ALJ may discount claimant’s testimony based on “unexplained or inadequately explained failure to seek treatment”
How later courts described this case
- ALJ may discount claimant’s testimony based on “unexplained or inadequately explained failure to seek treatment”
- the ALJ erred by finding improvement where claimant continued to have functional impairments and improvement was not sustained
- “[T]he ALJ appropriately considered the possibility of symptom exaggeration in the context of secondary gain in light of the shifting bases for [the claimant’s] complaints.”
- ALJ erred by finding improvement where claimant continued to have functional impairments and improvement was not sustained
Written by the judges who cited it.
The opinion
UNITED STATES DISTRICT COURT
DISTRICT OF OREGON
WILLIAM L., Ca se No. 6:23-cv-00795-AR
Plaintiff, OPINION AND ORDER
v.
COMMISSIONER SOCIAL SECURITY
ADMINISTRATION,
Defendant.
_____________________________________
ARMISTEAD, Magistrate Judge
In this judicial review of the Commissioner’s final decision denying Social Security
benefits, plaintiff William L. (his last name omitted for privacy) challenges the Administrative
Law Judge’s (ALJ) evaluations of his symptom allegations and the lay witness testimony of his
wife. As further explained below, the ALJ did not find malingering, and therefore, the clear and
convincing standard applies to evaluate plaintiff’s subjective symptom allegations. Although the
ALJ erred in discounting plaintiff’s testimony based on his activities of daily living, the ALJ
Page 1 – OPINION AND ORDER
identified other clear and convincing reasons that are supported by substantial evidence and,
therefore, that error is harmless. Likewise, any error in omitting discussion of the lay testimony
is harmless because the lay testimony did not describe limitations beyond those that were
identified by plaintiff and properly discounted by the ALJ. The Commissioner’s decision is
therefore AFFIRMED.1
ALJ’S DECISION
Plaintiff applied for Title II Disability Insurance Benefits (DIB) on April 15, 2019,
alleging disability beginning November 1, 2018. (Tr. 242.) His claim was initially denied on
September 6, 2019, and again upon reconsideration on May 8, 2020. (Tr. 88, 103.) Afterward,
plaintiff filed for a hearing that was held before the ALJ on March 29, 2022. (Tr. 45.)
In denying plaintiff’s application, the ALJ followed the five-step sequential evaluation
process.2 At step one, the ALJ determined plaintiff had not engaged in substantial gainful
activity since November 1, 2018, his alleged onset date. (Tr. 21.) At step two, the ALJ
determined that he had the following severe impairments:
degenerative disc disease of the lumbar spine with lumbar radiculopathy; obesity;
traumatic brain injury (TBI)/closed head injury with post-concussion syndrome; a
depressive, bipolar, or related disorder (variably called unspecified depressive
disorder, depressive disorder, or depression); an anxiety disorder (variably called
unspecified anxiety disorder, anxiety, mixed anxiety depressive disorder, or
anxiety disorder); and posttraumatic stress disorder (PTSD).
1 This court has jurisdiction under 42 U.S.C. §§ 405(g) and 1383(c)(3), and all parties have
consented to jurisdiction by magistrate judge under Federal Rule of Civil Procedure 73 and 28
U.S.C. § 636(c).
2 To determine a claimant’s disability, the ALJ must apply a five-step evaluation. See 20
C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). If the ALJ finds that a claimant is either disabled or not
disabled at any step, the ALJ does not continue to the next step. Id.; see also Parra v. Astrue, 481
F.3d 742, 746–47 (9th Cir. 2007) (discussing the five-step evaluation in detail).
Page 2 – OPINION AND ORDER
(Tr. 21.) At step three, the ALJ determined that plaintiff’s impairments singly or in combination
did not meet or medically equal the severity of any listed impairment. (Tr. 23.)
The ALJ determined that plaintiff has the residual functional capacity (RFC), 20 C.F.R. §
404.1545, to perform a reduced range of medium work with the following limitations:
He can stand and/or walk [six] hours and sit [six] hours of an [eight]-hour
workday. [He] can never climb ladders, ropes, or scaffolds, and he can frequently
stoop, crouch, or climb ramps and stairs. He can tolerate no exposure to hazards,
including unprotected heights or operating heavy machinery. Mentally, he is
limited to understanding, remembering, carrying out, and maintaining attention
and concentration on no more than simple tasks and instructions, defined
specifically as those job duties that can be learned in up to 30 days’ time. He can
sustain only ordinary routines and make no more than simple, work-related
decisions. He can tolerate no more than occasional interaction with coworkers and
supervisors, cannot perform team or tandem work, and can have no interaction
with the general public.
(Tr. 25-26.)
At step four, the ALJ determined that plaintiff cannot perform any past relevant work.
(Tr. 36.) In light of his age, education, work experience, and RFC, the ALJ found at step five that
jobs exist in significant numbers in the national economy that plaintiff can perform, including
such representative occupations as laundry worker and hand packager. (Tr. 37-38.)
STANDARD OF REVIEW
The district court must affirm the Commissioner’s decision if the Commissioner applied
proper legal standards and the findings are supported by substantial evidence in the record. 42
U.S.C. § 405(g); Ford v. Saul, 950 F.3d 1141, 1154 (9th Cir. 2020). Substantial evidence is
“more than a mere scintilla” and is “such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Biestek v. Berryhill, 587 U.S. 97, 103 (2019) (quotation and
citation omitted). To determine whether substantial evidence exists, the court must weigh all the
Page 3 – OPINION AND ORDER
evidence, whether it supports or detracts from the Commissioner’s decision. Garrison v. Colvin,
759 F.3d 995, 1009 (9th Cir. 2014).
DISCUSSION
A. Plaintiff’s Symptom Testimony
Plaintiff argues that the ALJ erred by failing to provide clear and convincing reasons for
discounting his subjective symptom testimony. Plaintiff contends that, after he was in a
catastrophic car accident in 2015, he cannot engage in full-time, competitive employment
because of his physical and mental health conditions, including traumatic brain injury, migraines,
memory loss, nerve pain, anxiety, panic attacks, neck/spinal cord injury, and motor function
impairment. (Tr. 64; 309.) In his 2019 function report, plaintiff wrote that he cannot go outside
or drive, and that he rarely leaves the house without experiencing anxiety and panic attacks. (Tr.
345.) He also does not handle stress well and does not get along with authority figures. (Tr. 350-
51.) Plaintiff described his daily activities as doing daily chores, completing “honey do’s,” taking
care of his two grandchildren, and playing video games. (Tr. 346, 348, 349.) In a function report
from 2020, plaintiff wrote that he cannot be outside for more than thirty minutes, due to
dizziness and headache. (Tr. 373.) He again described his daily activities as including household
chores, taking care of his two grandchildren, and playing video games. (Tr. 373.)
At his hearing, plaintiff testified that he was fired from his last job for being
“unprofessional” and trying to “physically attack” his manager. (Tr. 65.) He has a hard time
interacting with “lazy people” and he does not trust anyone anymore. (Tr. 65-66.) His anxiety is
his “prison” and he does not go out in public because he does not know “how to react to things
anymore.” (Tr. 66.) Plaintiff also forgets to take his medications and needs help managing his
calendar of appointments. (Tr. 68.) His testimony also included that he has constant headaches,
Page 4 – OPINION AND ORDER
has tremors in his hands, cannot sit for more than 30 minutes, and has used a walking stick for
about two years to prevent himself from falling. (Tr. 70, 72, 74, 75.)
Determining the credibility of a claimant’s testimony regarding subjective reports of pain
or symptoms requires the ALJ to undertake a two-step process of analysis. Trevizo v. Berryhill,
871 F.3d 664, 678 (9th Cir. 2017). In the first stage, the claimant must produce objective medical
evidence of an underlying impairment that could reasonably be expected to produce the alleged
symptoms. Treichler v. Comm’r Soc. Sec. Admin., 775 F.3d 1090, 1102 (9th Cir. 2014);
Tommasetti v. Astrue, 533 F.3d 1035, 1039 (9th Cir. 2008). At the second stage, if there is no
affirmative evidence of malingering, the ALJ must provide specific, clear and convincing
reasons for discounting the claimant’s testimony. Brown-Hunter v. Colvin, 806 F.3d 487, 488-89
(9th Cir. 2015); 20 C.F.R. § 404.1529. The specific, clear and convincing standard is “the most
demanding required in Social Security cases” and is “not an easy requirement to meet.”
Garrison, 759 F.3d at 1015; Trevizo, 871 F.3d at 678-79. The “clear and convincing” standard
requires an ALJ to “show [their] work” but, ultimately, the question is not whether the ALJ’s
rationale convinces the court, but whether the ALJ’s rationale “is clear enough that it has the
power to convince.” Smartt v. Kijakazi, 53 F.4th 489, 499 (9th Cir. 2022).
The ALJ concluded that evidence of symptom magnification and malingering “argue[d]
against assessing limitations consistent with [plaintiff’s] allegations.” Tr. 28. The ALJ also
discounted plaintiff’s subjective symptom testimony because: (1) plaintiff’s activities of daily
living were inconsistent with his claimed limitations; (2) his symptoms improved with treatment
and his treatment history was limited; and (3) objective medical records did not support the level
of limitations he alleged.
Page 5 – OPINION AND ORDER
1. Evidence of malingering
The Commissioner argues that the ALJ found “affirmative evidence of malingering” and
was therefore not required to provide clear and convincing reasons to discount plaintiff’s
symptom testimony. (Def. Br. at 3-5.) The clear-and-convincing standard does not apply where
the record evidence contains “affirmative evidence showing that the claimant is malingering.”
Valentine v. Comm’r Soc. Sec. Admin., 574 F.3d 685, 693 (9th Cir. 2009) (citation omitted);
Vertigan v. Halter, 260 F.3d 1044, 1049 (9th Cir. 2001). Evidence that a claimant is
exaggerating symptoms in order to manipulate an objective psychiatric test can itself constitute
evidence of malingering that “relieve[s] the ALJ from the burden of providing specific, clear,
and convincing reasons.” Baghoomian v. Astrue, 319 F. App’x 563, 565 (9th Cir. 2009).
Additionally, evidence of symptom exaggeration may constitute a clear-and-convincing reason
to discount testimony regarding impairment severity. See Austin v. Saul, 818 F. App’x 725, 727
(9th Cir. 2020) (evidence that the claimant exaggerated his need for a crutch was a clear-and-
convincing reason to reject his subjective symptom testimony); Haynes v. Colvin, 614 F. App’x
873, 875 (9th Cir. 2015) (“[T]he ALJ appropriately considered the possibility of symptom
exaggeration in the context of secondary gain in light of the shifting bases for [the claimant’s]
complaints.”) (internal brackets and quotations omitted).
The ALJ noted that several medical specialists raised the possibility that plaintiff engaged
in overreporting, symptom magnification, secondary gain, and malingering. (Tr. 28.) Based on
that evidence, the ALJ observed that such reports weighed against assessing limitations
consistent with plaintiff’s symptom allegations. (Tr. 28.) For example, the ALJ discussed that in
2016, independent medical examiners, Donna Wicher, Ph.D., and Stephen Ireland, M.D., raised
questions of malingering and symptom magnification in connection with plaintiff’s worker’s
Page 6 – OPINION AND ORDER
compensation claim following his 2015 accident. (Tr. 28-29, citing Tr. 422-23, 427-28, 430, 438,
439, 440, 441.) The ALJ, however, found both Dr. Wicher’s and Dr. Ireland’s opinions to be
unpersuasive for the relevant time period because they “predate[d] the alleged onset date by
several years and focused on the worker’s compensation injury.” (Tr. 32.) The ALJ rejected both
opinions for the relevant time period, and the court therefore does not consider either opinion to
constitute affirmative evidence of malingering. Austin, 818 F. App’x at 727-28 (rejecting the
Commissioner’s argument that a partially rejected medical opinion constituted affirmative
evidence of malingering).
The ALJ also noted a 2021 neuropsychological evaluation by examining William
Trueblood, Ph.D., who concluded that plaintiff’s neurocognitive tests were “unlikely to be valid”
due to “not identifiable” causes. (Tr. 29, citing Tr. 551.) Dr. Trueblood found, the ALJ noted, no
apparent “factors or combination of factors” in plaintiff’s history to cause the degree of
impairment in his functioning. (Tr. 30, citing Tr. 551.) However, the ALJ’s analysis ignored that
Dr. Trueblood identified several possible reasons for the invalid test results, including
nonstandard testing conditions, plaintiff’s high stress levels, and possible (though unlikely)
severe neurocognitive impairment. (Tr. 551.) Additionally, Dr. Trueblood addressed the
possibility of “intentionally poor performance” by plaintiff but emphasized that there were “not
bases to draw that conclusion.” (Tr. 551.) Considering that Dr. Trueblood’s assessment was
equivocal on the validity of the test results, it is unclear to the court how the ALJ concluded
otherwise. See Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998) (“[t]he ALJ must do more
than offer his conclusions . . . [h]e must set forth his own interpretations and explain why they,
rather than the doctors’, are correct.”). Moreover, the ALJ did not assess the persuasiveness of
Dr. Trueblood’s medical opinion, as required by the agency rules. See 20 C.F.R. § 404.1520c(b)
Page 7 – OPINION AND ORDER
(“We will articulate in our determination or decision how persuasive we find all of the medical
opinions and all of the prior administrative medical findings in your case record”). Although
neither the plaintiff nor the Commissioner raised this issue, the ALJ’s failure to evaluate the
persuasiveness of Dr. Trueblood’s opinion further frustrates the court’s ability to meaningfully
review the ALJ’s analysis on this point. Therefore, the court cannot conclude that the ALJ found
affirmative evidence of malingering. Accordingly, the ALJ was required to identify clear and
convincing reasons to discount plaintiff’s symptom testimony.
2. Activities of Daily Living
An ALJ may reject symptom allegations that are inconsistent with a claimant’s ability to
perform normal activities of daily living (ADLs). See 20 C.F.R. § 404.1529(c)(3)(i). There are
two ways ADLs may support such rejection: (1) the ADLs contravene the claimant’s allegations
of functional limitations; or (2) the ADLs “meet the threshold for transferrable work skills[.]”
Orn v. Astrue, 495 F.3d 625, 639 (9th Cir. 2007). “Even where those activities suggest some
difficulty functioning, they may be grounds for discrediting the claimant’s testimony to the
extent that they contradict claims of a totally disabling impairment.” Molina v. Astrue, 674 F.3d
1104, 1113 (9th Cir. 2012), superseded on other grounds by 20 C.F.R. § 404.1502(a).
Plaintiff argues that the ALJ improperly “sought to undermine some unspecified aspect”
of his symptom testimony based on his activities of daily living. (Pl. Br. at 4.) This error,
according to plaintiff, arises out of the ALJ’s failure to specify whether the activities cited by the
ALJ were performed throughout a substantial part of the day or whether the activities had
workplace transferability. (Pl. Br. at 4.) Plaintiff further alleges that the ALJ erred in failing to
link the cited activities to specific testimony that those activities undermined. (Pl. Br. at 5.)
Page 8 – OPINION AND ORDER
Finally, plaintiff asserts that the ALJ improperly relied on his activities to undermine an
allegation of total disability, despite his never having alleged total disability. (Pl. Br. at 5-6.)
The ALJ discounted plaintiff’s testimony because his activities of daily living were
inconsistent with “the severity of reported symptoms” and “undercut a finding of total
disability.” (Tr. 27.) The ALJ pointed to plaintiff’s function reports, noting plaintiff was
“independent in personal care activities” and other activities of daily living, including “preparing
simple meals and doing light cleaning.” (Tr. 27, citing Tr. 345-52; 373-81.) The ALJ further
noted that plaintiff plays video games and helps care for his grandchildren each day. (Tr. 27.)
Finally, records from 2021 cited by the ALJ indicated that plaintiff was working on his truck to
get it ready for sale. (Tr. 27, citing Tr. 593.) The ALJ’s findings here are not supported by
substantial evidence.
The Ninth Circuit has repeatedly held that carrying out minimal daily activities such as
light household chores does not detract from a claim of disability. Ghanim v. Colvin, 763 F.3d
1154, 1165 (9th Cir. 2014). Plaintiff did not describe more than minimal household chores in his
function reports or his hearing testimony. Additionally, the ALJ did not inquire into the
circumstances surrounding plaintiff’s childcare activities and references to preparing his truck
for sale. The ALJ first assumed, without clarifying, that plaintiff was caring for his grandchildren
unassisted for 32 hours a week. (Tr. 27.) Indeed, the ALJ repeatedly relied on the assumption
that plaintiff is the primary caregiver for the grandchildren, but records do not substantiate that
conclusion. (See Tr. 24, 27, 31, 35.) Plaintiff’s 2020 function report states only that he “helps”
get the children ready for school, and “helps” get them ready for bed in the evening. Plaintiff
later submitted a declaration, which was added to the record by the Appeals Council, stating that
his wife and daughter are the primary caregivers for his grandchildren, and that he is alone with
Page 9 – OPINION AND ORDER
the children for a maximum of two hours a week. (Tr. 415.) The ALJ similarly failed to inquire
as to what type of work and under what circumstances plaintiff was performing work on his
truck. Instead, the ALJ pointed to a single note from a counseling session and concluded that
whatever work was being done was sufficient to detract from his symptom testimony. (Tr. 593.)
The examples the ALJ relied on fall far from the substantial evidence standard required by the
court. As such, the ALJ erred in discounting plaintiff’s symptom testimony based on activities of
daily living. However, as discussed below, the error is ultimately harmless, because the ALJ
provided additional reasons backed by substantial evidence that are clear and convincing to
discount plaintiff’s testimony. See Carmickle v. Comm’r Soc. Sec. Admin., 533 F.3d 1155, 1162
(9th Cir. 2008) (upholding the ALJ’s overall credibility finding despite finding two factors the
ALJ relied on to be invalid).
3. Improvement with Treatment and Limited Treatment
The ALJ discounted the severity of symptoms plaintiff testified to because his symptom
testimony improved with treatment. (Tr. 27.) Plaintiff argues that the ALJ improperly relied on
medical improvement to undermine “some unspecified aspect” of his symptom testimony. (Pl.
Br. at 8.) According to plaintiff, the ALJ failed to define the extent and duration of
improvements of balance and mobility. (Pl. Br. at 8.) Furthermore, plaintiff contends that the
ALJ provided no evidence that improvements to “balance and mobility” equates to an RFC at the
medium range of exertion. (Pl. Br. at 8.)
An ALJ may consider evidence of improvement when assessing the functional limitations
of a claimant. 20 C.F.R. § 404.1520a(c). However, an ALJ may not rely on “a few isolated
instances of improvement in the medical record as a basis for concluding a claimant is capable of
working.” Garrison, 759 F.3d at 1017 (citation omitted). Mental health symptoms wax and
Page 10 – OPINION AND ORDER
wane, and an ALJ commits reversible error by cherry-picking the record for facts that support a
non-disability determination. “Reports of ‘improvement’ in the context of mental health issues
must be interpreted with an understanding of the [claimant’s] overall well-being and the nature
of her symptoms.” Id. (citing Ryan v. Comm’s of Soc. Sec., 528 F.3d 1194, 1200-01 (9th Cir.
2008)); see also Attmore v. Colvin, 827 F.3d 872, 877-79 (9th Cir. 2016) (the ALJ erred by
finding improvement where claimant continued to have functional impairments and
improvement was not sustained). Those symptoms, however, may also improve during
treatment. “With adequate treatment some individuals with chronic mental disorders not only
have their symptoms and signs ameliorated, but they also return to a level of function close to the
level of function they had before they developed symptoms or signs of their mental disorders.”
20 C.F.R. pt. 404, subpt. P, app. 1 (2014). Such evidence of medical treatment successfully
relieving symptoms can undermine a claim of disability. See 20 C.F.R. § 416.920a(c)(1); see
also Warre v. Comm’r of Soc. Sec. Admin., 439 F.3d 1001, 1006 (9th Cir. 2006) (“Impairments
that can be controlled effectively with medication are not disabling”) (citations omitted).
Additionally, an ALJ may rely on limited treatment or lack of treatment when
considering a plaintiff’s symptom allegations. See 20 C.F.R. § 404.1529(c)(3)(v); SSR 16-3p,
available at 2017 WL 5180304, at *9 (ALJ may consider frequency and extent of treatment
sought when evaluating the alleged intensity and persistence of a claimant’s symptoms).
The ALJ relied on physical therapy records stating that plaintiff was doing well, had
improved balance and mobility, and that he was “more active and more social.” (Tr. 28, citing
Tr. 631, 633.) The ALJ cited plaintiff’s ability to work on his truck, suggesting he retained
“adequate dexterity and coordination.” (Tr. 28, 30.) The ALJ further stated that plaintiff’s mental
status findings improved with treatment. (Tr. 31, citing Tr. 593.) The ALJ pointed out that
Page 11 – OPINION AND ORDER
treatment notes for a November 18, 2018, annual medical exam stated that he “continue[d] to do
well on Prozac and propranolol” and needed only infrequent diazepam for anxiety. (Tr. 30, 406.)
Additionally, plaintiff sought no significant treatment between November 1, 2018, his alleged
onset date and December of 2019. The ALJ’s finding as to improvements in plaintiff’s physical
health are supported by substantial evidence; however, the ALJ’s findings as to improvements
with plaintiff’s mental impairments are not supported by substantial evidence.
For example, the ALJ discussed that plaintiff’s physical therapy records showed that he
consistently improved his overall functionality during treatment. Medical records from February
11, 2022, show that plaintiff re-initiated physical therapy to address a host of issues including
headaches, loss of balance, and decreased functional mobility/activity tolerance. (Tr. 623.) At his
treatment intake interview, plaintiff told his physical therapist that he was able to take walks with
his wife but was limited to one mile due to increasing headache and leg pain. (Tr. 623.)
Subsequent treatment notes show that plaintiff steadily improved. For example, treatment notes
stated that plaintiff had “[g]ood gains in mobility” (February 23, 2022); “has been taking walks,
overall doing [] better with balance and mobility, has been more active and more social” (March
9, 2022); “[h]as been walking consistently, feeling more confident and stable” and had “no
headache today” (March 16, 2022). (Tr. 630, 631, 633, 634.) Based on those records, the ALJ
could reasonably conclude that plaintiff’s overall physical health improved during the relevant
period – a finding supported by substantial evidence.
In contrast, substantial evidence does not support the ALJ’s finding of improved mental
health symptoms. Rather, plaintiff’s mental health exams demonstrate varying degrees of
consistently poor mental status findings. (See, e.g., Tr. 501, 518-19, 520-21, 574, 576, 578, 582,
593.) “Reports of ‘improvement’ in the context of mental health issues must be interpreted with
Page 12 – OPINION AND ORDER
an understanding of the patient’s overall well-being and the nature of her symptoms.” Garrison,
759 F.3d at 1017 (citation omitted) (citing Ryan, 528 F.3d at 1200-01); see also Attmore, 827
F.3d at 877-79 (ALJ erred by finding improvement where claimant continued to have functional
impairments and improvement was not sustained). The ALJ again relied on assumptions as to
plaintiff providing care for his grandchildren, stating that “despite abnormal mental status
findings, [plaintiff] was the primary caregiver for two grandchildren on an almost 40 hour/week
basis while his wife was at work.” (Tr. 31.) As discussed above, that finding is not supported by
substantial evidence because the record does not disclose the duration, frequency, and level of
care that plaintiff was providing to his grandchildren.
The significant gap in plaintiff’s medical treatment, however, is an appropriate basis upon
which to discount plaintiff’s subjective symptom testimony. Indeed, as the ALJ determined,
there are no records showing that plaintiff sought treatment for either his physical or mental
ailments after his alleged onset date until December 2019, over a year’s time. (Tr. 496-97.)
Based on the absence of treatment, the ALJ reasonably concluded that plaintiff’s subjective
symptoms were not as disabling as alleged. Molina, 674 F.3d at 1112 (ALJ may discount
claimant’s testimony based on “unexplained or inadequately explained failure to seek
treatment”) (internal quotation marks and citation omitted).
In short, the ALJ’s findings that plaintiff’s physical limitations improved with treatment
and the gap in treatment are supported by substantial evidence in the record and, when
combined, provide a clear and convincing basis to discount plaintiff’s subjective symptom
testimony.
\ \ \ \ \
\ \ \ \ \
Page 13 – OPINION AND ORDER
4. Inconsistency with Objective Medical Evidence
Plaintiff argues that the ALJ incorrectly interpreted the objective medical evidence, and
improperly concluded that plaintiff’s “physical examination findings were fairly minimal.” (Pl.
Br. at 7.) Specifically, plaintiff takes issue with the ALJ’s interpretation of “profound
radiographic findings” from a single emergency room visit and accompanying MRI in March
2022, wherein plaintiff was diagnosed with lumbosacral radiculopathy with his right nerve root
described as “flattening.” (Pl. Br. at 7.) However, plaintiff failed to identify any legal error
connected with the ALJ’s objective evidence analysis in his opening brief. Only in his reply brief
did plaintiff clarify that his argument turns on the premise that the ALJ failed to link evidence to
specific symptom testimony. (Pl. Repl. Br. at 10.) Either way, plaintiff’s argument fails because
the ALJ properly evaluated the objective medical findings from the 2022 emergency room visit.
In evaluating a claimant’s subjective symptom testimony, an ALJ may consider whether
it is consistent with objective medical evidence. 20 C.F.R. § 404.1529(c)(1)-(3); SSR 16-3p,
available at 2017 WL 5180304, at *7-8. A lack of objective medical evidence may not form the
sole basis for discounting a claimant’s testimony. Reddick, 157 F.3d at 722 (“[T]he
Commissioner may not discredit [a] claimant’s testimony as to the severity of symptoms merely
because they are unsupported by objective medical evidence.”). But when coupled with other
permissible reasons, objective medical evidence may be used to discount a claimant’s testimony.
Batson v. Comm’r Soc. Sec. Admin., 359 F.3d 1190, 1197-98 (9th Cir. 2004)).
The ALJ discussed that the examination findings were minimal, with tenderness to
palpitation and reduced strength rated at 4/5 in his right leg, yet all other extremities retained
normal strength and reflexes. (Tr. 28, citing Tr. 638.) Moreover, as the ALJ pointed out, the
consulting neurosurgeon did not recommend surgical intervention and noted that plaintiff was a
Page 14 – OPINION AND ORDER
“good candidate” for outpatient management of his symptoms. (Tr. 28, citing Tr. 640.) Plaintiff
was discharged from the emergency room with a limited prescription for methylpredisone, a
short course of oxycodone, and gabapentin. (Tr. 640.) Plaintiff was further instructed to take
Tylenol and ibuprofen at home. (Tr. 640.) The ALJ also noted that plaintiff’s 2022 physical
therapy records revealed improved balance and mobility, increased activity, and consistent
walking. (Tr. 28.) Based on that evidence, the ALJ could reasonably conclude that the objective
medical evidence did not support the severity of his asserted physical limitations. Thus, the ALJ
did not err in his analysis of the objective evidence connected to plaintiff’s 2022 emergency
room visit and accompanying MRI results. Furthermore, the ALJ sufficiently explained his
conclusions as to the 2022 spinal MRI findings and plaintiff’s symptom testimony, and the court
can follow his reasoning.3 See Guthrie v. Kijakazi, No. 21-36023, 2022 WL 15761380, at *1
(9th Cir. 2022) (finding no error where the ALJ’s sufficiently explained her reasoning, allowing
the court to meaningfully review her decision).
In sum, although the court agrees the ALJ erred in evaluating plaintiff’s activities of daily
living and his mental health limitations, ultimately those errors are harmless because the ALJ
identified other reasons that are supported by substantial evidence that when taken together,
provide a clear and convincing rationale for discounting his subjective symptom testimony.
Accordingly, the ALJ did not err.
\ \ \ \ \
\ \ \ \ \
3 The court observes that plaintiff’s March 2022 back injury would not meet the 12-month
durational requirement. 42 U.S.C. § 423(d) (providing that a “disability” must have lasted or
“can be expected to last” for “a continuous period of not less than 12 months”).
Page 15 – OPINION AND ORDER
B. Lay Witness Testimony
Lay witness testimony about a claimant’s symptoms is competent evidence that an ALJ
must consider unless he “expressly determines to disregard such testimony and gives reasons
germane to each witness for doing so.” Lewis v. Apfel, 236 F.3d 503, 511 (9th Cir. 2001).
Omitting discussion of lay testimony entirely is error. An exception to that rule applies, however,
“[w]here lay witness testimony does not describe any limitations not already described by the
claimant, and the ALJ’s well-supported reasons for rejecting the claimant’s testimony apply
equally well to the lay witness testimony.” Molina, 674 F.3d at 1117; see also Valentine, 574
F.3d at 694 (“In light of our conclusion that the ALJ provided clear and convincing reasons for
rejecting [the claimant’s] own subjective complaints, and because [the claimant’s wife’s]
testimony was similar to such complaints, it follows that the ALJ also gave germane reasons for
rejecting her testimony.”).
Plaintiff argues that the ALJ erred by rejecting the lay testimony of plaintiff’s wife
without comment. Plaintiff asserts that, in the Ninth Circuit, the ALJ must offer reasons germane
for rejecting competent lay testimony. (Pl. Br. at 10.) The Commissioner responds that the ALJ
need not address the lay testimony, as it largely mirrors plaintiff’s own testimony, which the ALJ
properly rejected.4 The court agrees. Plaintiff does not identify limitations described by his wife
that are different from his own testimony. Because the ALJ has provided clear and convincing
4 The Commissioner also contends that the revised regulations have removed an ALJ’s
obligation to provide germane reasons to discount lay witness testimony. The court declines to
address this alternative argument and notes that the issue has not been resolved by the Ninth
Circuit. See Wilson v. O’Malley, No. 23-35463, 2024 WL 2103268, at *2 (9th Cir. May 10,
2024) (stating the Ninth Circuit has not yet determined whether an ALJ is required to provide
germane reasons to discount lay witness statements under the revised regulations); Trisha F. v.
Comm’r Soc. Sec. Admin., Case No. 6:23-cv-00433-SB, 2024 WL 3409966, at *8-9 (July 15,
2024) (noting same and collecting cases).
Page 16 – OPINION AND ORDER
reasons to discount plaintiff's testimony, that rationale applies with equal force to the lay
testimony. Molina, 674 F.3d at 1118-19. The ALJ did not err.
In summary, the ALJ’s findings are supported by substantial evidence, and are a
reasonable reading of the record.
CONCLUSION
For the above reasons, the court AFFIRMS the Commissioner’s final decision.
DATED: August 14, 2024
| MISTEAD
United States Magistrate Judge
Page 17 — OPINION AND ORDER