stating that it is error for an 24 ALJ to paraphrase medical evidence in a manner that is “not entirely accurate regarding 25 the content or the tone of the record.”
How later courts described this case
- stating that it is error for an 24 ALJ to paraphrase medical evidence in a manner that is “not entirely accurate regarding 25 the content or the tone of the record.”
- when there is 17 suggestion of mental impairment, an ALJ must inquire into the current status of that 18 impairment and its possible effect on the claimant’s ability to work.
- a claimant who raises a suspicion 20 concerning their alleged cognitive impairment triggers the need for development of an 21 adequate record.
Written by the judges who cited it.
The opinion
1
2
3
4
5
6
7
8 UNITED STATES DISTRICT COURT
9 SOUTHERN DISTRICT OF CALIFORNIA
10
11 LARRY A., Case No.: 3:23-cv-01101-W-DTF
12 Plaintiff,
REPORT AND
13 v. RECOMMENDATION REGARDING
JOINT MOTION FOR JUDICIAL
14 MARTIN O’MALLEY, Commissioner of
REVIEW
Social Security,
15
Defendant. [ECF No. 11]
16
17
18
19 On June 13, 2023, Plaintiff Larry A.1 commenced this action against Defendant
20 Kilolo Kijakazi2, Acting Commissioner of Social Security, for judicial review under 42
21 U.S.C. 42 U.S.C. § 405(g) of the finding that Plaintiff was not disabled under the Social
22 Security Act. (ECF No. 1.) Defendant filed the Administrative Record on August 11,
23 2023. (ECF Nos. 6, 7.) On December 27, 2023, the parties filed a Joint Motion for
24
25
26
1 The Court refers to Plaintiff using only his first name and last initial pursuant to the Court’s Civil
27 Local Rules.
2 Martin O’Malley is now the Commissioner of Social Security and is automatically substituted as a
28
1 Judicial Review of Final Decision of the Commissioner of Social Security. (ECF No.
2 11.)
3 This Report and Recommendation is submitted to United States District Judge
4 Thomas J. Whelan under 28 U.S.C. § 636(b)(1) and Local Civil Rule 72.1(c). For the
5 following reasons, the Court recommends that the final decision of the Commissioner be
6 REVERSED, and this matter be REMANDED for further administrative proceedings
7 consistent with this Report and Recommendation.
8 I. BACKGROUND
9 A. Procedural History
10 On April 15, 2011, Plaintiff, born in 1963, filed an application for supplemental
11 social security income under Title XVI of the Social Security Act. (AR 52.)3 In that
12 application, he alleged disability due to hypertension, carpal tunnel syndrome, chest pain,
13 and depression. (AR 54.) The claims were denied on July 26, 2011, and again on
14 February 22, 2012 after reconsideration. (AR 52.) An administrative hearing was
15 conducted on July 11, 2013 before Administrative Law Judge (“ALJ”) O. Lisa Dabreu.
16 (Id.) On December 27, 2013, the ALJ issued a decision and concluded that Plaintiff was
17 not disabled. (AR 52-61.)
18 Plaintiff appealed this decision to the Appeals Council who remanded the matter
19 for a new hearing and directed the ALJ to consider the opinion of Dr. Mierhofer who
20 performed a consultative examination on September 23, 2013 and further noted that “an
21 evaluation of the [Plaintiff’s] mental impairments was necessary.” (AR 130.) A new
22 hearing was scheduled for March 10, 2016 but Plaintiff was unable to attend due to lack
23 of access to transportation. (Id.)
24
25
26 3 “AR” refers to the Administrative Record filed on August 11, 2023. (ECF Nos. 6, 7.) The Court’s
citations to the AR use the page references in the original document rather than the page numbers
27 designated by the Court’s case management/electronic case filing system (“CM/ECF”). For all other
documents, the Court’s citations are to the page numbers affixed by CM/ECF.
28
1 Plaintiff filed a new application on July 19, 2016. (AR 137.) In this application,
2 he alleged disability since December 31, 2010 due to “adjustment disorder with anxious
3 mood, borderline intellectual functioning, history of substance abuse, depression, carpal
4 tunnel syndrome, and hypertension.” (AR 133.) On December 2, 2016 ALJ Karen A.
5 Cornick-Craig issued a decision and again concluded that Plaintiff was not disabled and
6 denied both claims of supplemental security income and disability insurance benefits.
7 (AR 142.)
8 On September 20, 2018, Plaintiff filed a new application for disability insurance
9 benefits and supplemental security income under Titles II and XVI, respectively, of the
10 Social Security Act. (AR 315-325.) He alleges that he has been disabled and unable to
11 engage in substantial gainful activity since September 1, 2017, due to “angina,
12 hypertension, early arthritic changes of the left wrist, history of carpal tunnel syndrome,
13 cervical, thoracic and lumbar strain/sprain, and bilateral shoulder strain/sprain.” (AR
14 151.) These claims were denied on February 13, 2019, and again on reconsideration on
15 July 26, 2019. (AR 148.) A telephonic hearing was held on July 7, 2020. (Id.) On
16 November 4, 2020, ALJ Howard K. Treblin issued a decision and concluded that Plaintiff
17 was not disabled. (AR 148-157.) Plaintiff appealed that decision to the Appeals Council
18 who remanded the case for a new hearing on August 3, 2021. (AR 164-166.)
19 Specifically, the Appeals Council found that the ALJ had relied on the previous 2014
20 unfavorable decision rather than evaluating the more recent 2016 unfavorable decision.
21 (AR 164.)
22 A new hearing was held by on January 7, 2022. (AR 10-19.) On March 14, 2022,
23 ALJ Treblin issued a decision and concluded that Plaintiff was not disabled. (Id.)
24 Plaintiff requested a review of the ALJ’s decision; the Appeals Council denied the
25 request on April 13, 2023. (AR 1-6.) He then commenced this action pursuant to 42
26 U.S.C. § 405(g).
27 / / /
28 / / /
1 B. ALJ’s Decision
2 In rendering his decision, the ALJ followed the Commissioner’s five-step
3 sequential evaluation process. See 20 C.F.R. § 404.1520; see also Tackett v. Apfel, 180
4 F.3d 1094, 1098-99 (9th Cir. 1999) (describing five steps). The ALJ determined at step
5 one that Plaintiff had not engaged in substantial gainful activity since September 1, 2017,
6 the alleged onset date of his disability. (AR 13.)
7 At step two, the ALJ found that Plaintiff had the following severe impairments:
8 “angina; hypertension; early arthritic changes of the left wrist; history of carpal tunnel
9 syndrome; cervical, thoracic, and lumbar strain/sprain; and bilateral shoulder
10 strain/sprain.” (Id.) The ALJ also determined that “[t]he claimant has not alleged any
11 mental impairments nor is there any medical evidence of a medically determinable
12 mental impairment. The most recent treatment records since the prior unfavorable
13 hearing decision reported normal mental status examinations.” (Id.) The ALJ
14 determined at step three that Plaintiff did not have an impairment or combination of
15 impairments that met or medically equaled a listed impairment. (Id.)
16 The ALJ found that Plaintiff had the following residual functional capacity
17 (“RFC”):
18 [M]edium work as defined in 20 CFR 404.1567(c) and 416.967(c). The claimant
can lift and/or carry 50 pounds occasionally and 25 pounds frequently; can stand
19
and/or walk for 6 hours out of an 8-hour workday; can sit for 6 hours out of an 8-
20 hour workday; is unlimited with respect to pushing, pulling, postural and
manipulative activities, other than as indicated for lifting and/or carrying.
21
22 (AR 13.)
23
At step four, the ALJ concluded that Plaintiff “did not perform his past work at
24
substantial gainful activity levels, thus, under the regulations his work activity is not past
25
relevant work.” (AR 18.)
26
At step five, the ALJ found, based on testimony from a vocational expert, that
27
Plaintiff was capable of performing the requirements of the representative unskilled
28
1 medium occupations of dining room attendant, counter supply, and kitchen helper. (AR
2 19.) Accordingly, the ALJ found that Plaintiff had not been under a disability from
3 September 6, 2018, through the date of his decision. (Id.)
4 C. Disputed Issues
5 The parties have briefed two issues4 in their joint motion which Plaintiff asserts are
6 grounds for reversal: (1) whether the AJB was required to consider and develop the
7 record as to Plaintiff’s borderline intellectual functioning; and (2) whether the ALJ
8 properly formulated Plaintiff’s RFC.
9 I. LEGAL STANDARDS
10 Section 405(g) of the Social Security Act allows unsuccessful applicants to seek
11 judicial review of a final agency decision of the Commissioner. 42 U.S.C. § 405(g). The
12 scope of judicial review is limited, however, and the denial of benefits “‘will be disturbed
13 only if it is not supported by substantial evidence or is based on legal error.’” Brawner v.
14 Sec’y of Health & Human Servs., 839 F.2d 432, 433 (9th Cir. 1988) (quoting Green v.
15 Heckler, 803 F.2d 528, 529 (9th Cir. 1986)); see also Garrison v. Colvin, 759 F.3d 995,
16 1009 (9th Cir. 2014). Substantial evidence means “‘more than a mere scintilla but less
17 than a preponderance; it is such relevant evidence as a reasonable mind might accept as
18 adequate to support a conclusion.’” Sandgathe v. Chater, 108 F.3d 978, 980 (9th Cir.
19 1997) (quoting Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995)); see also Biestek
20 v. Berryhill, 587 U.S. ----, ----, 139 S. Ct. 1148, 1154, 203 L. Ed. 2d 504 (2019)
21 (“[W]hatever the meaning of ‘substantial’ in other contexts, the threshold for . . .
22 evidentiary sufficiency [under the substantial evidence standard] is not high.”). The court
23 must consider the entire record, including the evidence that supports and detracts from
24 the Commissioner’s conclusions. Desrosiers v. Sec’y of Health & Human Servs., 846
25 F.2d 573, 576 (9th Cir. 1988). If the evidence supports more than one rational
26
27
4 The Court has reordered Plaintiff’s arguments to approximate the order in which these issues would
28
1 interpretation, the court must uphold the ALJ’s decision. Burch v. Barnhart, 400 F.3d
2 676, 679 (9th Cir. 2005); Ford v. Saul, 950 F.3d 1141, 1154 (9th Cir. 2020). The district
3 court may affirm, modify, or reverse the Commissioner’s decision. 42 U.S.C. § 405(g).
4 The matter may also be remanded to the Social Security Administration for further
5 proceedings. Id.
6 III. DISCUSSION
7 A. Borderline Intellectual Functioning
8 Plaintiff argues that the ALJ erred in failing to consider his borderline intellectual
9 functioning and by failing to develop the record regarding Plaintiff’s borderline
10 intellectual functioning. (Jt. Mot., ECF No. 11, at 11-14.) Specifically, in Plaintiff’s
11 previous claims in 2014 and 2016, the ALJ found that Plaintiff had severe mental
12 impairments including finding that Plaintiff had borderline intellectual functioning in
13 2016. (AR 133.) However, in 2022, the ALJ found “no mental impairment” and further
14 stated that there was no “evidence of a medically determinable mental impairment.” (AR
15 13.)
16 Defendant argues in response that Plaintiff “has not alleged any mental
17 impairments nor is there evidence of a medically determinable mental impairment.” (Jt.
18 Mot. at 15.)
19 1. Applicable standards
20 It is an issue of legal error when determining whether an ALJ satisfied their duty to
21 develop the record. See Garcia v. Comm’r of Soc. Sec., 768 F.3d 925, 929 (9th Cir.
22 2014.) A Social Security hearing is “inquisitorial rather than adversarial. It is the ALJ’s
23 duty to investigate the facts and develop the arguments both for and against granting
24 benefits.” Sims v. Apfel, 530 U.S. 103, 111 (2000). That duty “extends to the represented
25 as well as to the unrepresented claimant.” Tonapetyan v. Halter, 242 F.3d 1144, 1150
26 (9th Cir. 2001). “In Social Security cases, the ALJ has a special duty to develop the
27 record fully and fairly and to ensure that the claimant’s interests are considered, even
28 when the claimant is represented by counsel.” Mayes v. Massanari, 276 F.3d 453, 459
1 (9th Cir. 2001). “The ALJ is responsible for studying the record and resolving any
2 conflicts or ambiguities in it.” Diedrick v. Berryhill, 874 F.3d 634, 638 (9th Cir. 2017).
3 Here, the Court agrees that the ALJ should have further developed the record
4 related to Plaintiff’s intellectual functioning. Specifically, the Appeals Council directed
5 the ALJ in the August 2021 remand order to “evaluate the most recent unfavorable
6 decision,” which was the December 2016 ruling at that time. In that 2016 decision, the
7 ALJ found that Plaintiff had the “following severe impairments: adjustment disorder with
8 anxious mood, borderline intellectual functioning, history of substance abuse, depression,
9 carpal tunnel syndrome, and hypertension.” (AR 133.) (emphasis added.) The 2016 RFC
10 limited Plaintiff to:
11 “performing simple repetitive work with instructions given verbally or by
demonstration to accommodate limitations in reading ability. He can have
12
occasional interaction with other employees, supervisors, and the public. He can
13 perform jobs that require only basic math skills, and he needs to avoid work related
hazards.”
14
15 (AR 136.)
The ALJ in the 2016 decision considered the opinions of Dr. Maierhofer, who
16
conducted a psychological exam of Plaintiff in 2011, along with Dr. Leaf, and found that
17
Plaintiff had moderate difficulties in social functioning, “concentration, persistence, or
18
pace.” (AR 134-35.) Because the ALJ was specifically directed to consider the 2016
19
decision in their 2022 findings, it is evident in the record that Plaintiff had a history of
20
mental impairment.
21
Instead, in 2022, the ALJ found that Plaintiff has “no mental impairment” and
22
there is “no medical evidence of a medically determinable mental impairment.” (AR 10,
23
13.) However, this conclusion is not supported by the evidence in the record. The 2016
24
ALJ decision noted that Dr. Maierhofer’s review of Plaintiff education records showed
25
that he had an “Individual Education Plan (IEP) while in high school” and received
26
special education in math, reading and spelling. (AR 137.) In September of 2018, Nurse
27
Practitioner Skopek noted that Plaintiff “appears to be a poor historian; doesn’t recall
28
1 meds, timeline, and is ambiguous with description of symptoms.” (AR 474.) A similar
2 notation was made by Dr. Sabourin on December 17, 2018 when he wrote that Plaintiff is
3 a “relatively poor historian” and cannot “remember any times or dates or much in the
4 way of any treatment he ever had.” (AR 506.) In December 14, 2019, Plaintiff was seen
5 by Dr. Bui, a cardiologist, who noted in the record “I do not know how much [Plaintiff]
6 actually understands of what is told to him in the office.” (AR 608.) As set forth above,
7 the 2016 ALJ decision itself found that Plaintiff had the severe impairment of borderline
8 intellectual functioning. (AR 133.)
9 Defendant argues in response that “since the prior unfavorable decision, Plaintiff
10 had normal mental status examinations.” (Jot. Mot. at 15 citing AR 702, 732, 743, 750,
11 786.) The first record the Defendant relies on is a cardiology examination on October 21,
12 2021. (AR 702.) There is no mental impairment assessment in this exam. The second
13 record is for an office visit indicating “patient is here for kidney labs . . . [h]e is being
14 followed by a cardiologist and they are requesting to have new labs for his kidneys.”
15 (AR 732.) Again, this is an office visit totally unrelated to mental impairment issues.
16 The third record is a visit with his primary care physician where he complained of
17 “dyspnea on exertion” which consists of shortness of breath while exerting himself.5
18 (AR 743.) Once again, this is not a medical examination focused on Plaintiff’s mental
19 capacity or potential limitations. The fourth record reports Plaintiff is being seen to treat
20 his hypertension, as well as an “Annual Health Assessment” and once again, there is no
21 specific mental or intellectual impairment examination conducted. (AR 750.) Finally,
22 the last record relied upon by Defendant is an examination by his primary care physician
23 for “muscle spasm, preventive care, and shortness of breath.” (AR 786.) This shows a
24 selective consideration of evidence when the ALJ found no evidence of mental health
25
26
27 5 See
https://www.ncbi.nlm.nih.gov/books/NBK499965/#:~:text=Dyspnea%20is%20a%20sensation%20of,%2
28
1 treatment which is engaging in impermissible cherry-picking of the record. See
2 Garrison,759 F.3d at 1018 n 23. Moreover, there are no medical opinions as to Plaintiff’s
3 mental impairments reviewed or considered by the ALJ in his opinion.
4 Here, the Court finds ALJ’s opinion that that there is no “mental evidence of a
5 medically determinable mental impairment” is not supported by the record. There is
6 sufficient evidence in the record to support Plaintiff’s borderline intellectual functioning,
7 as previously discussed in the 2016 opinion, as a medically determinable impairment.
8 Although the ALJ need not discuss every piece of evidence in the record, they cannot
9 ignore or omit evidence that is significant or probative. Hiler v. Astrue, 687 F.3d 1208,
10 1212 (9th Cir. 2012). The ALJ has “a special duty to fully and fairly develop the record
11 and to assure that the claimant’s interests are considered.” Brown v. Heckler, 713 F.2d
12 441, 443 (9th Cir. 1983). “In cases of mental impairments, this duty is especially
13 important.” DeLorme v. Sullivan, 924 F.2d 841, 849 (9th Cir. 1991). Throughout the
14 record there are references to Plaintiff’s possible mental and intellectual impairments and
15 thus, the ALJ’s duty to develop the record is “heightened.” See Tonapetyan, 242 F.3rd at
16 1150; see also Plummer v. Apfel, 186 F.3d 422, 434 (3rd Cir. 1999) (when there is
17 suggestion of mental impairment, an ALJ must inquire into the current status of that
18 impairment and its possible effect on the claimant’s ability to work.); Hilliard v.
19 Barnhart, 442 F.Supp.2d 813, 817 (N.D. Cal. 2006) (a claimant who raises a suspicion
20 concerning their alleged cognitive impairment triggers the need for development of an
21 adequate record.)
22 The Court concludes that the ALJ erred by failing to develop the record as to
23 Plaintiff’s mental and intellectual impairments. Moreover, the Court also finds that the
24 ALJ’s finding that there is no “medical evidence of a medically determinable mental
25 impairment” is not supported by substantial evidence.
26 Accordingly, the Court RECOMMENDS that the Commissioner’s decision be
27 remanded to further develop the record as to determine the extent of Plaintiff’s borderline
28 intellectual functioning.
1 B. Residual Functional Capacity
2 Plaintiff contends that the ALJ erred in his formulation of his residual functional
3 capacity (“RFC”) by failing to consider all of Plaintiff’s medical and mental limitations.
4 (Jot. Mot. at 3-8.) Defendant responds that the RFC is supported by substantial evidence
5 and the ALJ provided reasons for not fully crediting Plaintiff’s testimony as to the
6 severity of his symptoms. (Id. at 8-11.) As an initial matter, for the reasons set forth
7 above, remand is appropriate to reconsider Plaintiff’s RFC after developing the record as
8 to his possible intellectual impairments. These impairments may also affect the analysis
9 of the medical records as it relates to the reliance of the ALJ on Plaintiff’s self-reporting
10 medical symptoms.
11 1. Applicable standards
12 Residual functional capacity is defined as “the most you can still do despite your
13 limitations.” See 20 C.F.R. § 404.1545(a)(1). “Ordinarily, RFC is the individual’s
14 maximum remaining ability to do sustained work activities in an ordinary work setting
15 on a regular and continuing basis, . . . mean[ing] 8 hours per day, for 5 days a week, or
16 an equivalent work schedule." SSR 96-8P, 1996 WL 374184, at *2 (emphases omitted).
17 The RFC assessment is first used at step four of the sequential evaluation process to
18 decide if the claimant can perform her past relevant work. 20 C.F.R.
19 § 404.1545(a)(5)(i). If the ALJ decides that the claimant cannot perform his past
20 relevant work, the same RFC assessment is used at step five of the sequential evaluation
21 process to decide if the claimant can adjust to any other work that exists in the national
22 economy. Id. § 404.1545(a)(5)(ii). In determining a claimant’s RFC at steps four and
23 five, the ALJ must consider all relevant evidence in the record, including medical
24 history; medical signs and laboratory findings; lay evidence; the effects of treatment,
25 including disruption to routine and side effects of medication; and the effects of
26 symptoms, including pain. SSR 96-8P, 1996 WL 374184, at *5; see also Robbins v.
27 Soc. Sec. Admin., 466 F.3d 880, 883 (9th Cir. 2006).
28
1 RFC assessment must always consider and address medical source opinions and,
2 if the RFC conflicts with an opinion from a medical source, the ALJ must explain why
3 the opinion was not adopted. SSR 96-8P, 1995 WL 374184, at *7.
4 Here, as set forth above the ALJ found that Plaintiff had the following RFC:
5 [M]edium work as defined in 20 CFR 404.1567(c) and 416.967(c). The claimant
can lift and/or carry 50 pounds occasionally and 25 pounds frequently; can stand
6
and/or walk for 6 hours out of an 8-hour workday; can sit for 6 hours out of an 8-
7 hour workday; is unlimited with respect to pushing, pulling, postural and
manipulative activities, other than as indicated for lifting and/or carrying.
8
9 (AR 13.)
10 2. ALJ’s finding that Plaintiff could perform medium work not supported
11 by substantial evidence
12 The Court finds that substantial evidence in the record does not support the RFC
13 formulated by the ALJ. First, the ALJ found that “[c]ardiac workups were [] negative for
14 acute issues.” (AR 15.) To support this conclusion, the ALJ cites Exhibit 3F/3-4, 11 (AR
15 488-89, 496.) This exhibit is a medical record of Plaintiff’s examination at Tri-City
16 Medical Center on October 19, 2018 in which he “present[ed] . . . for evaluation of 3
17 days of left-sided chest pain” which he described as a “cramp-like sensation.” (AR 488,
18 Ex. 3F at 3.) Defendant then cites to the description of the chest x-ray Plaintiff received
19 that day which indicated that Plaintiff had “mild cardiomegaly” which is an “enlarged
20 heart.6 However, the Defendant does not cite to the record that shows later that same day
21 Plaintiff received a CT pulmonary angiogram. (AR 495, Ex. 3F at 10.) This scan
22 showed that Plaintiff had bilateral atelectasis which are collapsed lungs,7 a mild
23
24
25
26
27 6 See https://my.clevelandclinic.org/health/diseases/21490-enlarged-heart-cardiomegaly (website last
visited June 25, 2024.)
28
1 ascending thoracic aortic aneurysm, and suspected left ventricular hypertrophy which is a
2 thickening of the wall of the heart’s main pumping chamber.8 (Id.)
3 The ALJ also found that treatment records in 2019 include “examination findings
4 indicated normal heart, lung, musculoskeletal, and neurological findings.” (AR 15 citing
5 to Exhibit 7F/3-4, 8, 10 (AR 557-56, 562, 564); 8F/10, 14, 24 (AR 591, 595, 605); 9F/1-
6 2, 4-5; 608-09, 611-612.) Exhibit 7F is a medical record for an exam Plaintiff had with
7 Blue Coast Cardiology on February 15, 2019 in which cardiologist Dr. Kenneth Carr
8 noted after reviewing Plaintiff’s EKG and stress EKG that “[o]f concern was apical
9 thickening consistent with apical hypertrophic cardiomyopathy” which is a “rare variant
10 of hypertrophic cardiomyopathy characterized by abnormal heart muscle thickening,
11 specifically affecting the left ventricle's apex.”9
12 Second, the ALJ found that Plaintiff has “no significant ... respiratory impairment
13 that would corroborate his allegations of breathing problems limiting his functioning.”
14 (AR 16 citing Ex. 11F/1 (AR 702).) This exhibit involves an exam by Blue Coast
15 Cardiology where Plaintiff presented with “chest discomfort and shortness of breath” and
16 Defendant claims this “physical examination was normal.” (AR 16, 702.) However,
17 Defendant does not include the assessment and treatment notes which indicate that
18 Plaintiff has “dyspnea on exertion,” high blood pressure, and high levels of cholesterol.
19 (AR 703.) In addition, it is indicated that Plaintiff “continues to have shortness of
20 breath” and the doctor decided to “move forward with exercise treadmill stress test to
21 evaluate for any myocardial ischemia that could be causing his shortness of breath.” (Id.)
22 The ALJ also states that the treatment records from Vista Community Clinic in
23 2021 showed “no worsening in claimant’s impairments” and he was “treated with
24 routine, conservative medication management for his hypertension and other conditions
25
26
27 8 https://www.mayoclinic.org/diseases-conditions/left-ventricular-hypertrophy/symptoms-causes/syc-
20374314 (website last visited June 25, 2024.)
28
1 such as Albuterol for complaints of shortness of breath.” (AR 16 citing Ex. 12F/1-3 (AR
2 730-732).) This exhibit is a visit Plaintiff had at the Vista Community Clinic on
3 December 6, 2021 and the notes indicate that it was not a physical examination but
4 instead it is indicated that “patient is here for kidney labs… [h]e is being followed by
5 cardiologist and they are requesting to have new labs for his kidneys.” (Id.)
6 The ALJ also found that Plaintiff’s treatment records in 2019 contained
7 “examination findings indicat[ing] normal … musculoskeletal . . . findings.” (AR 15
8 citing Exhibits 7F/3-4, 8, 10 (AR 557-56, 562, 564); 8F/10, 14, 24 (AR 591, 595, 605);
9 9F/1-2, 4-5; 608-09, 611-612).) The ALJ refers to a portion of the medical records for an
10 exam Plaintiff had on January 2, 2019, see AR 605, but fails to refer to other pages from
11 that examination where it is indicated that Plaintiff had joint pain and muscle cramps,
12 while also noting that he had been diagnosed with carpal tunnel syndrome in 2018. (AR
13 602, 604.) At this visit Plaintiff also complained of “constant locking of joints of his
14 hands and legs bilaterally,” and “associated numbness.” (AR 603.) On April 24, 2019,
15 Plaintiff presented with “muscle cramping,” which continued even after he discontinued
16 the atorvastatin per the instructions as a possible reason for the cramping. (AR 671.)
17 Plaintiff presented with muscle spasms and cramping in his “thighs and calves” on
18 December 9, 2019. (AR 665.) He also stated that it was “exacerbated with walking.”
19 (Id.) On January 7, 2020 Plaintiff reported that he was experiencing “spasms [and]
20 cramping [that] are exacerbated by walking.” (AR 652.) It was also noted that he had a
21 diagnosis of bilateral carpal tunnel syndrome. (AR 653.)
22 The Court finds that ALJ’s characterization of the record is misleading. See
23 Reddick v. Chater, 157 F.3d 715, 722-23 (9th Cir. 1998) (stating that it is error for an
24 ALJ to paraphrase medical evidence in a manner that is “not entirely accurate regarding
25 the content or the tone of the record.”). Contrary to the ALJ’s statements that Plaintiff
26 had received “minimal treatment,” had “physical examination findings [that] are
27 unremarkable,” and “examination findings indicat[ing] normal heart, lung,
28 musculoskeletal, and neurological findings,” the record is replete with medical records
1 indicating Plaintiff presented with and was deemed to have serious medical issues (See,
2 e.g., AR 474 (reporting hand numbness, heavy arms due to carpal tunnel, chest pains,
3 difficulty breathing, fatigue while walking.); AR 488, 495 (emergency room visit after
4 which diagnosed with bilateral atelectasis, mild ascending thoracic aortic aneurysm, and
5 suspected left ventricular hypertrophy; AR 529 (told to reduce amount of time walking
6 due to cramping feet); AR 536, 545, 550, 652, 665) (multiple reports of muscle cramping
7 and spasms).
8 The ALJ also relied on the medical opinion of the CE consultant, Dr. Sabourin, an
9 orthopedic surgeon, who issued a report in 2018, as well as the “prior administrative DDS
10 medical consultants’ determinations” issued in January and May of 2019. (AR 15, 16.)
11 None of these opinions, which were provided at various stages of Plaintiff’s claimed
12 disability period, are based on a full record. Dr. Sabourin’s examination was conducted
13 in December 2018 and only addresses the musculoskeletal pain and does not reference
14 the multitude of medical records following this exam where Plaintiff had multiple
15 complaints of muscular cramping and spasms. Therefore, the value of his opinion
16 regarding Plaintiff’s RFC for the period at issue following the date of the opinion is
17 questionable.
18 Moreover, to the extent that the DDS medical consultants had opinions with regard
19 to Plaintiff’s heart condition in early 2019, many of Plaintiff’s symptoms and ultimate
20 diagnoses came well after their consideration of his heart issues. (AR 551-581, 608-640,
21 702-729.) Therefore, these opinions hold little persuasive value regarding Plaintiff’s heart
22 issues. See Carmickle v. Comm’r Soc. Sec. Admin, 533 F.3d 1155, 1165 (9th Cir. 2008)
23 (“Medical opinions that predate the alleged onset of disability are of limited relevance.”)
24 Therefore, the Court finds that these opinions are not based on the entirety of the record,
25 and the opinions lack adequate supporting explanation.
26 Based on the current state of the record, the ALJ’s finding that Plaintiff had an
27 RFC to perform medium work is not supported by substantial evidence.
28
1 B. Remand
2 As set forth above, the Court finds that the ALJ erred by failing to develop the
3 record as to Plaintiff’s intellectual and mental impairments. At step-two of the five-step
4 sequential evaluation process for determining whether an individual is disabled, the ALJ
5 did not properly develop the record which necessarily impacts the step two analysis.
6 Moreover, because the Court found that RFC is defective as it did not reflect his
7 limitations related to his borderline intellectual functioning and the ALJ improperly relied
8 on medical opinions which did not consist of a review the entire medical record, the
9 ALJ’s errors were not harmless. An error is harmless if it is “’inconsequential to the
10 ultimate nondisability determination’ in the context of the record as a whole.” Molina v.
11 Astrue, 674 F.3d 1104, 1122 (9th Cir. 2012) (quoting Stout v. Comm’r of Soc. Sec., 454
12 F.3d 1050, 1055 (9th Cir. 2006); see also Tommasetti v. Astrue, 533 F.3d 1035, 1038
13 (9th Cir. 2008). An error in step two analysis can be harmless if the ALJ had considered
14 Plaintiff’s borderline intellectual functioning in determining his RFC but the ALJ did not
15 consider Plaintiff’s borderline intellectual functioning in their decision. See Lewis v.
16 Astrue, 498 F.3d 909, 911 (9th Cir. 2007) (as amended) (any step-two error would be
17 harmless given ALJ’s consideration of all impairments at step four).
18 “Remand for further administrative proceedings is appropriate if enhancement of
19 the record would be useful.” Benecke v. Barnhart, 379 F.3d 587, 593 (9th Cir. 2004). In
20 addition, “[w]hen the ALJ denies benefits and the court finds error, the court ordinarily
21 must remand to the agency for further proceedings before directing an award of benefits.”
22 Leon v. Berryhill, 880 F.3d 1041, 1045 (9th Cir. 2018) (internal quotations and citations
23 omitted.)
24 Plaintiff requests that the Court that the Court remand for benefits, or in the
25 alternative, additional proceedings. (Jot. Mot. at 18.) The decision whether to remand for
26 further proceedings or for immediate payment of benefits is within the discretion of the
27 court. 42 U.S.C. § 405(g); Treichler, 775 F.3d at 1099. “If additional proceedings can
28 remedy defects in the original administrative proceedings, a social security case should
1 be remanded.” Lewin v. Schweiker, 654 F.2d 631, 635 (9th Cir. 1981); see also Garrison,
2 759 F.3d at 1019 (noting that a Social Security case should usually be remanded to
3 remedy defects in the administrative proceeding).
4 The evidence in this case does not conclusively establish that Plaintiff is disabled
5 under the Social Security disability regulations. Rather the evidence must still be weighed
6 and evaluated properly. Accordingly, the Court recommends that remand for additional
7 proceedings is appropriate. On remand, the ALJ should be required to: (1) obtain and
8 consider all evidence regarding Plaintiff’s borderline intellectual functioning; and (2)
9 consider the entirety of the record in assessing Plaintiff’s RFC.
10 CONCLUSION AND RECOMMENDATION
11 For the reasons stated above, the Court recommends that the final decision of the
12 Commissioner be REVERSED, and the case REMANDED for further proceedings.
13 This Report and Recommendation will be submitted to the Honorable Thomas J.
14 Whelan, United States District Judge assigned to this case, pursuant to the provisions of
15 28 U.S.C. § 636(b)(1). Any party may file written objections with the Court and serve a
16 copy on all parties on or before July 22, 2024 The document should be captioned
17 “Objections to Report and Recommendation.” Any reply to the objections shall be served
18 and filed on or before July 29, 2024. The parties are advised that failure to file
19 objections within the specified time may waive the right to appeal the district court’s
20 order. See Martinez v. Ylst, 951 F.2d 1153 (9th Cir. 1991).
21 IT IS SO ORDERED.
22
23 Dated: July 8, 2024 ______________________
Hon. D. Thomas Ferraro
24
United States Magistrate Judge
25
26
27
28