United States District Court, D. Arizona
M.A. Bullard, Plaintiff,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.
ORDER
David
G. Campbell Senior United States District Judge
Plaintiff,
M.A. Bullard, seeks review under 42 U.S.C. § 405(g) of
the final decision of the Commissioner of Social Security
which denied her disability insurance benefits under sections
216(i), 223(d), and 1614(a)(3)(A) of the Social Security Act.
For reasons set forth below, the Court will vacate the
Commissioner's decision and remand for an award of
benefits.
I.
Background.
Plaintiff
is a 51 year-old woman with an eighth grade education. A.R.
38. She previously worked as housekeeper, salesperson, and a
cleaning person. A.R. 39-40. Plaintiff applied for disability
benefits on January 2, 2014, alleging disability beginning
January 1, 2013. A.R. 17. Plaintiff later amended her alleged
onset date to July 28, 2014. A.R. 17. On May 17, 2016,
Plaintiff and a vocational expert appeared and testified at a
hearing before the ALJ. A.R. 36-57. On September 29, 2016,
the ALJ issued an unfavorable decision, finding Plaintiff not
disabled within the meaning of the Social Security Act. A.R.
27-28. The ALJ's decision became the Commissioner's
final decision when the Appeals Council denied
Plaintiff's request for review on November 3, 2017. A.R.
1-3.
II.
Legal Standard.
The
Court reviews only those issues raised by the party
challenging the ALJ's decision. See Lewis v.
Apfel, 236 F.3d 503, 517 n.13 (9th Cir. 2001). The Court
may set aside the Commissioner's disability determination
only if the determination is not supported by substantial
evidence or is based on legal error. Orn v. Astrue,
495 F.3d 625, 630 (9th Cir. 2007). Substantial evidence is
more than a scintilla, less than a preponderance, and
relevant evidence that a reasonable person might accept as
adequate to support a conclusion considering the record as a
whole. Id. In determining whether substantial
evidence supports a decision, the Court must consider the
record as a whole and may not affirm simply by isolating a
“specific quantum of supporting evidence.”
Id. (internal citations and quotation marks
omitted). As a general rule, “[w]here the evidence is
susceptible to more than one rational interpretation, one of
which supports the ALJ's decision, the ALJ's
conclusion must be upheld.” Thomas v.
Barnhart, 278 F.3d 947, 954 (9th Cir. 2002) (citations
omitted). The ALJ is responsible for resolving conflicts in
medical testimony, determining credibility, and resolving
ambiguities. Andrews v. Shalala, 53 F.3d 1035, 1039
(9th Cir. 1995). In reviewing the ALJ's reasoning, the
Court is “not deprived of [its] faculties for drawing
specific and legitimate inferences from the ALJ's
opinion.” Magallanes v. Bowen, 881 F.2d 747,
755 (9th Cir. 1989).
III.
The ALJ's Five-Step Evaluation Process.
To
determine whether a claimant is disabled for purposes of the
Social Security Act, the ALJ follows a five-step process. 20
C.F.R. § 404.1520(a). The claimant bears the burden of
proof on the first four steps, and the burden shifts to the
Commissioner at step five. Tackett v. Apfel, 180
F.3d 1094, 1098 (9th Cir. 1999). At the first step, the ALJ
determines whether the claimant is engaging in substantial
gainful activity. 20 C.F.R. § 404.1520(a)(4)(i). If so,
the claimant is not disabled and the inquiry ends.
Id. At step two, the ALJ determines whether the
claimant has a “severe” medically determinable
physical or mental impairment. § 404.1520(a)(4)(ii). If
not, the claimant is not disabled and the inquiry ends.
Id. At step three, the ALJ considers whether the
claimant's impairment or combination of impairments meets
or medically equals an impairment listed in Appendix 1 to
Subpart P of 20 C.F.R. Pt. 404. § 404.1520(a)(4)(iii).
If so, the claimant is automatically found to be disabled.
Id. If not, the ALJ proceeds to step four. At step
four, the ALJ assesses the claimant's residual functional
capacity (“RFC”) and determines whether the
claimant is still capable of performing past relevant work.
§ 404.1520(a)(4)(iv). If so, the claimant is not
disabled and the inquiry ends. Id. If not, the ALJ
proceeds to the fifth and final step, where he determines
whether the claimant can perform any other work based on the
claimant's RFC, age, education, and work experience.
§ 404.1520(a)(4)(v). If so, the claimant is not
disabled. Id. If not, the claimant is disabled.
Id.
At step
one, the ALJ found that Plaintiff met the insured status
requirements of the Social Security Act through December 31,
2018, and that she had not engaged in substantial gainful
activity since July 28, 2014. A.R. 19. At step two, the ALJ
found that Plaintiff had the following severe impairments:
lumbar spine degenerative disc disease and
obesity.[1] A.R. 20. At step three, the ALJ determined
that Plaintiff did not have an impairment or combination of
impairments that meets or medically equals a listed
impairment. A.R 22. At step four, the ALJ found that
Plaintiff had the RFC to perform light work, including her
past work as a housekeeper and salesclerk. A.R. 22, 27.
IV.
Analysis.
Plaintiff
argues the ALJ's decision is defective for three reasons:
(1) the ALJ erred in rejecting Dr. Yamaguchi's
assessment; (2) the ALJ rejected Plaintiff's symptom
testimony without specific, clear, and convincing reasons,
supported by substantial evidence; and (3) the ALJ erred by
determining Plaintiff's RFC without giving reasons
supported by substantial evidence.
A.
Medical Opinion Evidence.
1.
Legal Standard.
A
physician's opinion may be a treating source, examining
source, or non-examining source. See 20 C.F.R.
§ 404.1527 (evaluating opinion evidence for claims filed
before March 2017); Lester v. Chater, 81 F.3d 821,
830 (9th Cir. 1995). A treating physician is one who provides
or has provided the claimant with medical treatment or
evaluation, or who has an ongoing treatment relationship with
the claimant. Id. at § 404.1527(a)(2).
Generally, an ALJ should give greatest weight to a treating
physician's opinion and more weight to the opinion of an
examining physician than a non-examining physician. See
Andrews, 53 F.3d at 1040-41; see also 20 C.F.R.
§ 404.1527(c)(2)-(6) (factors ALJ considers when
evaluating opinion evidence). If it is not contradicted by
another doctor's opinion, the opinion of a treating or
examining physician can be rejected only for “clear and
convincing” reasons. Lester, 81 F.3d at 830
(citing Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir.
1988)). “The ALJ must do more than offer his
conclusions. He must set forth his own interpretations and
explain why they, rather than the doctors', are
correct.” Embrey, 849 F.2d at 421-22. The
Commissioner is responsible for determining whether a
claimant meets the statutory definition of disability and
does not give significance to a statement by a medical source
that the claimant is “disabled” or “unable
to work.” 20 C.F.R. § 416.927(d).
2.
Dr. Yamaguchi.
The ALJ
gave Dr. Yamaguchi's opinion no weight. A.R. 26. Because
Dr. Yamaguchi is a treating physician whose opinion is not
contradicted by another doctor, the ALJ could discount his
opinion only for clear and convincing reasons.
Lester, 81 F.3d at 830-31.
On
August 31, 2016, Dr. Yamaguchi completed a check-box form
indicating that Plaintiff was significantly disabled. He
opined that Plaintiff could continuously sit for only 30
minutes; continuously stand for only 30 minutes; sit for two
hours or less in an eight-hour workday; stand and walk for
two hours or less in an eight-hour workday; rarely lift ten
pounds; rarely carry five pounds; rarely stoop, squat, crawl,
climb, and reach; occasionally handle, grip or grasp, and
push or pull hand controls; rarely perform fingering and fine
manipulation; and not use her feet for repetitive movements.
A.R. 793-95. Dr. Yamaguchi opined that Plaintiff would have a
total restriction around unprotected heights, moving
machinery, exposure to dust, fumes, and gases, and exposure
to marked changes in temperature or humidity. Id.
Dr. Yamaguchi also opined that Plaintiff would have a
moderate restriction with occupational driving. Id.
The ALJ
identified several reasons for giving the opinion no weight:
it (1) was inconsistent with objective medical findings in
the record; (2) was so extreme that Plaintiff would be
bedridden, when she was not; (3) included no contemporaneous
treatment records; (4) did not list any current diagnosis of
conditions which supported Plaintiff's extreme
limitations; (5) did not include any indication of a need for
a handheld device, such as a cane, even though the form
included a space for such an indication; and (6) appeared to
be based on claimant's subjective complaints rather than
objective clinical findings. A.R. 25-26.
With
respect to his first basis, the ALJ identified two medical
findings: (1) a lumbar spine x-ray in April 2014, which
showed mild curvature in the lumbar spine, minimal
hypertrophic degenerative changes, no fractures or focal
osseous lesions, no subluxations and only mild facet
arthropathy at ¶ 5 to S1 (A.R. 330); and (2) a lumbar
spine MRI in July 2015, showing no severe spinal canal or
neural foraminal narrowing, normal alignment of the lumbar
spine, normal lumbar vertebrae in appearance and signal
without fracture or focal lesions, and mild degenerative disc
disease at all levels, with the exception of L1-L2, which had
moderate degenerative disc disease (A.R. 383). The ALJ
attempted to ...