finding general rejection of claimant’s testimony was insufficient and that ALJ committed legal error when she did not specify what testimony she rejected and why
How later courts described this case
- finding general rejection of claimant’s testimony was insufficient and that ALJ committed legal error when she did not specify what testimony she rejected and why
Written by the judges who cited it.
The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF OREGON
SCOTT M.1, Case No. 6:18-cv-1801-SI
Plaintiff, OPINION AND ORDER
v.
ANDREW M. SAUL, Commissioner of
Social Security,
Defendant.
Robyn M. Rebers, ROBYN M. REBERS LLC, PO Box 3530, Wilsonville, OR 97070. Of Attorneys
for Plaintiff.
Billy J. Williams, United States Attorney, and Renata Gowie, Assistant United States Attorney,
UNITED STATES ATTORNEY’S OFFICE, 1000 SW Third Avenue, Suite 600, Portland, OR 97204;
Ryan Ta Lu, Special Assistant United States Attorney, OFFICE OF GENERAL COUNSEL, Social
Security Administration, 701 Fifth Avenue, Suite 2900 M/S 221A, Seattle, WA 98104. Of
Attorneys for Defendant.
Michael H. Simon, District Judge.
Scott M. (“Plaintiff”) seeks judicial review of the final decision of the Commissioner of
the Social Security Administration (“Commissioner”) denying his application for supplemental
1 In the interest of privacy, this opinion uses only the first name and the initial of the last
name of the non-governmental party in this case. When applicable, this opinion uses the same
designation for a non-governmental party’s immediate family member.
social security income (“SSI”). Because the Commissioner’s findings were not supported by
substantial evidence, the decision is REVERSED and this case REMANDED for further
proceedings.
STANDARD OF REVIEW
The district court must affirm the Commissioner’s decision if it is based on the proper
legal standards and the findings are supported by substantial evidence. 42 U.S.C. § 405(g); see
also Hammock v. Bowen, 879 F.2d 498, 501 (9th Cir. 1989). “Substantial evidence” means
“more than a mere scintilla but less than a preponderance.” Bray v. Comm’r of Soc. Sec.
Admin., 554 F.3d 1219, 1222 (9th Cir. 2009) (quoting Andrews v. Shalala, 53 F.3d 1035, 1039
(9th Cir. 1995)). It means “such relevant evidence as a reasonable mind might accept as adequate
to support a conclusion.” Id. (quoting Andrews, 53 F.3d at 1039).
Where the evidence is susceptible to more than one rational interpretation, the
Commissioner’s conclusion must be upheld. Burch v. Barnhart, 400 F.3d 676, 679 (9th
Cir. 2005). Variable interpretations of the evidence are insignificant if the Commissioner’s
interpretation is a rational reading of the record, and this Court may not substitute its judgment
for that of the Commissioner. See Batson v. Comm’r of Soc. Sec. Admin., 359 F.3d 1190, 1193,
1196 (9th Cir. 2004). “[A] reviewing court must consider the entire record as a whole and may
not affirm simply by isolating a specific quantum of supporting evidence.” Orn v. Astrue, 495
F.3d 625, 630 (9th Cir. 2007) (quoting Robbins v. Soc. Sec. Admin., 466 F.3d 880, 882 (9th
Cir. 2006) (quotation marks omitted)). A reviewing court, however, may not affirm the
Commissioner on a ground upon which the Commissioner did not rely. Id.; see also Bray, 554
F.3d at 1226.
BACKGROUND
A. Plaintiff’s Application
Plaintiff initially alleged that his disability began on December 28, 2010. At the
administrative hearing he amended the alleged onset date to April 26, 2012—Plaintiff’s 55th
birthday. AR 48. He filed an application for SSI on December 28, 2014. He claimed disability
caused by right superior canal dehiscence, vertigo, low tone hearing loss, autophony, short term
memory issues, brain fog, tinnitus, depression, MTHFR gene mutations, fatigue, tight band
around forehead, Hashimoto’s hypothyroidism, peripheral neuropathy, TIA mini-stroke, and
neurovascular disease. AR 98.
His application was denied first on April 21, 2015 and then upon reconsideration on
September 18, 2015. Plaintiff then filed a written request for a hearing before an Administrative
Law Judge (“ALJ”). Plaintiff appeared and testified at the hearing on September 20, 2017 in
Eugene, Oregon. He was represented by a non-attorney representative. AR 48. The ALJ issued a
written decision denying Plaintiff’s application on December 13, 2017. AR 45. Plaintiff
requested review of the ALJ’s decision on December 27, 2017 but the Appeals Council denied
this request on August 20, 2018, making the ALJ’s decision the final decision of the
Commissioner. Plaintiff now seeks judicial review of the Commissioner’s final decision.
B. The Sequential Analysis
A claimant is disabled if he or she is unable to “engage in any substantial gainful activity
by reason of any medically determinable physical or mental impairment which . . . has lasted or
can be expected to last for a continuous period of not less than 12 months[.]” 42 U.S.C.
§ 423(d)(1)(A). “Social Security Regulations set out a five-step sequential process for
determining whether an applicant is disabled within the meaning of the Social Security Act.”
Keyser v. Comm’r Soc. Sec. Admin., 648 F.3d 721, 724 (9th Cir. 2011); see also 20 C.F.R.
§§ 404.1520 (DIB), 416.920 (SSI); Bowen v. Yuckert, 482 U.S. 137, 140 (1987). Each step is
potentially dispositive. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The five-step sequential
process asks the following series of questions:
1. Is the claimant performing “substantial gainful activity?” 20 C.F.R.
§§ 404.1520(a)(4)(i), 416.920(a)(4)(i). This activity is work involving
significant mental or physical duties done or intended to be done for pay
or profit. 20 C.F.R. §§ 404.1510, 416.910. If the claimant is performing
such work, she is not disabled within the meaning of the Act. 20 C.F.R.
§§ 404.1520(a)(4)(i), 416.920(a)(4)(i). If the claimant is not performing
substantial gainful activity, the analysis proceeds to step two.
2. Is the claimant’s impairment “severe” under the Commissioner’s
regulations? 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). An
impairment or combination of impairments is “severe” if it significantly
limits the claimant’s physical or mental ability to do basic work activities.
20 C.F.R. §§ 404.1521(a), 416.921(a). Unless expected to result in death,
this impairment must have lasted or be expected to last for a continuous
period of at least 12 months. 20 C.F.R. §§ 404.1509, 416.909. If the
claimant does not have a severe impairment, the analysis ends. 20 C.F.R.
§§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). If the claimant has a severe
impairment, the analysis proceeds to step three.
3. Does the claimant’s severe impairment “meet or equal” one or more of the
impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix 1? If so,
then the claimant is disabled. 20 C.F.R. §§ 404.1520(a)(4)(iii),
416.920(a)(4)(iii). If the impairment does not meet or equal one or more of
the listed impairments, the analysis continues. At that point, the ALJ must
evaluate medical and other relevant evidence to assess and determine the
claimant’s “residual functional capacity” (“RFC”). This is an assessment
of work-related activities that the claimant may still perform on a regular
and continuing basis, despite any limitations imposed by his or her
impairments. 20 C.F.R. §§ 404.1520(e), 404.1545(b)-(c), 416.920(e),
416.945(b)-(c). After the ALJ determines the claimant’s RFC, the analysis
proceeds to step four.
4. Can the claimant perform his or her “past relevant work” with this RFC
assessment? If so, then the claimant is not disabled. 20 C.F.R.
§§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). If the claimant cannot perform
his or her past relevant work, the analysis proceeds to step five.
5. Considering the claimant’s RFC and age, education, and work experience,
is the claimant able to make an adjustment to other work that exists in
significant numbers in the national economy? If so, then the claimant is
not disabled. 20 C.F.R. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v),
404.1560(c), 416.960(c). If the claimant cannot perform such work, he or
she is disabled. Id.
See also Bustamante v. Massanari, 262 F.3d 949, 954 (9th Cir. 2001).
The claimant bears the burden of proof at steps one through four. Id. at 953; see also
Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999); Yuckert, 482 U.S. at 140-41. The
Commissioner bears the burden of proof at step five. Tackett, 180 F.3d at 1100. At step five, the
Commissioner must show that the claimant can perform other work that exists in significant
numbers in the national economy, “taking into consideration the claimant’s residual functional
capacity, age, education, and work experience.” Id.; see also 20 C.F.R. §§ 404.1566, 416.966
(describing “work which exists in the national economy”). If the Commissioner fails to meet this
burden, the claimant is disabled. 20 C.F.R. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v). If, however,
the Commissioner proves that the claimant is able to perform other work existing in significant
numbers in the national economy, the claimant is not disabled. Bustamante, 262 F.3d at 953-54;
Tackett, 180 F.3d at 1099.
C. The ALJ’s Decision
At step one, the ALJ determined that Plaintiff had not engaged in any substantial gainful
activity since December 28, 2014—the date Plaintiff applied for disability benefits. AR 50. At
step two, the ALJ found that Plaintiff suffered from two severe medically determinable
impairments: Meniere’s disease and neuropathy. AR 50. The ALJ determined that Plaintiff’s
medically determinable impairments of mood disorder NOS, anxiety disorder, and cognitive
disorder did not significantly limit his ability to perform basic work activities. AR 51. At step
three, the ALJ found that Plaintiff did not have an impairment or combination of impairments
that meets or medically equals the severity of the listed impairments in 20 C.F.R. Part 404.
AR 52.
Between step three and step four, the ALJ determined that Plaintiff had the residual
functional capacity (“RFC”) to perform medium work as defined in 20 CFR 416.967(c). Id. The
ALJ added the following qualifications:
The claimant can sit for 6 hours of an 8-hour workday, and stand
or walk for up to 6 hours of an 8-hour workday. The claimant can
push and pull the same weight as for the lifting and carrying
limitations. The claimant can climb ramps and stairs occasionally.
The claimant should avoid ladders, ropes, or scaffolding. The
claimant should never be required to balance. The claimant should
never work at unprotected heights and around moving mechanical
parts. The claimant should never be required to operate a motor
vehicle for commercial purpose. The claimant should be restricted
to moderate noise environments. Time off-task would be able to be
accommodated by normal breaks.
Id. At step four, the ALJ found that Plaintiff had no past relevant work experience. AR 56. At
step five, the ALJ found that there were jobs that existed in significant numbers in the national
economy that Plaintiff could have performed, including agricultural produce packer, cook helper,
and sandwich maker. AR 57.
DISCUSSION
Plaintiff argues that the ALJ’s decision finding Plaintiff not disabled was not supported
by substantial evidence. Specifically, Plaintiff argues that the ALJ improperly rejected Plaintiff’s
subjective symptom testimony, ignored lay witness testimony, improperly weighed the medical
opinion testimony of Dr. Samuel Fellin, and did not include all supported functional limitations
in formulating Plaintiff’s RFC.
A. Plaintiff’s Subjective Symptom Testimony
Plaintiff contends that the ALJ failed to give clear and convincing reasons for rejecting
Plaintiff’s subjective symptom testimony. There is a two-step process for evaluating a claimant’s
testimony about the severity and limiting effect of the claimant’s symptoms. Vasquez v. Astrue,
572 F.3d 586, 591 (9th Cir. 2009). “First, the ALJ must determine whether the claimant has
presented objective medical evidence of an underlying impairment ‘which could reasonably be
expected to produce the pain or other symptoms alleged.’” Lingenfelter v. Astrue, 504 F.3d 1028,
1036 (9th Cir. 2007) (quoting Bunnell v. Sullivan, 947 F.2d 341, 344 (9th Cir. 1991) (en banc)).
When doing so, “the claimant need not show that her impairment could reasonably be expected
to cause the severity of the symptom she has alleged; she need only show that it could reasonably
have caused some degree of the symptom.” Smolen v. Chater, 80 F.3d 1273, 1282 (9th Cir.
1996).
“Second, if the claimant meets this first test, and there is no evidence of malingering, ‘the
ALJ can reject the claimant’s testimony about the severity of her symptoms only by offering
specific, clear and convincing reasons for doing so.’” Lingenfelter, 504 F.3d at 1036 (quoting
Smolen, 80 F.3d at 1281). It is “not sufficient for the ALJ to make only general findings; he must
state which pain testimony is not credible and what evidence suggests the complaints are not
credible.” Dodrill v. Shalala, 12 F.3d 915, 918 (9th Cir. 1993). Those reasons must be
“sufficiently specific to permit the reviewing court to conclude that the ALJ did not arbitrarily
discredit the claimant’s testimony.” Orteza v. Shalala, 50 F.3d 748, 750 (9th Cir. 1995) (citing
Bunnell, 947 F.2d at 345-46).
The ALJ summarized Plaintiff’s symptom testimony as follows:
The claimant has alleged that he is unable to work on a regular and
continuous basis due to right superior semicircular canal
dehiscence, vertigo, low tone hearing loss, autophony, brain fog,
tinnitus, depression, MTHFR gene mutations, fatigue, tight band
around the forehead, Hashimoto's hypothyroidism, peripheral
neuropathy, transient ischemic attack (TIA) ministrokes, and
neurovascular disease (Ex. 4E/2; BF/3-12). The claimant indicated
that his conditions adversely affect his abilities to lift more than 20
pounds, hear, remember, complete tasks, concentrate, understand,
and follow instructions (Ex. 7E/6).
At the hearing, the claimant testified that he had disabling
symptoms of fatigue, malaise, disequilibrium, and vertigo that
made him feel as if he were on a merry-go-round. The claimant
also testified that he had difficulty with bis cognitive functioning,
especially short-term memory, and difficulty tracking
conversations. The claimant also testified that he felt overwhelmed
and mentally tired, if he were to attempt to do too many tasks.
Further, the claimant testified that he continued to experience
moderate to severe migraine headaches approximately three times
per week, despite treatment.
AR 53. The ALJ concluded that Plaintiff’s medically determinable impairments could reasonably
be expected to cause the alleged symptoms, thereby satisfying step one of the framework. Id. The
ALJ, however, determined that Plaintiff’s statements concerning the intensity, persistence, and
limiting effects of his symptoms were “not entirely consistent with the medical evidence and
other evidence in the record for the reasons explained in this decision.” Id.
The ALJ’s step two analysis is deficient for two reasons, both related to specificity.
Although the decision contains a detailed and specific list of Plaintiff’s symptom allegations, the
ALJ did not specify which of Plaintiff’s statements he rejected. He instead broadly referred to all
statements “concerning the intensity, persistence, and limiting effects of these symptoms.” AR
53. The ALJ also did not provide specific reasons for rejecting Plaintiff’s symptom testimony—
he only stated that it is “not entirely consistent with the medical evidence and other evidence in
the record for reasons explained in this decision.” Id. The ALJ later described several sources of
medical evidence, but did not specify which pieces of evidence contradict which pieces of
Plaintiff’s symptom testimony. See Brown-Hunter v. Colvin, 806 F.3d 487, 489 (9th Cir. 2015)
(finding general rejection of claimant’s testimony was insufficient and that ALJ committed legal
error when she did not specify what testimony she rejected and why). Although the ALJ
discussed medical evidence in the context of weighing medical opinions, he never connected any
part of the medical record to Plaintiff’s symptom testimony. He identified several inconsistencies
between medical record evidence and specific medical opinions, but he did not make the same
connection between medical record evidence and Plaintiff’s symptom testimony. The ALJ only
vaguely refers to the “reasons explained in this decision.” AR 53 This is legal error because the
ALJ did not state “which . . . testimony is not credible and what evidence suggests the
complaints are not credible.” Dodrill, 12 F.3d at 918.
B. Lay Witness Testimony
The ALJ failed to mention the lay testimony of Plaintiff’s father, James M. The Ninth
Circuit has stated that “lay witness testimony ‘cannot be disregarded without comment’” Molina,
674 F.3d at 1114 (quoting Nguyen, 100 F.3d at 1467). The ALJ indisputably erred in failing to
mention James M.’s lay witness testimony at all.
Courts have long recognized that harmless error principles apply in the Social Security
Act context. Id. Courts “have, for example, deemed errors harmless where . . . [the court was]
able to conclude from the record that the ALJ would have reached the same result absent the
error.” Id. As a general principle, an error is harmless when it is “inconsequential to the ultimate
nondisability determination.” Carmickle v. Comm'r, Soc. Sec. Admin., 533 F.3d 1155, 1162 (9th
Cir. 2008). In Stout, the ALJ similarly erred by neglecting to comment on competent lay witness
testimony, and the testimony that the ALJ disregarded identified limitations not considered by
the ALJ, was uncontradicted by anything in the record, and was highly probative of Stout’s
inability to work. Stout v. Comm’r Soc. Sec. Admin., 454 F.3d 1050, 1056 (9th Cir. 2006). As
such, the court found that it was not harmless error to ignore the lay witness testimony. Id.
“[W]here the ALJ’s error lies in a failure to properly discuss competent lay testimony favorable
to the claimant, a reviewing court cannot consider the error harmless unless it can confidently
conclude that no reasonable ALJ, when fully crediting the testimony, could have reached a
different disability determination.” Id.
James M. described Plaintiff’s impaired mental and physical capabilities. AR 230 – 32.
He noted that Plaintiff has trouble concentrating for more than 15-30 minutes, has difficulty
following written and verbal instructions, and cannot lift more than 20 pounds without worsening
his vertigo and tinnitus. Id. Defendant argues that the ALJ’s omission of any discussion of James
M.’s witness statement is harmless error because the same record evidence that discredited
Plaintiff’s testimony discredits James M.’s claims. See Molina, 674 F.3d at 1122. James M.’s
statement does overlap with Plaintiff’s discredited testimony. But as discussed above the ALJ did
not give specific, clear and convincing reasons for rejecting Plaintiff’s symptom testimony. The
ALJ only stated that Plaintiff’s “statements concerning the intensity, persistence, and limiting
effects of [his] symptoms are not entirely consistent with the medical evidence and other
evidence in the record for the reasons explained in this decision.” AR 53. Even if the ALJ had
specifically identified “what testimony is not credible and what evidence undermines the
claimant’s complaints,” the reasoning is inapplicable to James M.’s statements about Plaintiff’s
inability to lift more than 20 pounds. Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998)
(quotation marks omitted). Plaintiff testified that he could lift no more than 25-30 pounds.
AR 86. The ALJ did not specifically address this testimony or point to any facts in the record for
rejecting Plaintiff’s testimony about this particular physical limitation. Thus, even if the ALJ had
properly rejected other portions of Plaintiff’s symptom testimony, it would not neutralize James
M.’s testimony about his physical limitations.
James M.’s description of Plaintiff’s lifting limitation is favorable to Plaintiff. The Court
cannot conclude that no reasonable ALJ, when fully crediting James M.’s testimony, would have
decided this case differently. The ALJ did not even mention James M.’s testimony, and the Court
can have no way of knowing what impact, if any, James M.’s testimony might have had on the
ALJ’s opinion. Thus, the ALJ’s failure to address James M.’s statements is not harmless error.
C. Medical Opinion Testimony
The ALJ generally will give more weight to opinions from treating sources, because they
have treated the claimant over a period of time and “bring a unique perspective to the medical
evidence that cannot be obtained from the objective medical findings alone” or from one-time
evaluations performed by consulting physicians. 20 C.F.R. §§ 404.1527(c), 416.927(c)(2). If a
treating physician’s medical opinion is not inconsistent with other evidence in the record and is
supported by medical findings, the treating physician’s opinion should be given controlling
weight. See Holohan v. Masasnari, 246 F.3d 1195, 1202 (9th Cir. 2001). In the hierarchy of
medical evidence, the opinion of a treating physician is entitled to greater weight than that of an
examining physician, which in turn is entitled to greater weight than that of a non-examining
physician. Garrison, v. Colvin, 759 F.3d 995, 1012 (9th Cir. 2014).
The ALJ serves as “the final arbiter with respect to resolving ambiguities in the medical
evidence.” Tommasetti v. Astrue, 533 F.3d 1035, 1041-42 (9th Cir. 2008). In that capacity, the
ALJ is responsible for making credibility determinations, resolving conflicts in the medical
evidence, and resolving ambiguities.” Vazquez v. Astrue, 572 F.3d 586, 591 (9th Cir. 2009).
“Where the treating doctor’s opinion is not contradicted by another doctor, it may be rejected
only for ‘clear and convincing’ reasons.” Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995). If,
however, “a treating or examining doctor’s opinion is contradicted by another doctor’s opinion,
an ALJ may reject it by providing specific and legitimate reasons that are supported by
substantial evidence.” Garrison, 759 F.3d at 1012 (quoting Ryan v. Comm’r of Soc. Sec., 528
F.3d 1194, 1198 (9th Cir. 2008)). However, “even when contradicted, a treating or examining
physician’s opinion is still owed deference and will often be ‘entitled to the greatest weight . . .
even if it does not meet the test for controlling weight.’” Garrison, 759 F.3d at 1012 (quoting
Orn v. Astrue, 495 F.3d 625, 633 (9th Cir. 2007)).
Dr. Fellin was Plaintiff’s treating physician. Dr. Fellin identified eight medical conditions
that Plaintiff was suffering from. In Dr. Fellin’s opinion, Plaintiff’s medical conditions would
“adversely affect his ability to independently and effectively sustain any kind of work.” AR
1265. He noted Plaintiff’s limited balance and mobility, his impaired hearing, and his impaired
strength. He recommended that Plaintiff would need to take more than one “mini-break” per
hour, and that he would need to lie down frequently due to his vertigo. He limited Plaintiff to
lifting less than ten pounds due to Plaintiff’s fall risk. In addition to affecting Plaintiff’s balance
and hearing, the medical conditions also impaired Plaintiff’s vision to a high degree according to
Dr. Fellin. Dr. Fellin’s assessment of Plaintiff’s ability to perform work-related mental activites
was similarly pessimistic. He rated most of Plaintiff’s capabilities in the areas of “Understanding
and Memory,” “Sustained Concentration and Persistence,” and “Adaptation” as either severely
impaired or moderately severely impaired. AR 1270.
The ALJ gave Dr. Fellin’s opinion “little weight” because of perceived inconsistency
with the treatment notes. AR 56. It is a specific and legitimate reason to discredit a physician’s
opinion when the opinion in incongruent with the physician’s medical records. Tommassetti, 495
F.3d at 1041. It is also a specific and legitimate reason to reject a physician’s opinion when the
opinion is inconsistent with the record as a whole. Orn, F.3d at 631. The ALJ did not identify
any inconsistencies between Dr. Fellin’s opinion and his own treatment notes. The perceived
inconsistencies arise between Dr. Fellin’s opinion and the treatment notes of two other doctors.
Dr. Spettel saw Plaintiff once in 2017 to follow up on a ureteral stricture and place a catheter. Dr.
Lee saw Plaintiff twice in 2015 on referral from Dr. Fellin. But the ALJ here did not specifically
cite any other parts of the record as contradicting Dr. Fellin’s opinion. The ALJ only noted
inconsistencies with the treatment notes of other physicians, which is not a specific and
legitimate reason as discussed above. Nor did the ALJ identify any other physician opinions that
Dr. Fellin’s opinion conflicts with. Again, the ALJ noted only conflict with other treatment
notes. This, by itself, is insufficient to discredit Dr. Fellin’s opinion. The ALJ’s decision to
afford little weight to Dr. Fellin’s opinion is not supported by substantial evidence.
D. RFC Formulation
The RFC represents the most that a claimant can do despite his or her physical or mental
impairments. 20 C.F.R. § 404.1545. In formulating the RFC, the ALJ must consider all
medically determinable impairments, including those that are not “severe,” and evaluate “all of
the relevant medical and other evidence.” Id. In determining a claimant’s RFC . . . the ALJ is
responsible for resolving conflicts in the medical testimony and translating the claimant’s
impairments into concrete functional limitations. Stubbs-Danielson v. Astrue, 539 F.3d 1169,
1174 (9th Cir. 2008). Only those limitations that are supported by substantial evidence must be
incorporated into the RFC. Osenbrock v. Apfel, 240 F.3d 1157, 1163-65 (9th Cir. 2001). That is,
the ALJ need not “incorporate evidence from opinions . . . which were permissibly discounted.”
Batson, 359 F.3d at 1197.
Here, the ALJ’s RFC finding that Plaintiff can lift up to 50 pounds occasionally and up
to 25 pounds frequently is not supported by substantial evidence. The ALJ did not state any basis
for this finding. Plaintiff testified that he could lift no more than 25 or 30 pounds. Plaintiff’s
father stated that Plaintiff could lift a maximum of 20 pounds. AR 230. Dr. Jensen thought that
Plaintiff could lift no more than 10 pounds frequently and 20 pounds occasionally. AR 106.
Dr. Fellin would have limited Plaintiff to lifting 10 pounds at most. The Court found that the
ALJ improperly rejected Dr. Fellin’s medical opinion, Plaintiff’s testimony, and the statements
from Plaintiff’s father. The ALJ correctly rejected Dr. Jensen’s opinion on the lifting limitation
because the ALJ cited several normal physical examinations—Dr. Jensen’s opinions was
permissibly discounted. AR 55. This analysis, however, does not affirmatively establish support
for the lifting limitations the ALJ described in the RFC. The ALJ rejected all the statements that
Plaintiff could not lift more than 25-30 pounds but did not cite any specific evidence that
Plaintiff could lift 50 pounds. Although the ALJ is responsible for “translating and incorporating
clinical findings into a succinct residual functional capacity,” the ALJ did not identify any
“clinical findings” that Plaintiff could lift up to 25 pounds frequently and up to 50 pounds
occasionally. Rounds, 807 F.3d at 1006. The lifting and carrying limitations in the RFC are not
supported by substantial evidence.
The ALJ limited Plaintiff to work in moderate noise environments. Plaintiff argues that
the ALJ should have restricted Plaintiff to work in quiet noise environments. Defendant responds
that even if the evidence in the record might support restricting Plaintiff to quiet noise
environments, there is substantial evidence that supports a moderate noise restriction. The ALJ,
however, did not identify any specific evidence supporting the moderate noise restriction in his
written opinion. He only mentioned Plaintiff’s hearing loss in the context of Plaintiff’s symptom
testimony. At the hearing, the ALJ even mentioned that he “didn’t see any hearing tests in the
record.” AR 87. This is not the case—the record includes at least five different hearing tests from
five different sources. AR 29, 531-33, 606-09. The tests consistently demonstrated that Plaintiff
suffers from a degree of hearing loss. The ALJ did not address these tests, instead erroneously
claiming that there were no hearing tests in the record. Thus, the moderate noise environment
restriction in the RFC is not supported by substantial evidence.
The ALJ’s RFC did not include any limitations to account for Plaintiff’s claimed
attention, memory, or concentration impairments. In his decision, the ALJ noted that Plaintiff
suffered from medically determinable mental impairments but that these impairments were non-
severe. AR 51. Still, it is the ALJ’s duty to consider “all of the relevant medical . . . evidence.”
20 C.F.R. § 404.1545.
The ALJ considered the opinions of several physicians who assessed Plaintiff’s mental
capabilities. The ALJ properly considered the opinion of Dr. LeBray. The ALJ weighed heavily
Dr. LeBray’s opinion that Plaintiff would “fare best with simple to semi-complex mental related
tasks.” AR 55. The ALJ assigned little weight to portions of Dr. LeBray’s opinions that he felt
were inconsistent with the objective results, which were predominantly in the normal range. This
was a specific and legitimate reason to partially discredit Dr. LeBray’s opinion. The ALJ noted
that Dr. LeBray found that Plaintiff’s auditory verbal recall was moderately deficient. AR 54.
The ALJ did not, however, assign any weight to this opinion.
The ALJ gave little weight to the opinion of Dr. Cole (an examining physician) that
Plaintiff suffered from a moderate memory deficits and some problems in the areas of attention
and concentration. The ALJ noted that Dr. Cole’s opinion that Plaintiff had attention and
concentration problems was inconsistent with his observation that Plaintiff did not exhibit any
significant problems in the areas of attention and concentration. AR 54. This is a specific and
legitimate reason to reject Dr. Cole’s opinion on Plaintiff’s attention and concentration abilities.
It is not, however, a specific and legitimate reason for rejecting Dr. Cole’s opinion that Plaintiff’s
moderate memory deficits would be a primary factor affecting his overall level of vocational
success. The ALJ did not identify any inconsistencies between Dr. Cole’s testing and his opinion
that Plaintiff suffered from moderate memory deficits which would impact his ability to work. In
fact, Plaintiff’s test results are consistent with this opinion—he scored no higher than the 16th
percentile on any element of the Wechsler Memory Scale-IV, and three of his five scores were at
the third percentile or lower. AR 651. The ALJ did not provide specific and legitimate reasons
for rejecting Dr. Cole’s opinion that Plaintiff had moderate memory deficits. This was legal
error.
The ALJ noted that Dr. Kennemer and Dr. Boyd (both reviewing physicians) found that
Plaintiff had moderate limitations in his ability to concentrate, persist, or maintain pace and only
mild limitations in other functional areas. AR 55. The ALJ properly accorded these opinions
partial weight due to discrepancies with the findings of Dr. Cole and Dr. LeBray about Plaintiff’s
attentional limitations. Id.
To summarize, the ALJ’s exertional lifting and carrying limitation was not supported by
substantial evidence. At the very least, the ALJ did not affirmatively cite any evidence in support
of the decision that Plaintiff could lift up to 25 pounds frequently and up to 50 pounds on
occasion. The moderate noise environment limitation was not supported by substantial evidence.
The ALJ did not cite any evidence in support of this limitation beyond stating it in the RFC.
Furthermore, the transcript indicates that the ALJ believed there were no hearing tests, when in
fact Plaintiff underwent several. Although the ALJ properly excluded and limitations related to
Plaintiff’s attentional capacity, the ALJ erred by not including limitations related to Plaintiff’s
memory problems, which were supported by substantial evidence.
E. Remand for Further Proceedings
Within the Court’s discretion under 42 U.S.C. § 405(g) is the “decision whether to
remand for further proceedings or for an award of benefits.” Holohan, 246 F.3d at 1210 (citation
omitted). Although a court should generally remand to the agency for additional investigation or
explanation, a court has discretion to remand for immediate payment of benefits. Treichler v.
Comm’r of Soc. Sec. Admin., 775 F.3d 1090, 1099-1100 (9th Cir. 2014). The issue turns on the
utility of further proceedings. A remand for an award of benefits is appropriate when no useful
purpose would be served by further administrative proceedings or when the record has been fully
developed and the evidence is insufficient to support the Commissioner’s decision. Id. at 1100. A
court may not award benefits punitively and must conduct a “credit-as-true” analysis on evidence
that has been improperly rejected by the ALJ to determine if a claimant is disabled under the Act.
Strauss v. Comm’r of Soc. Sec. Admin., 635 F.3d 1135, 1138 (9th Cir. 2011).
In the Ninth Circuit, the “credit-as-true” doctrine is “settled” and binding on this Court.
Garrison, 759 F.3d 995, 999 (9th Cir. 2014). The Ninth Circuit articulates the rule as follows:
The district court must first determine that the ALJ made a legal
error, such as failing to provide legally sufficient reasons for
rejecting evidence. If the court finds such an error, it must next
review the record as a whole and determine whether it is fully
developed, is free from conflicts and ambiguities, and all essential
factual matters have been resolved. In conducting this review, the
district court must consider whether there are inconsistencies
between the claimant’s testimony and the medical evidence in the
record, or whether the government has pointed to evidence in the
record that the ALJ overlooked and explained how that evidence
casts into serious doubt the claimant’s claim to be disabled. Unless
the district court concludes that further administrative proceedings
would serve no useful purpose, it may not remand with a direction
to provide benefits.
If the district court does determine that the record has been fully
developed and there are no outstanding issues left to be resolved,
the district court must next consider whether the ALJ would be
required to find the claimant disabled on remand if the improperly
discredited evidence were credited as true. Said otherwise, the
district court must consider the testimony or opinion that the ALJ
improperly rejected, in the context of the otherwise undisputed
record, and determine whether the ALJ would necessarily have to
conclude that the claimant were disabled if that testimony or
opinion were deemed true. If so, the district court may exercise its
discretion to remand the case for an award of benefits. A district
court is generally not required to exercise such discretion,
however. District courts retain flexibility in determining the
appropriate remedy and a reviewing court is not required to credit
claimant’s allegations regarding the extent of their impairments as
true merely because the ALJ made a legal error in discrediting
their testimony.
Dominguez v. Colvin, 808 F.3d 403, 407-08 (9th Cir. 2015) (internal citations and quotation
marks omitted).
Here, the ALJ committed reversible errors in assessing the medical opinions of Drs.
Fellin and Cole. This led to errors in formulation of the RFC. The ALJ also did not provide a
legally sufficient rationale for rejecting Plaintiff’s symptom testimony and did not consider the
testimony of Plaintiff’s father at all. However, the Court cannot find that the record as a whole is
fully developed and free from all conflicts and ambiguities.
CONCLUSION
The Commissioner’s decision that Plaintiff was not disabled is REVERSED AND
REMANDED for further proceedings consistent with this Opinion and Order.
IT IS SO ORDERED.
DATED this 25th day of November, 2019.
/s/ Michael H. Simon
Michael H. Simon
United States District Judge