Carl v. Commissioner of Social Security Administration ( 2023 )

1 WO 2 3 4 5 6 IN THE UNITED STATES DISTRICT COURT 7 FOR THE DISTRICT OF ARIZONA 8 9 Elizabeth Dawn Carl, No. CV-23-00203-PHX-MTL 10 Plaintiff, ORDER 11 v. 12 Commissioner of Social Security Administration, 13 Defendant. 14 15 Plaintiff Elizabeth Dawn Carl (“Plaintiff”) challenges the denial of her application 16 for Disability Insurance Benefits and for Supplemental Security Income (“SSI”) by 17 Defendant Social Security Administration under Titles II and XVI the Social Security 18 Act. Plaintiff filed a Complaint (Doc. 1) with the Court seeking review of these claims. 19 But in her Opening and Reply Briefs, Plaintiff only briefed and analyzed two issues 20 related to the SSI claim for the Court’s consideration. (Docs. 13, 16) As such, the Court 21 only reviews the denial of the SSI claim. See Lewis v. Apfel, 236 F.3d 503, 517 n.13 (9th 22 Cir. 2001); Greenwood v. FAA, 28 F.3d 971, 977 (9th Cir. 1994) (holding that issues 23 presented without “a specific, cogent argument” are waived). The Court has reviewed the 24 briefs (Docs. 13, 15, 16) and the Administrative Record (Docs. 9-10, “A.R.”), and now 25 affirms the Administrative Law Judge’s (“ALJ”) decision. 26 I. BACKGROUND 27 Plaintiff filed an application for disability insurance benefits under Title II and SSI 28 under Title XVI on May 15, 2020, for a period of disability beginning on February 5, 1 2020. (A.R. at 66, 78.) Plaintiff’s applications were initially denied on May 20, 2020 (id. 2 at 92-99), and upon reconsideration on April 19, 2021 (id. at 103-110). Thereafter, 3 Plaintiff filed a request for a hearing, and a telephonic hearing was held on November 9, 4 2021. (Id. at 35-61.) The ALJ dismissed Plaintiff’s disability insurance benefits 5 application and denied her SSI application. (Id. at 18-29.) The Appeals Council denied 6 Plaintiff’s request for review. (Id. at 3-7). Plaintiff now seeks judicial review with this 7 Court pursuant to 42 U.S.C. §§ 405(g), 1383(c). 8 The Court has reviewed the record and will discuss the pertinent evidence in 9 addressing the issues raised by the parties. Upon considering the medical evidence and 10 opinions, the ALJ evaluated Plaintiff’s disability claim based on the following severe 11 impairments: head injury with headaches and left knee injury. (Id. at 20.) 12 The ALJ dismissed Plaintiff’s disability insurance benefits claim because the 13 claim did not meet the period of disability and disability insurance benefit requirements 14 under 42 U.S.C. §§ 416(i) and 423(a). (Id. at 18.) As for the SSI claim, the ALJ found 15 that Plaintiff did not have an impairment or combination of impairments that meets or 16 medically equals the severity of one of the listed impairments of 20 C.F.R. Part 404, 17 Subpart P, Appendix 1. (Id. at 21-23.) Next, the ALJ determined Plaintiff’s residual 18 functional capacity (“RFC”).1 The ALJ found: 19 After careful consideration of the entire record, the 20 undersigned finds that the claimant has the [RFC] to perform sedentary work as defined in 20 CFR [§] 416.967(a) except 21 no crawling, climbing of ladders or scaffolds, occasional 22 crouching, kneeling or climbing stairs, rare (5% of day or less) stooping, and limited to simple work. 23 24 (Id. at 23.) Based on this RFC, the ALJ found Plaintiff capable of performing jobs such 25 as assembler, document preparer, and telephone information clerk. (Id. at 28.) Ultimately, 26 having reviewed the medical evidence and testimony, the ALJ concluded that Plaintiff 27 was not disabled under § 1614(a)(3)(A) of the Social Security Act. (Id.) 28 1 Residual functional capacity refers to the most a claimant can still do in a work setting despite his or her limitations. 20 C.F.R. § 416.945(a)(1). 1 II. LEGAL STANDARD 2 In determining whether to reverse an ALJ’s decision, the district court reviews 3 only those issues raised by the party challenging the decision. See Lewis, 236 F.3d at 517 4 n.13. The Court may set aside the Commissioner’s determination only if it is not 5 supported by substantial evidence or is based on legal error. Orn v. Astrue, 495 F.3d 625, 6 630 (9th Cir. 2007). Substantial evidence is relevant evidence that a reasonable person 7 might accept as adequate to support a conclusion considering the entire record. Id. To 8 determine whether substantial evidence supports a decision, the Court must consider the 9 entire record and may not affirm simply by isolating a “specific quantum of supporting 10 evidence.” Id. (citation omitted). Generally, “[w]here the evidence is susceptible to more 11 than one rational interpretation, one of which supports the ALJ’s decision, the ALJ’s 12 conclusion must be upheld.” Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002) 13 (citation omitted). The substantial evidence threshold “defers to the presiding ALJ, who 14 has seen the hearing up close.” Biestek v. Berryhill, 587 U.S. —, 139 S. Ct. 1148, 1157 15 (2019); see also Thomas v. CalPortland Co., 993 F.3d 1204, 1208 (9th Cir. 2021) (noting 16 substantial evidence “is an extremely deferential standard”). 17 To determine whether a claimant is disabled, the ALJ follows a five-step process. 18 20 C.F.R. § 416.920(a). The claimant bears the burden of proof on the first four steps, but 19 the burden shifts to the Commissioner at step five. Tackett v. Apfel, 180 F.3d 1094, 1098 20 (9th Cir. 1999). At the first step, the ALJ determines whether the claimant is presently 21 engaging in substantial gainful activity. 20 C.F.R. § 416.920(a)(i), (b). If so, the claimant 22 is not disabled, and the inquiry ends. Id. At step two, the ALJ determines whether the 23 claimant has a “severe” medically determinable physical or mental impairment. 20 C.F.R. 24 § 416.920(a)(ii), (c). If not, the claimant is not disabled, and the inquiry ends. Id. At step 25 three, the ALJ considers whether the claimant’s impairment or combination of 26 impairments meets or medically equals an impairment listed in Appendix 1 to Subpart P 27 of 20 C.F.R. Part 404. 20 C.F.R. § 416.920(a)(iii), (d). If so, the claimant is automatically 28 found to be disabled. Id. At step four, the ALJ assesses the claimant’s RFC and 1 determines whether the claimant is still capable of performing past relevant work. 2 20 C.F.R. § 416.920(a)(iv), (e). If so, the claimant is not disabled, and the inquiry ends. 3 Id. If not, the ALJ proceeds to the fifth and final step, where the ALJ determines whether 4 the claimant can perform any other work in the national economy based on the claimant’s 5 RFC, age, education, and work experience. 20 C.F.R. § 416.920(a)(v), (f). If not, the 6 claimant is disabled. Id. 7 III. DISCUSSION 8 Plaintiff raises two issues before the Court. First, Plaintiff contends that the ALJ 9 failed to rely on any medical opinion evidence when making the physical RFC 10 determination, making the determination unsupported by substantial evidence. (Doc. 13 11 at 11-18.) Second, Plaintiff argues that the ALJ failed to rely on any medical opinion 12 evidence and to account for moderate limitations in concentration, persistence, or pace 13 when making the mental RFC determination, making the determination unsupported by 14 substantial evidence. (Doc. 13 at 18-25.) 15 A. Physical Determination 16 Plaintiff argues that when the ALJ found Dr. Charles Combs’ opinion 17 unpersuasive “the record lacked sufficient evidence necessary” to make Plaintiff’s 18 physical RFC determination.2 (Doc. 13 at 12-13.) Specifically, Plaintiff argues that the 19 ALJ erred by excluding the “only medical opinion” and relying on his own “layperson 20 interpretation of raw medical evidence.” (Id. at 14.) The Court disagrees. 21 In 2017, the Commissioner revised the regulations for evaluating medical 22 evidence for all claims filed on or after March 27, 2017. See Revisions to Rules 23 Regarding the Evaluation of Medical Evidence, 82 Fed. Reg. 5844, 5844 (Jan. 18, 2017). 24 As Plaintiff’s claim was filed after the effective date, the revised rules apply. (A.R. at 66, 25 78.) Unlike the old regulations, the revised rules do not require an ALJ to defer to the 26 opinions of a treating physician nor assign every medical opinion a specific evidentiary 27 2 Plaintiff’s argument challenges the ALJ’s findings even though these findings were 28 more favorable for Plaintiff than the limitations Dr. Combs assessed. (Compare A.R. at 23, with id. at 27, 84-86.) 1 weight. 20 C.F.R. § 416.920c(a). 2 The revised rules instead require the ALJ to consider all opinion evidence and 3 determine the persuasiveness of each medical opinion’s findings based on factors 4 outlined in the regulations. 20 C.F.R. § 416.920c(a)-(b). The most important factors 5 considered by an ALJ are “consistency” and “supportability.” Id. § 416.920c(b)(2). The 6 regulations provide supportability as “relevant the objective medical evidence and 7 supporting explanations presented by a medical source are to support his or her medical 8 opinion(s) or prior administrative medical findings.” Id. § 416.920c(c)(1). In contrast, 9 consistency means “[t]he more consistent a medical opinion . . . is with the evidence from 10 other medical sources and nonmedical sources in the claim, the more persuasive the 11 medical opinion . . . will be.” Id. § 416.920c(c)(2). Lastly, the ALJ may also consider, to 12 a lesser degree, other factors, such as the length and purpose of the treatment relationship, 13 the kinds of examinations performed, and whether the medical source examined the 14 claimant. Id. § 416.920c(b)(3). 15 The Ninth Circuit has held that the revised rules clearly intended to abrogate its 16 precedent requiring ALJs to provide “specific and legitimate reasons” for rejecting a 17 treating physician’s opinion. Woods v. Kijakazi, 32 F.4th 785, 792 (9th Cir. 2022) 18 (citation omitted). Nevertheless, “[e]ven under the new regulations, an ALJ cannot reject 19 an examining or treating doctor’s opinion as unsupported or inconsistent without 20 providing an explanation supported by substantial evidence.” Id. Therefore, an ALJ, 21 “must ‘articulate . . . how persuasive’ it finds ‘all of the medical opinions’ from each 22 doctor or other source, and ‘explain how it considered the supportability and consistency 23 factors’ in reaching these findings.” Id. (quoting 20 C.F.R. § 404.1520c(b), (b)(2)) 24 (internal citation omitted). 25 The ALJ’s finding that Dr. Combs’ opinion was inconsistent with the weight of 26 the evidence in the record is supported by substantial evidence. Here, the ALJ concluded 27 that Dr. Combs’ opinion contradicted the Plaintiff’s record of “objective evidence of 28 radiographic scans, physical neurological examinations, and follow-up treatment notes, 1 which showed [Plaintiff’s] severe physical knee condition.” (A.R. at 27.) The ALJ found 2 Dr. Combs’ conclusion that Plaintiff “could do light exertional work with occasional 3 pushing and pulling with the left lower extremity, occasional postural activity, except no 4 climbing of ladders, ropes, or scaffolds” was unsupported by the underlying records, 5 which showed Plaintiff could only perform sedentary work under 20 C.F.R.§ 416.967(a). 6 (Id. at 23, 27.) 7 Plaintiff’s argument that the ALJ relied on his own “layperson” interpretation of 8 the medical records is unfounded. (See Doc. 15 at 7; Doc. 13 at 14.) The ALJ’s analysis 9 here is unlike cases where an ALJ interpreted raw medical data to reach a conclusion that 10 no other physician did. See, e.g., Howell v. Kijakazi, No. 20-CV-2517-BLM, 2022 WL 11 2759090, *7-*8 (S.D. Cal. July 14, 2022) (holding that an ALJ erred by interpreting raw 12 medical data, such as MRIs, radiology studies, and x-rays, to find Plaintiff’s functional 13 capabilities rather than rely on medical opinions). Instead, the ALJ cited multiple treating 14 physician notes when reaching his conclusion. (A.R. at 27.) For example, the ALJ 15 considered Dr. Todd Runyan’s notes, which identified Plaintiff’s “chronic knee plain and 16 mobility deficits” that create “difficulty bending and extending the knee” and the ability 17 to stand for more than five minutes or walk more than 10 minutes. (Id. at 25, 27, 602.) 18 The ALJ also cited Nurse Practitioner Yesenia Gianaros’ evaluation and treatment notes, 19 which identified Plaintiff’s decreased range of motion in her left knee. (Id. at 25, 27, 559- 20 63.) The ALJ also considered Dr. Samar Tawakkol’s assessment that Plaintiff’s left 21 knee’s range of motion was limited to about 85 to 90 degrees. (Id. at 25, 27, 682.) The 22 ALJ therefore supported his conclusion that Dr. Combs’ opinion was unpersuasive with 23 substantial evidence. 24 The ALJ properly assessed Plaintiff’s physical RFC. The responsibility of 25 determining RFC falls on the ALJ, not the physician. Vertigan v. Halter, 260 F.3d 1044, 26 1049 (9th Cir. 2001). The ALJ considers a claimant’s ability to meet physical and mental 27 demands, sensory requirements, and other functions. See 20 C.F.R. § 416.945(b)-(d). An 28 ALJ’s responsibility includes “translating and incorporating clinical findings into a 1 succinct RFC.” Rounds v. Comm’n Soc. Sec. Admin., 807 F.3d 996, 1006 (9th Cir. 2015). 2 The ALJ found Plaintiff possessed the RFC “to perform sedentary work as defined in 20 3 C.F.R. [§] 416.967(a) except no crawling, climbing of ladders or scaffolds, occasional 4 crouching, kneeling or climbing stairs, rare (5% of day or less) stooping.” (A.R. at 23.) 5 Under 20 C.F.R. § 416.967(a), “sedentary work” involves occasional walking and 6 standing and “lifting no more than 10 pounds at a time and occasionally lifting or 7 carrying articles like docket files, ledgers, and small tools.” Id. As discussed, the ALJ 8 rejected Dr. Combs’ opinion when the opinion conflicted with the record of objective test 9 results and other medical records, including treating physician’s notes (A.R. at 23-27). 10 See Magallanes v. Bowen, 881 F.2d 747, 751-52 (1989). Instead, the ALJ determined that 11 the record reflected that Plaintiff’s knee pain would limit her standing and walking, 12 which validated limiting Plaintiff to sedentary work rather than Dr. Combs’ 13 recommendation of “light exertional work.” (A.R. at 27.) The ALJ outlined the Plaintiff’s 14 entire medical record, documenting and citing test results, physician’s notes, and other 15 medical records, to reach this conclusion. (Id. at 20-28.) As Defendant points out (Doc. 16 15 at 10), the ALJ’s findings were more restrictive than the limitations that Dr. Combs 17 assessed. See 20 C.F.R. § 416.967(a) (defining “light work” as a job that “requires a good 18 deal of walking or standing” and “lifting no more than 20 pounds at a time with frequent 19 lifting or carrying of objects weighting up to 10 pounds”). No harm exists in the 20 “overinclusion of debilitating factors.” See Johnson v. Shalala, 60 F.3d 1428, 1436 n.9 21 (9th Cir. 1995) (“However, this overinclusion of debilitating factors is harmless simply 22 because if a person can do a job that requires increased concentration, the claimant is also 23 capable of performing work that requires less concentration.”). 24 The Court therefore finds that the ALJ’s physical RFC determination is supported 25 by substantial evidence and free from legal error. 26 B. Mental Impairments 27 Plaintiff argues that the ALJ erred by not finding Drs. E. Campbell, Ralph 28 Mertens, and David Beil-Adaskin persuasive when making Plaintiff’s mental RFC 1 determination.3 (Doc. 13 at 18-20.) Specifically, Plaintiff argues that the ALJ erred by 2 “rejecting the only available medical opinion evidence” and “improperly interpreting the 3 raw medical evidence.” (Id. at 20.) In addition, Plaintiff claims that ALJ erred by failing 4 to “adequately account for his own findings that Plaintiff has moderate limitations in 5 concentration, persistence, and pace into his RFC, without explanation.” (Id. at 23.) The 6 Court disagrees. 7 When evaluating mental impairment severity, the ALJ must follow a two-step 8 procedure. See 20 C.F.R. § 416.920a(a). The first step requires evaluating a claimant’s 9 “pertinent symptoms, signs, and laboratory findings” to find if the claimant has a 10 medically determined impairment. Id. § 416.920a(b)(1). In doing so, the ALJ must also 11 “specify the symptoms, signs, and laboratory findings that substantiate the presence of 12 [each determined] impairment and document [the] findings . . . . ” Id. 13 The second step involves the ALJ rating “the degree of functional limitation 14 resulting from [claimant’s] impairment.” 20 C.F.R. § 416.920a(b)(2). This process varies 15 case-by-case. For every claimant, the ALJ must consider all relevant evidence and 16 determine the degree that the claimant’s “ability to function independently, appropriately, 17 effectively, and on a sustained basis” is hindered by his or her mental impairment. Id. 18 § 416.920a(c). The ALJ does this by rating the claimant’s degree of functional limitation 19 in four areas: “Understand, remember, or apply information; interact with others; 20 concentrate, persist, or maintain pace; and adapt or manage oneself.” Id. The rating 21 system is based on a five-point scale: “None, mild, moderate, marked, and extreme.” Id. 22 Beyond this determination, an “ALJ [is] not required to make any more specific findings 23 of the claimant’s functional limitations.” Hoopai v. Astrue, 499 F.3d 1071, 1077-78 (9th 24 Cir. 2007). Next, the ALJ determines the severity of the mental impairment. See 20 25 C.F.R. § 416.920a(d). During this process, to explain and record his or her administrative 26 review, an ALJ must provide the proper documentation including a standard document 27 3 Plaintiff’s argument challenges the ALJ’s findings even though these findings were 28 more favorable for Plaintiff than the limitations assessed by Drs. Campbell, Mertens, and Beil-Adaskin. (Compare A.R. at 23, with id. at 27, 73-74, 79-84, 721.) 1 accounting how the technique was applied. See id. § 416.920a(e). Later reviews by 2 written decision must also “document application of the technique.” See id. 3 The ALJ’s finding that Drs. Campbell’s, Mertens’, and Beil-Adaskin’s opinions 4 were inconsistent with the weight of the evidence in the record is supported by substantial 5 evidence. Drs. Campbell and Mertens classified Plaintiff’s mental limitations as “non- 6 severe conditions, with only mild limitations in understand, remember, or apply 7 information and concentrate, persist, or maintain pace.” (A.R. at 26, 73-74, 81-82.) Dr. 8 Beil-Adaskin concluded that Plaintiff had “no severe mental limitations.” (Id. 26-27, 9 721.) Here, the ALJ found Drs. Campbell’s, Mertens’, and Beil-Adaskin’s opinions 10 unpersuasive because the “objective evidence of radiographic scans, physical and 11 neurological examinations, and follow-up notes” supported a severe mental condition 12 limiting Plaintiff to “simple work.” (Id. at 27.) 13 Plaintiff’s argument that the ALJ relied on his own interpretation of “raw medical 14 records” is unfounded. (See Doc. 15 at 9; Doc. 13 at 20.) The ALJ cited multiple treating 15 physician notes when reaching his conclusion. (A.R. at 22, 27.) For example, the ALJ 16 cited Ms. Gianaros’ treatment plan, which identified continued follow-up and treatment 17 for Plaintiff’s post-concussion recovery included avoiding activities that required 18 prolonged concentration and attention. (Id. at 26-27, 554.) The ALJ also cited Dr. Kendra 19 Foreman’s and Dr. B. Aluri’s notes, which both indicate Plaintiff suffered memory 20 problems from her head injury. (Id. at 26-27, 730, 736.) This analysis is consistent with 21 the ALJ’s finding earlier in the decision that the medical record only supported Plaintiff’s 22 head injury with headaches as a severe impairment and all other mental conditions as 23 non-severe (see id. at 20, 22). See Kaufmann v. Kijakazi, 32 F.4th 843, 851 (9th Cir. 24 2022) (holding that district court did not err when it reviewed “all the pages of the ALJ’s 25 decision” to find that the ALJ findings were supported by substantial evidence (emphasis 26 in original)). Specifically, the ALJ concluded that Plaintiff’s post-concussion syndrome 27 with headaches resulted in moderate limitations in concentration. (Id. at 22-23.) The ALJ 28 therefore supported his conclusion that Drs. Campbell’s, Mertens’, and Beil-Adaskin’s 1 opinions were unpersuasive with substantial evidence. See Magallanes, 881 F.2d at 755 2 (concluding substantial evidence existed when the ALJ “summarized the facts and 3 conflicting clinical evidence in a detailed and through fashion, stating his interpretation 4 and making findings”). 5 The ALJ properly accounted for his own findings that Plaintiff has moderate 6 limitations in concentration, persistence, and pace into the RFC determination. See 7 Rounds, 807 F.3d at 1006. The ALJ found Plaintiff possessed in relation to her mental 8 impairment an RFC “limited to simple work.” (A.R. at 23.) As discussed, the ALJ 9 outlined the Plaintiff’s entire medical record to come to this conclusion. (Id. at 20-28.) If 10 the ALJ had followed the recommendations of Drs. Campbell, Mertens, and Beil- 11 Adaskin, the Plaintiff would likely be considered to perform “basic work” rather than 12 “simple work.” See 20 C.F.R. § 416.922(a) (defining non-severe impairment as “[a]n 13 impairment or combination of impairments is not severe if it does not significantly limit 14 your physical or mental ability to do basic work activities” (emphasis added)). Instead, 15 the ALJ’s RFC was more restrictive, accounting for her moderate limitations in 16 concentration, persistence, and pace. See, e.g., Stubbs-Danielson v. Astrue, 539 F.3d 17 1169, 1174 (9th Cir. 2008) (affirming ALJ’s RFC determination limiting claimant to 18 “simple tasks” for a claimant with deficiencies in concentration, persistence, and pace). 19 Also, no harm exists in the “overinclusion of debilitating factors.” See Johnson, 60 F.3d 20 at 1436 n.9. Based on a review of the record, the Court therefore concludes that the ALJ’s 21 RFC finding properly incorporated Plaintiff’s moderate limitations. See Stubbs- 22 Danielson, 539 F.3d at 1174 (“This represents the type of credibility determination 23 charged to the ALJ which we may not disturb where, as here, the evidence reasonably 24 supports the ALJ’s decision.”). 25 The Court therefore finds that the ALJ’s mental impairment determination is 26 supported by substantial evidence and free from legal error. 27 . . . 28 . . . IV. CONCLUSION 2 Accordingly, 3 IT IS ORDERED affirming the January 24, 2022 decision by the Administrative 4|| Law Judge and the Commissioner of the Social Security Administration (AR at 18-29). 5 IT IS FURTHER ORDERED directing the Clerk to enter final judgment 6 || consistent with this Order and close this case. 7 Dated this 6th day of October, 2023. 8 Micha T. Sihurde Michael T, Liburdi 11 United States District Judge 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 -ll-