Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_16-cv-02854/USCOURTS-casd-3_16-cv-02854-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:0423 Social Security Act (Disability Insurance Benefit Payments)

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UNITED STATES DISTRICT COURT 

SOUTHERN DISTRICT OF CALIFORNIA 

Jennifer Michelle CLARK, 

Plaintiff,

v. 

Nancy A. BERRYHILL, Acting 

Commissioner of Social Security, 

Defendant.

 Case No.: 16-cv-2854-BEN-AGS 

REPORT AND RECOMMENDATION 

ON SUMMARY JUDGMENT 

MOTIONS (ECF Nos. 26 & 27) 

This Social Security case concerns the treating physician rule and the procedure for 

assessing a treating doctor’s opinion that does not warrant “controlling weight.” 

BACKGROUND 

 After a disability hearing, the Administrative Law Judge found that plaintiff Jennifer 

Clark had three severe physical impairments, a severe learning disorder, and non-severe 

anxiety and depression. (AR 15-16.) Four mental-health experts—two examining 

psychologists and two agency consultants—concluded that Clark could work. (AR 21, 23.) 

Yet Clark’s own treating psychiatrist, Deborah Birnbaum, D.O., believed that Clark’s 

mental impairments made it “unlikely” that she can “maintain stability during a workday.” 

(AR 23.) In denying Clark disability benefits, the ALJ favored the opinions of the four 

non-treating experts over Dr. Birnbaum’s opinion. 

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On appeal, Clark argues that Dr. Birnbaum’s opinion deserved controlling weight. 

In the alternative, she argues that the ALJ failed to consider the required regulatory factors 

in weighing Dr. Birnbaum’s opinion. 

DISCUSSION 

A. Standard of Review 

 This Court will only set aside the denial of Social Security benefits when the ALJ’s 

decision is “based on legal error or not supported by substantial evidence in the record.” 

Trevizo v. Berryhill, 871 F.3d 664, 674 (9th Cir. 2017) (citation omitted). “Substantial 

evidence means more than a mere scintilla, but less than a preponderance. It means such 

relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” 

Id. (citation omitted). Even when “the evidence is susceptible to more than one rational 

interpretation, we must uphold the ALJ’s findings if they are supported by inferences 

reasonably drawn from the record.” Rounds v. Comm’r Soc. Sec. Admin., 807 F.3d 996, 

1002 (9th Cir. 2015) (citation omitted). The “substantial evidence” standard is even “more 

deferential [to the agency] than ‘clearly erroneous.’” Stern v. Marshall, 564 U.S. 462, 515 

(2011) (citation omitted); see also Dickinson v. Zurko, 527 U.S. 150, 152-53 (1999) 

(explaining that the “clearly erroneous” standard allows “somewhat closer judicial review” 

than the more deferential “substantial evidence” standard used for evaluating agency 

decisions (citations omitted)). 

B. Treating Physician Rule 

“A treating physician’s opinion is generally due ‘controlling weight.’” O’Neal v. 

Astrue, 391 F. App’x 614, 616 (9th Cir. 2010) (citation omitted). If a treating doctor’s 

opinion is contradicted, “an ALJ may only reject it by providing specific and legitimate 

reasons that are supported by substantial evidence.” Trevizo, 871 F.3d at 675 (citation 

omitted). This standard is satisfied when the ALJ relies on the contrary opinion of an 

examining physician that is based on “objective medical tests that the treating physician 

has not herself considered.” Orn v. Astrue, 495 F.3d 625, 632 (9th Cir. 2007) (citation 

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omitted); see also Andrews v. Shalala, 53 F.3d 1035, 1041 (9th Cir. 1995); Magallanes v. 

Bowen, 881 F.2d 747, 751 (9th Cir. 1989). 

1. Conflicting Medical Opinions Based on Independent Clinical Findings

Although Clark’s treating psychiatrist believed she was “unlikely . . . to maintain 

stability during a workday,” the ALJ noted that four medical experts disagreed. (See AR 23, 

454.) Two of those experts—psychologists Ted Shore and Dan Whitehead—personally 

tested Clark, including conducting intelligence and mental-status examinations. (AR 21, 

248-54, 458-63.) In particular, the ALJ gave “great weight” to Dr. Shore’s opinion because 

he is “an expert in the claimant’s impairment and based his opinion on a thorough 

evaluation of the claimant.” (AR 23.) The treating doctor could not have considered 

Dr. Shore’s evaluation, because it took place after she gave her contrary opinion. (AR 454, 

457-58.) By “noting” the “conflicting medical opinions in the record, which themselves 

were based on independent clinical findings,” the ALJ satisfied the “specific and legitimate 

reasons” standard. Brumfield v. Astrue, 281 F. App’x 681, 683 (9th Cir. 2008) (citation 

omitted); see also Flores v. Comm’r of Soc. Sec., 237 F. App’x 251, 252 (9th Cir. 2007). 

2. Mental Status Examinations

Apart from the medical-opinion discussion, which was by itself sufficient 

justification to disregard the treating doctor’s opinion, the ALJ also pointed out that Clark 

showed only “mild limitations on mental status examinations.” (AR 23.) If a treating 

doctor’s opinion is “inadequately supported by clinical findings,” the ALJ may reject it. 

Gopher v. Comm’r of Soc. Sec., __ F. Supp. 3d __, No. 1:16-cv-03100-MKD, 2017 WL 

5135360, at *12 (E.D. Wash. Sept. 25, 2017). 

Clark argues, however, that this is not a specific and legitimate reason for 

discounting Dr. Birnbaum’s opinion, because: (1) the ALJ’s analysis is conclusory, and 

(2) that conclusion isn’t supported by the evidence, which the ALJ either mischaracterizes 

or cherry-picks. The “ALJ must do more than offer his conclusions.” Orn, 495 F.3d at 632 

(citation omitted). And the ALJ must not “selectively focus[]” on aspects of the medical 

record “which tend to suggest non-disability,” Edlund v. Massanari, 253 F.3d 1152, 1159 

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(9th Cir. 2001), nor support findings with an “inaccurate characterization of the evidence,” 

Regennitter v. Comm’r of Soc. Sec. Admin., 166 F.3d 1294, 1297 (9th Cir. 1999). 

But the ALJ committed none of those sins. The ALJ accurately summarized the 

relevant medical evidence and properly focused on the mental status examinations. There 

are at least 36 of those exams in the record,1

 and they make up the majority of Clark’s 

mental-health evidence, especially with regard to clinical findings. (See generally AR 248-

558.) For example, the ALJ offered this balanced summary of the

mental-status-examination results within the eligibility period, noting all of Clark’s areas 

of difficulty: 

With regard to concentration, persistence or pace, the claimant has moderate 

difficulties. The claimant generally displayed impaired insight and judgment 

on examination. Further, she showed signs of mildly to moderately decreased 

intellect, concentration, and memory. However, her thought process was 

normal, she was generally able to follow the conversation at her appointments, 

and she often showed no difficulty with concentration or memory at her 

routine appointments, suggesting her limitations were at most moderate. 

(AR 18 (citations omitted).) Later, in discussing these same examinations, the ALJ pointed 

out that “she often displayed mildly impaired insight and judgment, and rarely 

demonstrated impaired language, thought content, intellect, memory, concentration, and 

attention.” (AR 20 (citation omitted).) Finally, the ALJ explicitly considered Clark’s 

Global Assessment of Functioning scores, which were included in many of the mentalstatus results, and which ranged “from 48, suggestive of serious symptoms, to 75, 

suggestive of transient symptoms.” (AR 23-24.) 

 Because the ALJ’s examination-results summary was detailed and thorough, the 

only question is whether his conclusion about the data was rational. Clark’s mental-status 

results ranged from nearly spotless (see, e.g., AR 274, 282, 354, 372) to more impaired, 

                                               

1

 Nine of the mental status examinations fell outside the disability-eligibility period 

(see generally AR 419-531), leaving 27 exams within that timeframe. 

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including tangential thoughts, flat affect, depression, and anxiety (see, e.g., AR 332, 352). 

Once she even had slurred speech. (AR 332; cf. AR 524 (another slurred-speech result, but 

outside the eligibility period).) As for her GAF scores, during the relevant timeframe she 

had five in the “transient” (80-71) or “mild” range (70-61), two in the “moderate” range 

(60-51), and three in the “serious” range (50-41); she had no scores in the top two GAF 

decile ranges (superior or good) nor any in the bottom four ranges. See Keyes-Zachary v. 

Astrue, 695 F.3d 1156, 1162 n.1 (10th Cir. 2012) (defining GAF ranges); (AR 253, 262, 

272, 339, 346, 374, 537, 541, 548, 551 (Clark’s GAF scores)). 

Clark may quibble with the ALJ’s conclusion that this amounts to only mild 

limitations, but it was a rational reading of the record. Thus, Clark’s mental-status results 

were a specific and legitimate reason for discounting her treating doctor’s opinion. 

3. Other Reasoning

Finally, Clark assails the ALJ’s finding that her treating doctor’s opinion “is 

inconsistent with the claimant’s relatively normal activities of daily living.” (See AR 23.) 

Because the preceding analysis already fully justifies the ALJ’s decision, any error as to 

this final ground is harmless and the Court need not address it. See Rounds, 807 F.3d at 

1007 (“[T]he error was harmless because it was ‘inconsequential to the ultimate 

nondisability determination.’” (citation omitted)); Minnick v. Berryhill, Case No. 

C17-93 BAT, 2017 WL 4174330, at *3 (W.D. Wash. Sept. 21, 2017) (“[E]ven if some of 

the other reasons are invalid, because the ALJ gave one valid reason supported by 

substantial evidence, any error the ALJ might have made is harmless.” (citation omitted)). 

C. Regulatory Factors 

Even if the treating doctor’s opinion did not merit “controlling weight,” Clark 

contends the ALJ erred by not using the correct procedure to determine what lesser weight 

to give it. Defendant did not respond to this argument. “When a treating physician’s 

opinion is not controlling, it is weighted according to [regulatory] factors such as the length 

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

treatment relationship, supportability, consistency with the record, and specialization of the 

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physician.” Trevizo, 871 F.3d at 675 (citing 20 C.F.R. § 404.1527(c)(2)-(6)). “Trevizo does 

not demand a full-blown written analysis of all the regulatory factors; it merely requires 

some indication that the ALJ considered them.” Hoffman v. Berryhill, Case No. 

16-cv-1976-JM-AGS, 2017 WL 3641881, at *4 (S.D. Cal. Aug. 24, 2017).2

In this case, as in Trevizo, there is no indication that the ALJ considered certain 

mandatory factors, such as “the length of the treating relationship, the frequency of 

examination, [or] the nature and extent of the treatment relationship.” Trevizo, 871 F.3d at 

676 (citation omitted). From the medical record, it appears that Dr. Birnbaum treated Clark 

from September 2013 to November 2014. (See AR 406-07, 419-20, 472-73, 557-58.) But 

the ALJ never mentions this. The closest the ALJ gets is discussing relevant dates 

throughout Clark’s psychiatric treatment history, noting that Clark “presented for mental 

health treatment in April 2012, indicating that she saw a therapist briefly in 2011,” and that 

she “received therapy and psychiatric treatment approximately monthly through 

November 2014.” (AR 20.) Nothing in the ALJ’s decision suggests that he considered the 

length, frequency, or nature of Clark’s specific relationship with Dr. Birnbaum. “This 

failure alone constitutes reversible legal error.” Trevizo, 871 F.3d at 676; see also Laborin 

v. Berryhill, 692 F. App’x 959, 961 (9th Cir. 2017) (“The ALJ did not evaluate Dr. Tran’s 

opinion in light of the factors set forth in 20 C.F.R. § 404.1527(c). This failure by the ALJ 

is reversible legal error.” (citation omitted)). 

D. Harmless Error 

While not contesting the regulatory-factor error, defendant argues that this Court 

should uphold the ALJ’s final determination. (See ECF No. 27-1, at 8.) “The burden is on 

the party claiming error to demonstrate not only the error, but also that it affected his 

‘substantial rights,’ which is to say, not merely his procedural rights.” Ludwig v. Astrue, 

                                               

2 Hoffman analyzed an earlier version of the Trevizo decision, but the relevant 

language is the same on this issue in both Trevizo opinions. Compare Trevizo v. Berryhill, 

862 F.3d 987, 997-98 (9th Cir. 2017), with 871 F.3d at 675-76. 

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681 F.3d 1047, 1054 (9th Cir. 2012). Among other factors, the harmless-error analysis 

turns on: “the likelihood that the result would have been different, an awareness of what 

body . . . has the authority to reach that result, a consideration of the error’s likely effects 

on the perceived fairness, integrity, or public reputation of judicial proceedings,” and 

humility about generalizing “too broadly about particular kinds of errors.” Id. (citation 

omitted). 

The procedural error here caused no prejudice. According to the record, Clark saw 

psychiatrist Dr. Birnbaum 12 times in 14 months for mental status examinations, treatment, 

and medical prescriptions. (See AR 472-75, 480-81, 496-97, 507-08, 512-13, 530-31, 536-

37, 540-41, 547-48, 550-51, 557-58; see also AR 406-07, 419-22, 427-28, 443-44 

(duplicate reports).) The ALJ should have considered these facts before giving 

Dr. Birnbaum’s opinion “little weight.” (See AR 23.) But it wouldn’t change the outcome. 

These details merely add a feather to Clark’s side of the scales of justice, not nearly enough 

to overcome the pile of bricks on the other side: four contrary opinions (especially 

Dr. Shore’s assessment, which merited “great weight”) and years of mental status 

examinations showing only “mild limitations.” (See id.) Furthermore, the ALJ twice 

asserted that he “considered opinion evidence in accordance with the requirements of 

20 C.F.R. § 404.1527” (AR 18, 22); he simply didn’t memorialize all the relevant facts 

considered. But since the ALJ ruled two years before Trevizo clarified this requirement, 

the ALJ’s error should not undermine public confidence in social security proceedings. 

Thus, Clark has not carried her burden of proving that the error affected her substantial 

rights. 

CONCLUSION 

After properly justifying his decision not to accord the treating doctor’s opinion 

“controlling weight,” the ALJ erred by giving it “little weight” without considering all the 

appropriate regulatory factors. But this error did not affect Clark’s substantial rights and so 

is harmless. Thus, the Court recommends that plaintiff’s summary judgment motion (ECF 

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No. 26) be denied, that defendant’s cross-motion for summary judgment (ECF No. 27) be 

granted, and that the denial of disability benefits be affirmed. 

The parties must file any objections to this report by February 12, 2018. See 

28 U.S.C. § 636(b)(1). A party may respond to any such objection within 14 days of being 

served with it. See Fed. R. Civ. P. 72(b)(2). 

Dated: January 29, 2018 

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