“An ALJ’s failure to cite specific evidence does not 19 indicate that such evidence was not considered[.]”
How later courts described this case
- “An ALJ’s failure to cite specific evidence does not 19 indicate that such evidence was not considered[.]”
- “Impairments 16 that can be controlled effectively with medication are not disabling for 17 the purpose of determining eligibility for SSI benefits.”
Written by the judges who cited it.
The opinion
1 Jan 14, 2026
SEAN F. MCAVOY, CLERK
2
3
UNITED STATES DISTRICT COURT
4 EASTERN DISTRICT OF WASHINGTON
5
CARIE L.,1 No. 4:25-cv-5077-EFS
6
Plaintiff,
7 ORDER REVERSING THE
v. ALJ’S DENIAL OF BENEFITS,
8 AND REMANDING FOR
FRANK BISIGNANO, LIMITED PROCEEDINGS
9 Commissioner of Social Security,
10 Defendant.
11
Plaintiff Carie L. asks the Court to reverse the Administrative
12
Law Judge’s (ALJ) denial of Title 2 and Title 16 benefits for the closed
13
period of March 21, 2019, to August 3, 2021, because the ALJ erred by
14
finding that she did not have severe impairments of bipolar disorder
15
and anxiety. As is explained below, the ALJ erred by not finding
16
17
18
1 For privacy reasons, Plaintiff is referred to by first name and last
19
initial or as “Plaintiff.” See LCivR 5.2(c).
20
1 Plaintiff’s bipolar disorder to be a severe error. A limited remand to
2 obtain an opinion from a vocational expert is ordered to determine if
3 this error impacted the nondisability findings.
4 I. Background
5 Plaintiff protectively filed applications for disability insurance
6 benefits and supplemental security income, alleging an onset date of
7 March 21, 2019, with a date last insured of December 31, 2023.2 The
8 applications were denied initially and on reconsideration, and a
9 hearing was requested.3 These denials followed a denial of Plaintiff’s
10 prior application for disability benefits in 2017.4 In the prior
11 proceeding, the ALJ’s denial of benefits was affirmed by the district
12 court—both decisions are part of the instant record.5
13 In February 2024, a telephonic hearing was held before
14 Administrative Law Judge (ALJ) Lori Freund regarding Plaintiff’s
15
16
2 AR 17, 304–42.
17
3 AR 202–21.
18
4 AR 17.
19
5 AR 47–65, 72–96.
20
1 current applications. Plaintiff’s counsel and medical expert Dr. Ann
2 Kegge/Monis6 attended; Plaintiff did not attend.7 At the hearing,
3 Plaintiff’s counsel requested a closed period of disability from March
4 21, 2019, to August 3, 2021, as Plaintiff returned to substantial gainful
5 activity.8 The ALJ and Plaintiff’s counsel discussed trying to obtain a
6 medical release to receive additional medical records for the earlier
7 portion of the at-issue period.9 Obtaining additional medical records
8 presented a challenge because the SSA-827 form authorizing the
9 disclosure of medical information to the Social Security Administration
10 previously signed by Plaintiff had expired, and Plaintiff’s counsel was
11
12
6 The transcript from the administrative hearing referred to the
13
testifying medical expert as Dr. Ann Kegge. AR 31–33, 39. The medical
14
expert testified that the admitted CV was an accurate reflection of the
15
expert’s qualifications. The admitted CV was for Dr. Ann Monis, PA.
16
AR 662–65.
17
7 AR 18, 31–46.
18
8 AR 34.
19
9 AR 43–44.
20
1 unable to reach Plaintiff.10 The testifying medical expert stated that
2 she would benefit from additional medical records to form an opinion as
3 to Plaintiff’s non-exertional abilities.11 The ALJ granted Plaintiff’s
4 counsel more time to obtain additional medical records before issuing a
5 decision.12 After the hearing, Plaintiff’s counsel notified the ALJ that
6 “[w]e were informed that there are no additional records outstanding
7 for” Plaintiff.13
8 The ALJ then issued a decision denying benefits.14 The ALJ found
9 Plaintiff’s alleged symptoms were “not entirely consistent” because the
10 objective evidence did not support the extent of her reported symptoms
11
12
13
14
10 See AR 34–46, 515.
15
11 AR 41–44.
16
12 AR 42–46.
17
13 AR 445.
18
14 AR 14–30. Per 20 C.F.R. §§ 404.1520(a)–(g), 416.920(a)–(g), a five-
19
step evaluation determines whether a claimant is disabled.
20
1 and the prescribed medication improved her symptoms.15 The ALJ also
2 found:
3 • the statement of Suzanne Kieffer, LICSWA, MHP, MSW, not
4 persuasive.
5 • the prior administrative medical findings of Sheri Tomak,
6 PsyD, and Don Johnson, PhD, “less persuasive in considering
7 the severity of the claimant’s mental impairments, but they
8 are somewhat persuasive in determining any limitations from
9 those impairments.”16
10 As to the sequential disability analysis, the ALJ found:
11
12
15 AR 22. As recommended by the Ninth Circuit in Smartt v. Kijakazi,
13
the ALJ should consider replacing the phrase “not entirely consistent”
14
with “inconsistent.” 53 F.4th 489, 499, n.2 (9th Cir. 2022).
15
16 AR 23–24. Because Plaintiff does not challenge the physical-
16
functioning findings, the prior administrative physical-functioning
17
findings are not discussed. See Nadon v. Bisignano, 145 F.4th 1133,
18
1138 (9th Cir. 2025) (deciding that the claimant forfeited an argument
19
by not challenging the ALJ’s findings in that regard).
20
1 • Plaintiff met the insured status requirements through
2 December 31, 2023.
3 • Step one: Plaintiff had not engaged in substantial gainful
4 activity since March 21, 2019, the alleged onset date, through
5 August 3, 2021.
6 • Step two: Plaintiff had the following medically determinable
7 impairments: bipolar disorder and hypothyroidism; however,
8 these impairments were not severe either individually or in
9 combination.17
10 Therefore, the ALJ found that Plaintiff was not disabled during the
11 closed period.18
12 Plaintiff timely requested review of the ALJ’s decision by the
13 Appeals Council and now this Court.19
14
15
16
17
17 AR 17–25.
18
18 AR 25.
19
19 AR 1–6; ECF No. 1.
20
1 II. Standard of Review
2 The ALJ’s decision is reversed “only if it is not supported by
3 substantial evidence or is based on legal error” and such error
4 impacted the nondisability determination.20 Substantial evidence is
5 “more than a mere scintilla but less than a preponderance; it is such
6 relevant evidence as a reasonable mind might accept as adequate to
7 support a conclusion.”21 The court looks to the entire record to
8 determine if substantial evidence supports the ALJ’s findings.22
9
10
20 Hill v. Astrue, 698 F.3d 1153, 1158 (9th Cir. 2012). See 42 U.S.C. §
11
405(g); Molina v. Astrue, 674 F.3d 1104, 1115 (9th Cir. 2012),
12
superseded on other grounds by 20 C.F.R. § 416.920(a) (recognizing that
13
the court may not reverse an ALJ decision due to a harmless error—
14
one that “is inconsequential to the ultimate nondisability
15
determination”).
16
21 Hill, 698 F.3d at 1159 (quoting Sandgathe v. Chater, 108 F.3d 978,
17
980 (9th Cir. 1997)).
18
22 Kaufmann v. Kijakazi, 32 F4th 843, 851 (9th Cir. 2022). See also
19
Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007) (requiring
20
1 III. Analysis
2 Plaintiff argues the ALJ erred by ending the analysis at step two,
3 by failing to develop the record, when evaluating Plaintiff’s symptom
4 reports, and by rejecting the assessments of her treating mental health
5 therapist. The Commissioner argues the ALJ did not error and that the
6 nondisability finding is supported by substantial evidence. As is
7 explained below, the ALJ erred by not finding bipolar disorder to be a
8 severe impairment at step two. This error requires a limited remand.
9 A. Step Two (Severe Impairment): Plaintiff establishes error.
10 Plaintiff contends the ALJ erred at step two by failing to find her
11 impairments of bipolar disorder and anxiety as severe impairments. In
12 response, the Commissioner counters that Plaintiff did not establish
13 anxiety as a medically determinable impairment and that the ALJ
14
15
16
the court to consider the entire record, not simply the evidence cited by
17
the ALJ or the parties) (cleaned up); Black v. Apfel, 143 F.3d 383, 386
18
(8th Cir. 1998) (“An ALJ’s failure to cite specific evidence does not
19
indicate that such evidence was not considered[.]”).
20
1 reasonably found Plaintiff does not have a severe mental impairment.
2 As is explained below, the ALJ erred at step two as to bipolar disorder.
3 1. Standard
4 At step two, the ALJ determines whether the claimant suffers
5 from a “severe” impairment, i.e., one that significantly limits her
6 physical or mental ability to do basic work activities.23 This involves a
7 two-step process: 1) determining whether the claimant has a medically
8 determinable impairment and 2), if so, determining whether the
9 impairment is severe.24 To be severe, the medical evidence must
10 establish that the impairment would have more than a minimal effect
11 on the claimant’s ability to work.25
12 Step two “is not meant to identify the impairments that should be
13 taken into account when determining the RFC” as step two is meant
14
15
16
23 20 C.F.R. §§ 404.1520(c), 416.920(c).
17
24 Id. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii).
18
25 Id. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii); see Soc. Sec. Rlg. (SSR) 85-
19
28 (Titles II and XVI: Medical Impairments That Are Not Severe).
20
1 only to screen out weak claims, whereas the crafted RFC must consider
2 all impairments, both severe and non-severe.26
3 2. The ALJ’s step-two findings
4 The ALJ acknowledged that Dr. Tomak and Dr. Johnson, who
5 issued the prior administrative medical findings as to Plaintiff’s
6 mental-health conditions, opined that Plaintiff was moderately limited
7 in the paragraph B criteria of adapting or managing herself.27 Yet, the
8 ALJ found this moderate adaptation limitation “unsupported by the
9 records from the alleged period of disability,” and instead were based
10 solely on the prior ALJ decision; and as to Dr. Johnson, the ALJ also
11 found that his opinion that Plaintiff was unable to handle complex
12 instructions was not related to her ability to adapt or manage herself.28
13 As a result, the ALJ found that Plaintiff was only mildly limited in
14 each of the four functional areas: understanding, remembering, or
15 applying information; interacting with others; concentrating,
16
17
26 Buck v. Berryhill, 869 F.3d 1040, 1048–49 (9th Cir. 2017).
18
27 AR 23–24.
19
28 AR 24–25.
20
1 persisting, or maintaining pace; and adapting or managing herself.29
2 Because the ALJ determined that Plaintiff’s mental-health
3 impairments did not have more than a minimal effect on her ability to
4 work, the ALJ found that Plaintiff did not have a severe mental-health
5 impairment.
6 3. Analysis
7 a. Anxiety
8 As an initial step-two matter, the Court agrees with the
9 Commissioner that Plaintiff failed to adequately support her bare-
10 bones contention that the ALJ erred by failing to find anxiety to be a
11 severe impairment.30 Moreover, like the prior ALJ determined in 2019,
12 the medical records reveal that anxiety is a symptom of Plaintiff’s
13
14
29 AR 24.
15
30 See Indep. Towers of Wash. v. Washington, 350 F.3d 925, 930 (9th
16
Cir. 2003) (“We require contentions to be accompanied by reasons.”);
17
McPherson v. Kelsey, 125 F.3d 989, 995-96 (6th Cir. 1997) (“[I]ssues
18
adverted to in a perfunctory manner, unaccompanied by some effort at
19
developed argumentation, are deemed waived.”).
20
1 bipolar disorder. Therefore, the Court’s review focuses on the ALJ’s
2 evaluation of bipolar disorder.
3 b. Bipolar Disorder
4 As to Plaintiff’s bipolar disorder, the ALJ erred by not finding it
5 to be a severe impairment. This error resulted from the ALJ’s mistaken
6 finding that Dr. Tomak and Dr. Johnson based their determinations
7 that Plaintiff suffers from a severe bipolar disorder solely on the prior
8 ALJ decision rather than a review of the medical evidence for the at-
9 issue period.31
10 Dr. Tomak did review the prior ALJ decision and agree with the
11 prior ALJ’s RFC, but this agreement was based on Dr. Tomak’s review
12 of medical records received in July 2021 from Lourdes Counseling
13 Center and Prosser Primary Care for the at-issue period.32 Based on
14 Dr. Tomak’s review of the received medical records, Dr. Tomak found
15 Plaintiff to have a severe bipolar disorder because she was moderately
16 limited in her ability to adapt or manage herself in that she would have
17
18
31 AR 24.
19
32 AR 97–127.
20
1 difficulty responding appropriately to changes in the work setting.33 To
2 explain the adaptation limitation, Dr. Tomak wrote, “See [prior]
3 ALJ.”34 The 2019 ALJ’s RFC limited Plaintiff to “a routine, predictable
4 work environment with no more than occasional changes, and no travel
5 required as a job duty.”35 Dr. Tomak’s reference to the prior RFC does
6 not equate to a finding that Dr. Tomak only concluded that Plaintiff
7 had a severe bipolar disorder because of the prior ALJ decision.
8 Instead, Dr. Tomak based her finding that Plaintiff had a severe
9 bipolar disorder on the received at-issue medical evidence.
10
11
12
13
33 AR 99–107. See AR 102 (“RPC: Case reviewed. The alleged severity
14
of psychological impairment does not appear fully supported. Updated
15
objective TS MER does not seem to suggest significant changes since
16
the ALJ. Consequential, the 3/20/19 ALJ decision remains reasonable
17
and is adopted.”).
18
34 AR 107.
19
35 AR 55.
20
1 More medical records for the at-issue period were received prior
2 to Dr. Johnson’s reconsideration-level review.36 After reviewing these
3 additional medical records, Dr. Johnson initially agreed with
4 Dr. Tomak’s assessment that Plaintiff was moderately limited in her
5 ability to adapt or manage herself because her ability to respond
6 appropriately to changes in the work setting was moderately limited.37
7 Like Dr. Tomak, Dr. Johnson wrote “see [prior] ALJ” to explain
8 Plaintiff’s adaptation limitations, meaning routine, predictable work
9 environment with no more than occasional changes, and no travel
10 required as a job duty.38 Yet, Dr. Johnson then also wrote, “She is able
11 to understand, carry out and remember detailed not complex
12 instructions, make decisions, concentrate for extended periods, and
13 interact appropriately with others, and respond to changes in a work
14 setting.”39 This extra language creates an ambiguity as to what
15
16
36 AR 132–33.
17
37 AR 129–77.
18
38 AR 174, 55.
19
39 AR 141, 157, 174, 192.
20
1 Dr. Johnson’s opinions were as to Plaintiff’s ability to respond to
2 changes in a work setting, i.e., could she handle more than occasional
3 changes if the work instructions were not complex? This ambiguity was
4 not clarified either at the administrative level or by the ALJ.
5 Regardless of the ambiguity as to what RFC accommodated Plaintiff’s
6 moderate adaption limitations, Dr. Johnson clearly listed bipolar
7 disorder as a severe impairment. Moreover, on review, the Court
8 construes this ambiguity in Plaintiff’s favor and accepts that
9 Dr. Johnson recommended that Plaintiff be limited to non-complex
10 instructions and that both Dr. Johnson and Dr. Tomak recommended
11 that Plaintiff be limited to a routine, predictable work environment
12 with no more than occasional changes, and no travel required as a job
13 duty.
14 In summary, the ALJ erred by rejecting each of the prior
15 administrative medical findings that Plaintiff was moderately limited
16 in her ability to adapt and manage herself—and that bipolar disorder
17 was a severe impairment. Thus, and for the additional reasons
18 discussed below, the ALJ’s determination that Plaintiff’s adaptation
19 limitations were minimal is not supported by substantial evidence.
20
1 B. Impact of Step-Two Error
2 Plaintiff argues the ALJ’s failure to find bipolar disorder as a
3 severe impairment—along with the ALJ’s evaluation of MSW Kieffer’s
4 assessments and Plaintiff’s symptom reports—requires a development
5 of the medical record and further proceedings. Although the Court
6 agrees that remand is needed to remedy the step-two error, it is
7 unnecessary to develop the medical record; only a limited remand to
8 obtain vocational expert testimony is needed.
9 1. Further development of the medical record is unnecessary.
10 “The ALJ always has a special duty to fully and fairly develop the
11 record” to make a fair determination as to disability, even where, as
12 here, “the claimant is represented by counsel.”40 This “affirmative
13 responsibility to develop the record” is necessary to ensure that the
14 ALJ’s decision is based on substantial evidence.41
15 As was discussed at the administrative hearing, there are few
16 mental-health records for the first part of the closed period—with the
17
18
40 Celaya v. Halter, 332 F.3d 1177, 1183 (9th Cir. 2003) (cleaned up).
19
41 Id. at 1184.
20
1 first medication-management record being dated January 13, 2021,
2 and counseling record dated January 14, 2021.42 However, other
3 records in the file make clear that Plaintiff was receiving mental-
4 health treatment prior to January 2021. The medication-management
5 record from January 2021 reveals that Plaintiff had a medication-
6 management appointment in December 2020.43 And the prior ALJ
7 decision and the district court opinion affirming that prior ALJ
8 decision—both of which are part of this file—reveal that Plaintiff was
9 receiving mental-health treatment, both counseling with MSW Kieffer
10 and medication management—years prior to the at-issue closed period,
11 although such treatment may have been paused during the Covid
12 pandemic as mentioned by Plaintiff’s counsel.44
13 Plaintiff’s counsel argues that further steps should have been
14 taken by the ALJ to obtain medical records for the earlier part of the
15
16
42 AR 473–75, 484–87.
17
43 AR 485.
18
44 See, e.g., AR 57; AR 80 (stating that Plaintiff was in counseling with
19
Ms. Kieffer from the fall of 2016 through 2018).
20
1 at-issue period, particularly because the testifying medical expert said
2 she needed to review more records to assess how Plaintiff was impacted
3 by her bipolar disorder. On this point, at the hearing, Plaintiff’s
4 counsel stated, “I know she had some problems during COVID of not
5 having treatment for a while, but there should be some records prior to
6 that January ’21. But by then our records authorizations had
7 surpassed the date set, and I can’t get a hold of the client to get an
8 updated one.”45 Plaintiff’s counsel offered to reach out to Lourdes
9 Counseling Center46 to try and get the records for the earlier portion of
10 the closed period but discussed difficulties getting such without a new
11 approval from Plaintiff, with whom counsel was having difficulties
12 contacting.47 The ALJ paused the administrative-hearing process to
13 allow Plaintiff’s counsel the opportunity to obtain additional medical
14 records. Thereafter, Plaintiff’s counsel notified the ALJ, “We were
15 informed that there are no additional records outstanding for”
16
17
45 AR 36.
18
46 See, e.g., AR 46 (transcribing incorrectly “Lourdes” as “Lawrence”).
19
47 AR 43–46.
20
1 Plaintiff.48 Further, Plaintiff did not submit an updated form SSA-827
2 (Authorization to Disclose Information to the Social Security
3 Administration), nor did Plaintiff attend the hearing.
4 Under these circumstances, the ALJ satisfied her duty to develop
5 the medical record.
6 2. Evaluating Plaintiff’s reported symptoms.
7 Because Plaintiff did not attend the hearing, she did not offer
8 testimony about her symptoms. She did report symptoms on her July
9 2021 Function Report, including reporting that she has abrupt mood
10 swings, variable sleep causing fatigue and emotional lability, the need
11 for reminders to take medications, difficulty going to stores, deficits in
12 social interactions, and difficulties with focus and concentration
13 affecting her ability to follow directions and stay on-task.49
14 If the ALJ finds inconsistency between the claimant’s reported
15 symptoms and the evidence, the ALJ must identify what symptom
16 claims are being discounted and clearly and convincingly explain the
17
18
48 AR 445.
19
49 AR 383–90.
20
1 rationale for discounting the symptoms with supporting citation to
2 evidence.50 This requires the ALJ to “show her work” and provide a
3 “rationale . . . clear enough that it has the power to convince” the
4 reviewing court.51
5 Plaintiff argues the ALJ improperly rejected her reported
6 disabling symptoms without providing clear and convincing reasons for
7 doing so. The Court largely disagrees. Substantial evidence supports
8 the ALJ’s discounting of Plaintiff’s more disabling symptom reports but
9 substantial evidence does not support discounting Plaintiff’s reported
10 symptoms consistent with moderate adaptation limitations.
11 The ALJ found Plaintiff’s symptom reports “inconsistent because
12 the objective evidence does not support the level of limitation
13 claimed.”52 The ALJ summarized several medical records, emphasizing
14
15
50 20 C.F.R. §§ 404.1529(c), 416.929(c); Smartt v. Kijakazi, 53 F.4th
16
489, 499 (9th Cir. 2022); Ghanim v. Colvin, 763 F.3d 1154, 1163 (9th
17
Cir. 2014); Soc. Sec. Rlg. 16-3p, 2016 WL 1119029, at *7.
18
51 Smartt, 53 F.4th at 499 (alteration added).
19
52 AR 22.
20
1 the improvement Plaintiff experienced with her symptoms when taking
2 medication:
3 • In February 2021, Plaintiff reported to her medication-
4 management provider that she was “actually doing pretty
5 good” with the addition of Risperdal.”53
6 • In the spring of 2021, she was reminded to use her
7 hydroxyzine if she was anxious when she went out in public.54
8 • In July 2021, “she recognized how well her medications worked
9 for her and that she could not miss them.”55
10 Plaintiff does not contest that medication assisted and that
11 ultimately she achieved sufficient stability to maintain full-time work;
12 however, she argues that the ALJ failed to fairly consider that during
13 the closed period her mental-health symptoms would wax to an extent
14 preventing her from maintaining fulltime work. Plaintiff accurately
15 identifies that medical records reveal that her bipolar symptoms
16
17
53 AR 22 (citing AR 505).
18
54 AR 22.
19
55 AR 22–23.
20
1 waxed. For instance, medical records reflect both waxing and waning
2 symptoms:
3 • January 13, 2021: Plaintiff was observed with rapid speech.56
4 • January 14, 2021: Plaintiff was talking very fast, her thought
5 process was not linear, and she had cycling thoughts.57
6 • February 5, 2021: No abnormal mental-health observations
7 noted and Plaintiff reported that she was “feeling much better
8 than I was,” as she was able to sleep more with the new
9 medications.58
10 • February 24, 2021: She was observed with tight associations,
11 fluid speech, and euthymic mood.59
12 • March 23, 2021: She was observed with rapid speech but
13 within normal limits.60
14
15
56 AR 484–87.
16
57 AR 473–75.
17
58 AR 471–72.
18
59 AR 505–06.
19
60 AR 496.
20
1 • April 15, 2021: She was observed with slightly tangential
2 stream of thought although attention and speech were normal
3 rate.61
4 • May 19, 2021: She reports that she has a new part-time job
5 and that she believes the medications are working well as she
6 has not been depressed, manic, or very anxious, and she was
7 observed with fluid speech and tight associations.62
8 • July 22, 2021: She was observed with a slightly labile mood
9 with linear thought stream, reporting that she forgot to take
10 medications for several days due to her night shift.63
11 As this sampling of medical records reflect, Plaintiff’s mental-
12 health symptoms, particularly her rate of speech and her thought
13 processes, were impacted when her symptoms waxed. As the ALJ
14 recognized, Plaintiff’s symptoms waned when she consistently took her
15 medication as prescribed. Substantial evidence supports the ALJ’s
16
17
61 AR 494.
18
62 AR 477.
19
63 AR 582–83.
20
1 finding that Plaintiff’s more disabling symptom reports were
2 inconsistent with the medical evidence.64 A full and fair review of the
3 Plaintiff’s symptom reports support a moderate-adaptation limitation
4 as opined by Dr. Tomak (and possibly Dr. Johnson)—not the mild
5 limitation as found by the ALJ.
6 3. The ALJ did not err by finding MSW Kieffer’s assessments
7 unpersuasive.
8 MSW Kieffer, who counseled Plaintiff for many years, completed
9 a Mental Residual Functional Capacity assessment on January 20,
10 2021.65 She checked that Plaintiff was markedly limited in her abilities
11 to carry out very short simple instructions, sustain an ordinary routine
12 without special supervision, and be aware of normal hazards and take
13
14
64 See 20 C.F.R. §§ 416.929(c)(3), 404.1529(c)(3); Warre v. Comm'r of
15
Soc. Sec. Admin., 439 F.3d 1001, 1006 (9th Cir. 2006) (“Impairments
16
that can be controlled effectively with medication are not disabling for
17
the purpose of determining eligibility for SSI benefits.”).
18
65 AR 459–63. The parties agree that Ms. Kieffer does not qualify as a
19
medical source. See 20 C.F.R. §§ 404.1502c(d), 416.902c(d).
20
1 appropriate precautions.66 In each of the other listed mental activities,
2 MSW Kieffer checked that Plaintiff was severely limited.67 She also
3 checked that Plaintiff was markedly limited in her ability to adapt or
4 manage herself and extremely limited in her abilities to interact with
5 others; understand, remember, or apply information; or concentrate,
6 persist, or maintain pace.68 She believed that Plaintiff would be off task
7 more than 30 percent of the work day and would miss 4 or more days of
8 work per month.69 MSW Kieffer wrote:
9 Carie has a very serious and persistent mental health
disorder Bipolar II Disorder (F31.81) depressed/hypomanic.
10 Carie has severe impairments due to diagnosis. Carie
suffers prolonged dramatic shifts in her mood, energy, and
11 ability to think and reason clearly. Carie has severe
hypomania episodes that rapidly cause her to suffer
12 extreme uncontrollable irritability, unpredictable judgment
impairment, reckless decision making and unusual risk
13 taking. Depression phase of Bipolar Disorder II causes
Carie to suffer persistent feelings of sadness, irritability or
14 anger, loss of interest in self-care and activities of daily
living, excessive and inappropriate guilt, hopelessness, too
15
16
66 AR 459–60.
17
67 AR 459–60.
18
68 AR 461.
19
69 AR 462.
20
1 much or not enough sleep, appetite changes, fatigue,
problems with concentration, feels of severe worthlessness,
2 and thoughts of death/suicide. Bipolar Disorder II also
causes Carie’s co-existing psychiatric condition such as
3 anxiety, and isolating, migraine headaches, and feelings of
unwellness. Carie’s severe mental illness causes patterns of
4 instability of interpersonal relationships, her self-image and
communication patterns; poor concentration and memory
5 decline; sleep disturbances, symptoms of PTSD.70
6 The ALJ found MSW Kieffer’s ratings and references to Plaintiff’s
7 symptoms wholly unsupported by the medical records, commenting
8 that “such extreme limitations would essentially require
9 institutionalization.”71 The ALJ also found that MSW Kieffer’s ratings
10 were more extreme than Plaintiff’s own symptom testimony and
11 inconsistent with the testifying medical expert’s need for more medical
12 records to rate Plaintiff’s impairments during the closed period.72
13 This latter ground—that the testifying medical expert needed
14 more medical information—was not a valid ground for the ALJ to reject
15 MSW Kieffer’s ratings, as MSW Kieffer had treated Plaintiff for several
16
17
70 AR 462.
18
71 AR 23.
19
72 AR 23.
20
1 years and therefore had a broader base of information to form her
2 assessments than the testifying medical expert.
3 Nonetheless, substantial evidence supports the ALJ’s overall
4 decision to find MSW Kieffer’s assessments inconsistent with the
5 record. Plaintiff concedes that the assessed limitations are extreme
6 considering the record evidence but argues that MSW Kieffer’s
7 assessed limitations apply for periods of active bipolar. Contrary to
8 Plaintiff’s argument, the medical records during the closed period bely
9 that Plaintiff’s bipolar symptoms—even when waxing—were so severe
10 as to substantiate MSW Kieffer’s assessments. The observations noted
11 in MSW Kieffer’s treatment notes, and the observations and Plaintiff’s
12 reports memorialized in the other medical records, do not support
13 MSW Kieffer’s extreme assessments. For instance, although Plaintiff
14 had rapid speech during her medication-management appointment in
15 January 2021, her speech was still within normal limits, her affect was
16 appropriate, her judgment and insight were within normal limits, and
17 she reported an ability to do housework, work outside, watch a movie
18 with her children, and follow along with the recent political news,
19
20
1 although her interest in politics had led to disagreements with family
2 and friends.73
3 Accordingly, the ALJ’s decision to find MSW Kieffer’s extreme
4 assessments unpersuasive is supported by substantial evidence.
5 4. Summary
6 Although the ALJ erred by not finding bipolar disorder to be a
7 severe impairment and failed to explain why the adaptation limitations
8 recommended by Dr. Tomak (and Dr. Johnson) should not be adopted,
9 substantial evidence supports the ALJ’s decision to reject Plaintiff’s
10 more disabling symptom reports and MSW Kieffer’s extreme
11 assessments. The ALJ’s step-two error does not require a full remand
12 to develop the medical record—as there are no such records—or to
13 determine Plaintiff’s work-related limitations for the closed period.
14 Instead, the adaptation limitations set forth by Dr. Tomak (and Dr.
15 Johnson) and Dr. Johnson’s limitation to non-complex work are
16 accepted.
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73 AR 484–87.
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1 On remand, the ALJ is to obtain testimony from a vocational
2 expert—either through written interrogatories or testimony at a
3 hearing—as to whether there is work that exists in significant
4 numbers in the national economy that Plaintiff can do given her age,
5 education, work experience, and the following RFC: a full range of
6 medium work in a routine, predictable work environment with no more
7 than occasional changes, without complex instructions, and no travel
8 required as a job duty.74
9 IV. Conclusion
10 Plaintiff establishes the ALJ erred at step two. To remedy the
11 step-two error, a limited remand is directed.
12 Accordingly, IT IS HEREBY ORDERED:
13 1. Plaintiff’s Motion for Summary Judgment, ECF No. 11, is
14 GRANTED.
15
16
17
74 The ALJ previously submitted written interrogatories to a vocational
18
expert. AR 446–50. However, the hypothetical medium-work RFC did
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not include any non-exertional limitations. AR 452–53.
20
1 2. The ALJ’s nondisability decision is REVERSED, and this
2 matter is REMANDED to the Commissioner of Social
3 Security pursuant to sentence four of 42 U.S.C. §
4 405(g).
5 3. The Clerk’s Office shall TERM the Commissioner’s brief,
6 ECF No. 138, enter JUDGMENT in favor of Plaintiff, and
7 CLOSE the case.
g IT IS SO ORDERED. The Clerk’s Office is directed to file this
9 ||order and provide copies to all counsel.
10 DATED this 14* day of January 2026.
12 EDWARD F.SHEA
Senior United States District Judge
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DISPOSITIVE ORDER - 30