Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_12-cv-00188/USCOURTS-azd-4_12-cv-00188-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

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WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

M.B. a minor (by the mother, Deborah 

Beymer), 

Plaintiff, 

v. 

Carolyn W. Colvin, Acting Commissioner 

of Social Security, 

Defendant.

No. CV-12-00188-TUC-BPV

ORDER 

 Plaintiff’s mother filed this action for review of the final decision of the 

Commissioner of Social Security pursuant to 42 U.S.C. § 405(g). The United States 

Magistrate Judge presides over this case pursuant to 28 U.S.C. § 636 (c) and Fed.R.Civ.P. 

73, having received the written consent of both parties. 

I. PROCEDURAL HISTORY

Plaintiff’s mother protectively filed an application for Supplemental Security 

Income (“SSI”) on January 11, 2008, alleging an onset of disability beginning January 

11, 2008 due to mental problems: learning difficulties; behavioral impairments; difficulty 

taking care of personal needs; and difficulty paying attention and sticking to a task. 

Transcript/Administrative Record (“Tr.”) 106-12, 113, 117-128. The application was 

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denied initially and on reconsideration. Tr. 69-71, 72-74. A hearing before an 

Administrative Law Judge (“ALJ”) was held on January 22, 2010. Tr. 57-68. The ALJ 

issued a decision on June 4, 2010, finding Plaintiff, 9 years old on the date of the ALJ’s 

decision, had severe impairments of attention deficit hyperactivity disorder (ADHD; 

learning disorder; and explosive disorder, but was not disabled within the meaning of the 

Social Security Act. Tr. 18-38. This decision became the Commissioner’s final decision 

when the Appeals Council denied review. Tr. 1-4. 

Plaintiff’s mother then commenced this action for judicial review pursuant to 42 

U.S.C. § 405(g). (Doc. 1) For reasons that follow, the Court reverses the decision of the 

Commissioner and remands for an immediate award of benefits.

II. STANDARD OF REVIEW 

A person under the age of 18 will be considered disabled and eligible for 

Supplemental Security Income (SSI) if he has a “medically determinable physical or 

mental impairment, which results in marked and severe functional limitations, and which 

can be expected to result in death or which has lasted or can be expected to last for a 

continuous period of not less than 12 months.” 42 U.S.C. § 1382c(a)(3)(C)(i). The 

Commissioner employs a three-step sequential process to evaluate SSI claims for minors. 

First, if the claimant is engaged in substantial gainful activity, he is not disabled. 20 

C.F.R. § 416.924(b). Second, if the claimant does not have a medically determinable 

severe impairment(s), in that the impairment does not cause more than minimal 

functional limitations, he is not disabled. 20 C.F.R. § 426.924(c). Third, if the claimant’s 

impairment does not meet, medically equal, or functionally equal an impairment in the 

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listings, he is not disabled. 20 C.F.R. § 924(d). There are six areas the Commissioner 

assesses for functional equivalence: acquiring and using information; attending and 

completing tasks; interacting and relating with others; moving about and manipulating 

objects; caring for yourself; and health and physical wellbeing. 20 C.F.R. § 416.926a(b). 

The findings of the Commissioner are meant to be conclusive if supported by 

substantial evidence. 42 U.S.C. § 405(g). Substantial evidence is “more than a mere 

scintilla but less than a preponderance.” Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 

1999) (quoting Matney v. Sullivan, 981 F.2d 1016, 1018 (9th Cir. 1992)). The court may 

overturn the decision to deny benefits only “when the ALJ’s findings are based on legal 

error or are not supported by substantial evidence in the record as a whole.” Aukland v. 

Massanari, 257 F.3d 1033, 1035 (9th Cir. 2001). This is so because the ALJ “and not the 

reviewing court must resolve conflicts in the evidence, and if the evidence can support 

either outcome, the court may not substitute its judgment for that of the ALJ.” Matney,

981 F.2d at 1019 (quoting Richardson v. Perales, 402 U.S. 389, 400 (1971)); Batson v. 

Comm’r of Soc. Sec. Admin., 359 F.3d 1190, 1198 (9th Cir. 2004). The Commissioner’s 

decision, however, “cannot be affirmed simply by isolating a specific quantum of 

supporting evidence.” Sousa v. Callahan, 143 F.3d 1240, 1243 (9th Cir. 1998) (citing 

Hammock v. Bowen, 879 F.2d 498, 501 (9th Cir. 1989)). Reviewing courts must consider 

the evidence that supports as well as detracts from the Commissioner’s conclusion. Day 

v. Weinberger, 522 F.2d 1154, 1156 (9th Cir. 1975). 

III. DISCUSSION 

Plaintiff argues that the ALJ failed to give controlling weight to his treating 

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psychiatrist’s opinion. In May, 2006, Plaintiff underwent a psychiatric intake evaluation 

with psychiatric nurse practitioner Karen Van Wie of Providence Service Corp., because 

of worsening temper tantrums and aggressive behavior towards others. Tr. 355. Ms. Van 

Wie assessed generalized anxiety disorder and post-traumatic stress disorder, as well as 

victim of neglect and rule out attention deficit hyperactivity disorder (ADHD). Ms. Van 

Wie assigned Plaintiff a GAF score of 45 to 50.1

 She prescribed medication and 

recommended an evaluation to rule out dyslexia, learning disorder, and color blindness. 

Tr. 359. 

In November 2006, Plaintiff’s care was transferred to treating psychiatrist Michael 

Mardis, M.D., at Providence, who conducted an initial exam of Plaintiff and diagnosed 

him with ADHD, Intermittent Explosive Disorder, and Anxiety Disorder, and considered 

a diagnosis of Pervasive Developmental Disorder Syndrome. Tr. 393. The administrative 

record contains medical records from Dr. Mardis dated from the initial evaluation 

through October 2009. Tr. 345-47, 361-64, 367-80, 383-86, 388-89, 391-95, 407-21, 423, 

 

1

 GAF Scores range from 1-100. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, (4th ed.) (DSM-IV), at 32. “A GAF score is a 

rough estimate of an individual's psychological, social, and occupational functioning used to reflect the individual's need for treatment.” Vargas v. Lambert, 159 F .3d 1161, 1164 n. 

2 (9th Cir. 1998). In arriving at a GAF Score, the clinician considers psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. DSMIV, at 34. In children, a GAF, or Children’s Global Assessment Scale score of 41-50 

indicates: 

Moderate degree of interference in functioning in most social areas or 

severe impairment of functioning in one area, such as might result from, for 

example, suicidal preoccupations and ruminations, school refusal and other 

forms of anxiety, obsessive rituals, major conversion symptoms, frequent 

anxiety attacks, poor to inappropriate social skills, frequent episodes of 

aggressive or other antisocial behaviour with some preservation of 

meaningful social relationships. 

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454-59, 462, 482-84. During the course of treatment, Dr. Mardis prescribed numerous 

medications for Plaintiff’s various symptoms, summarized in Dr. Mardis’s psychiatric 

update containing a detailed medication report and description of each medication’s 

efficacy, dated October 30, 2009.2

 Tr. 482. In October 2009, Dr. Mardis diagnosed 

Plaintiff with Asperger’s disorder, ADHD not otherwise specified, mood disorder not 

otherwise specified, generalized anxiety disorder, and multiple learning disorders, and 

noted: 

[Plaintiff] has shown some improvement with his ADHD symptoms with 

medications, however he continues to have difficulties in that area. Some of 

the ADHD symptoms may actually be related to anxiety. The aggression 

has been a continual problem, and has shown some improvement with 

medications. Anxiety has not improved at all in the past few years. Even 

with the recent addition of an anti-anxiety agent. Social skills have shown 

some improvement with time, as he now has one good friend that he gets 

together with fairly often and expresses a desire to be with. He has not 

required any psychiatric hospitalizations or residential treatment 

placements. 

Tr. 482, 484. Dr. Mardis completed a Childhood Disability Evaluation Form and 

opined that Plaintiff had marked limitations in acquiring and using information, with 

“some difficulties with learning disabilities – with reading and math, as well as writing”; 

marked limitations with attending and completing tasks, with “significant difficulties 

with sustaining his attention in tasks, and in focusing on relevant stimuli, leading to 

difficulties in school and poor follow through at home”’ extreme limitations in interacting 

and relating with others, with “frequent episodes of aggression to family members, 

 

2

 These medications included, in various dosages and combinations: Vyvanse; Dexedrine; Risperdal; BuSpar; Strattera; Metadate CD; Adderall; Prozac; Tenex; Abilify; and Lithium Carbonate. Tr. 483. At the time of the report, Plaintiff’s medication regimen included Vyvanse, Dexedrine, Risperdal and BuSpar. Tr. 482. 

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leading to extreme disruption at home”; marked limitations in health and physical wellbeing, “due to aggressive incidents, anger, and significant anxiety over timing of events, 

contamination fears.” Tr. 485-86. 

The ALJ acknowledged Dr. Mardis as Plaintiff’s treating psychiatrist but gave Dr. 

Mardis’s opinion minimal weight, finding the opinion and evaluation over-restrictive 

based on Dr. Mardis’s own treatment notes and other evidence of record. Tr. 26. The ALJ 

further discounted Dr. Mardis’s opinion because of the possibility that Dr. Mardis 

submitted his opinion in an effort to assist Plaintiff because Dr. Mardis sympathized with 

the Plaintiff. Tr. 26. The ALJ gave great weight to the opinions of reviewing State 

Agency psychologist Jocelyn Fuller, Ph.D., and the other State Agency reviewing 

physicians who affirmed Dr. Fuller’s assessment.3

 Tr. 26. Reviewing psychologist Dr. 

Fuller’s opinion contradicted Dr. Mardis’s opinion. Dr. Fuller found no limitation in 

health and physical well-being, and less than marked limitations in all other functional 

equivalence categories. Tr. 447-452. Plaintiff was examined by State Agency 

psychologist and speech pathologist Judith Kroese, Ph.D., who concluded that, with 

regard to intellectual functioning, “his overall score was within the Borderline range” and 

his “verbal intellectual functioning was within the Low Average range as well as his 

working memory.” Tr. 436. Plaintiff’s speed of processing and nonverbal intellectual 

functioning were also within the Borderline range. Id. His scores in the area of math 

 

3

 Because the State Agency reviewing psychologist and physician who reviewed 

Dr. Fuller’s assessment did not indicate what records they reviewed and failed to provide any explanation for the conclusions they reached, (Tr. 468-76) their assessments carry no additional weight and merit no further discussion in this order. 

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calculation and writing were significantly lower than would be expected for his overall 

level of intellectual functioning, and his behavior during the one-to-one evaluation was 

consistent with a diagnosis of ADHD. Id. 

Where a treating doctor’s ultimate conclusion is contradicted, as in this case by 

Dr. Fuller, it may be rejected only for specific and legitimate reasons that are supported 

by substantial evidence in the record. Carmickle v. Comm’r Soc.Sec. Admin., 533 F.3d 

1155, 1164 (9th Cir. 2008)(citing Murray v. Heckler, 722 F.2d 499, 502 (9th Cir. 1983)); 

see also Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir. 1988) (detailed, reasoned, and 

legitimate rationales required to reject treating doctor’s ultimate conclusions). When 

rejecting the opinion of a treating physician, the ALJ can meet this "'burden by setting out 

a detailed and thorough summary of the facts and conflicting clinical evidence, stating his 

interpretation thereof, and making findings.'" Tommasetti v. Astrue, 533 F.3d 1035, 1041 

(9th Cir. 2008)(quoting Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989)). The 

Social Security Administration has explained that an ALJ's finding that a treating source 

medical opinion is not well-supported by medically acceptable evidence or is inconsistent 

with substantial evidence in the record means only that the opinion is not entitled to 

controlling weight, not that the opinion should be rejected. Orn v. Astrue, 495 F.3d 625, 

632 (9th Cir. 2007) (citing 20 C.F.R. § 404.1527). Treating source medical opinions are 

still entitled to deference and, “[i]n many cases, will be entitled to the greatest weight and 

should be adopted, even if it does not meet the test for controlling weight." Orn, 495 F.3d 

at 632; see also Murray,722 F.2d at 502 ("If the ALJ wishes to disregard the opinion of 

the treating physician, he or she must make findings setting forth specific, legitimate 

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reasons for doing so that are based on substantial evidence in the record.") 

As a non-examining physician, Dr. Fuller’s opinion, cannot, by itself “constitute 

substantial evidence that justifies the rejection of the opinion of either an examining 

physician or a treating physician.” Lester v. Chater, 81 F.3d 821, 831 (9th Cir. 1995). 

Further, while it is not clear what medical evidence of record Dr. Fuller reviewed, Dr. 

Fuller’s notes indicate that, if she in fact reviewed the entirety of the record, she ignored 

or failed to discuss in any detail treatment notes by Plaintiff’s primary mental health 

provider Dr. Mardis. (See Tr. 449-50.) 

The ALJ’s finding that “Dr. Mardis’s opinion and evaluation of the claimant’s 

limitations in each domain is over-restrictive based on Dr. Mardis’s own treatment notes 

and other evidence of record” (Tr. 26) does not set forth the specific detail necessary, nor 

does it achieve the level of specificity required to reject a treating physician’s conclusion. 

See Embrey, 849 at 421-422 (“To say that medical opinions are not supported by 

sufficient objective findings or are contrary to the preponderant conclusions mandated by 

the objective findings does not achieve the level of specificity our prior cases have 

required... .”) The ALJ states that, “[a]s discussed more fully below, Dr. Mardis reports 

on a number of occasions that the claimant’s behavior at school has improved, and that 

the medication is helping the claimant’s symptoms.” Tr. 26 (emphasis added). The ALJ, 

however, does not discuss Dr. Mardis’s report more fully in the rest of the opinion, and, 

in fact, does not discuss Dr. Mardis’s report, or Dr. Mardis’s treatment notes consisting of 

nearly three years of treatment, in any more detail at all. See Tr. 26-34. While the 

Commissioner attempts to substantiate the ALJ’s conclusion by referring to Dr. Mardis’s 

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treatment notes, in opposition to Plaintiff’s opening brief, (see Doc. 20, at 15-17), this 

Court reviews only the reasons provided by the ALJ in the disability determination and 

may not affirm the ALJ on a ground upon which he did not rely. Orn, 495 F.3d 625 at 

630 (citing Connett v. Barnhart, 340 F.3d 871, 874 (9th Cir. 2003)). See Pinto v. 

Massanari, 249 F.3d 840, 847-48 (9th Cir. 2001)(the district court may not affirm the 

ALJ's decision “on a ground not invoked by the Commissioner in denying the benefits 

originally”); Accord Varney v. Sec’y Health & Human Serv., 859 F.2d 1396, 1399 (9th

Cir. 1988) (“there may exist valid grounds on which to discredit a claimant's pain 

testimony.... But if grounds for such a finding exist, it is both reasonable and desirable to 

require the ALJ to articulate them in the original decision.”) (internal quotes and citation 

omitted). For example, Dr. Mardis’s opined that Plaintiff had marked limitations in health 

and physical well-being. Tr. 486. Examining consultative physician Dr. Kroese opined 

that Plaintiff’s difficulties with attention, hyperactivity, and aggression had greatly 

interfered with his well-being. Tr. 438. Despite these two physician’s opinions, the ALJ 

concluded, with no reference to the record at all, that Plaintiff had no limitations in health 

and physical well-being. Tr. 34. The ALJ’s errs by rejecting both the treating and 

examining physicians’ opinions without stating a reason, much less a specific and 

legitimate reason for doing so, based on substantial evidence in the record. 

Finally, the ALJ errs by speculating, without introducing evidence of any actual 

improprieties, that Dr. Mardis fabricated his opinion in order to assist Plaintiff to collect 

disability benefits. Lester, 81 F.3d at 832. 

IV. CONCLUSION 

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The court has the discretion to make a determination to remand for further 

proceedings or to simply award benefits. Lewin v. Schweiker, 654 F.2d 631, 635 (9th Cir. 

1981). At a minimum, the failure to make adequate findings necessitates a remand for a 

redetermination of fault. Id. “If additional proceedings can remedy defects in the original 

administrative proceedings, a social security case should be remanded.” Id. 

Plaintiff requests that the Court award benefits. Defendant requests that the Court 

deny relief or, if the Court concludes there was reversible error, remand for further 

proceedings. A federal court may affirm, modify, reverse, or remand a social security 

case. 42 U.S.C. § 405(g). “'[T]he decision whether to remand the case for additional 

evidence or simply to award benefits is within the discretion of the court.' " Rodriguez v. 

Bowen, 876 F.2d 759, 763 (9th Cir. 1989) (quoting Stone v. Heckler, 761 F.2d 530, 533 

(9th Cir. 1985)). "Remand for further administrative proceedings is appropriate if 

enhancement of the record would be useful." Benecke v. Barnhart, 379 F.3d 587, 593 (9th

Cir. 2004)(citing Harman v. Apfel, 211 F.3d 1172, 1178 (9th Cir. 2000)). Conversely, 

remand for an award of benefits is appropriate where: 

(1) the ALJ failed to provide legally sufficient reasons for rejecting the 

evidence; (2) there are no outstanding issues that must be resolved before a 

determination of disability can be made; and (3) it is clear from the record 

that the ALJ would be required to find the claimant disabled were such 

evidence credited. 

Id. (citations omitted) Where the test is met, "we will not remand solely to allow the ALJ 

to make specific findings ... Rather we take the relevant testimony to be established as 

true and remand for an award of benefits." Benecke, 379 F.3d at 593 (citations omitted); 

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see also Lester, 81 F.3d at 834 (same). 

“Where the Commissioner fails to provide adequate reasons for rejecting the 

opinion of a treating or examining physician, we credit that opinion ‘as a matter of law.’” 

Lester, 81 F.3d at 834 (quoting Hammock, 879 F.2d at 502); Benecke, 379 F.3d at 594 

(“Because the ALJ failed to provide legally sufficient reasons for rejecting Benecke's 

testimony and her treating physicians' opinions, we credit the evidence as true.”). The 

ALJ failed to provide legally sufficient reasons to reject Dr. Mardis’s opinion. Dr. 

Mardis’s opinion established marked limitations in three functional domains, and extreme 

limitations in one functional domain of the six areas the Commissioner assesses for 

functional equivalence. Adopting Dr. Mardis’s opinion as true results in the conclusion 

that Plaintiff’s impairment functionally equaled the listings. Under these circumstances, it 

is evident from the record that no outstanding issues must be resolved, and if Dr. 

Mardis’s opinion is credited as true, the ALJ would be required to find the Plaintiff 

disabled. See Benecke, 379 F.3d at 593-595 (remanding for an award of benefits where 

no outstanding issues remain and ALJ would be required to find claimant disabled if 

evidence is credited); Regennitter v. Comm’r Soc. Sec. Admin., 166 F.3d 1294, 1300 (9th

Cir. 1999)(where the court "conclude[s] that ... a doctor's opinion should have been 

credited and, if credited, would have led to a finding of eligibility, we may order the 

payment of benefits."); Lester, 81 F.3d at 834 (remanding for payment of benefits 

because, after crediting doctor's opinion as true, inter alia, "the evidence ... demonstrates 

that ..." the plaintiff was disabled.); 

VI. Conclusion

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IT IS THEREFORE ORDERED that the Commissioner’s final decision in this 

matter is REVERSED. 

IT IS FURTHER ORDERED that Plaintiff’s claim for benefits is REMANDED to 

the Commissioner of Social Security Administration for an immediate payment of 

benefits. 

The Clerk of Court is instructed to enter judgment accordingly and close this case. 

Dated this 7th day of August, 2013. 

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