Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_16-cv-01401/USCOURTS-casd-3_16-cv-01401-0/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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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

Alethea Elin Fox,

Plaintiff,

v.

Nancy A. Berryhill,

Defendant.

Case No.: 16-cv-1401-BEN-AGS

REPORT AND RECOMMENDATION 

ON SUMMARY JUDGMENT 

MOTIONS

This Social Security case turns on the treating physician rule, which generally 

accords a treating doctor’s opinion “controlling weight.” The two treating physicians here 

believe that plaintiff’s mental health conditions render her disabled. The issue is whether 

the Administrative Law Judge supplied sufficient reasons to reject those opinions.

BACKGROUND

In 2012, Alethea Elin Fox applied for disability insurance benefits based on a variety 

of mental health problems. State agency medical consultants denied her application twice 

the next year, on initial review and reconsideration. (AR 16.) Those consultants analyzed

records from treating psychiatrist Dr. Wendy Khentigan, but none from treating 

psychiatrist Dr. Clark Smith, who had just begun seeing Fox. (AR 127, 131, 472-80.) By 

Fox’s 2014 hearing, however, the Administrative Law Judge had the entire treatment 

history, including a year’s worth of Dr. Smith’s treatment notes. The ALJ ultimately found 

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that Fox suffered from a severe mental health impairment known as affective disorder, but 

that it was not disabling. (AR 18, 29.) In so ruling, he gave “great weight” to the 2013 

analysis of the state agency medical consultants and “some weight” to a consulting 

psychiatric examiner’s opinion—all of whom found her able to work. (AR 25-26.) On the 

other hand, he assigned “little weight” to the opinions of Fox’s treating psychiatrists, who 

both believed her mental health issues were serious enough to force her to miss more than 

four days of work per month. (AR 26, 486, 492.)

Fox appeals, claiming that the ALJ improperly disregarded her two treating doctors’ 

opinions as well as her own testimony.

DISCUSSION

A. Treating Physician Rule

If a treating physician’s opinion is well-supported and consistent with the rest of the 

record, it must be given “controlling weight.” 20 C.F.R. § 404.1527(c)(2). When the 

treating physician’s opinion is contradicted by another doctor, as here, “an ALJ may only 

reject it by providing specific and legitimate reasons that are supported by substantial 

evidence.” Trevizo v. Berryhill, ___ F.3d ___, No. 15-16277, 2017 WL 2925434, at *7 

(9th Cir. July 10, 2017) (citation omitted). “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.” Id. (citations omitted).

The Court first addresses the reasons the ALJ rejected Dr. Smith’s treating-physician 

opinion, which are set forth below.

1. Inconsistent with Medical Records

The ALJ gave “little weight” to Dr. Smith’s opinion, in part, because he found it 

“inconsistent with claimant’s medical records.” (AR 26.) But the ALJ provides no analysis 

for this conclusion whatsoever. He certainly failed to set out any “conflicting clinical 

evidence, stat[e] his interpretation thereof, and mak[e] findings.” Trevizo, 2017 WL 

2925434, at *7 (citations omitted); see also id. at *8 (rejecting ALJ’s “conclusory 

determination that [the treating doctor’s] opinion was contradicted” where “the ALJ 

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pointed to nothing . . . in the clinical record that contradicted the treating physician’s 

opinion”).

Ignoring this fatal oversight for the moment, this Court has scoured the clinical 

history and identified instances when Fox may have been well enough to work. Indeed, 

defendant argues that “Dr. Smith’s own treatment notes showed improvement and normal 

findings inconsistent with his opinion,” including notations of improved function on at 

least five separate occasions during one year. (ECF No. 18-1, at 6-7.) But the Ninth Circuit 

has repeatedly warned that sporadic stretches of progress do not necessarily undermine a 

mental-health disability finding, as psychiatric symptoms naturally wax and wane. See, 

e.g., Garrison v. Colvin, 759 F.3d 995, 1017 (9th Cir. 2014) (“Cycles of improvement and 

debilitating symptoms are a common occurrence, and in such circumstances it is error for 

an ALJ to pick out a few isolated instances of improvement over a period of months or 

years and to treat them as a basis for concluding a claimant is capable of working.” 

(citations omitted)). The ALJ must interpret progress in the context of the overall clinical 

course and “with an awareness that improved functioning while being treated and while 

limiting environmental stressors does not always mean that a claimant can function 

effectively in a workplace.” Id. (citation omitted).

The ALJ’s conclusory assertion fails this standard and thus is neither specific nor 

legitimate.

2. Insignificant Treatment History

Next, the ALJ discounted Dr. Smith’s opinion because his “treatment records reveal 

an insignificant treatment history[.]” (AR 26.) The ALJ fails to mention that, before 

offering his opinion, Dr. Smith treated Fox six times in under five months (and they had 

14 sessions during the full year of treatment). (AR 473-80, 492.) Nor does the ALJ say 

why he deems this history insignificant. Since shorter treatment periods have passed 

muster, this conclusion required some explanation. See Colcord v. Colvin, 91 F. Supp. 3d 

1189, 1196 (D. Or. 2015) (rejecting “short treatment history” as a rationale for discounting 

a treating psychiatrist’s opinion when the treatment lasted “three months” and at the time 

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of the opinion the doctor was “meeting with plaintiff on a bi-weekly basis”). Indeed, one 

might ask: If Dr. Smith’s opinion cannot be trusted after six sessions, then how can the 

ALJ give so much more weight to the opinions of the agency consultants (who never saw 

Fox) and the examining physician (who saw Fox once, but never treated her)? See Gottuso 

v. Colvin, No. SACV 12-01705-MAN, 2014 WL 1286221, at *8 (C.D. Cal. Mar. 28, 2014) 

(criticizing ALJ who found that the opinion of a treating physician who had “significant 

gaps in his treatment of [plaintiff]” was entitled to “little weight,” without explaining why 

“the lack of any treatment history had no effect on the weight afforded to the opinions of 

the nontreating doctors”). Thus, the ALJ’s treatment-history point is also insufficient.

3. Conservative Treatment

According to the ALJ, Dr. Smith’s “conservative psychiatric treatment” of Fox 

belied his pessimistic assessment of her ability to work. “While conservative treatment 

records are generally ‘sufficient to discount a claimant’s testimony regarding severity of 

an impairment,’ they are not generally relied upon to discount the opinion of the treating 

physician.” Goucher v. Colvin, No. C-14-3009 EMC, 2015 WL 4051976, at *5 (N.D. Cal. 

July 2, 2015) (quoting Parra v. Astrue, 481 F.3d 742, 751 (9th Cir. 2007); other citation 

omitted). At any rate, it is not clear that Fox’s treatment—including a number of 

psychotropic prescription medications—can fairly be characterized as “conservative.” See 

Lapeirre-Gutt v. Astrue, 382 F. App’x 662, 664 (9th Cir. 2010) (suggesting that a “regimen 

of powerful pain medications and injections” was not “conservative treatment”). At a 

minimum, the ALJ could not rely on this ground without first demonstrating that “more 

aggressive treatment options are appropriate or available.” Id.; cf. Chong v. Colvin, 

No. CV 13-1044-SP, 2013 WL 6633073, at *7 (C.D. Cal. Dec. 16, 2013) (requiring that 

“at a minimum” ALJs must explain their treatment-history criticisms). Since the ALJ never 

did so, this reason also falls short.

4. Unsupported or Incorrect Statement

Finally, the ALJ criticizes a supposedly incorrect fact: “. . . Dr. Smith opines the 

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

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support such a conclusion.” (AR 26.) But the ALJ is wrong. Dr. Smith’s July 8, 2013 

treating notes—which are evidence in the record—reflect that Fox has been “Disabled x 10 

yrs [that is, since 2003].” (AR 474; cf. AR 453-54 (Dr. Maris states that symptoms began 

in the 1980s “between [ages] 13 and 15”); AR 486 (Dr. Khentigan notes that “symptoms 

started at age 13 [around 1981]”).) It is unclear where Dr. Smith obtained that information;

perhaps it was from other medical records or from Fox herself (which is still evidence). 

Regardless, there was record evidence to support the onset date that Dr. Smith mentioned, 

so this was not a legitimate reason to give his opinion little weight. Indeed, even if 

Dr. Smith had made a single mistake on a date, that would not necessarily justify rejecting 

his treating-physician opinion wholesale.

Because none of the ALJ’s reasons withstand scrutiny, Dr. Smith’s opinion should 

have been given controlling weight and the case must be remanded. This is especially true 

given the timing of the ALJ’s preferred expert opinions. None of those experts reviewed 

Fox’s yearlong course of treatment with Dr. Smith, which occurred almost entirely after 

they submitted their expert reports. As the Court concludes that the ALJ’s treatment of 

Dr. Smith’s treating-physician opinion is dispositive, it need not address Fox’s other 

arguments.

B. Remedy

“The decision whether to remand a case for additional evidence, or simply to award 

benefits, is within the discretion of the court.” Trevizo, 2017 WL 2925434, at *13 

(alterations and citation omitted). Courts generally remand for calculation of benefits 

when: (1) the record is “fully developed,” (2) the ALJ failed to provide “legally sufficient 

reasons for rejecting evidence,” and (3) crediting the rejected evidence as true, the ALJ 

would be required to find the claimant disabled. Id. (citation omitted). But when “the record 

as a whole creates serious doubt as to whether the claimant is, in fact, disabled,” the court 

should remand for further proceedings. Garrison v. Colvin, 759 F.3d 995, 1021 (9th Cir. 

2014). “If additional proceedings can remedy defects in the original administrative 

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proceeding, a social security case should be remanded for further proceedings.” Trevizo, 

2017 WL 2925434, at *13 (alterations and citation omitted).

Fox has strong arguments for disability benefits, and two treating psychiatrists are 

convinced she is disabled. But the administrative record—which already spans 492 

pages—could be further developed. While Dr. Smith’s opinion may ultimately carry the 

day, his treating relationship with Fox began after the insured period ended. This fact may 

not undermine Dr. Smith’s conclusions about Fox’s longstanding disabilities, but it must 

be explored. Also, many of Dr. Khentigan’s notes, which bear on the analysis, are illegible 

and should be deciphered. (See, e.g., AR 357-68.) At all events, these concerns raise 

sufficient doubt about the correct outcome to warrant further proceedings.

CONCLUSION

Thus, the Court recommends that Fox’s summary judgment motion (ECF No. 16) 

be GRANTED, defendant’s cross-motion for summary judgment (ECF No. 18) be 

DENIED, and the case be remanded for additional evidence. The parties have until 

August 14, 2017, to object to this order. See Fed. R. Civ. P. 72(b)(2). A party may respond 

to any objection within 14 days of being served with it. Id.

Dated: July 31, 2017

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