Deal v. Kijakazi

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5 UNITED STATES DISTRICT COURT

6 NORTHERN DISTRICT OF CALIFORNIA

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S.D., Case No. 23-cv-04631-NC

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Plaintiff,

ORDER REVERSING

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v. ADMINISTRATIVE LAW

11 JUDGE DECISION IN PART

KILOLO KIJAKAZI, et al., AND REMANDING FOR

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FURTHER PROCEEDINGS

Defendants.

13 Re: ECF 1, 7, 11, 12

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Claimant S.D. appeals from an Administrative Law Judge’s denial of her

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application for social security benefits. Claimant contends the ALJ erred in (1) rejecting

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medical opinion evidence; and (2) finding Claimant’s testimony inconsistent with the

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record. This Court finds that the ALJ did not provide an explanation supported by

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substantial evidence for rejecting the medical opinion evidence but did give clear and

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convincing evidence for finding Claimant’s testimony inconsistent. Accordingly, this

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Court reverses the ALJ’s decision in part and remands for further proceedings.

21 I. BACKGROUND

22 A. Procedural History

23 Claimant filed for disability insurance benefits on November 15, 2017, under Title

24 II of the Social Security Act, alleging that she had become disabled on April 22, 2017. AR

25 337–338. Claimant’s application was denied initially and upon reconsideration. AR 134–

26 136, 138–140. An ALJ held an administrative hearing on June 13, 2022, at which

27 Claimant and a vocational expert testified. AR 47–49. The ALJ issued an unfavorable

1 in disability determinations and found that (1) Claimant had not engaged in substantial

2 gainful activity since April 22, 2017, the alleged onset date; (2) Claimant had several

3 severe impairments; (3) Claimant’s impairments did not meet or equal the criteria in the

4 Listing of Impairments; (4) Claimant had the residual functional capacity (RFC) to

5 perform light work as defined in 20 C.F.R. § 404.1567(b), except she was able to

6 occasionally perform postural activities and her job should not include regular interaction

7 and communication with the general public for primary duties; (5) Claimant’s statements

8 concerning the intensity, persistence, and limiting effects of her symptoms were not

9 entirely consistent with the medical evidence and other evidence in the record; (6)

10 Claimant could not perform any past relevant work, and (7) that jobs existed in significant

11 numbers matching Claimant’s RFC. AR 23–36. Therefore, the ALJ found that Claimant

12 was not disabled at any time from Claimant’s alleged onset date of April 22, 2017, through

13 the date of the ALJ’s decision. AR 36. Claimant timely filed a complaint with this Court

14 on September 11, 2023. ECF 1. All parties have consented to magistrate judge

15 jurisdiction. ECF 3, 5.

16 B. Factual History

17 1. Medical Opinion Evidence

18 Claimant challenges the ALJ’s weighing of opinions from physicians Dr.

19 Radabaugh, Dr. Regets, and Dr. Brown. This Court briefly summarizes the findings of

20 those physicians below.

21 a. Dr. Radabaugh

22 Dr. Radabaugh performed a psychological consultative examination of Claimant on

23 March 26, 2018. AR 810–815. Dr. Radabaugh opined that Claimant’s functioning in

24 several areas was fair to poor. AR 810–815.

25 b. Dr. Regets

26 Dr. Regets completed a mental RFC assessment, finding, among other things, that

27 Claimant was capable of understanding, carrying out, and remembering short, simple, and

1 normal workday/workweek while remaining focused and attentive for extended, two-hour

2 or more segments. AR 92. Dr. Regets found that Claimant would be able to work in an

3 independent work setting requiring only quick and short social demands/interactions with

4 the general public and coworkers. AR 92. Dr. Regets also opined that Claimant had the

5 ability to ask and accept simple instructions. AR 92. Dr. Regets found that Claimant had

6 depressive, bipolar and related disorder, and anxiety and obsessive-compulsive disorders.

7 AR 89. Dr. Regets found that Claimant had moderate impairments in the ability to interact

8 with others and moderate impairments in concentration, persistence, or pace, as well as no

9 limitations in understanding, remembering, or applying information and adapting or

10 managing oneself. AR 89.

11 c. Dr. Brown

12 Dr. Brown made similar findings to Dr. Regets but also included the ability to

13 function with well-learned semi-skilled work. AR 129.

14 2. Symptom Testimony

15 Claimant testified that the following impairments limit her ability to work: bipolar

16 disorder, depression, anxiety, grief, thyroid, arthritis, bladder leakage, stress, oral lichen

17 planus, and carpal tunnel syndrome. AR 28. She reported she is 5’3” and 226 pounds,

18 establishing the presence of obesity, and she is unable to lose weight because of her

19 thyroid problems. AR 28–29. Claimant testified that she does not engage in any social

20 activities, reported conflict with her landlord, and said she had lost a job due to erratic

21 behavior. AR 28. Claimant stated that she has been unable to work since her boyfriend

22 died in 2017, which caused her to develop PTSD. AR 29. Claimant testified that she is

23 tired frequently because of her depression and thyroid problems. AR 29.

24 II. LEGAL STANDARD

25 A district court has the “power to enter, upon the pleadings and transcript of the

26 record, a judgment affirming, modifying, or reversing the decision of the Commissioner of

27 Social Security, with or without remanding the case for a rehearing.” 42 U.S.C. § 405(g).

1 v. Colvin, 759 F.3d 995, 1010 (9th Cir. 2014).

2 A court should disturb the decision of the Commissioner only if it is not supported

3 by substantial evidence or if it is based on legal error. Burch v. Barnhart, 400 F.3d 676,

4 679 (9th Cir. 2005). Substantial evidence is evidence that a reasonable mind would accept

5 as adequate to support the conclusion. Bayliss v. Barnhart, 427 F.3d 1211, 1214 n.1 (9th

6 Cir. 2005) (“[It] is more than a mere scintilla but less than a preponderance.”). Even when

7 the ALJ commits legal error, the decision must be upheld if the error is harmless.

8 Treichler v. Comm’r of Soc. Sec. Admin., 775 F.3d 1090, 1099 (9th Cir. 2014). “A

9 reviewing court may not make independent findings based on the evidence before the ALJ

10 to conclude that the ALJ’s error was harmless.” Brown-Hunter v. Colvin, 806 F.3d 487,

11 492 (9th Cir. 2015). Where evidence is susceptible to more than one rational

12 interpretation, the ALJ’s decision should be upheld. Andrews v. Shalala, 53 F.3d 102,

13 1039–40 (9th Cir. 1995).

14 III. DISCUSSION

15 This Court addresses Claimant’s two challenges to the ALJ’s decision: (1) weighing

16 of medical evidence, and (2) consistency determination on Claimant’s symptom testimony.

17 A. Medical Opinion Evidence

18 An ALJ must consider all medical opinion evidence. See Tommasetti v. Astrue, 533

19 F.3d 1035, 1038 (9th Cir. 2008). And where medical opinions contradict one another, the

20 ALJ must resolve the conflict. Andrews, 53 F.3d at 1041 (citing Magallanes v. Bowen,

21 881 F. 2d 747, 751 (9th Cir. 1989)). This requires “setting out a detailed and thorough

22 summary of the facts and conflicting clinical evidence, stating his interpretation thereof,

23 and making findings.” Id. (citing Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998)).

24 Under the revised rules, the ALJ is no longer required to defer to or assign each medical

25 opinion a specific evidentiary weight. 20 C.F.R. §§ 404.1520c(a), 416.920c(a). Instead,

26 the ALJ will articulate the persuasiveness of the medical opinions or prior administrative

27 findings, the most important factors being consistency and supportability. 20 C.F.R. §§

1 2022). Supportability means the extent to which a medical source supports the medical

2 opinion by explaining the “relevant…objective medical evidence.” Woods, 32 F.4th at

3 791–92 (quoting 20 C.F.R. § 404.1520c(c)(1)). “Consistency means the extent to which a

4 medical opinion is consistent…with the evidence from other medical sources and

5 nonmedical sources in the claim.” Woods, 32 F.4th at 792 (quoting 20 C.F.R. §

6 404.1520c(c)(2)). Other factors may be considered, including the treatment relationship,

7 specialization, and whether the source has familiarity with other evidence in the claim or

8 an understanding of the disability program’s policies and evidentiary requirements. 20

9 C.F.R. §§ 404.1520c(a), (c), 416.829c(a), (c). Even under the new regulations, an ALJ

10 cannot reject an examining or treating doctor’s opinion as unsupported or inconsistent

11 without providing an explanation supported by substantial evidence. Woods, 32 F.4th at

12 792. The agency must “articulate…how persuasive” it finds “all of the medical opinions”

13 from each doctor or source, and “explain how [it] considered the supportability and

14 consistency factors” in reaching these findings. Id. (citing 20 C.F.R. § 404.1520c(b) and §

15 404.1520c(b)(2)).

16 The ALJ did not provide an explanation supported by substantial evidence for

17 rejecting the opinion evidence from Dr. Radabaugh and prior administrative findings. Dr.

18 Radabaugh opined that Claimant’s functioning in several areas was fair to poor. AR 810–

19 815. The ALJ found this opinion “not persuasive,” reasoning that the assessment appeared

20 to be based on Claimant’s own statements, and the level of dysfunction Claimant described

21 was not documented throughout the relevant period. AR 33, 810–815. However, the ALJ

22 did not cite specific parts of Dr. Radabaugh’s opinion that appeared to be based on

23 Claimant’s own statements, nor provide specific and detailed reasons why he believed the

24 assessment appeared to be based on Claimant’s own statements. The ALJ did not identify

25 any inconsistency in history, treatment, or current level of function as assumed by Dr.

26 Radabaugh and the medical records. The ALJ also did not point to any aspects of Dr.

27 Radabaugh’s evaluation that do not correspond with the standard of care or the

1 ability to interact with others. For each of these conclusions about the issues with the

2 ALJ’s evaluations of the Dr. Radabaugh opinion, the Court itself also did not find

3 substantial evidence in the record to support the ALJ’s conclusions.

4 The ALJ specifically referenced Dr. Regets’ State agency initial determination,

5 noting that Dr. Regets’ opinion was deemed insufficient during a quality review. AR 32.

6 However, the ALJ did not discuss the details of the quality review, specifically why Dr.

7 Regets’ opinion was deemed insufficient, or the methodology of the quality review. The

8 quality review assessment was not in the record, and referring to a non-exhibit fails to

9 provide a basis for assigning weight that has the support of substantial evidence. Woods v.

10 Kijakazi, 32 F.4th 785, 792 (9th Cir. 2022).

11 The ALJ specifically found that Dr. Brown’s opinion was partially persuasive, but

12 the record did not support limitations in regard to interacting with coworkers or

13 supervisors, or in performing simple, repetitive tasks. AR 33. In assessing Claimant’s

14 disability claim, the ALJ noted that Claimant did not have any cognitive impairments, and

15 there was no evidence of significant limitations in this area, other than Dr. Radabaugh’s

16 report showing possible learning disorder. AR 26–27, 810–815. The ALJ also noted that

17 in later examinations in August 2019, October 2019, November 2020, December 2020,

18 January 2021, and April 2021, Claimant continued to report doing well and medical

19 reviews of systems were normal. AR 30–34, 1004–1095. The ALJ thoroughly evaluated

20 the evidence of record. AR 26–34.

21 Accordingly, this Court finds that the ALJ failed to provide an explanation

22 supported by substantial evidence for rejecting the opinion evidence of Dr. Radabaugh and

23 Dr. Regets.

24 B. Symptom Testimony

25 Claimant argues that the ALJ failed to properly credit her symptom testimony.

26 When evaluating a claimant’s testimony about subjective symptoms, an ALJ must engage

27 in a two-step analysis. Garrison, 759 F.3d at 1014–1015. First, the ALJ evaluates whether

1 produce the” symptoms alleged. Id. (quoting Lingenfelter v. Astrue, 504 F.3d 1028,

2 1035–36 (9th Cir. 2007)). The claimant is not expected to show that her impairment is

3 expected to cause the severity of symptoms claimed; she only needs to show that the

4 impairment could cause some degree of symptoms. Smolen v. Chater, 80 F.3d 1273, 1282

5 (9th Cir. 1996). Second, if the claimant satisfies step one and there is no evidence of

6 malingering, the ALJ can reject the claimant’s testimony about the severity of his

7 symptoms only by offering specific, clear, and convincing reasons for doing so. Id. at

8 1281. “This is not an easy requirement to meet: the clear and convincing standard is the

9 most demanding required in Social Security cases.” Garrison, F.3d at 1014–15 (quoting

10 Moore v. Comm’r of Soc. Sec. Admin., 278 F.3d 290, 294 (9th Cir. 2002)) (internal

11 quotation marks omitted). General findings are insufficient; rather, the ALJ must identify

12 what testimony is not credible and what evidence undermines the claimant’s complaints.

13 Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998). Factors that an ALJ may consider in

14 weighing a claimant’s credibility include reputation for truthfulness, inconsistencies in

15 testimony or between testimony and conduct, daily activities, and unexplained, or

16 inadequately explained, failure to seek treatment or follow a prescribed course of

17 treatment. Orn, 495 F.3d at 636.

18 Here, at step one the ALJ found Claimant’s medically determinable impairments

19 could reasonably be expected to cause the alleged symptoms. AR 29. At step two, the

20 ALJ found Claimant’s statements concerning the intensity, persistence, and limiting effects

21 of these symptoms were not entirely consistent with the medical evidence and other

22 evidence in the record. AR 29.

23 The ALJ addressed inconsistencies in Claimant’s statements about the intensity,

24 persistence, and limiting effects of her symptoms in clear and convincing detail. See

25 Smolen, 80 F.3d at 1282. The ALJ stated that the medical record did not support the level

26 of dysfunction alleged by the claimant. AR 29. The ALJ identified Claimant’s testimony

27 regarding depression, manic episodes, failure of medications, and poor sleep as not

1 || medical appointments at the time of this testimony was normal. AR 30. The ALJ pointed

2 || to specific exhibits in the record containing testimony from Claimant that she was much

3 || happier that she had her own apartment with more space and privacy, and that a large part

4 || of her mood issue was living in a single room in a residence with other people. AR 30.

5 || The ALJ found Claimant’s issues with motivation attributable to season and living

6 || circumstances and cited to Claimant’s medical provider’s report stating this. AR 30.

7 || Finally, the ALJ acknowledged that Claimant’s complaints of low energy and lack of

8 || motivation were well-documented in the medical record but pointed to the fact that there

9 || was marijuana use documented through 2018 and a stressful living situation through 2020,

10 || with improvement noted when these factors were eliminated. AR 31.

1] Based on the ALJ’s detailed review of these combined inconsistencies, this Court

3 12 || finds the ALJ provided clear and convincing reasons for this consistency determination.

13 |} IV. CONCLUSION

14 On AR 24 and 26, the ALJ states they do not find a disability from April 2017

2 15 || through the date of this decision. The definition of disability is for any 12 month period.

16 || 42 U.S.C. § 423(d)(1)(A). On remand, the ALJ should be sure to look at whether there

5 17 || was any 12 month period from the alleged onset of disability when the claimant was

5 18 || disabled, particularly during the time before the claimant’s symptoms improved.

19 Finding that the ALJ failed to provide an explanation supported by substantial

20 || evidence for rejecting the opinion evidence of Dr. Radabaugh and Dr. Regets, this court

21 || REVERSES the ALJ’s decision in part and REMANDS for further proceedings consistent

22 || with this order.

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24 IT IS SO ORDERED.

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26 || Dated: July 10, 2024 he □

27 NATHANAEL M. COUSINS

28 United States Magistrate Judge