. The same is true here. 1 Here, the ALJ has pointed to specific medical evidence in Dr. Peachy’s opinion and 2 specific medical evidence from treating providers, but the ALJ fails to take the last step in 3 explaining how that evidence conflicts with Dr. Peach’s opinion. The ALJ cites to evidence 4 that treating providers opined Plaintiff had normal strength and sensation in her bilateral 5 upper extremities and she has normal gait. (R. at 321, 327, 333, 351, 355, 359, 371, 423, 6 433, 439, 444, 495, 533–34, 549, 559–60, 657, 672, 724, 729, 757–58, 771, 841, 1173, 7 1205, 1313, 1329–30, 1339, 1435–46.) But the ALJ does not describe how these findings 8 conflict with Dr. Peachy’s opinion that Plaintiff had limitations on lifting, sitting, standing 9 and walking, and would need to alternate these activities periodically, as set forth above. 10 The ALJ also found that Dr. Peachy’s opinion that Plaintiff would need to miss 4 to 11 5 days of work a month conflicted with other medical opinions that Plaintiff was in no 12 acute distress. (R. at 808, 841; Pl. Br. at 22.) This is an insufficient conclusion drawn by 13 the ALJ. (Pl. Br. at 22.) The ALJ does not explain how Plaintiff not appearing in acute 14 distress contradicts Dr. Peachy’s finding that Plaintiff would need to miss 4 to 5 days of 15 work a month. 16 The ALJ has, again, not provided specific and legitimate reasons in explaining why 17 Dr. Peachy’s opinion should be awarded little weight. The ALJ took one step further this 18 time in pointing to specific evidence in the record and specific components of Dr. Peachy’s 19 opinion, but does not describe how Dr. Peachy’s opinion and the other medical evidence 20 cited actually conflict with each other. 21 C. The appropriate remedy is to remand Plaintiff’s case for a new disability finding. 22 23 Plaintiff asks the Court to apply the “credit-as-true” rule, which would result in a 24 remand of Plaintiff’s case for payment of benefits rather than for further proceedings. 25 (Pl. Br. at 24–25.) The credit-as-true rule only applies in cases where three elements are 26 present. Treichler v. Comm’r of Soc. Sec., 775 F.3d 1090, 1099–1102 (9th Cir. 2014). First, 27 the ALJ must have failed to provide legally sufficient reasons for rejecting medical 28 evidence. Id. at 1100. Second, the record must be fully developed, there must be no 1 || outstanding issues that must be resolved before a determination of disability can be made, and the Court must find that further administrative proceedings would not be useful. /d. at || 1101. Further proceedings are considered useful when there are conflicts and ambiguities 4|| that must be resolved. Jd. Third, if the above elements are met, the Court may “find[] the 5 || relevant testimony credible as a matter of law . . . and then determine whether the record, 6|| taken as a whole, leaves ‘not the slightest uncertainty as to the outcome of [the] 7\| proceeding.’” Jd. (citations omitted). 8 Here, all the elements of the credit-as-true rule are met. As discussed above, the ALJ 9|| erred by rejecting Plaintiff's symptom testimony and Dr. Peachy’s opinion. Next, the || record is fully developed, and further proceedings would serve no useful purpose. The 11 || record is free of significant conflict and does not require further development. Finally, the 12 || improperly discredited evidence, if credited as true, would require the ALJ to find Plaintiff disabled. At Plaintiff's hearing, the vocational expert testified that limitations consistent with Dr. Peachy’s opinion would be inconsistent with full-time employment. (R. at 870.) 15 || The vocational expert also testified that limitations consistent with Plaintiffs symptom 16 || testimony would be inconsistent with full-time employment. (R. at 871-73.) Since the 17 || Court finds the record raises no serious doubt that Plaintiff is, in fact, disabled, the Court 18 || will remand Plaintiff's case for computation and award of benefits. 19 Accordingly, the Court applies the credit-as-true rule and will remand this matter 20 || for computation and award of benefits. 21 IT IS THEREFORE ORDERED remanding this matter to the Social Security 22 || Administration for computation and award of benefits consistent with the Order. 23 IT IS FURTHER ORDERED directing the Clerk to enter judgment accordingly 24 || and close this case. 25 Dated this 25th day of June, 2021. CN 26 “wok: 97 wefehlee— Unifga State#District Judge 28 -10-