The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF OREGON
TONIA G.,1 Case No. 6:24-cv-01779-SB
Plaintiff, OPINION AND ORDER
v.
COMMISSIONER SOCIAL SECURITY
ADMINISTRATION,
Defendant.
BECKERMAN, U.S. Magistrate Judge.
Tonia G. (“Plaintiff”) filed this appeal challenging the Commissioner of Social Security’s
(“Commissioner”) denial of her application for Disability Insurance Benefits (“DIB”) under Title
II of the Social Security Act. The Court has jurisdiction over this matter pursuant to 42 U.S.C.
§ 405(g). For the reasons explained below, the Court reverses the Commissioner’s decision and
remands for further administrative proceedings.
///
///
1 In the interest of privacy, this opinion uses only the first name and the initial of the last
name of the non-governmental party.
STANDARD OF REVIEW
“As with other agency decisions, federal court review of social security determinations is
limited.” Treichler v. Comm’r of Soc. Sec. Admin., 775 F.3d 1090, 1098 (9th Cir. 2014). That is
because “[f]or highly fact-intensive individualized determinations like a claimant’s entitlement to
disability benefits, Congress places a premium upon agency expertise, and, for the sake of
uniformity, it is usually better to minimize the opportunity for reviewing courts to substitute their
discretion for that of the agency.” Id. (quoting Consolo v. Fed. Mar. Comm’n, 383 U.S. 607, 621
(1966)). Adhering to this principle, courts “follow three important rules” in reviewing social
security determinations. Brown-Hunter v. Colvin, 806 F.3d 487, 492 (9th Cir. 2015).
First, courts “leave it to the [agency] to determine credibility, resolve conflicts in the
testimony, and resolve ambiguities in the record.” Id. (quoting Treichler, 775 F.3d at 1098).
Second, courts “will ‘disturb the Commissioner’s decision to deny benefits only if it is not
supported by substantial evidence or is based on legal error.’” Id. (quoting Treichler, 775 F.3d at
1098). Third, if the agency “‘commits legal error, [courts] uphold the decision where that error is
harmless,’ meaning that ‘it is inconsequential to the ultimate nondisability determination,’ or
that, despite the legal error, ‘the agency’s path may reasonably be discerned, even if the agency
explains its decision with less than ideal clarity.’” Id. (quoting Treichler, 775 F.3d at 1098); see
also Smith v. Kijakazi, 14 F.4th 1108, 1111 (9th Cir. 2021) (“And even where this modest
[substantial evidence] burden is not met, [courts] will not reverse an [agency] decision where the
error was harmless.” (citing Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012), superseded
on other grounds by regulation as recognized in Farlow v. Kijakazi, 53 F.4th 485, 487 (9th Cir.
2022))).
///
///
BACKGROUND
I. PLAINTIFF’S APPLICATION
Plaintiff filed her DIB application on March 22, 2022, alleging a disability onset date of
July 30, 2020.2 (Tr. 15.) She had at least a high school education and past relevant work as a loan
processor. (Id. at 24.) In her application, Plaintiff alleged disability due to arthritis in her hands,
swollen fingers, and pinched nerves in her right shoulder. (Id. at 36-38, 196.)
The Commissioner denied Plaintiff’s application initially on July 21, 2022, and upon
reconsideration on February 8, 2023. (Id. at 15, 58-65, 74-78.) On February 15, 2023, Plaintiff
requested a hearing before an Administrative Law Judge (“ALJ”). (Id. at 84-85.) Plaintiff and a
vocational expert (“VE”) testified at an administrative hearing held on November 30, 2023. (Id.
at 33-49.) On January 5, 2024, the ALJ issued a written decision denying Plaintiff’s application.
(Id. at 15-26.) On August 27, 2024, the Appeals Council denied Plaintiff’s request for review,
making the ALJ’s written decision the final decision of the Commissioner. (Id. at 1-6.) Plaintiff
now seeks judicial review of the ALJ’s decision.
///
///
2 To be eligible for DIB, “a worker must have earned a sufficient number of [quarters of
coverage] within a rolling forty quarter period.” Herbert v. Astrue, No. 1:07-CV-01016 TAG,
2008 WL 4490024, at *4 (E.D. Cal. Sept. 30, 2008) (citation omitted). Workers accumulate
quarters of coverage based on their earnings. Id. Typically, “the claimant must have a minimum
of twenty quarters of coverage [during the rolling forty-quarter period to maintain insured
status]. . . . The termination of a claimant’s insured status is frequently referred to as the ‘date
last insured’ or ‘DLI.’” Id. (citation omitted). Thus, Plaintiff’s date last insured (“DLI”) of
December 31, 2025 (Tr. 17) reflects the date on which her insured status terminated based on the
previous accumulation of quarters of coverage. If Plaintiff established that she was disabled on
or before December 31, 2025, she is entitled to DIB. See Truelsen v. Comm’r of Soc. Sec., No.
2:15-CV-2386-KJN, 2016 WL 4494471, at *1 (E.D. Cal. Aug. 26, 2016) (“To be entitled to DIB,
plaintiff must establish that he was disabled . . . on or before his date last insured.” (citing
Tidwell v. Apfel, 161 F.3d 599, 601 (9th Cir. 1998))).
II. THE SEQUENTIAL PROCESS
A claimant is considered disabled if he or she is unable to “engage in any substantial
gainful activity by reason of any medically determinable physical or mental impairment
which . . . has lasted or can be expected to last for a continuous period of not less than 12
months[.]” 42 U.S.C. § 423(d)(1)(A). “Social Security Regulations set out a five-step sequential
process for determining whether an applicant is disabled within the meaning of the Social
Security Act.” Keyser v. Comm’r Soc. Sec. Admin., 648 F.3d 721, 724 (9th Cir. 2011) (citation
omitted). Those five steps are: (1) whether the claimant is engaged in substantial gainful activity;
(2) whether the claimant has a severe impairment; (3) whether the impairment meets or equals a
listed impairment; (4) whether the claimant can return to any past relevant work; and (5) whether
the claimant can perform other work that exists in significant numbers in the national economy.
Id. at 724-25.
The claimant bears the burden of proof for the first four steps. See Bustamante v.
Massanari, 262 F.3d 949, 953-54 (9th Cir. 2001). If the claimant fails to meet the burden at any
of those steps, the claimant is not disabled. See id. at 954. The Commissioner bears the burden of
proof at step five, where the Commissioner must show the claimant can perform other work that
exists in significant numbers in the national economy, “taking into consideration the claimant’s
residual functional capacity, age, education, and work experience.” Tackett v. Apfel, 180 F.3d
1094, 1100 (9th Cir. 1999) (citation omitted). If the Commissioner fails to meet this burden, the
claimant is disabled. See Bustamante, 262 F.3d at 954.
III. THE ALJ’S DECISION
The ALJ applied the five-step sequential evaluation process to determine if Plaintiff is
disabled. (Tr. 17-26.) At step one, the ALJ determined that Plaintiff had not engaged in
substantial gainful activity since July 30, 2020, the alleged onset date. (Id. at 17.) At step two,
the ALJ found that Plaintiff suffered from the following severe, medically determinable
impairments: polymyositis, bilateral hand osteoarthritis, and chronic right trapezius spasm. (Id.)
At step three, the ALJ concluded that Plaintiff did not have an impairment that meets or
medically equals a listed impairment. (Id. at 20.) The ALJ then concluded that Plaintiff had the
residual functional capacity (“RFC”) to perform light work, subject to these limitations:
[S]he can lift up to [ten] pounds at a time and occasionally lift or carry articles
like docket files, ledgers, and small tools. She can occasionally climb ladders,
ropes, and scaffolds and crawl. [Plaintiff] can occasionally reach with the right
upper extremity and occasionally handle and finger bilaterally. She must avoid
concentrated exposure to hazards and extreme cold.
(Id. at 19.)
At step four, the ALJ concluded that Plaintiff has past relevant work as a loan processor
but is unable to perform such work due to her RFC limitation of occasional handling and
fingering. (Id. at 24.) At step five, the ALJ concluded that there are jobs that exist in significant
numbers in the national economy that Plaintiff can perform, including gate guard. (Id. at 25.)
DISCUSSION
In this appeal, Plaintiff argues that the ALJ erred by failing to identify specific, clear, and
convincing reasons supported by substantial evidence in the record to discount Plaintiff’s
symptom testimony (Pl.’s Br. at 3-16, ECF No. 12) and by failing properly to evaluate the
medical opinion of Rola Baker, M.D. (“Dr. Baker”). (Id. at 16-19.)
I. SUBJECTIVE SYMPTOM TESTIMONY
Plaintiff argues that the ALJ committed harmful error by failing to link Plaintiff’s
discounted symptom testimony to specific medical records and explain why those records
contradict her symptom testimony. (Pl.’s Br. at 3-16; Pl.’s Reply at 1-15, ECF No. 18.) The
Commissioner responds that substantial evidence supported the ALJ’s discounting of Plaintiff’s
symptom testimony. (Def.’s Br. at 2-10, ECF No. 15.)
A. Applicable Law
The Ninth Circuit has “established a two-step analysis for determining the extent to
which a claimant’s symptom testimony must be credited[.]” Trevizo v. Berryhill, 871 F.3d 664,
678 (9th Cir. 2017). “First, the ALJ must determine whether the claimant has presented objective
medical evidence of an underlying impairment ‘which could reasonably be expected to produce
the pain or other symptoms alleged.’” Garrison v. Colvin, 759 F.3d 995, 1014 (9th Cir. 2014)
(quoting Lingenfelter v. Astrue, 504 F.3d 1028, 1035-36 (9th Cir. 2007)). Second, “[i]f the
claimant meets the first test and there is no evidence of malingering, the ALJ can only reject the
claimant’s testimony about the severity of the symptoms if she gives specific, clear and
convincing reasons for the rejection.” Ghanim v. Colvin, 763 F.3d 1154, 1163 (9th Cir. 2014)
(citation omitted).
B. Analysis
There is no evidence of malingering here and the ALJ determined that Plaintiff provided
objective medical evidence of underlying impairments which might reasonably produce the
symptoms alleged. (Tr. 19.) The ALJ was therefore required to provide clear and convincing
reasons for discounting Plaintiff’s testimony. See Ghanim, 763 F.3d at 1163. The Court finds that
the ALJ did not meet that standard here.
1. Plaintiff’s Testimony
At the ALJ hearing, Plaintiff testified that she previously worked in the field of mortgage
loans for sixteen years and stopped working due to her diagnosis of osteoarthritis which causes
“lots of swelling and bending of [her] fingers.” (Tr. 36.) She testified that she can no longer lay
her hands flat, which makes it difficult for her to hold a pen to write, type, or perform other
computer work. (Id. at 37.) Her symptoms were worse than when she stopped working and she
can only perform tasks with her hands for five minutes and then must stop due to pain. (Id.)
Plaintiff claimed that all ten of her fingers have swelling and that the bending of her joints is
“permanent.” (Id. at 38.)
With respect to her right shoulder impairment, Plaintiff testified that she has “a lot of
pinched nerves which then causes tingling and numbness down [her] arm.” (Id.) She testified that
these symptoms could be caused by her recent diagnosis of polymyositis,3 and when asked by
the ALJ about the improvement of her symptoms with Prednisone, she answered that it did help
with muscle pain but that she could no longer take it due to its long-term negative effects. (Id. at
38-39.) Plaintiff testified that she takes Norco for pain and Celebrex and Orphenadrine Citrate as
muscle relaxers to control her symptoms. (Id. at 39.) She indicated that these medications have
negative side effects too, including insomnia. (Id.) She also experiences weight gain and
drowsiness with these medications and only gets four-to-five hours of sleep per night due to the
pain in her hands. (Id. at 39-40.) Finally, Plaintiff testified that her ability to focus and
concentrate on tasks has become “increasingly difficult” because it takes her a lot longer to
complete an individual task, she loses her train of thought, and it takes her a “few hours” to go
back to the original task at hand. (Id. at 40.)
///
///
3 “According to Stedman’s Medical Dictionary, polymyositis is the ‘[i]inflammation of a
number of voluntary muscles simultaneously.’ The Myositis Association describes polymyositis
as ‘[m]uscle weakness [that] usually happens over days, weeks or months. The weakness begins
with muscles closest to and within the trunk of the body. Neck, hip, back and shoulder muscles
are examples. Some patients also have weakness in muscles farther from the trunk, like hands
and fingers. Some PM patients experience muscle pain, breathing problems, and trouble
swallowing.’” Dumas v. Comm’r of Soc. Sec., No. 04-CV-4625 (SLT), 2008 WL 4104685, at *1
(E.D.N.Y. Sept. 4, 2008) (citations omitted).
2. The ALJ’s Evaluation of Plaintiff’s Testimony
The ALJ discounted Plaintiff’s symptom testimony because it was inconsistent with the
objective medical evidence, as well as symptom control and “improvement” with medication.
(Id. at 21-22.)
3. Disposition
The Court concludes that the ALJ failed to provide clear and convincing reasons,
supported by substantial evidence in the record, to discount Plaintiff’s symptom testimony.
a. Medical Evidence
Plaintiff argues that the ALJ failed to link Plaintiff’s specific symptom testimony that the
ALJ found not credible to contradictory medical evidence and thus did not provide the necessary
information for meaningful judicial review. (See Pl.’s Br. at 4-7, citing Brown-Hunter, 806 F.3d
at 492); see also Brown-Hunter, 806 F.3d at 494 (holding that the ALJ erred by failing to
identify the testimony she found not credible and consequently “did not link that testimony to the
particular parts of the record supporting her non-credibility determination”).
The Court need not reach Plaintiff’s arguments because even if the ALJ satisfied the
Brown-Hunter specificity requirements and provided clear and convincing reasons to discount
Plaintiff’s symptom testimony based on the objective medical evidence, that cannot be the only
reason in light of the Court’s finding below that substantial evidence did not support the ALJ’s
other reason to discount Plaintiff’s testimony. See Valdez v. Berryhill, 746 F. App’x 676, 677
(9th Cir. 2018) (“[T]he ALJ may properly include lack of supporting medical evidence in the
reasons to discredit claimant testimony as long as it is not the only reason[.]” (citing Burch v.
Barnhart, 400 F.3d 676, 680 (9th Cir. 2005))).
///
b. Improvement with Treatment
Plaintiff argues that the ALJ erred by discounting her testimony based on her
improvement when complying with appropriate treatment. (See Pl.’s Br. at 6-14.) The Court
agrees.
An ALJ may discount a claimant’s testimony based on evidence that the claimant’s
symptoms improved with treatment or medication. See Walker v. Kijakazi, No. 22-35351, 2023
WL 3017946, at *1 (9th Cir. Apr. 20, 2023) (concluding that the ALJ had provided specific,
clear, and convincing reasons for discounting the plaintiff’s subjective symptom testimony where
substantial evidence demonstrated that the plaintiff’s pain improved with treatment and
medication); Wellington v. Berryhill, 878 F.3d 867, 876 (9th Cir. 2017) (“[E]vidence of medical
treatment successfully relieving symptoms can undermine a claim of disability.”) (citations
omitted). That rationale assumes that “[i]mpairments that can be controlled effectively with
medication are not disabling[.]” Warre v. Comm’r of Soc. Sec. Admin., 439 F.3d 1001, 1006 (9th
Cir. 2006).
Here, the ALJ first included standard boilerplate language: “[Plaintiff’s] statements
concerning the intensity, persistence and limiting effects of [her] symptoms are not entirely
consistent with the medical evidence and other evidence in the record for the reasons explained
in this decision.” (Tr. 21.) This language alone does not meet the Ninth Circuit’s specificity
requirements. See Finney, 2022 WL 17830000, at *1 (“The ALJ . . . made use of boilerplate
language stating that [the plaintiff’s] statements are ‘not entirely consistent with the medical
evidence and other evidence in the record.’ This boilerplate explanation is insufficiently
specific.”) (citation omitted). However, the ALJ did not rely solely on this boilerplate language,
but also cited examples of Plaintiff’s symptom improvement with Prednisone, Mobic, Norco,
and Methotrexate. (Tr. 22.) Nevertheless, the ALJ failed to provide specific, clear, and
convincing reasons for discounting Plaintiff’s symptom testimony, particularly regarding her
osteoarthritis and polymyositis.
The ALJ noted that “[Plaintiff’s] pain was stated to be ‘well[-]controlled’ with Mobic and
Norco, ‘which enables her to do her [activities of daily living (‘ADL’)] and take care of her
infirm mother.’” (Id., citing id. at 374.) The ALJ also cited Plaintiff’s Prednisone prescription,
“to which she had a ‘fairly dramatic response,’ or ‘significant improvement[.]’” (Id., citing id. at
366-67.) The ALJ further noted that Plaintiff was “still ‘doing well’ with Prednisone as of
September 2023” but was then “transitioned to [M]ethotrexate and this was ‘helping’ as of her
last contact with Dr. Baker.” (Id., citing id. at 365, 494, 521.)
As Plaintiff persuasively argued in her brief (Pl.’s Br. at 7), these cited improvements
were inconsistent with the medical record as a whole. Plaintiff notes that while she experienced
some improvement with Prednisone, her provider took her off of the medication due to side
effects and her symptoms worsened. (Id., citing id. at 38.) Indeed, an emergency department note
corroborates that Plaintiff “was on a [P]rednisone taper for her osteoarthritis but was having
blood pressure spikes and was retaining water so she was taken off the [P]rednisone and placed
on Lasix to get the fluid off.” (Id. at 289.) Dr. Baker also noted that “Prednisone did not
appreciably help with the inflammatory effects of [Plaintiff’s osteoarthritis] but it has increased
her appetite and weight” and “[t]herefore [we] will discontinue[.]” (Id. at 370.) This evidence is
consistent with Plaintiff’s hearing testimony that Prednisone was not meant to be “long-term”
and caused significant weight gain. (Id. at 39.) Thus, the ALJ erred in discounting Plaintiff’s
testimony on the ground that Prednisone improved her symptoms.
///
Similarly, the ALJ erred by relying on Plaintiff’s Methotrexate prescription to discount
her symptom testimony. Although the record indicates that Methotrexate was “helping” at one
point in time (id. at 521), some temporary improvement in symptoms is not enough to support
the ALJ’s conclusion that Plaintiff’s impairments no longer seriously affected her ability to
function in a workplace. See Holohan v. Massanari, 246 F.3d 1195, 1205 (9th Cir. 2001) (“[The
treating physician’s] statements must be read in context of the overall diagnostic picture he
draws. That a person . . . makes some improvement does not mean that the person’s impairments
no longer seriously affect her ability to function in a workplace.”). The Court finds that the cited
evidence does not rise to the level of substantial evidence of improvement and effective
treatment for Plaintiff’s impairments (osteoarthritis, polymyositis, and right shoulder spasm) to
discount her symptom testimony.
Furthermore, the ALJ’s other citations to the medical record relating to Plaintiff’s right
shoulder pain do not directly address her primary complaints of osteoarthritis, polymyositis, or
right shoulder spasm. Although the record supports a finding that physical therapy relieved
Plaintiff’s right trapezius pain temporarily in May 2023, her symptoms related to osteoarthritis,
polymyositis, and right shoulder spasm persisted. (See, e.g., Tr. 410.) In fact, the medical record
cited by the ALJ reflects that “[t]he patient has improved in [range of motion] but continues to
present with impairments in strength and difficulty with functional activities including gripping,
reaching, recreation and would benefit from additional intervention.” (Id.) The ALJ’s reliance on
this treatment record does not support a conclusion that Plaintiff’s symptoms were adequately
controlled and improved with treatment. (See id. at 521-22, reflecting that Plaintiff continued to
experience cervical pain and tenderness on both sides of her neck in November 2023, along with
decreased range of motion, despite being discharged from physical therapy and taking
Prednisone before her switch to Methotrexate).
Based on its review of the record as a whole, the Court concludes that substantial
evidence does not support the ALJ’s discounting of Plaintiff’s symptom testimony based on
evidence of improvement and effective treatment. As a result, the Court finds that the ALJ erred
in discounting Plaintiff’s subjective symptom testimony. See Garrison, 759 F.3d at 1015
(holding that the ALJ improperly cited effective treatment as a reason to discount the plaintiff’s
pain testimony where the treatment provided only partial and temporary relief).
II. MEDICAL OPINION EVIDENCE
Plaintiff also argues that substantial evidence does not support the ALJ’s reasons for
partially discounting the opinion of her treating physician, Dr. Baker. (Pl.’s Br. at 16-19.) The
Commissioner responds that the ALJ properly found Dr. Baker’s opinion partially persuasive
because it was poorly supported and inconsistent with other evidence. (Def.’s Br. at 10-14.)
A. Applicable Law
“In January 2017, the Social Security Administration issued revised regulations for
evaluating medical opinions relating to claims filed on or after March 27, 2017.” Cross v.
O’Malley, 89 F.4th 1211, 1214 (9th Cir. 2024) (citation omitted). The revised “regulations
provide that ALJs will no longer ‘defer or give any specific evidentiary weight’ to any medical
opinions.” Id. (quoting 20 C.F.R. § 416.920c(a)). Instead, “ALJ[s] must assess the
persuasiveness of each medical opinion after considering specified factors.” Stiffler v. O’Malley,
102 F.4th 1102, 1106 (9th Cir. 2024) (first citing Woods v. Kijakazi, 32 F.4th 785, 791-92 (9th
Cir. 2022); and then citing 20 C.F.R. §§ 404.1520c(a)-(c), 416.920c(a)-(b))).
Specifically, the revised “regulations require an ALJ to discuss the supportability and
consistency of medical evidence—the factors the agency has historically found to be the most
important in evaluating medical opinions—while allowing for discussion of other factors listed
in paragraphs (c)(3) through (c)(5), as appropriate.” Cross, 89 F.4th at 1215 (citing 20 C.F.R. §
416.920c(a)); see also Woods, 32 F.4th at 791 (“‘The most important factors’ that the agency
considers when evaluating the persuasiveness of medical opinions are ‘supportability’ and
‘consistency.’” (quoting 20 C.F.R. § 404.1520c(a))). “Supportability focuses on whether ‘a
medical source supports a medical opinion by explaining the relevant objective medical
evidence.’” Stiffler, 102 F.4th at 1106 (quoting Woods, 32 F.4th at 791-92); see also Kitchen v.
Kijakazi, 82 F.4th 732, 740 (9th Cir. 2023) (“Supportability concerns how ‘a medical source
supports a medical opinion’ with relevant evidence[.]” (quoting Woods, 32 F.4th at 791-92)).
“Consistency means the extent to which a medical opinion is consistent with the evidence from
other medical sources and nonmedical sources[.]” Stiffler, 102 F.4th at 1106 (quoting Woods, 32
F.4th at 792).
In addition to supportability and consistency, “[a]n ALJ may discuss other factors [listed
in paragraphs (c)(3) through (c)(5)], such as the medical source’s ‘relationship with the claimant’
or ‘specialization,’ but generally has no obligation to do so.” Cross, 89 F.4th at 1214 (citing 20
C.F.R. § 416.920c(b)(2)). If, however, an “ALJ finds two or more contradictory medical
opinions ‘both equally well-supported . . . and consistent with the record[,]’” “the regulations
mandate discussion of these other factors[.]” Id. at 1214-15 (quoting 20 C.F.R. § 416.920c(b)(3),
(c)(3)-(5)).
A district court reviews the ALJ’s evaluation of a medical opinion for substantial
evidence. See Woods, 32 F.4th at 787 (“Now, [under the new regulations,] an ALJ’s decision,
including the decision to discredit any medical opinion, must simply be supported by substantial
evidence.”); id. at 792 (“Even under the new regulations, an ALJ cannot reject an examining or
treating doctor’s opinion as unsupported or inconsistent without providing an explanation
supported by substantial evidence.”); Metcalf v. Kijakazi, No. 22-35201, 2022 WL 17592194, at
*1 (9th Cir. Dec. 13, 2022) (observing that “under the revised regulations . . . , the ALJ’s
evaluation of a medical opinion is reviewed for substantial evidence” (citing Woods, 32 F.4th at
789)).
B. Analysis
The Court concludes that the ALJ erred in discounting Dr. Baker’s medical opinion.
1. Dr. Baker’s Medical Opinion
Dr. Baker completed a treating source statement on October 4, 2022. (See Tr. 386-90.)
Dr. Baker indicated that she had been treating Plaintiff monthly since 1994 and that her
diagnoses include “severe generalized osteoarthritis, axial [and] appendicular[.]” (Id. at 386.) Dr.
Baker indicated that Plaintiff’s conditions were expected to last at least twelve months, were
“progressive[,]” and “worsening over time[.]” (Id.) Dr. Baker listed Plaintiff’s symptoms to
include pain, decreased ability, sleep disruptions, impairment of ADLs, and an “inability to lift.”
(Id. at 387.) Dr. Baker described Plaintiff’s relevant clinical findings and test results as
“peripheral joint osteophytes [with] axial spondylosis[,] and neuromuscular impingement
syndromes from compensatory spasm[.]” (Id.) Dr. Baker opined that because of these
impairments, Plaintiff required rest periods two times per hour. (Id.) Dr. Baker reported that
Plaintiff’s impairments began in August 2016 and that she would be off task twenty-five percent
of the workday and absent more than four days per month due to the “pain, immobility, [and]
weakness” from her impairments. (Id. at 390.)
2. The ALJ’s Findings
The ALJ found Dr. Baker’s opinion only “partly persuasive.” (Id. at 23.) The ALJ stated
that Dr. Baker’s opinion was “partly persuasive in supporting the need for reduced exertion, but
not persuasive concerning the degree of limitation.” (Id.) The ALJ explained that Dr. Baker
provided “little explanation for the checkbox responses and cite[d] conditions not in evidence”
and “[i]maging fails to support the presence of spondylosis or generalized osteoarthritis.” (Id.)
To support this conclusion, the ALJ indicated that the “cervical x-rays specifically note ‘[n]o
spondylosis or spondylolistheses and shoulder x-rays show no abnormality.” (Id., citing id. at
339, 399-400.) Finally, the ALJ took issue with the fact that Dr. Baker noted Plaintiff’s
limitations began in August 2016, “yet [Plaintiff] continued to work at substantial gainful
activity for nearly four more years in a job that she described as requiring constant use of the
hands for writing, typing, or handling small objects.” (Id., citing id. at 164-73, 179-80.)
3. Disposition
The Court concludes that the ALJ erred in evaluating Dr. Baker’s opinion because the
ALJ did not adequately discuss the required supportability and consistency factors and failed to
articulate an explanation supported by substantial evidence. See Woods, 32 F.4th at 792 (holding
that an ALJ can “reject an examining or treating doctor’s opinion as unsupported or inconsistent”
if the ALJ “provid[es] an explanation supported by substantial evidence”).
With respect to the supportability factor, the ALJ was correct in noting that Plaintiff’s
imaging records did not support Dr. Baker’s opinion that Plaintiff exhibited axial spondylosis.
Indeed, Dr. Baker noted in January 2023 that Plaintiff’s “C-spine x-ray in February of last year
was within normal limits with no evidence of significant cervical spondylosis or disc space
narrowing.” (Id. at 498; see id. at 339.) However, the ALJ’s finding that imaging failed to
support Plaintiff’s “generalized osteoarthritis” is not supported by the record. The ALJ only
discussed imaging related to Plaintiff’s cervical spondylosis but did not explain how that
imaging related to her severe hand osteoarthritis. (See id. at 23.) In fact, Dr. Baker’s clinical
observations of Plaintiff over the years demonstrated the severity of the arthritis in Plaintiff’s
hands. (See id. at 374, “[P]rimarily problematic is severe osteoarthritis of both hands especially
the MCP joint of her right hand, which is inhibiting ADLs.”; id. at 375, “Generalized
osteoarthritis is ongoing”; id. at 379, “Marked increased pain over the long thumb extensor on
the right side . . . Positive Finklestein’s test.”) By omitting a supportability evaluation of Dr.
Baker’s findings relating to Plaintiff’s osteoarthritis, the ALJ’s supportability analysis was not
supported by substantial evidence. See, e.g., Schmitzer v. O’Malley, No. 1:22-cv-1038 JLT
BAM, 2024 WL 4345772, at *5 (E.D. Cal. Sept. 30, 2024) (finding that the ALJ erred in the
supportability discussion where “the ALJ did not make any findings as to what extent—if any—
[the provider] supported the limitations identified in” the opinions and “failed to explain to what
extent [the provider]’s own treatment records did not support his opinions”) This omission
undermines the ALJ’s decision given that osteoarthritis is Plaintiff’s primary impairment and the
cause of most of Plaintiff’s functional limitations.
The ALJ also erred in his evaluation of the consistency factor. The ALJ only cited the
fact that Plaintiff “continued to work” to conclude that Dr. Baker’s opinion was inconsistent with
the record. (Tr. 23.) The ALJ’s cited reason does not rise to the level of substantial evidence in
light of the statements from Plaintiff’s former supervisor regarding her actual work performance
during the relevant time period. Plaintiff’s former supervisor explained that from 2016 to 2020,
Plaintiff’s performance suffered and declined due to her impairments. (See id. at 267, “A few
years before she left, I started to notice her ability to function like she used to diminish. She
began to become slower in all her duties. I realized it was her hands and fingers as they were
swollen and crooked, not able to work the way they used to[], and she was in some pain . . .
[Plaintiff] could not do her job anymore . . . she had no choice but to resign.”) In light of this
evidence, the ALJ erred by relying only on Plaintiff’s ability to continue working to discount Dr.
Baker’s opinion. See 20 C.F.R. § 404.1520c(c)(2) (providing that the agency “will explain how
[the ALJ] considered the . . . consistency factor[]”); see also Woods, 32 F.4th at 792 (holding that
the agency must “explain how [it] considered the supportability and consistency factors”).
Furthermore, the ALJ did not address whether Dr. Baker’s opinion was consistent with
evidence from other medical sources, including Derek Leinenbach, M.D. (“Dr. Leinenbach”).
Dr. Leinenbach evaluated Plaintiff in January 2023 and observed the severity of Plaintiff’s
osteoarthritis and back pain, documenting “tense and tender right cervical paraspinal and
trapezius muscles, and mild to moderate swelling and enlargement of the joints of both hands.”
(Tr. 403.) The ALJ found Dr. Leinenbach’s opinion “largely persuasive” due to observations
during an in-person examination that Plaintiff could “reach for, grip and hold objects to the palm
by the last three digits of either hand but her grip is loose due to the arthritic hand pain in the
hands” and “[s]he can grasp and manipulate large and small objects with the first three digits but
does so slowly and mildly clumsily due to the arthritis in the hands.” (Id. at 23, citing id. at 401-
04.) The ALJ erred by not evaluating the consistency between Dr. Baker’s and Dr. Leinenbach’s
opinions where the findings of Dr. Leinenbach that the ALJ found persuasive align with Dr.
Baker’s long-term clinical observations. (Compare id. at 403, “The right cervical paraspinal and
trapezius muscles are tense and tender to palpation . . . There is mild to moderate swelling and
enlargement of the joints of both hands, most notably at the MCP and PIP joints. There is diffuse
tenderness to palpation at the MCP and PIP joints of the right hand with sparing of the thumb
CMC joint.” with id. at 374, “primarily problematic is severe osteoarthritis of both hands
especially the MCP joint of her right hand, which is inhibiting ADLs”; id. at 377, “Exam
confirms marked trapezius spasm bilaterally, worse on the right than on the left.”; id. at 379,
“Exam confirms again marked tenderness at C6/C7 right with decreased cervical range of motion
. . . Marked increased pain over the long thumb extensor on the right side . . . Positive
Finklestein’s test.”) As a result, the Court finds that substantial evidence does not support the
ALJ’s evaluation of Dr. Baker’s medical opinion. See, e.g., Thomas S. v. Comm’r of Soc. Sec.,
No. 2:20-cv-00169-FVS, 2021 WL 3132731, at *9 (E.D. Wash. July 22, 2021) (“However,
irrespective of whether the ALJ properly considered the supportability factor under the new
regulations, [the medical] opinion must be reconsidered on remand because the ALJ failed to
properly consider the consistency factor.”).
III. REMEDY
Plaintiff asks the Court to remand for an award of benefits. (Pl.’s Br. at 19; Pl.’s Reply at
15-19.) The Commissioner responds that “there are conflicting medical opinions in the record[,]”
citing the “unchallenged findings that the assessment of Dr. Wiggins was partially persuasive
and the opinion of Dr. Leinenbach was largely persuasive.” (Def.’s Br. at 15.)
A. Applicable Law
“Generally when a court of appeals reverses an administrative determination, ‘the proper
course, except in rare circumstances, is to remand to the agency for additional investigation or
explanation.’” Benecke v. Barnhart, 379 F.3d 587, 595 (9th Cir. 2004) (citations omitted). In
several cases, however, the Ninth Circuit “stated or implied that it would be an abuse of
discretion for a district court not to remand for an award of benefits when [the three-part credit
as-true standard is] met.” Garrison, 759 F.3d at 1020 (citations omitted). The credit-as-true
standard is met if three conditions are satisfied: “(1) the record has been fully developed and
further administrative proceedings would serve no useful purpose; (2) the ALJ has failed to
provide legally sufficient reasons for rejecting evidence, whether claimant testimony or medical
opinion; and (3) if the improperly discredited evidence were credited as true, the ALJ would be
required to find the claimant disabled on remand.” Id. (citations omitted). Even when the credit-
as-true standard is met, the court retains the “flexibility to remand for further proceedings when
the record as a whole creates serious doubt as to whether the claimant is, in fact, disabled within
the meaning of the Social Security Act.” Id. at 1021.
B. Analysis
Applying the credit-as-true standard here, the Court concludes that conflicts and
ambiguities in the record remain and require further administrative proceedings.
Specifically, the ALJ must resolve outstanding contradictions between the medical record
and Dr. Baker’s opinion. For example, Dr. Baker opined that Plaintiff could utilize her hands,
fingers, and arms for only fifteen percent of an eight-hour workday. (See Tr. 389.) While the ALJ
found this opinion “partly persuasive in supporting the need for reduced exertion,” the ALJ
nevertheless concluded that Plaintiff could handle and finger for up to two hours. (Id. at 23-24.)
In light of the Court’s finding that the ALJ erred in evaluating Dr. Baker’s opinion and Plaintiff’s
symptom testimony, ambiguities remain regarding the extent of Plaintiff’s vocational capabilities
relating to her bilateral hand osteoarthritis. In addition, the ALJ failed properly to analyze the
steady decline in Plaintiff’s work performance from 2016 to 2020 and overlooked her former
supervisor’s statements documenting that Plaintiff was forced to resign due to her severe
impairments. Furthermore, the ALJ erroneously relied on Plaintiff’s “fairly dramatic response”
to Prednisone and other medications to discount her symptom testimony, while failing
adequately to consider why her provider discontinued Prednisone or evaluate the efficacy of
Methotrexate in addressing her symptoms. (See id. at 521.)
Further proceedings will allow the ALJ to reevaluate the medical opinions, Plaintiff’s
impairments and resulting functional limitations, reformulate the RFC, and obtain updated VE
testimony. Accordingly, further proceedings would serve a “useful purpose” here. See Garrison,
759 F.3d at 1020; Treichler, 775 F.3d at 1094 (“Given the conflicts and ambiguity that remain in
the record, however, we remand for further proceedings rather than for an award of benefits.”);
see also McAuley v. Kijakazi, No. 21-16334, 2022 WL 2235462, at *1 (9th Cir. June 22, 2022)
(holding that where “the district court determined that . . . ‘conflicts and ambiguities’ existed, . . .
it was not an abuse of discretion for the district court to conclude that additional administrative
proceedings were warranted” (citing Treichler, 775 F.3d at 1104-05)).
For these reasons, the Court reverses the Commissioner’s decision and remands the case
for further administrative proceedings.
CONCLUSION
For the reasons stated, the Court REVERSES the Commissioner’s decision and
REMANDS this case for further proceedings consistent with this opinion.
IT IS SO ORDERED.
DATED this 2nd day of July, 2026.
/s/ Stacie F. Beckerman
HON. STACIE F. BECKERMAN
United States Magistrate Judge