“[W]e can affirm the 4 agency's decision to deny benefits only on the grounds invoked by the agency . . . .”
How later courts described this case
- “[W]e can affirm the 4 agency's decision to deny benefits only on the grounds invoked by the agency . . . .”
Written by the judges who cited it.
The opinion
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8 UNITED STATES DISTRICT COURT
9 SOUTHERN DISTRICT OF CALIFORNIA
10
11 VAUGHN J.,1 Case No.: 24cv1124-SBC
12 Plaintiff,
ORDER RESOLVING JOINT
13 v. MOTION FOR JUDICIAL REVIEW
IN FAVOR OF PLAINTIFF AND
14 FRANK BISIGNANO, Acting
Commissioner of Social Security,2 REMANDING TO THE
15 COMMISSIONER
Defendant.
16
[ECF No. 21]
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18 On June 27, 2024, Plaintiff Vaughn J. commenced this action against Defendant
19 Frank Bisignano, Commissioner of Social Security, for judicial review under 42 U.S.C. §
20 405(g) of a final adverse decision for supplemental security income. (ECF No. 1.) The
21 Administrative Law Judge (“ALJ”) found that Plaintiff was not disabled and denied
22 Plaintiff’s claim for benefits since June 29, 2021, the date the application was filed. (ECF
23 No. 11 at 40 [Administrative Record “AR”].) On August 8, 2024, Magistrate Judge Valerie
24 E. Torres determined that Plaintiff’s complaint did not survive screening under 28 U.S.C.
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1 The Court refers to Plaintiff using only his first name and last initial pursuant to the
27 Court’s Civil Local Rules. See S.D. Cal. Civ. R. 7.1(e)(6)(b).
2 Frank Bisignano is now the Commissioner of Social Security and is automatically
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1 § 1915(e)(2)(B), and dismissed the complaint with leave to amend. (ECF No. 8.) That same
2 day, Plaintiff filed an amended complaint, which is the operative complaint in this case.
3 (ECF No. 9.)
4 Now pending before the Court is the parties’ joint motion for judicial review of the
5 final decision of the Commissioner of Social Security, filed on January 21, 2025. (ECF No.
6 21.) On February 3, 2025, Plaintiff consented to the undersigned’s jurisdiction to conduct
7 all proceedings in this case. (ECF No. 22.)3 For the reasons set forth below, the Court
8 REVERSES the final decision of the Commissioner and REMANDS this matter for
9 further administrative proceedings consistent with the findings presented herein.
10 I. PROCEDURAL HISTORY
11 On June 29, 2021, Plaintiff filed an application for supplemental social security
12 benefits, alleging disability beginning June 1, 2020, due to autism and a mental breakdown.
13 (AR at 230-239, 255.) Plaintiff’s application was denied on November 24, 2021, and again
14 on reconsideration on February 15, 2022. (Id. at 147-151, 155-160.) On February 28, 2022,
15 Plaintiff submitted a written request for a de novo hearing by an ALJ. (Id. at 161-164.) On
16 December 14, 2022, ALJ Joseph Doyle presided over the hearing. (Id. at 45-80.) Plaintiff
17 appeared by online video, and was not represented by an attorney. (Id. at 47.) Plaintiff,
18 Plaintiff’s mother, Anna Romero, and vocational expert, Kent Granat, testified at the
19 hearing. (Id at 45.)
20 On July 6, 2023, the ALJ issued an unfavorable decision denying Plaintiff’s request
21 for disability benefits. (AR at 19-40.) On August 24, 2023, Plaintiff submitted a written
22 request for review to the Appeals Council. (Id. at 226-227.) On May 28, 2024, the Appeals
23 Council denied Plaintiff’s request for review. (Id. at 1-4.) Having exhausted all
24 administrative remedies, Plaintiff brought this timely civil action, seeking judicial review
25 pursuant to 42 U.S.C. § 405(g). (See ECF No. 9.)
26 / / / /
27
3 The United States has informed the Court of its general consent to Magistrate Judge
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1 II. SUMMARY OF THE ALJ’S FINDINGS
2 In rendering his decision, the ALJ followed the Commissioner’s five-step sequential
3 evaluation process. See 20 C.F.R. § 416.920; Tackett v. Apfel, 180 F.3d 1094, 1098-99 (9th
4 Cir. 1999) (describing five steps).4 The ALJ determined at step one that Plaintiff had not
5 engaged in substantial gainful activity since June 29, 2021, the date of his application. (AR
6 at 25.) At step two, the ALJ found that Plaintiff had the following severe impairments: (1)
7 autism spectrum disorder; (2) schizoaffective disorder; (3) generalized anxiety disorder;
8 (4) obesity; and (5) asthma. (Id.) He noted that the record contains some complaints of left
9 shoulder pain, but the ALJ found the record fails to establish a medically determinable
10 impairment because of no imaging of the shoulder, or any substantive treatment. (Id.) He
11 found Plaintiff’s gastroesophageal reflux disease non-severe because “the record fails to
12 indicate related symptoms that would have more than minimally interfered with the ability
13 to perform work-related activities for 12-consecutive months.” (Id.) For any other
14 impairments alleged within the record, the ALJ found that they were “non-severe or not
15 medically determinable as they have been responsive to treatment, cause no more than
16 minimally vocationally relevant limitations, have not lasted or are not expected to last at a
17 ‘severe’ level for a continuous period of 12 months, are not expected to result in death, or
18 have not been properly diagnosed by an acceptable medical source.” (Id.)
19 At step three, the ALJ determined that Plaintiff did not have an impairment or
20 combination of impairments that met or medically equaled a listed impairment5. (Id.)
21 Regarding Plaintiff’s asthma, the ALJ stated that “the record does not establish the medical
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23 4 The disability insurance benefits (“DIB”) and supplemental security income (“SSI”)
regulations relevant to this case are virtually identical. Therefore, only the DIB regulations
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will be cited in the remainder of this order. Parallel SSI regulations are found in 20 C.F.R.
25 §§ 416.900–416.999 and correspond with the last digits of the DIB cite (e.g., 20 C.F.R. §
404.1520 corresponds with 20 C.F.R. § 416.920).
26
5 If the claimant’s impairment or combination of impairments is of a severity to meet or
27 medically equal the criteria of a listing and meets the duration requirement (20 CFR §§
404.1509 and 416.909), the claimant is deemed disabled. If it does not, the analysis
28
1 signs, symptoms, laboratory findings or degree of functional limitation required . . . and no
2 acceptable medical source . . . has concluded that [it] . . . medically equals a listed
3 impairment.” (Id.) Regarding Plaintiff’s obesity, the ALJ stated that “there is no listing for
4 obesity . . . but [it] has been carefully considered.” (Id.) The ALJ further stated that it has
5 not “resulted in any end-organ damage[,]” and although it may aggravate Plaintiff’s
6 complaints, particularly his asthma impairment, “it does not reasonably appear that the
7 extent of his obesity, even when considered in combination with his other documented
8 impairments, meets or equals a listed impairment or would preclude all work.” (Id. at 26.)
9 Lastly, the ALJ found that Plaintiff’s “mental impairments, considered singly and in
10 combination, do not medically equal the criteria of listings.” (Id.)
11 When a claimant’s impairments, or combination of impairments, do not meet the
12 criteria of a listed impairment, as was the case here, the ALJ next determines the claimant’s
13 residual functional capacity (“RFC”), i.e., the ability to do physical and mental work
14 activities despite the claimant’s impairments. (See AR at 28.) Step four then considers
15 whether the claimant is not disabled because he has the RFC to do past relevant work, and
16 step five looks at the claimant’s ability to do any other work considering his RFC, age,
17 education, and work experience. (Id. at 38-39.)
18 At step four, the ALJ determined that Plaintiff had no relevant past work. (AR at
19 38.) The ALJ concluded, however, that considering Plaintiff’s age, education, work
20 experience and RFC, “there are jobs that exist in significant numbers in the national
21 economy that the claimant can perform.” (Id. at 39.) The ALJ accepted the testimony of
22 the vocational expert, who determined that Plaintiff could perform the requirements of
23 Janitor (D.O.T. 381.687-018), Hand Launderer (D.O.T. 361.684-010), and Laundry Sorter
24 (D.O.T. 369.687-014). (Id. at 39.)
25 In reaching his decision, the ALJ assessed Plaintiff as retaining the RFC to perform
26 a range of medium work as defined in 20 C.F.R. § 416.967(c), with the following
27 limitations:
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1 [Plaintiff can] have exposure to up to moderate noise levels; could have only
occasional exposure to concentrated airborne irritants, such as fumes, odors,
2
dusts, gases and poorly ventilated areas; limited to the performance of simple,
3 routine and repetitive tasks; limited to work in a low-stress environment
defined as requiring only occasional decision-making and only occasional
4
changes in work setting; limited to work establishing only production quotas
5 based on end of workday measurements without fast-paced production quotas
or assembly line work; and limited to only occasional interaction with co-
6
workers. The claimant should have no interaction with the public but can work
7 in the vicinity of the public.
8 (AR at 28.)
9 The ALJ stated that the RFC assessment was based on “all symptoms and the extent
10 to which these symptoms can reasonably be accepted as consistent with the objective
11 medical evidence and other evidence, based on the requirements of 20 CFR 416.929 and
12 SSR 16-3p.” (AR at 29.) The ALJ also stated that he considered the medical opinions and
13 prior administrative medical findings in accordance with 20 C.F.R. § 416.920(c). (Id.)
14 Accordingly, the ALJ concluded that Plaintiff had not been under a disability since June
15 29, 2021, the date Plaintiff’s application was filed. (Id. at 40.)
16 III. ISSUE IN DISPUTE
17 The sole issue in dispute is whether the ALJ’s RFC determination is supported by
18 substantial evidence. (See ECF No. 21.) In resolving this question, the Court considers the
19 ALJ’s evaluation of the medical opinions, and whether the ALJ’s duty to develop the record
20 was triggered.
21 IV. STANDARD OF REVIEW
22 On appeal, the Court reviews claims for SSI benefits under Title XVI of the Social
23 Security Act either for an absence of substantial evidence supporting the ALJ’s decision or
24 for legal error. Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995). Substantial
25 evidence is “more than a mere scintilla but less than a preponderance” and is “such relevant
26 evidence as a reasonable mind might accept as adequate to support a conclusion.” Id.
27 (citing 42 U.S.C. § 405(g)). It is therefore the Court’s duty to review the entire record and
28 determine whether substantial evidence exists to support the ALJ’s findings. Smolen v.
1 Chater, 80 F.3d 1273, 1279 (9th Cir. 1996). However, the Court may not make independent
2 findings, it is limited to reviewing the determinations presented by the ALJ in their
3 decision. Brown-Hunter v. Colvin, 806 F.3d 487, 492 (9th Cir. 2015) (“[W]e can affirm the
4 agency's decision to deny benefits only on the grounds invoked by the agency . . . .”). If
5 the evidence in the record reasonably supports the ALJ’s decision, the decision will be
6 upheld. Andrews, 53 F.3d at 1039-40 (citing Magallanes v. Bowen, 881 F.2d 747, 750 (9th
7 Cir. 1989)) (“We must uphold the ALJ's decision where the evidence is susceptible to more
8 than one rational interpretation.”). The Court may also affirm the ALJ’s decision even if
9 the ALJ committed error, so long as the error is harmless. Ford v. Saul, 950 F.3d 1141,
10 1154 (9th Cir. 2020). A harmless error is one that is inconsequential to the ultimate
11 decision, id., or that is not prejudicial to the claimant. Stout v. Comm'r, Soc. Sec. Admin.,
12 454 F.3d 1050, 1055 (9th Cir. 2006).
13 V. DISCUSSION
14 A. Whether the ALJ Properly Evaluated the Medical Opinion Evidence
15 Plaintiff contends that the ALJ’s RFC determination is not supported by substantial
16 evidence because the ALJ failed to properly evaluate the medical evidence. (ECF No. 21
17 at 4-8.) Plaintiff argues that the RFC assessment is based on lay opinion since the ALJ
18 improperly rejected the opinions of Dr. Hawkins, Dr. Rozenfeld, Dr. Taylor, and Dr. Kugel,
19 as unpersuasive. (Id.) Accordingly, Plaintiff asserts that the ALJ failed to “adequately
20 explain how he arrived at his RFC assessment.” (Id. at 7.) In response, Defendant maintains
21 that the ALJ properly rejected the medical opinions, and correctly assessed Plaintiff’s RFC.
22 (Id. at 9-15.)
23 Under the new regulations applicable to Plaintiff’s claim, the ALJ does not need to
24 give special deference to treating physicians, but instead must evaluate the persuasiveness
25 of each medical opinion according to the factors set out in 20 C.F.R. §§ 404.1520c,
26 416.920c. Woods v. Kijakazi, 32 F.4th 785, 791 (9th Cir. 2022). Now, the ALJ must
27 evaluate the persuasiveness of medical source opinions by considering prescribed
28 enumerated factors. 20 C.F.R. §§ 404.1520c(c)(1)-(5); 416.920c(c)(1)-(5). The “most
1 important factors” considered are consistency and supportability. Id. §§ 404.1520c(b)(2);
2 416.920c(b)(2). The regulations describe supportability as: “[t]he more relevant the
3 objective medical evidence and supporting explanations presented by a medical source are
4 to support his or her medical opinion(s) . . . the more persuasive the medical opinion(s) . .
5 . will be.” 20 C.F.R. §§ 404.1520c(c)(1), 416.920c(c)(1). Consistency is described as:
6 “[t]he more consistent a medical opinion(s) . . . is with the evidence from other medical
7 sources and nonmedical sources in the claim, the more persuasive the medical opinion(s) .
8 . . will be.” 20 C.F.R. §§ 404.1520c(c)(2), 416.920c(c)(2).
9 When the ALJ finds a medical opinion unpersuasive, courts treat this as rejecting the
10 medical opinion. See, e.g., Woods, 32 F.4th at 792-94; Steven R. T. v. Kijakazi, No. 20-CV-
11 2257-KSC, 2022 WL 2303950, at *12 (S. D. Cal. June 24, 2022). An ALJ cannot reject a
12 medical opinion as unsupported or inconsistent without explaining why, and that
13 explanation must be supported by substantial evidence. Woods, 32 F.4th at 792. The ALJ
14 must “articulate ... how persuasive” it finds “all of the medical opinions” from each doctor
15 or other source, 20 C.F.R. § 404.1520c(b), and “explain how [it] considered the
16 supportability and consistency factors” in reaching these findings, id. § 404.1520c(b)(2).”
17 Woods, 32 F.4th at 792. Factors that detract from a medical opinion’s persuasiveness
18 include extreme evaluations that do not comport with the rest of the evidence on record,
19 opinions that contradict the medical source’s records, and “check box form[s]” that contain
20 little or no explanation of their conclusion. Kitchen v. Kijakazi, 82 F.4th 732, 740 (9th Cir.
21 2023).
22 Here, the ALJ found the opinions of Dr. Kugel, Dr. Hawkins, Dr. Rozenfeld, and
23 Dr. Taylor, unpersuasive. The Court examines the ALJ’s evaluation of the medical
24 opinions below.
25 1. Dr. Kugel
26 In September 2020, Dr. Uri Kugel, a licensed clinical psychologist, performed a
27 psychological evaluation of Plaintiff via telehealth due to the COVID-19 pandemic. (AR
28 at 394-404.) Dr. Kugel observed that Plaintiff’s “overall demeanor was disengaged,
1 uninterested, and awkward” during the examination. (Id. at 396.) However, he was
2 “cooperative and respectful[,]” and “showed motivation to perform well but did report
3 anxiety.” (Id. at 397.) Dr. Kugel diagnosed Plaintiff with autism spectrum disorder, and
4 found that he displayed severe symptoms, including “poor social understanding and
5 interest, impaired social communication, and difficulty with hyper-focused behavior.” (Id.
6 at 402.) Dr. Krugel stated the following regarding Plaintiff’s results:
7 As this evaluation was conducted using telehealth services and due to limited
internet connectivity, only several subtests were administrable. Therefore, the
8
following results should be taken with caution. It is recommended that
9 Vaughn’s cognitive functioning will be reevaluated when a face-to-face
meeting will become possible. Due to limited data, the FSIQ and most WAIS
10
Indexes scores were not calculated. However, limited data suggest overall
11 cognitive performance within the Average to the High Average range. Vaughn
performed within the Average range on the VCI. On the Matrix Reasoning
12
subtest which measures fluid reasoning and grasping nonverbal concepts,
13 Vaughn performed within the High Average range.
14 (AR at 400.)
15 Dr. Kugel concluded that, based on the evaluation, prior testing reports, records
16 review, and interviews with Plaintiff and Plaintiff’s mother, Plaintiff does not meet the
17 intellectual disability criteria. (AR at 402.) Dr. Kugel also noted the following:
18
[Plaintiff] displayed [s]everely [i]mpaired listening response. He displayed
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[m]oderately [i]mpaired social emotional understanding, emotional
20 expression and regulation, adaptation to change and restricted interests, fear
response, and intellectual response. He displayed [m]ildly [i]mpaired relating
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to people, body use, object use in play, visual response, touch response, verbal
22 communication, nonverbal communication, and cognitive integration skills.
23
(AR at 402.) Dr. Kugel further noted “significant impairments” in socialization and
24
communication, “maladaptive speech[,]” and “hypersensitivity to sensory stimuli and
25
obsessive behavior . . . that often interferes with his functioning.” (Id.)
26
The ALJ acknowledged Dr. Kugel’s opinion, but found it unpersuasive. (AR at 38.)
27
The ALJ explained that while the opinion suggested “some deficits in the identified areas,”
28
1 (Id.) For example, the ALJ noted that terms such as “significant impairments,” is not
2 defined as “mild, moderate, marked or extreme,” and “poor social understanding, impaired
3 social communication, and difficulty with hyper-focused behavior[,]” are not defined in
4 Agency-recognized terms. (Id.) (internal quotations omitted.) The ALJ concluded that
5 “[w]ithout clarity, the opinion statements, albeit accompanied by a narrative evaluation
6 report as attempted support, are too vague and ambiguous to be found consistent with the
7 evidence as a whole.” (Id.)
8 a. Consistency & Supportability
9 The ALJ is required to articulate how he considered both the consistency and
10 supportability factors of a medical source’s opinion when determining its persuasiveness.
11 Woods, 32 F.4th at 792. Here, the ALJ addressed consistency, finding that Dr. Kugel’s
12 opinion was “too vague” to be consistent with the record because it did not define
13 Plaintiff’s limitations in Agency-recognized terms. (AR at 38.) The Court, therefore, finds
14 that substantial evidence supports the ALJ’s finding that Dr. Kugel’s opinion was
15 unpersuasive under the consistency factor.
16 However, the ALJ did not adequately evaluate the supportability factor that affected
17 his analysis of Dr. Kugel’s opinion. Although the ALJ noted that Dr. Kugel’s opinion was
18 “accompanied by a narrative evaluation report as attempted support,” he made no explicit
19 finding as to whether the opinion was supported by objective medical evidence, or why the
20 narrative evaluation report was insufficient. (See AR at 38.) Instead, the ALJ summarized
21 the opinion, and generally stated that it was “too vague and ambiguous” to be consistent
22 with the record. (See id.) The ALJ must explain his reasoning under both the consistency
23 and supportability factors. Woods, 32 F.4th at 792. Accordingly, the Court finds that the
24 ALJ erred by not sufficiently evaluating the supportability factor in finding Dr. Kugel’s
25 opinion unpersuasive.
26 2. Dr. Hawkins & Dr. Rozenfeld
27 Dr. Pamela Hawkins is a state agency medical consultant who reviewed Plaintiff’s
28 medical records and performed an initial disability determination evaluation in November
1 2021. (AR at 108-126.) Dr. Hawkins found that Plaintiff was not disabled, noting that his
2 “condition results in some limitations . . . to perform work related activities but does not
3 prevent [Plaintiff] from working.” (Id. at 124-125.) She identified two severe impairments:
4 (1) autism spectrum disorder; and (2) depressive, bipolar, and related disorders. (Id. at 116.)
5 Dr. Hawkins further found that Plaintiff’s symptoms included “[s]ustained concentration
6 and persistence limitations,” “[s]ocial interaction limitations,” and “[a]bility to adapt
7 limitations.” (Id. at 118.) However, she concluded that Plaintiff was able to understand
8 and remember instructions and procedures, and was capable of “maintain[ing] attention
9 and concentration for at least two hours at a time as required to perform simple tasks,
10 sufficiently to complete an 8 hour day and a 40 hour week.” (Id. at 119-121.)
11 Regarding social interaction limitations, Dr. Hawkins found Plaintiff “best suited to
12 a non-public setting. [Plaintiff] can work in proximity with coworkers but not on joint or
13 shared tasks. [Plaintiff] is able to handle occasional supervisory contact.” (AR at 122.) She
14 also found Plaintiff to be moderately limited in adapting to changes in work environments,
15 nothing that he would “work best in structured environments with predictable work tasks
16 and with minimal social contacts with others that do not require a great deal of decision
17 making or goal setting.” (Id.)
18 Dr. Ellen Rozenfeld, another state agency medical consultant, reviewed Plaintiff’s
19 medical records and performed a disability evaluation on reconsideration in February 2022.
20 (AR at 127-146.) Dr. Rozenfeld noted Plaintiff’s recent report that his mental condition
21 was “worsening” due to “breakdowns every 2 weeks, sharp pains in chest, excessive
22 thoughts, uncontrollable emotions(anger/sadness),” inability to shower, and needing
23 assistance with most activities of daily living. (Id. at 134.) Dr. Rozenfeld affirmed
24 Dr. Hawkins’ initial finding that Plaintiff was not disabled, and reached the same
25 conclusions regarding Plaintiff’s capabilities and limitations. (See id. at 139-144.)
26 The ALJ found Dr. Hawkins and Dr. Rozenfeld’s opinions unpersuasive because
27 “although accompanied by some narrative discussions of the evidence as attempted
28 support, they are unable to be found consistent with the evidence as a whole.” (AR at 36-
1 37.) The ALJ explained that neither doctor “appreciated a pace limit,” which would have
2 addressed Plaintiff’s documented difficulties with distractibility. (Id.) The ALJ also noted
3 that the doctors’ opinions that Plaintiff have no contact with coworkers and only limited
4 contact with supervisors was inconsistent with other evidence, such as Plaintiff being
5 polite, capable of creating rapport, and exhibiting no signs of aggression. (Id.) For these
6 reasons, the ALJ concluded that the evidence was “most consistent with [the] ability to
7 have occasional interactions with co-workers.” (Id.) Furthermore, the ALJ found that the
8 opinions failed to appreciate Plaintiff’s trouble adapting to changes in routine or stressors,
9 rendering their opinions further inconsistent with Plaintiff’s documented “adaptive
10 functioning deficits.” (Id.)
11 The ALJ also highlighted that the opinions focused on “what situations [Plaintiff]
12 was best-suited for, which does not address the maximum he is capable of performing.”
13 (Id. at 37.) He found the opinions “somewhat vague, as [they] did not define to what extent,
14 if any, in Agency-recognized terms, the [Plaintiff] could engage in decision-making or goal
15 setting.” (Id.) Ultimately, the ALJ concluded that because the opinions “lack pace or
16 adaptability limits and otherwise offer interacting limits inconsistent with the record, they
17 are generally inconsistent with the record, and thus, unpersuasive.” (Id.)
18 a. Consistency & Supportability
19 As previously mentioned, the ALJ is required to articulate how he considered both
20 the consistency and supportability factors of a medical source’s opinion when determining
21 its persuasiveness. Woods, 32 F.4th at 792. Here, the ALJ addressed how Dr. Hawkins and
22 Dr. Rozenfeld’s opinions regarding Plaintiff’s ability to interact with others, the failure to
23 address adaptive functioning deficits, and the need for a pace limit, were inconsistent with
24 other medical evidence in the record. Therefore, the Court finds that substantial evidence
25 supports the ALJ’s finding that Dr. Hawkins and Dr. Rozenfeld’s opinions were
26 unpersuasive under the consistency factor.
27 However, the ALJ did not evaluate the supportability factor that affected his analysis
28 of the doctors’ opinions. While the ALJ stated that Dr. Hawkins and Dr. Rozenfeld’s
1 opinions were “accompanied by some narrative discussion of the evidence as attempted
2 support” he made no explicit determination of supportability. (See AR at 36-37.) The ALJ
3 identified Dr. Hawkins and Dr. Rozenfeld’s findings and presented other medical evidence
4 that was inconsistent with their opinions, but did not explain whether their opinions were
5 supported by objective medical evidence, or why the narrative discussion of the evidence
6 was insufficient. (See id.) The ALJ must explain his reasoning under both the consistency
7 and supportability factors. Woods, 32 F.4th at 792. Accordingly, the Court finds that the
8 ALJ erred by not sufficiently evaluating the supportability factor in finding Dr. Hawkins
9 and Dr. Rozenfeld’s opinions unpersuasive.
10 3. Dr. Taylor
11 Dr. Clifford Taylor, who is a licensed psychologist, consultatively examined
12 Plaintiff during his initial claim for SSI benefits in September 2021. (AR at 414-420.)
13 Dr. Taylor concluded that Plaintiff was mildly or moderately impaired in his ability to
14 perform detailed and complex work, perform work activities consistently, perform work
15 without specialized supervision, complete a workday without a psychologically caused
16 interruption, accept instructions from supervisors, be around coworkers and the public, and
17 manage usual workplace stress. (Id. at 419.) Dr. Taylor, however, concluded that Plaintiff’s
18 ability to complete simple and repetitive tasks, and maintain regular attendance at work,
19 was unimpaired. (Id.) Dr. Taylor noted that Plaintiff’s autism symptoms “were not
20 significantly readily apparent” during the exam. (Id.) Dr. Taylor recognized, however,
21 Plaintiff’s social difficulties, but concluded they were “likely associated with
22 schizoaffective disorder.” (Id.)
23 The ALJ stated that Dr. Taylor’s findings of “moderate limits in concentrating,
24 persisting, or maintaining pace, adapting or managing oneself and interacting with
25 others[,]” were “largely consistent with the evidence.” (AR at 37.) However, the ALJ
26 found Dr. Taylor’s opinion unpersuasive because “although accompanied by a narrative
27 exam report as attempted support, the evidence is inconsistent with need for a restriction
28
1 on interaction with supervisors.” (Id. at 37.) The ALJ noted the following regarding the
2 inconsistency:
3 The claimant does have autism with anxiety and schizoaffective disorders.
Testimony emphasized social anxiety. The claimant was also observed as
4
anxious as of his consultative exam. Still, rapport was adequate. He also
5 answered questioned directly. Moreover, he has been described as polite and
soft-spoken. The record also generally lacks indications of aggressive or
6
volatile behavior. Notably, he and his mother suggested he has some fear of
7 some authority figures (Exs. 33E and 4). Yet, as of his hearing, the claimant
admitted that he had interviewed for a sales job about two years ago. While
8
he never heard back, he made no mention of difficulties during the interview.
9 His mother’s testimony also made no mention of significant difficulties
interacting with authority figures . . . As the evidence, in its entirety, appears
10
inconsistent with need for a limit on supervisor contact, Dr. Taylor’s opinion
11 is unpersuasive.
12 (AR at 37-38.)
13 a. Consistency & Supportability
14 As previously mentioned, the ALJ is required to articulate how he considered both
15 the consistency and supportability factors of a medical source’s opinion when determining
16 its persuasiveness. Woods, 32 F.4th at 792. Here, the ALJ addressed how Dr. Taylor’s
17 opinion regarding Plaintiff’s need for a limit on supervisor contract was inconsistent with
18 the evidence by highlighting that Plaintiff answered questions directly, has been described
19 as polite and soft-spoken, has no aggressive or volatile tendencies, and while there has been
20 some suggested fear or authority figures, there is no mention of significant difficulties. (AR
21 at 37-38.) Therefore, the Court finds that there is substantial evidence for finding
22 Dr. Taylor’s opinion unpersuasive under the consistency factor.
23 However, the ALJ did not sufficiently evaluate the supportability factor that affected
24 his analysis of Dr. Taylor’s opinion. While the ALJ stated that Dr. Taylor’s opinion was
25 “accompanied by a narrative exam report as attempted support” he made no explicit
26 determination of supportability. (See AR at 36-37.) The ALJ merely identified Dr. Taylor’s
27 findings and presented other evidence that was inconsistent with his opinion. (See id.) He
28 did not explain whether Dr. Taylor’s opinion was supported by objective medical evidence,
1 or why the narrative exam report was insufficient. The ALJ must explain his reasoning
2 under both the consistency and supportability factors. Woods, 32 F.4th at 792. Accordingly,
3 the Court finds that the ALJ erred by not sufficiently articulating the supportability factor
4 in finding Dr. Taylor’s opinion unpersuasive.
5 For the above reasons, the Court finds that the ALJ’s evaluation of Dr. Kugel, Dr.
6 Hawkins, Dr. Rozenfeld, and Dr. Taylor’s opinions were inadequate. The ALJ articulated
7 the consistency factor when evaluating the medical opinions, but he did not sufficiently
8 articulate the supportability factor. The ALJ's swift evaluation of the medical opinions does
9 not allow the Court to trace the path of the ALJ's reasoning, which is required. See 82 Fed.
10 Reg. at 5858 (stating that the articulation requirements in the rules will allow a subsequent
11 reviewer or reviewing court to trace the path of the adjudicator's reasoning).
12 The Court next considers whether the ALJ’s duty to further develop the record was
13 triggered.
14 B. Whether the ALJ’s Duty to Further Develop the Record was Triggered
15 Plaintiff argues that because the ALJ found all the medical opinions unpersuasive,
16 he had a duty to develop the record regarding Plaintiff’s functional limitations. (ECF No.
17 21 at 7-8.) Plaintiff contends that the ALJ could have, for example, ordered another
18 consultative examination, called a medical expert to testify, remanded for a new
19 determination, or recontacted Dr. Kugel to clarify his opinion. (Id.) Defendant counters
20 that the record was thorough, and no such duty was triggered. (Id. at 14-15.)
21 “In Social Security cases, the ALJ has a special duty to develop the record fully and
22 fairly and to ensure that the claimant's interests are considered, even when the claimant is
23 represented by counsel.” Mayes v. Massanari, 276 F.3d 453, 459 (9th Cir. 2001). The duty
24 is “triggered only when there is ambiguous evidence or when the record is inadequate to
25 allow for proper evaluation of the evidence.” Id. at 453, 459-60. The duty is heightened
26 when the claimant is unrepresented, and “the ALJ must be especially diligent in exploring
27 for all the relevant facts.” Tonapetyan v. Halter, 242 F.3d 1144, 1150 (9th Cir. 2001).
28 Additionally, “[t]he ALJ's duty to develop the record is heightened when a claimant's
1 ability to protect his or her interests is adversely affected by a mental impairment.”
2 Bousquet v. Apfel, 118 F. Supp. 2d 1049, 1056 (C.D. Cal. Oct. 30, 2000) (citing Higbee v.
3 Sullivan, 975 F.2d 558, 562 (9th Cir. 1992)). The ALJ may discharge this duty in several
4 ways, including subpoenaing the claimant's physicians, submitting questions to the
5 claimant's physicians, continuing the hearing, or keeping the record open after the hearing
6 to allow supplementation of the record. Tidwell v. Apfel, 161 F.3d 599, 602 (9th Cir. 1998);
7 Smolen, 80 F.3d at 1288; Tonapetyan, 242 F.3d 1144, 1150 (9th Cir. 2001).
8 Here, the ALJ found that Plaintiff suffers from severe impairments of anxiety,
9 autism, and schizoaffective disorder. (AR at 32.) Significantly, the record also reflects that
10 Plaintiff was not represented by counsel until after the ALJ’s decision was issued. (Id. at
11 47, 228-229.) Accordingly, the ALJ’s duty to develop the record was heightened.
12 Furthermore, the medical opinions in the record reflect that the evidence was not
13 sufficient to allow for a complete evaluation of Plaintiff’s functional limitations, and that
14 further development of the record was needed. First, Dr. Kugel, the psychologist who first
15 diagnosed Plaintiff with autism, explained that Plaintiff’s psychological evaluation results
16 “should be taken with caution” since it was based on “limited data” due to COVID-19
17 restrictions. (AR at 394-404.) Dr. Kugel recommended that Plaintiff’s cognitive
18 functioning be reevaluated in person when possible. (Id. at 400.) The ALJ did not address
19 this recommendation, or the limitations of the data, and simply concluded that Dr. Kugel’s
20 opinion was unpersuasive and vague because it did articulate the extent of Plaintiff’s
21 limitations in Agency-recognized terms. (See id. at 38.)
22 Second, the state agency reviewing doctors, Dr. Hawkins and Dr. Rozenfeld, both
23 stated that a consultative examination was necessary because “[a]dditional evidence is
24 required to establish [the] current severity of the individual’s impairment(s).” (AR at 113,
25 133.) In other words, the state agency doctors concluded that the evidence before them was
26 insufficient to determine the severity of Plaintiff’s impairments. Therefore, the agency’s
27 own reviewing doctors indicated that the record was inadequate. Again, the ALJ did not
28 address this limitation, and instead simply concluded that their opinions were unpersuasive
1 because they did articulate Plaintiff’s limitations in Agency-recognized terms, or include a
2 pace and adapting limitation. (Id. at 36-37.) The ALJ further stated that “[t]he consultants
3 were tasked with assessing the most the [Plaintiff] could do from a mental capacity
4 standpoint[,” and that “[s]uch statements did not answer that question.” (Id. at 37.)
5 Furthermore, while the ALJ concluded that the record was inconsistent with the need
6 for a limitation on supervisor contact, Dr. Hawkins and Dr. Rozenfeld stated that Plaintiff
7 is only capable of “occasional supervisory contact,” and Dr. Taylor stated that Plaintiff’s
8 ability to accept instructions from supervisors was moderately impaired. (AR at 122, 141,
9 419.) The ALJ found Dr. Taylor’s opinion unpersuasive, focusing primarily on his
10 recommendation to limit Plaintiff’s contact with supervisors. (See AR at 37, 38.) The
11 record, however, may not contain sufficient information to make this determination. For
12 example, Dr. Hawkins noted that she was “unsure how moderated limits interacting with
13 supervisors, coworkers and public . . . [and] dealing with . . . unusual stress . . . would play
14 out in the work place.” (Id. at 115.) Dr. Kugel did not address supervisor contact, but again,
15 he explicitly stated that his findings were based on limited data. The ALJ appeared to rely
16 on observations that Plaintiff was able to answer questions directly, that he was “polite and
17 soft-spoken,” that there are no indications of aggressive or volatile behavior, and that he
18 applied for a job at the mall two years earlier to make the determination. (Id. at 37-38.)
19 In sum, despite finding the medical opinions vague, ambiguous, or otherwise
20 unpersuasive, and despite finding that three opinions did not articulate Plaintiff’s
21 limitations in Agency-recognized terms, and that two opinions did not assess “the most the
22 Plaintiff do from a mental capacity standpoint” (information necessary to formulate the
23 RFC), the ALJ crafted an RFC with highly specific limitations regarding Plaintiff’s ability
24 for task complexity, decision-making, changes in the work setting, quota-based work, co-
25 worker interaction, and public contact. (See AR at 28.) It is important that this
26 determination be accurate, as it dictates the jobs that Plaintiff is allegedly capable of
27 performing. The ALJ’s decision, however, does not reflect sufficient medical basis for
28 these specific functional findings since the majority of the medical opinions explicitly
1 stated that more information was needed to assess the severity of Plaintiff’s impairments,
2 and his related limitations.
3 Given Dr. Hawkins and Dr. Rozenfeld’s recognition that the record was insufficient,
4 Dr. Kugel’s recommendation for an in-person reevaluation, the ALJ’s rejection of all the
5 medical opinions as unpersuasive and/or vague, Plaintiff’s lack of representation and
6 severe mental impairments, the Court finds that the ALJ did not satisfy the heightened duty
7 to develop the record. For example, another in-person psychological reevaluation could
8 have been ordered, clarification could have been sought regarding the opinions found to be
9 vague, and Plaintiff’s functional limitations could have been defined in Agency-recognized
10 terms.
11 Based on the above, the Court finds that the ALJ erred by overlooking the lack of
12 evidence in the record that accurately or completely described Plaintiff's functional
13 limitations. Consequently, the ALJ's RFC assessment is not supported by substantial
14 evidence. See Rivera v. Berryhill, 2017 WL 5054656, at **4-5 (C.D. Cal. Oct. 31, 2017)
15 (holding that ALJ's RFC determination was not supported by substantial evidence where
16 the record did not provide sufficient indications of the Plaintiff’s functional limitations and
17 the few findings that could translate to functional limitations were ambiguous).
18 Additionally, it is not clear to the Court how a proper interpretation of the medical
19 opinion evidence, or further development of the record, would have affected Plaintiff’s
20 RFC. Accordingly, the Court cannot conclude that this error was harmless. See Danielle L.
21 v. Saul, No. 1:18-CV-3213-FVS, 2020 WL 3619081, at *9 (E.D. Wash. Mar. 11, 2020)
22 (citing, e.g., Carmickle v. Comm'r, Soc. Sec. Admin., 533 F.3d 1155, 1162 (9th Cir. 2008))
23 (error supporting a less restrictive RFC is harmless where it would not affect the ultimate
24 non-disability determination).
25 II. CONCLUSION
26 The only remaining question for the Court is whether to remand for further
27 administrative proceedings or for the payment of benefits. “The decision of whether to
28 remand a case for additional evidence, or simply to award benefits[,] is within the
1 || discretion of the court.” Trevizo, 871 F.3d at 682 (quoting Sprague v. Bowen, 812 F.2d
2 || 1226, 1232 (9th Cir. 1987)). “Remand for further administrative proceedings is appropriate
3 enhancement of the record would be useful.” Benecke v. Barnhart, 379 F.3d 587, 593
4 || (9th Cir. 2004). A remand for an immediate award of benefits is appropriate only in rare
5 || circumstances. Leon v. Berryhill, 874 F.3d 1130 (9th Cir. 2017). The Court concludes that
6 || “[t]he rare circumstances that result in a direct award of benefits are not present in this
7 || case.” Ud.)
8 Instead, the Court finds further administrative proceedings would serve a meaningful
9 || purpose. On remand, the ALJ must evaluate and explain both the consistency and the
10 || supportability factor in discussing each medical opinion, and develop the record further if
11 |/necessary. All reasons set forth by the ALJ’s decision must be clearly articulated so that
12 subsequent reviewer can assess how the ALJ evaluated the claimant’s symptoms and
13 || the record. Stout, 454 F.3d at 1054; Brown-Hunter, 806 F.3d at 492.
14 The Court is mindful that this case faced challenging circumstances brought about
15 || by the pandemic, which limited the ability of medical providers to give in-person medical
16 || care to patients. The Court further notes that the ALJ did a thorough review of the relevant
17 ||medical records. However, the fact that Plaintiff was not represented by counsel, coupled
18 || with his mental disability, created the need to have a more well-developed record. Based
19 || upon the record before the Court, the Court cannot conclude that this duty was fulfilled.
20 Based on the foregoing, the Court VACATES the ALJ’s decision and REMANDS
21 ||this case for further administrative proceedings consistent with the findings presented
22 herein. The Clerk is directed to issue a judgment and close this case.
23 IT IS SO ORDERED.
24 || Dated: September 26, 2025
Be FG.
27 United States Magistrate Judge
28
18