Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_05-cv-00631/USCOURTS-azd-2_05-cv-00631-0/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

Nora M. Mendoza, 

Plaintiff, 

vs.

Commissioner of Social Security, 

Defendant.

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No. CV-05-631-PHX-DGC

ORDER

Pending before the Court are Plaintiff’s motion for summary judgment and

Defendant’s cross-motion for summary judgment. Docs. ##12, 18. The parties have filed

responses to the motions and Plaintiff has filed a reply. Docs. ##18, 21. For the reasons set

forth below, the Court will grant the motions in part and remand the case to Defendant for

further proceedings.

Background

Plaintiff applied for disability insurance benefits and supplemental security income

benefits on July 26, 2002, claiming a disability onset date of April 22, 2002. Doc. #11A,

Tr. 106-09. The applications were denied initially and on reconsideration. Tr. 63-71,

285-94. A hearing before an Administrative Law Judge (“ALJ”) was held on May 27, 2004.

Tr. 315-59. The ALJ issued a written decision on June 22, 2004, finding that Plaintiff

was not disabled within the meaning of the Social Security Act. Tr. 46-53. This decision

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became Defendant’s final decision when the Appeals Council denied Plaintiff’s request for

review on September 10, 2004. Tr. 35-37. Plaintiff then commenced this action for judicial

review pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). Doc. #1.

Discussion

I. Standard of Review.

Defendant’s decision to deny benefits will be vacated “only if it is not supported by

substantial evidence or is based on legal error.” Magallanes v. Bowen, 881 F.2d 747, 750

(9th Cir. 1989). Substantial evidence is more than a mere scintilla, but less than a

preponderance. Reddick v. Charter, 157 F.3d 715, 720 (9th Cir. 1998). In determining

whether the decision is supported by substantial evidence, the Court must consider the record

as a whole, weighing both the evidence that supports the decision and the evidence that

detracts from it. Id.

II. Analysis.

The ALJ found that Plaintiff has the following severe impairments: carpal tunnel

syndrome, adjustment disorder with mixed anxiety and depressed mood, history of learning

disorder, pain associated with both psychological factors and a general medical condition,

and possible generalized anxiety disorder and dependent personality. Tr. 48, 52 ¶ 3. The

ALJ concluded that these impairments were not severe enough to meet or medically equal

a listed impairment. Id.; see 20 C.F.R. Pt. 404, Subpt. P, App. 1 (listing impairments for

which a claimant is presumed disabled). The ALJ further concluded that Plaintiff is able to

perform a range of sedentary work and that such work exists in significant numbers in the

national economy. Tr. 51, 53 ¶¶ 11-12.

Plaintiff contends that the ALJ erred by failing to consider Plaintiff’s borderline

intellectual functioning, opinions that Plaintiff has moderately severe pain, and limitations

caused by Plaintiff’s obesity. Doc. #14 at 7-12. Plaintiff further contends that the ALJ erred

by discrediting Plaintiff’s complaints of pain and improperly evaluating Plaintiff’s mental

impairments. Id. at 12-17. Defendant argues that the ALJ did not err and that her decision

is supported by substantial evidence. Doc. #19 at 3-13.

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Borderline intellectual functioning describes individuals with IQ scores between 71

and 84. See Thomas v. Sullivan, 876 F.2d 666, 668 n.1 (8th Cir. 1989).

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A. Did the ALJ Err by Not Considering Plaintiff’s Borderline Intellectual

Functioning?

 Plaintiff was evaluated by Dr. Robert Henley, Ph.D., on April 6, 2004. Tr. 242.

Plaintiff took an intelligence quotient (“IQ”) test during the evaluation and earned a verbal

IQ of 71, a performance IQ of 94, and a full scale IQ of 79. Tr. 244. Dr. Henley concluded

from these IQ scores that Plaintiff had borderline intellectual functioning. Tr. 244-46.1

Plaintiff contends that the ALJ erred in failing to consider whether Plaintiff’s

borderline intellectual functioning and carpal tunnel syndrome met the mental retardation

impairment described in Listing 12.05(C). Doc. #14 at 7. Defendant argues that the ALJ

did not err because Plaintiff’s IQ scores precluded a finding that Plaintiff met Listing

12.05(C). Doc. #19 at 5.

The Court agrees. A claimant meets Listing 12.05(C) only if she has an IQ of 70 or

less and some additional impairment. See 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 12.05(C);

Lewis v. Apfel, 236 F.3d 503, 514 (9th Cir. 2001). Plaintiff contends that her verbal IQ score

of 71 could be as low as 66 if a 5-point measurement error is applied to the score. Doc. #14

at 8, n.4 (citing Diagnostic and Statistical Manual of Mental Disorders–IV (Fourth Ed.);

Halsted v. Shalala, 862 F. Supp. 86, 90 (W.D. Pa. 1994) (“I.Q. scores are thought to have an

error of measurement of approximately five points. . . . Therefore, Ms. Halsted’s lowest I.Q.

score of 74 would have a range of error of 69 to 79, bringing her score within the criteria of

listing 12.05.”)). Applying a measurement error to Plaintiff’s IQ scores, however, would

violate the plain language of Listing 12.05(C), which requires “[a] valid verbal, performance,

or full scale IQ of 60 through 70[.]” 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 12.05(C)

(emphasis added); see Burns v. Barnhart, 312 F.3d 113, 125 (3d Cir. 2002) (abrogating

Halsted and refusing to ignore the plain language of the regulation and “assume that a score

of 75 should be read as ‘70’”); Lawson v. Apfel, 46 F. Supp. 2d 941, 948 (W.D. Mo. 1998)

(rejecting Halsted and stating that “‘incorporating a 5 point measurement error into a

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See also Howard v. Massanari, 255 F.3d 577, 582-83 (8th Cir. 2001) (holding that

the ALJ properly found that a claimant with an IQ of 71 did not meet Listing 12.05(C));

Anderson v. Sullivan, 925 F.2d 220, 223 (7th Cir. 1991) (“Mr. Anderson’s score is not

qualifying under [Listing] 12.05(C). Dr. Hurd found Mr. Anderson’s IQ to be 71 . . . . While

Mr. Anderson argues that a standard error range of three points should be factored into his

score; the Secretary was entitled to rely on the plain language of the regulation.”).

3

See also 20 C.F.R. §§ 404.1526(a) (“If you have more than one impairment . . . we

will review the symptoms, signs, and laboratory findings about your impairments to

determine whether the combination of your impairments is medically equal to any listed

impairment.”), 416.926(a)(2) (“If you have . . . a combination of impairments . . . we will

compare your medical findings with those for closely analogous listed impairments.”).

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claimant’s I.Q. test results would effectively expand the requisite I.Q. under listing 12.05(C)

from test scores of 60 to 70 to test scores of 60 to 75.’”) (citation and alteration omitted).

The Court concludes that the ALJ did not err by not considering whether Plaintiff met Listing

12.05(C) since all of Plaintiff’s IQ scores were above 70. See 20 C.F.R. Pt. 404, Subpt. P,

App. 1, § 12.05(C); Lewis, 236 F.3d at 514 (holding that the ALJ properly found that a

claimant with an IQ of 78 did not meet Listing 12.05(C)).2

Plaintiff further contends that the ALJ erred by failing to consider Plaintiff’s

borderline intellectual functioning in concluding that Plaintiff’s impairments did not meet or

equal any listed impairment. Doc. #14 at 9-10; see Tr. 48. 

The Court agrees. In determining whether Plaintiff’s impairments were severe enough

to meet or equal a listed impairment, the ALJ was required to consider the combined effects

of all of Plaintiff’s impairments, including her borderline intellectual functioning. See Lester

v. Chater, 81 F.3d 821, 828 (9th Cir. 1995) (“We agree that the Commissioner is required

to take into account the combined effect of a claimant’s physical and mental impairments in

determining whether his condition equals [a] listing.”); 20 C.F.R. §§ 404.1523, 416.923

(“[W]e will consider the combined effect of all of your impairments without regard to

whether any such impairment, if considered separately, would be of sufficient severity.”);

Soc. Sec. Ruling 83-19 (same).3

 The ALJ also was required to explain adequately her

evaluation of the evidence and the combined effects of Plaintiff’s impairments. See Marcia

v. Sullivan, 900 F.2d 172, 176 (9th Cir. 1990) (“We hold that, in determining whether a

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See also Holz v. Apfel, 191 F.3d 945, 947 (8th Cir. 1999) (“Holz’s borderline

intellectual functioning . . . was a significant nonexertional impairment that needed to be

considered . . . . We conclude that the case must be remanded to the Social Security

Administration for further proceedings to determine the effects of Holz’s borderline

intellectual functioning.”) (citations omitted).

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claimant equals a listing under step three of the Secretary’s disability evaluation process, the

ALJ must explain adequately his evaluation of alternative tests and the combined effects of

the impairments.”); Lewis, 236 F.3d at 512 (“An ALJ must evaluate the relevant evidence

before concluding that a claimant’s impairments do not meet or equal a listed impairment.

A boilerplate finding is insufficient to support a conclusion that a claimant’s impairment does

not do so.”) (citing Marcia, 900 F.2d at 176).

The ALJ failed to consider Plaintiff’s borderline intellectual functioning in concluding

that Plaintiff’s impairments were not severe enough to meet or equal any listed impairment.

Tr. 48. This constitutes legal error. See Lester, 81 F.3d at 830 (“The Commissioner erred

as a matter of law in isolating the effects of Lester’s physical impairment from the effects of

his mental impairment. Instead, she should have considered the combined effect of the

claimant’s physical and mental impairments[.]”); Frost v. Barnhart, 314 F.3d 359, 363-64

(9th Cir. 2002) (holding that the ALJ erred in failing to consider whether the claimant’s

mental impairments met or equaled Listing 12.03).4

 The ALJ also erred by failing to evaluate

the evidence and explain her conclusion that Plaintiff did not meet or equal any listed

impairment. See Frost, 314 F.3d at 363-64; Marcia, 900 F.2d at 176 (holding that the ALJ

erred because his conclusory statement that the claimant did not equal a listing was

insufficient); Connett v. Barnhart, 340 F.3d 871, 874 (9th Cir. 2003) (holding that the ALJ

erred by failing to provide specific facts or reasons in support of his decision to deny

benefits).

Defendant contends that the ALJ did not err by not considering whether Plaintiff’s

impairments equaled Listing 12.05(C) because Plaintiff did not meet the Listing’s diagnostic

description for mental retardation. Doc. #19 at 3-6. Specifically, Defendant contends that

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Listing 12.05 provides: “Mental retardation refers to significantly subaverage general

intellectual functioning with deficits in adaptive functioning initially manifested during the

developmental period; i.e., the evidence demonstrates or supports onset of the impairment

before age 22.” 20 C.F.R. Pt. 404, Subpt. P., App. 1, § 12.05. 

6

See also Brown v. Sec’y of Health & Human Servs., 948 F.2d 268, 271 (6th Cir.

1991) (“The Secretary . . . did not address the issue of whether the claimant’s mental

impairment ‘manifested during [claimant’s] developmental period’ . . . . Consequently, we

remand the case to the Secretary to resolve this undecided question.”) (quoting Listing 12.05;

alteration in original); Diehl v. Barnhart, 357 F. Supp. 2d 804, 819 (E.D. Pa. 2005)

(remanding for a determination as to whether the claimant’s impairments equaled Listing

12.05(C) where the claimant testified that he had difficulty learning in school and tests given

by an evaluating physician confirmed those difficulties).

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Plaintiff has not shown that she had deficits in adaptive functioning before age 22. Id.5

Plaintiff, however, testified at the hearing before the ALJ that she had problems

learning in school, attended special education classes throughout school, and had to repeat

third grade. Tr. 322-23. Plaintiff also informed Dr. Henley that she had to repeat third grade

and had difficulty learning in school. Tr. 242. Dr. Henley concluded that, absent evidence

of educational disadvantage, the difference between Plaintiff’s verbal and performance IQ

scores indicated that Plaintiff was learning disabled. Tr. 244.

The ALJ did not discuss this evidence or make a finding that Plaintiff had no deficits

in adaptive functioning before age 22. Tr. 48. This Court may not make independent

findings and is “constrained to review the reasons the ALJ asserts.” Connett, 340 F.3d at 874

(“[W]e cannot rely on independent findings of the district court. . . . It was error for the

district court to affirm the ALJ’s . . . decision based on evidence that the ALJ did not

discuss.”). A remand is required so that Defendant can consider whether the combined

effects of all of Plaintiff’s impairments equaled Listing 12.05(C) or met or equaled any other

listed impairment that Plaintiff has attempted to establish. See Lester, 81 F.3d at 830; Frost,

314 F.3d at 363-64; Lewis, 236 F.3d at 514.6

B. Did the ALJ Err by Not Considering the Opinion Dr. Vasant Patel?

On June 15, 2004, Dr. Vasant Patel completed a physical capacities evaluation form

opining that Plaintiff’s ability to function is limited by moderately severe pain. Tr. 277-79.

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Plaintiff states that this opinion is significant because Dr. Patel was her treating physician

and a vocational expert testified at the hearing before the ALJ that there would be no work

available to Plaintiff if she suffered from moderately severe pain. Doc. #14 at 10; see

Tr. 350. Plaintiff argues that the ALJ erred by failing to consider Dr. Patel’s opinion. Docs.

##14 at 10-12, 21 at 7-10 (citing 20 C.F.R. §§ 404.1527, 416.927).

Defendant contends that the ALJ was not required to consider Dr. Patel’s opinion

because Plaintiff did not produce the evaluation form containing the opinion until after the

hearing held on May 27, 2004. Doc. #19 at 7 (citing Tr. 7). Defendant, however, does not

dispute that the evaluation form was part of the record when the ALJ issued her decision on

June 22, 2004 and when the Appeals Council denied review of the ALJ’s decision on

September 10, 2004. See Tr. 7, 35-37, 46-53.

Both the ALJ and the Appeals Council have a duty to consider all relevant medical

opinions that are part of the administrative record. See 20 C.F.R. §§ 404.1527(b), 416.927(b)

(“In deciding whether you are disabled, we will always consider the medical opinions in your

case record together with the rest of the relevant evidence we receive.”); 20 C.F.R. §

404.970(b) (stating that the Appeals Council shall evaluate the entire record, including new

relevant evidence); Bates v. Sullivan, 894 F.2d 1059, 1063-64 (9th Cir. 1990) (“Social

Security regulations provide that where new and material evidence is submitted to the

Appeals Council with the request for review, the entire record will be evaluated[.]”) (citing

20 C.F.R. § 404.970). Ramirez v. Shalala, 8 F.3d 1449, 1451-52 (9th Cir. 1993) (“[T]he

government does not contend that the Appeals Council should not have considered the

additional report submitted after the hearing, or that we should not consider it on appeal.”)

(citing Bates, 894 F.2d at 1063-64; 20 C.F.R. § 404.970). Dr. Patel’s opinion that Plaintiff

suffers from moderately severe pain is part of the administrative record in this case. Tr. 7,

277-79. It was error for both the ALJ and the Appeals Council to disregard Dr. Patel’s

opinion. See 20 C.F.R. §§ 404.1527, 416.927; Ramirez, 8 F.3d at 1454 (“We conclude that

both the ALJ and the Appeals Council improperly disregarded Dr. Townsend’s opinion that

Ramirez suffered from an affective disorder[.]”).

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Defendant further contends that the ALJ was not required to consider Dr. Patel’s

opinion because there was no evidence that Dr. Patel ever examined or treated Plaintiff.

Doc. #19 at 7-8. This is an insufficient reason to completely disregard Dr. Patel’s opinion.

See 20 C.F.R. §§ 404.1527(d), 416.927(d) (“Regardless of its source, we will evaluate every

medical opinion we receive.”); Lester, 81 F.3d at 830 (discussing the weight an ALJ should

give to various medical opinions). A remand is required so that Defendant can consider

Dr. Patel’s opinion under the appropriate legal standards. See id.

C. Did the ALJ Err by Discounting the Opinion of Tony Demarco, P.A.?

On February 2, 2004, physician’s assistant Tony Demarco opined that Plaintiff’s

ability to function is limited by moderately severe pain. Tr. 225-27. The ALJ did not give

this opinion great weight because a physician’s assistant is not an acceptable medical source

under the regulations. Tr. 49 (citing 20 C.F.R. §§ 404.1513, 416.913). Plaintiff contends

that Mr. Demarco and Dr. Patel worked closely together during Plaintiff’s treatment and that

the ALJ was thus required to treat Mr. Demarco’s opinion as an opinion of Dr. Patel. Docs.

##14 at 10 n.6, 21 at 8 (citing Gomez v. Chater, 74 F.3d 967, 971 (9th Cir. 1996)).

In Gomez, the Ninth Circuit held that a nurse practitioner’s opinion could be

considered as part of a treating physician’s opinion where the evidence showed that during

the claimant’s treatment the nurse practitioner consulted with the physician numerous times,

worked closely under the physician’s supervision, and acted as the physician’s agent.

74 F.3d at 971. Plaintiff has presented no such evidence in this case. The ALJ did not err

by not according “great probative value” to Mr. Demarco’s opinion. Tr. 49; see 20 C.F.R.

§§ 404.1513, 416.913.

D. Did the ALJ Err by Not Considering Plaintiff’s Obesity?

Plaintiff contends that the ALJ erred by failing to consider the limitations caused by

Plaintiff’s obesity. Doc. #14 at 12. Defendant argues that the ALJ did not err because there

was no evidence in the record indicating that Plaintiff’s obesity limited her ability to

function. Doc. #19 at 8-9 (citing Burch v. Barnhart, 400 F.3d 676, 683 (9th Cir. 2005)).

The Court agrees. The only evidence Plaintiff cites regarding her obesity are medical

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records listing her height and weight along with other general patient information such as her

age and blood pressure. Tr. 25, 33, 200, 204, 251, 300, 302. Although these records indicate

that Plaintiff is 5 feet, 4 inches tall and weighs approximately 210 pounds, they do not

diagnose Plaintiff as obese or address whether obesity limits Plaintiff’s ability to function.

Id. The ALJ did not err by not considering Plaintiff’s obesity. See Burch, 400 F.3d at 683

(“[T]he only evidence in the record relating to [Burch’s] obesity are notes from doctors who

observed weight gain, indicated that Burch is obese, and recommended that she participate

in a medically supervised weight los program. We therefore conclude that the ALJ did not

commit reversible error by failing to consider Burch’s obesity[.]”).

E. Did the ALJ Err by Discrediting Plaintiff’s Testimony?

Plaintiff argues that the ALJ erred by discrediting Plaintiff’s testimony regarding the

severity of her pain. Docs. ##14 at 13-16, 21 at 11-13. Defendant argues that the ALJ made

sufficiently specific findings and did not arbitrarily discredit Plaintiff’s testimony. Doc. #19

at 9-12 (citing Thomas v. Barnhart, 278 F.3d 947, 957 (9th Cir. 2002)).

The ALJ set forth three specific reasons for rejecting Plaintiff’s testimony of disabling

pain. Tr. 49-50. First, Dr. Henley indicated in his evaluation report that Plaintiff had a

tendency to exaggerate her pain. Tr. 245-46. Second, Plaintiff chose not to have

recommended surgery that could have improved the symptoms caused by her carpal tunnel

syndrome. Tr. 184, 319-21, 340-41. Mr. Demarco’s treatment notes indicated that Plaintiff

chose not to have surgery in part because the pain caused by her carpal tunnel syndrome was

“OK” with Motrin. Tr. 229-34, 331-32. Third, Plaintiff had no major self-care limitations

and her daily activities included light housecleaning, grocery shopping, and cooking. Tr. 50;

see Tr. 243, 327-28. Plaintiff also watched television, took care of her four dogs, and had

an active role in the life of her granddaughter Tr. 244, 328.

The Court concludes that these reasons are clear and convincing and are supported by

substantial evidence. The ALJ did not err in discrediting Plaintiff’s pain testimony. See

Thomas, 278 F.3d at 958-59 (holding that the ALJ did not err in rejecting the claimant’s pain

testimony where the claimant “was able to perform various household chores such as

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The special technique is described in paragraphs (b) through (e) of §§ 404.1520a and

416.920a. 

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cooking, laundry, washing dishes, and shopping”); Rollins v. Massanari, 261 F.3d 853, 857

(9th Cir. 2001) (affirming the ALJ’s credibility analysis where the ALJ “pointed out ways

in which Rollins’ claim to have totally disabling pain was undermined by her own testimony

about her daily activities, such as . . . cooking, housekeeping, laundry, [and] shopping”);

Morgan v. Comm’r of Soc. Sec. Admin., 169 F.3d 595, 600 (9th Cir. 1999) (affirming the

ALJ’s credibility analysis where the ALJ “determined that Morgan’s ability to fix meals, do

laundry, work in the yard, and occasionally care for his friend’s child served as evidence of

Morgan’s ability to work”); Fair v. Bowen, 885 F.2d 597, 603-04 (9th Cir. 1989) (holding

that the ALJ did not err in rejecting the claimant’s pain testimony where the claimant’s daily

activities were inconsistent with such testimony and the claimant did not provide a good

reason for failing to follow a prescribed course of treatment).

F. Did the ALJ Err in Evaluating Plaintiff’s Mental Impairments?

Plaintiff argues that a remand is required because in evaluating Plaintiff’s mental

impairments the ALJ failed to apply the “special technique” mandated by the regulations.

Docs. ##14 at 16-17, 21 at 10-11 (citing 20 C.F.R. §§ 404.1520a(a), 416.920a(a); Gutierrez

v. Apfel, 199 F.3d 1048, 1051 (9th Cir. 2000)).7

 Defendant contends that the ALJ’s failure

to apply the special technique is immaterial because the ALJ found that Plaintiff’s mental

impairments were severe. Doc. #19 at 13 (citing Curry v. Sullivan, 925 F.2d 1127, 1131

(9th Cir. 1991) (applying the harmless error rule in a social security case)).

The Court disagrees. The special technique must be followed at each level of the

administrative review process if a claimant has presented a colorable claim of mental

impairment. 20 C.F.R. §§ 404.1520a(a), 416.920a(a); see Gutierrez, 199 F.3d at 1051

(applying an earlier version of the regulations requiring the ALJ to complete and attach to

the decision a psychiatric review technique form). “[T]he written decision issued by the

[ALJ] or Appeals Council must incorporate the pertinent findings and conclusions based on

the technique.” 20 C.F.R. §§ 404.1520a(e)(2), 416.920a(e)(2).

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In this case, Plaintiff’s borderline intellectual functioning and adjustment disorder

evidence a colorable claim of mental impairment. See Cassim v. Bowen, 824 F.2d 791, 795

(9th Cir. 1987) (“A claim is colorable if it is not ‘wholly insubstantial, immaterial, or

frivolous.’”) (citation omitted). The ALJ’s failure to apply the special technique was not

harmless merely because the ALJ concluded that Plaintiff’s mental impairments were severe.

The failure to apply the technique resulted in an inadequate consideration of Plaintiff’s

mental impairments at the latter steps of the evaluation process, such as in determining at step

three whether Plaintiff met or equaled a listed impairment. See 20 C.F.R. §§ 404.1520a(d),

416.920a(d) (“After we rate the degree of functional limitation resulting from your

impairment(s), we will determine the severity of your mental impairments. . . . If your

mental impairment(s) is severe, we will then determine if it meets or is equivalent in severity

to a listed mental disorder.”). A remand is required so that the ALJ can apply and document

the special technique for evaluating Plaintiff’s mental impairments. See Gutierrez, 199 F.3d

at 1051 (“[T]he case is remanded . . . for proper evaluation and documentation of the

claimant’s mental impairments.”).

IT IS ORDERED:

1. Plaintiff’s motion for summary judgment (Doc. #12) and Defendant’s crossmotion for summary judgment (Doc. #18) are granted in part and denied in part as set

forth in this order.

2. Defendant’s administrative decision is vacated.

3. The case is remanded to Defendant for further proceedings consistent with this

order.

DATED this 20th day of March, 2006.

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