Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_23-cv-00091/USCOURTS-caed-2_23-cv-00091-3/pdf.json

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

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UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF CALIFORNIA

CARRIE JUANNELL KISER,

Plaintiff,

v.

MARTIN O’MALLEY, Commissioner of 

Social Security,

Defendant.

Case No. 2:23-cv-00091-JDP (SS)

ORDER

GRANTING PLAINTIFF’S MOTION FOR 

SUMMARY JUDGMENT AND DENYING

THE COMMISSIONER’S MOTION FOR 

SUMMARY JUDGMENT

ECF Nos. 16 & 18

Plaintiff, who suffers from degenerative disc disease of the lumbar and cervical spine,

challenges the final decision of the Commissioner of Social Security (“Commissioner”) denying

her applications for a period of disability, disability insurance benefits (“DIB”), supplemental 

security income (“SSI”), and disabled widow’s benefits under Titles II and XVI of the Social 

Security Act. Both parties have moved for summary judgment. ECF Nos. 16 & 18. Because I 

find that the ALJ improperly rejected medical opinion evidence, plaintiff’s motion is granted, and 

the Commissioner’s cross-motion is denied.

Standard of Review

An Administrative Law Judge’s (“ALJ”) decision denying an application for disability 

benefits will be upheld if it is supported by substantial evidence in the record and if the correct 

legal standards have been applied. Stout v. Comm’r, Soc. Sec. Admin., 454 F.3d 1050, 1052 (9th 

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Cir. 2006). “‘Substantial evidence’ means more than a mere scintilla, but less than a 

preponderance; it is such relevant evidence as a reasonable person might accept as adequate to 

support a conclusion.” Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007). 

“The ALJ is responsible for determining credibility, resolving conflicts in medical 

testimony, and resolving ambiguities.” Edlund v. Massanari, 253 F.3d 1152, 1156 (9th Cir. 2001) 

(citations omitted). “Where 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). However, the court will not affirm on grounds upon 

which the ALJ did not rely. Connett v. Barnhart, 340 F.3d 871, 874 (9th Cir. 2003) (“We are 

constrained to review the reasons the ALJ asserts.”).

A five-step sequential evaluation process is used in assessing eligibility for Social Security 

disability benefits. Under this process, the ALJ is required to determine: (1) whether the claimant 

is engaged in substantial gainful activity; (2) whether the claimant has a medical impairment (or 

combination of impairments) that qualifies as severe; (3) whether any of the claimant’s 

impairments meet or medically equal the severity of one of the impairments in 20 C.F.R., Pt. 404, 

Subpt. P, App. 1; (4) whether the claimant can perform past relevant work; and (5) whether the 

claimant can perform other specified types of work. See Barnes v. Berryhill, 895 F.3d 702, 704 

n.3 (9th Cir. 2018). The claimant bears the burden of proof for the first four steps of the inquiry, 

while the Commissioner bears the burden at the final step. Bustamante v. Massanari, 262 F.3d 

949, 953-54 (9th Cir. 2001). 

Background

In August 2020, plaintiff filed an application for a period of disability and DIB, and an 

application for disabled widow’s benefits, alleging disability beginning May 1, 2020. In February 

2022, she filed an application for SSI, alleging the same disability onset date. Administrative 

Record (“AR”) 354-57, 366-68, 383-92. After her applications were denied both initially and 

upon reconsideration, plaintiff testified at a telephonic hearing before an Administrative Law 

Judge (“ALJ”). AR 72-98, 103-34, 137-76. On April 11, 2022, the ALJ issued a decision finding 

that plaintiff was not disabled. AR 31-50. Specifically, the ALJ found: 

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1. The claimant meets the insured status requirements of the Social 

Security Act through December 31, 2024.

2. It was previously found that the claimant is the unmarried widow 

of the deceased insured worker and has attained the age of 50. The 

claimant met the non-disability requirements for disabled widow’s 

benefits set forth in section 202(e) of the Social Security Act.

3. The prescribed period ends on March 31, 2024.

4. The claimant has not engaged in substantial gainful activity since 

May 1, 2020, the alleged onset date.

5. The claimant has the following severe impairments: Degenerative 

disc disease of cervical spine and degenerative disc disease of 

lumbar spine.

* * * 

6. The claimant does not have an impairment or combination of 

impairments that meets or medically equals the severity of one of 

the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1.

* * * 

7. After careful consideration of the entire record, I find that the 

claimant has the residual functional capacity to perform light work 

as defined in 20 CFR 404.1567(b) and 416.967(b) except 

occasional balancing, stooping, kneeling, crouching, and climbing 

ladders, ropes, scaffolds, ramps, or stairs. She can do frequent 

crawling. Avoid concentrated exposure to extreme cold and 

vibration and avoid even moderate exposure to dangerous moving 

machinery and unprotected heights. She can perform work 

involving simple tasks.

* * * 

8. The claimant is unable to perform any past relevant work.

* * *

9. The claimant was born [in] 1970 and was 49 years old, which is 

defined as a younger individual age 18-49, on the alleged disability 

onset date. The claimant subsequently changed age category to 

closely approaching advanced age.

10. The claimant has a limited education.

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11. Transferability of job skills is not material to the determination of 

disability because using the Medical-Vocational Rules as a 

framework supports a finding that the claimant is “not disabled,” 

whether or not the claimant has transferable job skills.

12. Considering the claimant’s age, education, work experience, and 

residual functional capacity, there are jobs that exist in significant 

numbers in the national economy that the claimant can perform.

* * *

13. The claimant has not been under a disability, as defined in the 

Social Security Act, from May 1, 2020, through the date of this 

decision.

AR 37-45 (citations to the code of regulations omitted).

Plaintiff requested review by the Appeals Council, but the request was denied. AR 3-6. 

She now seeks judicial review under 42 U.S.C. §§ 405(g), 1383(c)(3). 

Analysis

Plaintiff argues that remand is warranted because the ALJ did not properly consider the 

medical opinion evidence addressing mental and physical functional limitations. ECF No. 16-1 at 

3-7. 

A. Legal Standard for Evaluating Medical Opinion Evidence

In 2017, revised Social Security Administration regulations took effect concerning the 

evaluation of medical opinions. Under these regulations, the ALJ “will not defer or give any 

specific evidentiary weight, including controlling weight, to any medical opinion(s) or prior 

administrative medical finding(s), including those from [the claimant’s] medical sources.” See 20 

C.F.R. §§ 404.1520c(a), 416.920c(a). The ALJ determines which medical opinions are most 

“persuasive” by focusing on a variety of factors: (1) supportability; (2) consistency; 

(3) relationship with the claimant—including length of treatment, frequency of examinations, 

purpose and extent of treatment, and whether the medical source examined the claimant as 

opposed to reviewing only the documentary medical evidence; (4) the medical source’s area of 

specialty; and (5) “other” factors, such as the impact of any new evidence received after a medical 

source has provided a medical opinion. 20 C.F.R. §§ 404.1520c(c)(1)-(5), 416.920c(c)(1)-(5). 

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The factors of “supportability” and “consistency” are the “most important” when 

determining the persuasiveness of medical opinions, and the ALJ must explain how both were 

considered. 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2). Under the “supportability” factor, 

“[t]he more relevant the objective medical evidence and supporting explanations presented by a 

medical source are to support his or her medical opinion(s) . . . , the more persuasive the medical 

opinions . . . will be.” 20 C.F.R. §§ 404.1520c(c)(1), 416.920c(c)(1). Under the “consistency” 

factor, “[t]he more consistent a medical opinion(s) . . . is with the evidence from other medical 

sources and nonmedical sources in the claim, the more persuasive the medical opinion(s) . . . will 

be.” 20 C.F.R. §§ 404.1520c(c)(2), 416.920c(c)(2). The ALJ is only required to address the 

remaining factors when “two or more medical opinions . . . about the same issue are equally wellsupported . . . and consistent with the record . . . but are not exactly the same.” 20 C.F.R. 

§§ 404.1520c(b)(2)-(3), 416.920c(b)(2)-(3). 

B. Medical Opinions Concerning Mental Limitations

The court first considers the ALJ’s analysis of medical opinion evidence relating to 

plaintiff’s mental functioning. On July 29, 2021, Dr. Michelina Regazzi, a licensed psychologist, 

performed a comprehensive mental status evaluation. AR 1487-90. During the exam, plaintiff 

reported that she had a low attention span and that she was agitated most of the time. When 

describing her history, plaintiff stated that she was molested as a child, she had four children who 

were “adopted out,” she had been in relationships involving domestic violence, she had a “bad 

relationship” with her mother, and she abused alcohol and drugs. AR 1487-88. For daily 

activities, she was able to clean up after herself, visit people, go to the store as needed, and make 

simple meals for herself. AR 1488. She reported that she was not receiving treatment for her 

mental health problems. AR 1487. 

Dr. Regazzi noted that plaintiff was alert and oriented, but her speech was rapid, and her 

mood and affect were “irritable.” AR 1489. Plaintiff’s concentration and memory were “fair”; her 

insight and judgment were “poor”; her attention and fund of knowledge were “adequate”; and her 

ability to perform simple calculations was “poor.” Id. Plaintiff’s mental status was normal with 

respect to intelligence and thought processes. Id. Dr. Regazzi stated the following diagnostic 

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impression: amphetamine use disorder and unspecified mood disorder. AR 1490. Concerning 

functional limitations, Dr. Regazzi opined that plaintiff was moderately impaired in her ability to 

complete a normal workday or workweek without interruptions resulting from her psychiatric 

condition, and mildly impaired in the ability to interact with coworkers and the public. Id. Dr. 

Regazzi also opined that plaintiff was incapable of managing funds. Id.

The ALJ considered Dr. Regazzi’s opinion, and found it “somewhat persuasive,” but 

disagreed that plaintiff was moderately impaired in completing a normal workday or workweek. 

AR 43. The ALJ gave two reasons for discounting the moderate limitation: it was not consistent 

with plaintiff’s treatment, and it was not consistent with the opinions of the non-examining 

medical consultants. Id.

To the extent that the ALJ rejected Dr. Regazzi’s opinion because it was not consistent 

with plaintiff’s treatment history, the ALJ failed either to identify any specific medical records or 

findings that conflicted with Dr. Regazzi’s restriction, or otherwise to explain how the evidence 

supported the conclusion that plaintiff was able to maintain a regular work schedule without 

interruptions from her psychiatric symptoms. 

In the hearing decision, the ALJ discussed a selection of treatment records from 2019, 

noting that: (1) on May 28, 2019, plaintiff’s mental status examination was normal, see AR 40, 

599-600; (2) on August 15, 2019, plaintiff was agitated but had a normal mood, she complained

of uncontrolled depression and anxiety, and she reported that she had stopped taking psychotropic 

medication but agreed to see her primary care physician for another prescription, see AR 37, 814-

15; and (3) on September 17, 2019, plaintiff’s mood was again normal with matching affect, see

AR 40, 575-76. The ALJ also reviewed a treatment note from August 3, 2020, that states that 

plaintiff was homeless, she was tearful and angry, and she had used narcotics for fifteen years. 

See AR 37, 1435. Citing a subsequent treatment note from March 22, 2021, the ALJ observed that 

plaintiff’s affect was normal and that she was fully oriented. See AR 41, 1367-68. The ALJ 

further noted that when plaintiff was evaluated by Dr. Regazzi in July 2021, she reported that she 

was not taking any psychotropic medication and was not receiving mental health treatment. See

AR 41, 1487. Finally, the ALJ observed that on January 3, 2022, plaintiff was cooperative and 

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had a normal mood with matching affect. She reported that she had not used methamphetamine 

for approximately four months. Although plaintiff complained of memory problems, the examiner 

opined that her cognitive impairment did not affect her ability to perform activities of daily living. 

See AR 37, 41, 696-97. 

The ALJ’s synopsis primarily highlighted normal mental status examination findings while 

ignoring evidence of more pronounced symptoms. For example, although the ALJ pointed out 

specific instances in August 2019 and July 2021 when plaintiff reported that she was not taking 

medication, a broader view of the evidence reflects regular, ongoing treatment with prescribed 

antidepressants and anti-anxiety medications. The court notes that in 2017 and 2018, several 

years before the alleged disability onset date, plaintiff was prescribed medications for depression 

and anxiety, including Prozac, Abilify, and Cymbalta. See AR 490-91, 832, 857, 859, 904. 

Subsequent treatment notes from 2019 and early 2020 reflect that plaintiff had an irritated mood 

at times, had symptoms of depression and anxiety comorbid with PTSD, and that she was 

prescribed Lexapro. AR 829-30, 1031-32, 1283-86, 1312-13. Other treatment notes from 2020 

reflect that plaintiff had an anxiety disorder, panic attacks, depression, and PTSD, and was 

prescribed Paxil and Ativan. AR 1436-37, 1454-55, 1460-61. 

Although, as the ALJ observed, numerous treatment notes include unremarkable mental 

examination findings, other records—which the ALJ did not discuss—reflect mood abnormalities 

that indicate more severe symptoms. For example, in June 2020, plaintiff had a depressed mood 

with matching affect, and she was “weepy” when discussing her “current situation.” AR 1454. 

She also reported “breakthrough anxiety” and panic attacks, and that she had “reached out to 

mental health” for counseling. Id. Several months later, in October 2020, plaintiff was “very 

agitated” and had a labile mood with matching affect. During that visit, the examiner noted “tears 

of sadness and frustration” when plaintiff discussed recent events in her life. AR 1428-29. 

Treatment records from 2021 and 2022 further chronicle plaintiff’s struggle with anxiety 

and depression. In November 2021, plaintiff complained of anxiety that was difficult to control, 

panic attacks, and excessive worry, all of which caused significant distress and limited her ability 

to function. Plaintiff reported, however, that she had not been taking psychotropic medication

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and was again prescribed Lexapro. AR 713-14. In January 2022, plaintiff reported increased 

anxiety, problems with insomnia, and that she had feelings of helplessness and depression. The 

examiner, noting worsening depression, increased her dose of Lexapro and prescribed an 

emotional support animal. AR 696-97.

Because the court is unable discern what specific evidence the ALJ relied on to reject Dr. 

Regazzi’s opinion that plaintiff was moderately impaired in her ability to complete a workday or 

workweek, the court finds that the ALJ failed to meaningfully address the consistency factor. See

20 C.F.R. § 404.1520c(c)(2). As such, substantial evidence does not support the ALJ’s conclusion 

that Dr. Regazzi’s limitation was inconsistent with plaintiff’s treatment history.

Similarly, the ALJ erred in relying on the opinions of the non-examining consultants as a 

reason to reject Dr. Regazzi’s restriction. The record shows that S. Amon, M.D., and A. Gallucci, 

Psy.D., reviewed the medical evidence at the reconsideration stage. Dr. Amon opined that 

plaintiff could perform light work with certain postural and environmental limitations. AR 147, 

152-53. In turn, Dr. Gallucci opined that there was no evidence of a severe mental impairment 

and that plaintiff had only mild workplace limitations. AR 148. The ALJ accepted their opinions 

as persuasive, stating that they were consistent with plaintiff’s medical records, diagnostic test 

results, and the objective clinical findings. AR 43. 

The non-examining consultants’ report references Dr. Regazzi’s opinion that plaintiff is 

moderately impaired in the ability to complete a workday or workweek without interruption. 

Nevertheless, the report states, without any explanation, that based on Dr. Regazzi’s functional 

assessment, plaintiff “really is not too limited.” AR 146. The report then states Dr. Gallucci’s 

opinion that plaintiff’s mental impairments were not severe and resulted in only mild limitations. 

AR 148. There is neither any supporting explanation for Dr. Gallucci’s assessment nor any 

discussion of plaintiff’s capacity to complete a workday or workweek without interruption. 

Indeed, in opining that plaintiff had only mild impairments, Dr. Gallucci did not even 

acknowledge that this conflicted with Dr. Regazzi’s more restrictive limitation.

On this record, the court finds that the ALJ’s determination that Dr. Regazzi’s limitation is

inconsistent with the opinions of the non-examining consultants is not supported by substantial 

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evidence. See Garrison v. Colvin, 759 F.3d 995, 1012-13 (9th Cir. 2014) (“[A]n ALJ errs when he 

rejects a medical opinion or assigns it little weight while doing nothing more than ignoring it, 

asserting without explanation that another medical opinion is more persuasive, or criticizing it with 

boilerplate language that fails to offer a substantive basis for his conclusion.”). 

Having determined that the ALJ failed to provide legally sufficient reasons for rejecting 

Dr. Regazzi’s limitation, the court declines to address plaintiff’s remaining arguments. 

C. Remand for Further Proceedings

Because the ALJ’s rejection of medical opinion evidence was not supported by substantial 

evidence in the record, the matter must be remanded for further consideration. See Dominguez v. 

Colvin, 808 F.3d 403, 407 (9th Cir. 2015) (“A district court may reverse the decision of the 

Commissioner of Social Security, with or without remanding the case for a rehearing, but the 

proper course, except in rare circumstances, is to remand to the agency for additional investigation 

or explanation.”) (internal quotes and citations omitted); Treichler v. Comm’r of Social Sec., 775 

F.3d 1090, 1105 (9th Cir. 2014) (“Where . . . an ALJ makes a legal error, but the record is 

uncertain and ambiguous, the proper approach is to remand the case to the agency.”).

Conclusion

Accordingly, it is hereby ORDERED that: 

1. Plaintiff’s motion for summary judgment, ECF No. 16, is granted.

2. The Commissioner’s cross-motion for summary judgment, ECF No. 18, is denied. 

3. The matter is remanded for further proceedings consistent with this order.

4. The Clerk of Court is directed to enter judgment in plaintiff’s favor. 

IT IS SO ORDERED.

Dated: February 22, 2024 

JEREMY D. PETERSON

UNITED STATES MAGISTRATE JUDGE

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