Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_16-cv-01401/USCOURTS-casd-3_16-cv-01401-1/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:0405wc Review of HHS Decision (DIWC)

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8 UNITED STATES DISTRICT COURT

9 SOUTHERN DISTRICT OF CALIFORNIA

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11 ALETHEA ELIN FOX, Case No.: 3:16-cv-01401

12 Plaintiff,

ORDER:

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(I) ADOPTING REPORT AND

RECOMMENDATION; 14 NANCY A. BERRYHILL, Acting

Commissioner of Social Security, 15

Defendant.1 (2) GRANTING PLAINTIFF’S

MOTION FOR SUMMARY

JUDGMENT;

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18 (3) DENYING DEFENDANT’S

MOTION FOR SUMMARY

JUDGMENT; and

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(4) REMANDING FOR FURTHER

PROCEEDINGS

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PlaintiffAlethea Elin Fox filed this action seeking judicial review ofthe

Commissioner of Social Security’s denial of her application for disability insurance

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The Court substitutes Nancy A. Berryhill, the Acting Commissioner of Social Security,

for Carolyn W. Colvin, the former Acting Commissioner of Social Security, as Defendant

in this suit. See Fed. R. Civ. P. 25.

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benefits. Plaintifffiled a motion for summary judgment. (ECFNo. 16). Defendant filed

a cross-motion for summary judgment. (ECFNo. 18). The Honorable Andrew G.

Schopler issued a thoughtful and thorough Report and Recommendation recommending

that this Court grant Plaintiffs motion, deny Defendant’s motion, and remand the case

for further proceedings. (ECF No. 27). Defendant filed timely objections to the Report

and Recommendation (ECF No. 28), to which Plaintiffreplied (ECF No. 29).

Where a party files a timely objection to a report and recommendation, the Court

reviews de novo those portions ofthe report or specific proposed findings or

recommendations to which an objection is filed. 28 U.S.C. § 636(b)(1). Having

conducted a de novo review, the Court adopts the Report and Recommendation in full.

BACKGROUND

Plaintiff applied for disability benefits claiming she has been unable to work since

June 1, 2007. The Administrative Law Judge (“ALJ”) found that Plaintiffsuffered from

the severe impairment of affective disorder, but found that she has the residual functional

capacity to perform a full range ofwork at all exertional levels but is limited to

completing simple, routine tasks in a nonpublic setting. The ALJ’s decision gave “great

weight” to the opinions ofthe state agency medical consultants, “some weight” to the

opinion ofthe psychiatric consultative examiner, and “little weight” to the opinions of

Plaintiffs two treating physicians, Dr. Wendy Khentigan and Dr. Clark Smith. (AR 25-

26).

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The issue before the Court is whether the ALJ articulated specific and legitimate

reasons for rejecting the opinion ofDr. Smith. Dr. Smith is one ofPlaintiffs treating

psychiatrists. Plaintiffbegan seeing him on June 10, 2013. By the time ofthe

administrative hearing, the ALJ had Dr. Clark’s treatment records from fourteen visits by

Plaintiff. Those visits occurred on June 10, 2013, July 8, 2013, August 5, 2013,

September 4, 2013, October 2, 2013, October 30, 2013, December 2, 2013, January 2,

2014, February 3, 2014, March 3, 2014, April 2, 2014, April 30, 2014, May 25, 2014, and

June 26, 2014. (See AR Exs. 12F & 13F). As these records reveal, Plaintiffvisited Dr.

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Smith once approximately every thirty days for over a year. During her treatment, she

took a mix ofmedications to treat her mental health and block opiate cravings. These

medications included Subutex and Suboxone for the opiate cravings (AR 476, 487), and

Klonopin, Lamictal, Gabapentin, Wellbutrin, Zoloft, and Saphris to treat her mental

illnesses (AR 475, 480, 487). The records show that Plaintiff had good months and bad

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months. In some months, she reported feeling better with decreased depression and no

anger, mania, or mood swings. (See AR 477, 480). In other visits, she reported feeling

stressed out,” and “scared to go outside.” (See AR

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“really depressed,” “overwhelmed,

478-80).

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On November 8, 2013, Dr. Smith completed a “Mental Impairment Residual

Functional Capacity Questionnaire.” He noted that she has “[decreased]

focus/concentration/ability to concentrate, with scattered & disjointed thought process.”

(AR 487). In a check-box style form, he indicated that Plaintiffhas “pervasive loss of

interest [in] most activities,” “blunt, flat or inappropriate affect,” “mood disturbance,”

“difficulty thinking or concentrating,” “persistent disturbances ofmood or affect,”

“emotional withdrawal or isolation,” “bipolar syndrome with a history of episodic periods

manifested by a full symptomatic picture ofboth manic and depressive syndromes,

currently characterized by either or both syndromes,” “emotional lability,” “easy

distractibility,” and “oddities ofthought, perception, speech or behavior.” (AR 488). He

further noted that she has “moderate” restrictions on her activities of daily living,

“moderate” difficulties in maintaining social functioning, “marked” difficulties in

maintaining concentration, persistence, or pace, and “one or two” episodes of

decompensation within a 12-month period. (AR 497).

In assessing mental abilities needed to do unskilled work, Dr. Smith reported that

Plaintiffwas “unable to meet competitive standards” in eleven out offifteen categories,

such as “understand and remember short and simple instructions,” “maintain attention for

two hour segments,” and “make simple work-related decisions.” (AR 489). In the

remaining four categories—“maintain regular attendance and be punctual within

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customary, usual strict tolerances,” “ask simple questions or request assistance,” “get

along with co-workers or peers without causing them undue distraction or exhibiting

behavioral extremes,” and “be aware ofnormal hazards and take appropriate

precautions,”—Dr. Smith noted that Plaintiffis “seriously limited, but not precluded.”

(Id.) Dr. Smith explained that Plaintiffhas a “scattered & distracted thought process,

unstable mood, [and] inability to tolerate stress.” (Id.) He opined that Plaintiffwould be

expected to miss more than four days ofwork per month because of her impairments.

(AR 492).

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As noted, the ALJ accorded “little weight” to Dr. Smith’s opinion in the “Mental

Impairment Residual Functional Capacity Questionnaire.” In rejecting his opinion, the

ALJ wrote:

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The severity ofthe functional limitations assessed by Dr. Smith are

inconsistent with claimant’s medical records. Dr. Smith’s treatment records

reveal an insignificant treatment history with the claimant and conservative

psychiatric treatment. Additionally, Dr. Smith opines the claimant’s

impairments began in 2003; however, there is no evidence in the record to

support such a conclusion.

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(AR 26). Judge Schopler considered the ALJ’s reasons and found them neither specific

nor legitimate.

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19 STANDARD OF REVIEW

An applicant may seek judicial review of a final agency decision pursuant to 42

U.S.C. §§ 405(g), 1383(c)(3). An ALJ’s decision will be reversed by the reviewing court

only if “it is based upon legal error or is not supported by substantial evidence.” Bayliss

v. Barnhart, All F.3d 1211, 1214 n.l (9th Cir. 2005) (citation omitted). “Substantial

evidence means 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.” Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995). The Court must

consider the record as a whole, weighing both the evidence that supports and detracts

from the ALJ’s conclusion. See Mayes v. Massanari, 276 F.3d 453, 459 (9th Cir. 2001);

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Desrosiers v. Sec ’y of Health & Human Servs., 846 F.2d 573, 576 (9th Cir. 1988). “The

ALJ is responsible for determining credibility, resolving conflicts in medical testimony,

and for resolving ambiguities.” Andrews, 53 F.3d at 1039. Where the evidence is

susceptible to more than one rational interpretation, the ALJ’s decision must be upheld.

Id at 1039-40. The Court may not reverse an ALJ’s decision on account of an error that

is harmless. Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012).

DISCUSSION

The medical opinion of a claimant’s treating physician is given “controlling

weight” ifit is “well-supported by medically acceptable clinical and laboratory diagnostic

techniques and is not inconsistent with the other substantial evidence in [the claimant’s]

case record.” 20 C.F.R. § 404.1527(c)(2). When a treating physician’s opinion is not

controlling, it is weighted accorded to factors such as length ofthe treatment relationship

and the frequency of examination, the nature and extent ofthe treatment relationship,

supportability, consistency with the record, and specialization ofthe physician. Id. §

404.1527(c)(2)-(6).

If a treating or examining physician’s opinion is contradicted by another doctor’s

opinion, as here, an ALJ may only reject it by providing specific and legitimate reasons

that are supported by substantial evidence. Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th

Cir. 2005). “The ALJ can meet this burden by setting out a detailed and thorough

summary ofthe facts and conflicting clinical evidence, stating his interpretation thereof,

and making findings.” Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989) (quoting

Cotton v. Bowen, 799 F.2d 1403, 1408 (9th Cir. 1986)).

In this case, the ALJ set forth four reasons to reject Dr. Smith’s opinion: (1) the

opinion’s inconsistency with Plaintiffs medical records, (2) Plaintiffs insignificant

treatment history, (3) Plaintiffs conservative course oftreatment, and (4) an unsupported

or incorrect statement by Dr. Smith that Plaintiffs impairments began in 2003. For

reasons explained more fully in the Report and Recommendation, the Court concludes

that none ofthe ALJ’s reasons withstand scrutiny. Plaintiffsaw Dr. Smith monthly for

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1 over a year for psychotherapy. Such a history oftreatment is not “insignificant.” Nor

was Plaintiffs treatment “conservative.” In addition to the monthly psychotherapy

appointments, Dr. Smith treated Plaintiffs condition with a number of psychotropic

prescription medications. The ALJ does not point to any evidence to say that more

aggressive treatment was recommended. Without farther explanation why the ALJ

believes Plaintiffs treatment is “insignificant” and “conservative,” these conclusory

assertions fall short ofthe “specific and legitimate reasons” standard.

The ALJ also failed to explain his conclusory finding that Dr. Smith’s opinion is

inconsistent with the overall medical record. See Trevizo v. Berryhill, 862 F.3d 987, 999

(9th Cir. 2017) (rejecting ALJ’s “conclusory determination that the [treating physician’s]

opinion was contradicted where “the ALJ pointed to nothing in... the clinical record that

contradicted the treating physician’s opinion”). The Report and Recommendation notes,

and Defendant’s Objection observes, that Plaintiff exhibited some improvement. But

“[t]he ALJ failed to analyze the periods ofimprovement in the context of [Plaintiffs]

treatment history to ensure that the improvement was not temporary.” Colter v. Berryhill,

985 F. App’x 616, 617 (9th Cir. 2017) (citing Ghanim v. Colvin, 763 F.3d 1154,1164

(9th Cir. 2014) (explaining that treatment records reflecting improvement “must be

viewed in light ofthe overall diagnostic record”)).

Finally, the ALJ rejects the opinion because “there is no evidence in the record to

support” Dr. Smith’s statement that Plaintiffs impairments began in 2003. Even ifthe

ALJ were correct, such a reason is insufficient to justify a complete rejection ofDr.

Smith’s opinion. Nonetheless, as explained further in the Report and Recommendation,

there is evidence in Dr. Smith’s treatment notes that Plaintiff claims disability since 2003.

Accordingly, the Court overrules Defendant’s objections and adopts the Report and

Recommendation in its entirety.

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26 CONCLUSION

The Court ADOPTS the Report and Recommendation (ECF No. 27). Plaintiffs

motion for summary judgment is GRANTED (ECF No. 16) and Defendant’s motion for

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summary judgment is DENIED (ECF No. 18). This case is REMANDED for further

proceedings consistent with the Report and Recommendation.

IT IS SO ORDERED.

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Dated:

HOK. ROTkR T. BENITEZ

United States District Judge

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