(SS) Maravillas v. Commissioner of Social Security ( 2024 )

1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 FOR THE EASTERN DISTRICT OF CALIFORNIA 10 11 DANIEL A. MARAVILLAS, No. 2:23-cv-00782-CKD 12 Plaintiff, 13 v. ORDER 14 COMMISSIONER OF SOCIAL SECURITY, 15 Defendant. 16 17 18 Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security 19 (“Commissioner”) denying applications for Disability Income Benefits (“DIB”) and 20 Supplemental Security Income (“SSI”) under Titles II and XVI of the Social Security Act 21 (“Act”), respectively. The parties have consented to magistrate judge jurisdiction. For the 22 reasons discussed below, the court will grant plaintiff’s motion for summary judgment and deny 23 the Commissioner’s cross-motion for summary judgment. 24 BACKGROUND 25 Plaintiff, born in 1990, applied on March 13, 2020 for DIB and SSI, alleging disability 26 beginning January 15, 2020. Administrative Transcript (“AT”) 23, 31. Plaintiff alleged he was 27 unable to work due to Tourette’s Syndrome, PTSD, personality disorder, schizophrenia, and 28 ADHD. AT 75. In a decision dated December 10, 2021, the ALJ determined that plaintiff was 1 not disabled.1 AT 23-31. The ALJ made the following findings (citations to 20 C.F.R. omitted): 2 1. The claimant meets the insured status requirements of the Social Security Act 3 through June 30, 2025. 4 2. The claimant has not engaged in substantial gainful activity since January 15, 2020, the alleged onset date. 5 3. The claimant has the following severe impairments: 6 schizoaffective disorder, posttraumatic stress disorder, and bipolar disorder. 7 4. The claimant does not have an impairment or combination of 8 impairments that meets or medically equals one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1. 9 5. After careful consideration of the entire record, the undersigned 10 1 Disability Insurance Benefits are paid to disabled persons who have contributed to the 11 Social Security program, 42 U.S.C. § 401 et seq. Supplemental Security Income is paid to 12 disabled persons with low income. 42 U.S.C. § 1382 et seq. Both provisions define disability, in part, as an “inability to engage in any substantial gainful activity” due to “a medically 13 determinable physical or mental impairment. . . .” 42 U.S.C. §§ 423(d)(1)(a) & 1382c(a)(3)(A). A parallel five-step sequential evaluation governs eligibility for benefits under both programs. 14 See 20 C.F.R. §§ 404.1520, 404.1571-76, 416.920 & 416.971-76; Bowen v. Yuckert, 482 U.S. 137, 140-142, 107 S. Ct. 2287 (1987). The following summarizes the sequential evaluation: 15 Step one: Is the claimant engaging in substantial gainful 16 activity? If so, the claimant is found not disabled. If not, proceed to step two. 17 Step two: Does the claimant have a “severe” impairment? If 18 so, proceed to step three. If not, then a finding of not disabled is appropriate. 19 Step three: Does the claimant’s impairment or combination 20 of impairments meet or equal an impairment listed in 20 C.F.R., Pt. 404, Subpt. P, App.1? If so, the claimant is automatically determined 21 disabled. If not, proceed to step four. 22 Step four: Is the claimant capable of performing his past work? If so, the claimant is not disabled. If not, proceed to step five. 23 Step five: Does the claimant have the residual functional 24 capacity to perform any other work? If so, the claimant is not disabled. If not, the claimant is disabled. 25 Lester v. Chater, 81 F.3d 821, 828 n.5 (9th Cir. 1995). 26 27 The claimant bears the burden of proof in the first four steps of the sequential evaluation process. Bowen, 482 U.S. at 146 n.5, 107 S. Ct. at 2294 n.5. The Commissioner bears the 28 burden if the sequential evaluation process proceeds to step five. Id. 1 finds that the claimant has the residual functional capacity to perform a full range of work at all exertional levels but with the following 2 nonexertional limitations: the claimant requires work with simple instructions, involving simple tasks. He is capable of only brief, 3 superficial interactions with the public, in the work setting. He requires only occasional predictable changes in the work setting. 4 6. The claimant is unable to perform any past relevant work. 5 7. The claimant was born [in] 1990 and was 29 years old, which is 6 defined as a younger individual age 18-49, on the alleged disability onset date. 7 8. The claimant has at least a high-school education. 8 9. Transferability of job skills is not material to the determination of 9 disability[.] 10 10. Considering the claimant’s age, education, work experience, and residual functional capacity, there are jobs that exist in significant 11 numbers in the national economy that the claimant can perform.2 12 11. The claimant has not been under a disability, as defined in the Social Security Act, from January 15, 2020, through the date of this 13 decision. 14 AT 25-32. 15 ISSUES PRESENTED 16 Plaintiff argues that the ALJ committed the following errors in finding plaintiff not 17 disabled: (1) the ALJ erred in discounting plaintiff’s symptom allegations; (2) the Appeals 18 Council did not properly evaluate a new and material medical opinion submitted by plaintiff; (3) 19 the ALJ erred in evaluating the opinion of the consultative psychological examiner; and (4) the 20 ALJ erred in evaluating the prior administrative medical findings of the State agency physicians. 21 LEGAL STANDARDS 22 The court reviews the Commissioner’s decision to determine whether (1) it is based on 23 proper legal standards pursuant to 42 U.S.C. § 405(g), and (2) substantial evidence in the record 24 as a whole supports it. Tackett v. Apfel, 180 F.3d 1094, 1097 (9th Cir. 1999). Substantial 25 evidence is more than a mere scintilla, but less than a preponderance. Connett v. Barnhart, 340 26 F.3d 871, 873 (9th Cir. 2003) (citation omitted). It means “such relevant evidence as a reasonable 27 2 Relying on vocational expert (VE) testimony, the ALJ found that plaintiff could perform jobs 28 such as packer, order filler, and machine tender. AT 31. 1 mind might accept as adequate to support a conclusion.” Orn v. Astrue, 495 F.3d 625, 630 (9th 2 Cir. 2007), quoting Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005). “The ALJ is 3 responsible for determining credibility, resolving conflicts in medical testimony, and resolving 4 ambiguities.” Edlund v. Massanari, 253 F.3d 1152, 1156 (9th Cir. 2001) (citations omitted). 5 “The court will uphold the ALJ’s conclusion when the evidence is susceptible to more than one 6 rational interpretation.” Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 2008). 7 The record as a whole must be considered, Howard v. Heckler, 782 F.2d 1484, 1487 (9th 8 Cir. 1986), and both the evidence that supports and the evidence that detracts from the ALJ’s 9 conclusion weighed. See Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). The court may not 10 affirm the ALJ’s decision simply by isolating a specific quantum of supporting evidence. Id.; see 11 also Hammock v. Bowen, 879 F.2d 498, 501 (9th Cir. 1989). If substantial evidence supports the 12 administrative findings, or if there is conflicting evidence supporting a finding of either disability 13 or nondisability, the finding of the ALJ is conclusive, see Sprague v. Bowen, 812 F.2d 1226, 14 1229-30 (9th Cir. 1987), and may be set aside only if an improper legal standard was applied in 15 weighing the evidence. See Burkhart v. Bowen, 856 F.2d 1335, 1338 (9th Cir. 1988). 16 ANALYSIS 17 A. Medical Opinions 18 Plaintiff claims that the ALJ erred by failing to account for moderate mental limitations 19 opined by the psychological examiner, without explaining why he discounted these limitations in 20 formulating the RFC. Defendant contends that the ALJ did not discount them, and that the RFC 21 adequately incorporates these limitations. 22 On April 13, 2021, Dr. Michelina Regazzi conducted a psychological consultative 23 examination of plaintiff. AT 851-857. She noted that he had been “admitted to psychiatric 24 facilities several times.”3 AT 852. Dr. Regazzi also noted plaintiff’s statement that he had made 25 3 In his decision, the ALJ noted that, in May 2020, plaintiff underwent a three-day psychiatric hospitalization for suicidal ideation. AT 28. From June 5, 2020 through June 26, 2020, he 26 followed up with treatment in a “partial hospitalization” program. AT 28-29. In July 2020, he 27 underwent an additional four-day psychiatric hospitalization. AT 29. In October 2020, he “underwent a short hospitalization to stabilize symptoms in the context of medication 28 noncompliance.” AT 29. 1 “suicidal gestures” and had a “reported history of paranoia,” though he denied “current thoughts 2 of harm toward self or others.” AT 852-53. Dr. Regazzi diagnosed plaintiff with ADHD, 3 Unspecified Anxiety Disorder, Unspecified Psychotic Disorder, and R/O Cannabis Use Disorder. 4 AT 856. As to work-related abilities, Dr. Regazzi found plaintiff unimpaired in performing 5 detailed and complex tasks, maintaining regular workplace attendance, and accepting instructions 6 from supervisors. AT 857. She found him mildly impaired in the ability to perform work 7 activities without special supervision and the ability to interact with coworkers and the public. 8 AT 857. Dr. Regazzi found plaintiff moderately impaired in the “ability to complete a normal 9 workday or workweek without interruptions resulting from [his] psychiatric condition” and the 10 “ability to deal with the usual stresses encountered in competitive work environment.” AT 857. 11 The ALJ summarized Dr. Regazzi’s opinion, then continued: 12 State agency psychiatric consultant, T. Brody, Psy.D., opined the claimant is capable of simple tasks with superficial public interaction 13 and predictable work changes.4 State agency psychiatric consultant, K. Morris, Psy.D., affirmed the assessment.5 14 These opinions [including Dr. Regazzi’s] are persuasive, as they are 15 largely consistent with the above residual functional capacity. Their opinions are supported by Dr. Regazzi’s observations and testing and 16 State agency’s evaluation of the medical record. They are consistent with treatment reports and objective evidence, such as intermittent 17 mood instability and cognitive difficulties. [Record citations omitted.] I find State agency’s opinions more persuasive than Dr. 18 Regazzi (in areas of conflict), as their opinion considers a comprehensive review of the record. 19 20 AT 30. 21 The resulting RFC limited plaintiff to “work with simple instructions, involving simple 22 tasks”; “brief, superficial interaction with [the] public”; and “only occasional predictable changes 23 in the work setting.” AT 27. 24 “The ALJ is responsible for translating and incorporating clinical findings into a succinct 25 RFC.” Rounds v. Comm’r Soc. Sec. Admin., 807 F.3d 996, 1006 (9th Cir. 2015). In doing so, 26 the ALJ must articulate a “substantive basis” for rejecting a medical opinion or crediting one 27 4 Citing AT 75-98. 28 5 Citing AT 103-140. 1 medical opinion over another. Garrison v. Colvin, 759 F.3d 995, 1012 (9th Cir. 2014); see also 2 Marsh v. Colvin, 792 F.3d 1170, 1172-73 (9th Cir. 2015) (“an ALJ cannot in its decision totally 3 ignore a treating doctor and his or her notes, without even mentioning them”). 4 For disability applications filed on or after March 27, 2017, the Commissioner revised the 5 rules for the evaluation of medical evidence at the administrative level. See Revisions to Rules 6 Regarding the Evaluation of Medical Evidence, 82 Fed. Reg 5844-01 (Jan. 18, 2017). Because 7 plaintiff filed his application in 2020, it is subject to the new rules for the evaluation of medical 8 evidence. 9 The revised rules provide that adjudicators for the Social Security Administration, 10 including ALJs, evaluate medical opinions according to the following factors: supportability; 11 consistency; relationship with the claimant; specialization; and other factors such as the medical 12 source's familiarity with other evidence in the record or with disability program requirements. 20 13 C.F.R. § 416.920c(c)(1)-(5). The most important of these factors are supportability and 14 consistency. 20 C.F.R. § 416.920c(b)(2). Supportability is the extent to which an opinion or 15 finding is supported by relevant objective medical evidence and the medical source’s supporting 16 explanations. 20 C.F.R. § 416.920c(c)(1). Consistency is the extent to which an opinion or 17 finding is consistent with evidence from other medical sources and non-medical sources, 18 including the claimants themselves. 20 C.F.R. §§ 416.920c(c)(2), 416.902(j)(1). The ALJ will 19 articulate how he considered the most important factors of supportability and consistency, but an 20 explanation for the remaining factors is not required except when deciding among differing yet 21 equally persuasive opinions or findings on the same issue. 20 C.F.R. § 416.920c(b). The new 22 regulations “still require that the ALJ provide a coherent explanation of his reasoning” and 23 establish “a minimum level of articulation to be provided in determinations and decisions, in 24 order to provide sufficient rationale for a reviewing adjudicator or court.” Sam-Chankhiao v. 25 Kijakazi, 2:20-cv-0186 DB, 2022 WL 4226170, at *3 (E.D. Cal. Sept. 13, 2022), citing Hardy v. 26 Commissioner, 554 F.Supp.3d 900, 906 (E.D. Mich. 2021). 27 Here, plaintiff argues that the RFC did not account for Dr. Regazzi’s opinion that he was 28 moderately limited in his abilities to “complete a normal workday or workweek without 1 interruptions resulting from [his] psychiatric condition” and “deal with the usual stresses 2 encountered in competitive work environment.” The ALJ did not discuss the specific moderate 3 limitations opined by Dr. Regazzi. From the ALJ’s brief discussion of multiple medical opinions, 4 it is not clear whether he rejected the moderate limitations opined by Dr. Regazzi, or not. 5 Defendant asserts that the RFC did incorporate the moderate limitations opined by Dr. 6 Regazzi. Defendant points out that State agency physicians Drs. Brode and Morris also found 7 plaintiff moderately limited in these areas6, yet found him capable of simple tasks with superficial 8 public interaction and predictable work changes. Defendant argues that the court should find 9 “that the ALJ properly synthesized and translated Dr. Regazzi’s assessed limitations into” the 10 RFC, along with similar, somewhat more specific opinion evidence. ECF No. 16 at 19. 11 In Nambi v. Kijakazi, 2023 WL 2743577, *1 (N.D. Cal. March 30, 2023), the State 12 agency consulting psychiatrist found the plaintiff moderately impaired in the ability to complete a 13 normal workday and workweek without interruptions from psychological symptoms, among other 14 moderate limitations. The mental RFC limited him to simple, routine tasks and occasional 15 interaction with the public. Id. The Commissioner argued that the RFC included the opined 16 moderate limitations; however, the court found that the RFC did “not account for [the 17 psychiatrist’s] findings of moderate limitations in Nambi’s abilities to complete a workday or 18 workweek,” and other moderate limitations. Id. at *2. “The ALJ was required to either include 19 these limitations in [Nambi’s] RFC assessment or provide legally sufficient reasons for rejecting 20 them,” the court concluded. Id., citing Warren v. Saul, 2021 WL 259435, at *6 (C.D. Cal. Jan. 21 26, 2021). “The ALJ did neither and that was error.” Id. See also Morinskey v. Astrue, 458 Fed. 22 Appx. 640, 641 (9th Cir. 2011) (ALJ erred by not making “findings setting forth specific, 23 legitimate reasons for rejecting . . . opinion that Morinskey’s abilities to . . . complete a normal 24 work day or workweek without interruption from his bipolar disorder were moderately 25 impaired”). “While moderate limitations do not necessarily indicate that Plaintiff is unable to 26 27 6 Citing AT 83-84 (Dr. Brode opines moderate limitations in ability to complete normal workday/workweek without interruptions from psychological symptoms, and other moderate 28 mental limitations); AT 121-23 (Dr. Morris opines same). 1 perform all work activity, the ALJ was required to either include these limitations in Plaintiff's 2 RFC assessment or provide legally sufficient reasons for rejecting them.” Warren, 2021 WL 3 259435, *6. 4 In this case, plaintiff was hospitalized four times for mental symptoms during the two-year 5 period at issue. Three doctors opined that he was moderately limited in the ability to “complete a 6 normal workday or workweek without interruptions resulting from [his] psychiatric condition” 7 and his ability to cope with normal workplace stresses. Yet, the ALJ did not explain whether he 8 credited these portions of Dr. Regazzi’s opinion, and the supportability and consistency factors as 9 to these specific opined limitations were never addressed. Insofar as the ALJ credited the state 10 Agency doctors’ findings instead of Dr. Regazzi’s, he simply noted that “in areas of conflict” the 11 state Agency doctors’ “opinion considers a comprehensive review of the record.” But if this 12 generality were enough of a reason, every State agency opinion (based on a review of the 13 longitudinal record) would be entitled to more credit than every consultative exam. The ALJ’s 14 failure to explain his reasoning as to Dr. Regazzi’s opined moderate limitations was error. 15 At the hearing, the VE testified that if a person with plaintiff’s RFC missed even two days of 16 work a month, “there would be no work.” AT 67-68. Thus, the error was harmful, and plaintiff 17 is entitled to summary judgment on this claim.7 18 CONCLUSION 19 With error established, the court has the discretion to remand or reverse and award 20 benefits. McAllister v. Sullivan, 888 F.2d 599, 603 (9th Cir. 1989). A case may be remanded 21 under the “credit-as-true” rule for an award of benefits where: 22 (1) the record has been fully developed and further administrative proceedings would serve no useful purpose; (2) the ALJ has 23 failed to provide legally sufficient reasons for rejecting evidence, 24 whether claimant testimony or medical opinion; and (3) if the improperly discredited evidence were credited as true, the ALJ 25 would be required to find the claimant disabled on remand. 26 Garrison v. Colvin, 759 F.3d 995, 1020 (9th Cir. 2014). Even where all the conditions for the 27 28 7 The court does not reach the remaining claims. 1 | “credit-as-true” rule are met, the court retains “flexibility to remand for further proceedings when 2 || the record as a whole creates serious doubt as to whether the claimant is, in fact, disabled within 3 | the meaning of the Social Security Act.” Id. at 1021; see also Dominguez v. Colvin, 808 F.3d 4 | 403, 407 (9th Cir. 2015) (‘Unless the district court concludes that further administrative 5 || proceedings would serve no useful purpose, it may not remand with a direction to provide 6 || benefits.”); Treichler v. Commissioner of Social Sec. Admin., 775 F.3d 1090, 1105 (9th Cir. 7 || 2014) (‘Where ... an ALJ makes a legal error, but the record is uncertain and ambiguous, the 8 || proper approach is to remand the case to the agency.”). 9 Here, the record as a whole creates serious doubt as to whether the claimant was, in fact, 10 || disabled during the relevant period. On remand, the ALJ is free to develop the record as needed, 11 || mcluding asking a vocational expert hypothetical questions about available jobs based on a 12 || revised RFC. The court expresses no opinion regarding how the evidence should ultimately be 13 || weighed, and any ambiguities or inconsistencies resolved, on remand. The court also does not 14 | instruct the ALJ to credit any particular opinion or testimony. The ALJ may ultimately find 15 | plaintiff disabled during the entirety of the relevant period; may find plaintiff eligible for some 16 || type of closed period of disability benefits; or may find that plaintiff was never disabled during 17 || the relevant period, provided that the ALJ’s determination complies with applicable legal 18 || standards and is supported by the record as a whole. 19 Accordingly, IT IS HEREBY ORDERED THAT: 20 1. Plaintiff's motion for summary judgment (ECF No. 11) is granted; 21 2. The Commissioner’s cross motion for summary judgment (ECF No. 16) is denied; 22 3. The Clerk of Court shall enter judgment for plaintiff; and 23 4. This matter is remanded for further administrative proceedings consistent with this 24 order. 25 | Dated: September 26, 2024 / □□□ / 4 [iy ai 26 CAROLYNK. DELANEY 27 UNITED STATES MAGISTRATE JUDGE 28 2/marv0782.bothdibsssi.ckd