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Jacob M. v. Commissioner, Social Security Administration

United States District Court, D. Oregon, Eugene Division

May 28, 2019

JACOB M., [1] Plaintiff,
COMMISSIONER, Social Security Administration, Defendant.


          Michael J. McShane, United States District Judge.

         Plaintiff seeks judicial review of the Commissioner of Social Security's decision denying his application for Supplemental Security Income and Disability Insurance Benefits. This Court has jurisdiction under 42 U.S.C. §§ 405(g) and 1383(c)(3). Plaintiff filed his application for Supplemental Security Income and Disability Insurance Benefits on January 21, 2014. In both applications, Plaintiff alleged disability beginning on August 5, 2013. After a hearing, an Administrative Law Judge determined that Plaintiff was not disable under the Social Security Act. Plaintiff now contends that the decision was in error. The Court agrees. Because the Commissioner of Social Security's decision is not supported by substantial evidence, and because the record requires additional development, the Commissioner of Social Security's decision is REVERSED and the case REMANDED for further proceedings consistent with this Order.


         A reviewing court shall affirm the decision of the Commissioner of Social Security (“Commissioner”) if her decision is based on proper legal standards and the legal findings are supported by substantial evidence in the record. 42 U.S.C. § 405(g); Batson v. Comm'r of Soc. Sec. Admin., 359 F.3d 1190, 1193 (9th Cir. 2004). “Substantial evidence is ‘more than a mere scintilla but less than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'” Hill v. Astrue, 698 F.3d 1153, 1159 (9th Cir. 2012) (quoting Sandgathe v. Chater, 108 F.3d 978, 980 (9th Cir. 1997)). To determine whether substantial evidence exists, the district court must review the administrative record as a whole, weighing both the evidence that supports and detracts from the Administrative Law Judge's decision. Davis v. Heckler, 868 F.2d 323, 326 (9th Cir. 1989).


         The Social Security Administration utilizes a five-step sequential evaluation to determine whether a claimant is disabled. 20 C.F.R. §§ 404.1520, 416.920 (2012). The initial burden of proof rests upon the claimant to meet the first four steps. If the claimant satisfies his burden with respect to the first four steps, the burden then shifts to the Commissioner for step five. 20 C.F.R. § 404.1520 (2012). At step five, the Commissioner's burden is to demonstrate that the claimant can make an adjustment to other work after considering the claimant's Residual Functional Capacity (“RFC”), age, education, and work experience. Id.

         In the present case, the Administrative Law Judge (“ALJ”) found that Plaintiff was not disabled. Tr. 21.[2] At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since August 5, 2013, the alleged onset date of disability. Tr. 23. At step two, the ALJ determined Plaintiff had the following severe impairments: degenerative disc disease of the thoracic and lumbar spines; tobacco use disorder (in combination with Plaintiff's degenerative disc disease); morbid obesity; bipolar disorder; borderline intellectual functioning; and a conversion disorder. Tr. 23. He also determined at step three that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. Tr. 24.

         Before moving to step four, the ALJ found Plaintiff had the RFC to perform light work as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b), adding that Plaintiff could frequently climb ramps and stairs, never climb ladders, ropes, or scaffolds, and frequently stoop, kneel, crouch, and crawl. Tr. 26. He also limited Plaintiff to short and simple instructions, occasional changes in routine, and simple work-related judgments and decisions. Tr. 26. Next, at step four, the ALJ concluded Plaintiff was unable to perform any past relevant work. Tr. 29. Nevertheless, at step five, the ALJ found that Plaintiff could perform several jobs existing in substantial numbers in the national economy, including electronic worker, assembler of electronic accessories, and basket filler. Tr. 30. In doing so, he relied on the testimony of a vocational expert and considered Plaintiff's age, education, work experience, and RFC. Tr. 30-31. Finally, having identified jobs existing in substantial numbers in the national economy which Plaintiff could perform, the ALJ concluded that Plaintiff was not disabled and therefore did not qualify for benefits. Tr. 31.

         Plaintiff challenges the ALJ's determination on three grounds.[3] First, Plaintiff argues that the ALJ failed to provide clear and convincing reasons supported by substantial evidence for discrediting his subjective symptom testimony. Pl.'s Br. 21-24, ECF No. 13. Second, Plaintiff argues that the ALJ erred in evaluating the medical opinion evidence. Pl.'s Br. 14-17. Finally, Plaintiff argues that the ALJ failed to identify legally sufficient bases for rejecting “other” medical source opinions. Pl.'s Br. 17-21. The Court addresses each argument in turn.

         I. Subjective Symptom Testimony

         Plaintiff first argues the ALJ failed to provide clear and convincing reasons supported by substantial evidence for rejecting his symptom testimony. Pl.'s Br. 21-24. As the ALJ recognized, Plaintiff suffered from thoracic, lumbar, and cervical spine impairments, as well as a conversion disorder.[4] Tr. 23-24. Plaintiff testified that he was “unable to sit or stand for long periods of time” and could not walk more than 100 feet without needing to stop and rest. Tr. 312, 317. He added that he was unable to “lay down without having pain” and struggled to fall asleep due to persistent pain. Tr. 313. Plaintiff also stated that he required assistance with personal care when pain became “unmanageable” and, because of his difficulties standing for extended periods, received regular assistance with meal preparation and house work. Tr. 313-14. Finally, Plaintiff reported that, since the beginning of 2015, he had experienced constant weakness and intermittent tingling in his right upper extremity, as well as persistent numbness, tingling, and pain in his legs. Tr. 67.

         The ALJ found Plaintiff's physical symptom testimony to not be credible for three reasons. First, the ALJ noted inconsistencies between Plaintiff's allegations and the objective medical evidence. Tr.27. Although he conceded that imaging showed “some degenerative changes of a moderate to severe nature” in the thoracic spine and “mild degenerative disc disease of the lumbar spine, ” the ALJ opined that other imaging showed only “mild multilevel degenerative changes without neurological involvement.” Tr. 27. He further reasoned that Plaintiff “generally” had “full range of motion in all extremities and normal strength, reflexes, and motor function, ” as well as “normal gait [and] sensation.” Tr. 27. Second, the ALJ determined that Plaintiff's course of treatment, which he described as limited to “physical therapy and prescription medications, ” was “very conservative.” Tr. 27. Finally, the ALJ found that Plaintiff's activities of daily living were also inconsistent with his claimed limitations. Tr. 27. In particular, he opined that Plaintiff's ability to walk for “20 minutes a day” and “perform adequate self-care, prepare simple meals, do household chores and go out to the store” indicated a higher level of function. Tr. 27.

         An ALJ may only reject testimony regarding the severity of a claimant's symptoms if she offers “clear and convincing reasons” supported by “substantial evidence in the record.” Thomas v. Barnhart, 278 F.3d 947, 959 (9th Cir. 2002). “General findings are insufficient; rather, the ALJ must identify what testimony is not credible and what evidence undermines the claimant's complaints.” Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998) (quoting Lester v. Chater, 81 F.3d 821, 834 (9th Cir. 1993)). In assessing credibility, the ALJ may consider a wide range of factors, including “ordinary techniques of credibility evaluation, ” as well as the claimant's daily activities, objective medical evidence, treatment history, and inconsistencies in testimony. Molina v. Astrue, 674 F.3d 1104, 1163 (9th Cir. 2012) (citation omitted). When reaching an ultimate conclusion on the credibility of specific testimony, however, the ALJ must be “sufficiently specific to allow a reviewing court to conclude that the adjudicator rejected the claimant's testimony on permissible grounds and did not arbitrarily discredit a claimant's testimony regarding pain.” Bunnell v. Sullivan, 947 F.3d 586, 592 (9th Cir. 2009) (original emphasis and ellipses omitted).

         Here, the ALJ erred in rejecting Plaintiff's symptom testimony. The most glaring flaw in the ALJ's analysis stems from his omission of any discussion pertaining to Plaintiff's cervical spine impairment and symptoms. In addition to the thoracic and lumbar spine conditions addressed by the ALJ, Plaintiff was treated for several cervical spine-related conditions, including a herniated cervical disk, severe spinal stenosis in the cervical region, and cervical disk degeneration. Tr. 604. These conditions were distinct from Plaintiff's other back impairments and gave rise to a distinct body of symptoms. See tr. 66. Plaintiff, for instance, reported persistent neck and leg pain, as well as muscle weakness, numbness in his right upper extremity, and difficulty walking. Tr. 602, 604, 617. He received physical therapy and, when that was unsuccessful, a cervical diskectomy and fusion. Tr. 604. Importantly, after some initial improvement, Plaintiff's symptoms remained unresolved after the surgical intervention. Tr. 594-97, 617-30, 668. Although an ALJ's interpretation of the record is generally ...

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