Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_04-cv-01659/USCOURTS-cand-3_04-cv-01659-0/pdf.json

Parties Involved:
Jo Anne B. Barnhart
Defendant
Robert J. Denoris
Plaintiff

Document Text:

United States District Court

For the Northern District of California

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United States District Court

For the Northern District of California

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

ROBERT J DENORIS,

Plaintiff,

v

JO ANNE B BARNHART, 

COMMISSIONER OF

SOCIAL SECURITY,

Defendant. /

No C 04-01659 VRW

ORDER

Plaintiff Robert J Denoris appeals from the decision of

the Social Security Administration (SSA) denying plaintiff social

security disability benefits. The court now considers crossmotions for summary judgement. Pl Mot (Doc #13); Def Mot (Doc

#14). Because the court concludes that the ALJ’s decision was

based upon legal error, the court GRANTS plaintiff’s motion and

DENIES defendant’s motion.

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I 

A 

Plaintiff was fifty-three years old on September 8, 2001,

the date he alleges he became disabled. Administrative Record, Doc

# 8 (AR) 75. Plaintiff is a high school graduate and has past

relevant work experience as a lab technician and driver. AR 76. 

Plaintiff reports that as a lab technician he used technical skill

and knowledge, lifted weights as heavy as twenty pounds

occasionally and ten pounds frequently. Id. Plaintiff has not

worked since September 8, 2001. AR 75.

On September 11, 2001, plaintiff underwent open heart

bypass surgery and a mitral valve replacement. AR 78, 242. Since

the date of his surgery, plaintiff has complained of severe

depression, sleep deprivation, fatigue, shortness of breath and

dizziness. AR 100. Plaintiff’s medical history is primarily

reported in the records of his three treating physicians: Dr

Kenneth Jiang, MD, Dr Martin Bress, MD, and Dr Niel Starksen, MD. 

One month after surgery, Dr Steven Schwartz, plaintiff’s surgeon,

wrote that plaintiff’s heart had a regular rate and rhythm and good

valve click. AR 242. After examining plaintiff on November 30,

2001, Dr Starksen wrote that the prosthetic mitral valve was

functioning normally, and that plaintiff had no further symptoms. 

AR 346. On August 7, 2002, Dr Starksen recorded that plaintiff’s

cardiac exam and stress echocardiogram were both normal, and that

there was no evidence of ischemia. AR 337. Dr Starksen also noted

that plaintiff was “possibly depressed.” AR 339. Dr Bress, in a

letter to Dr Jiang, stated that on March 26, 2003, plaintiff had

completed thirty-six sessions of cardiac rehabilitation, that there

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was no evidence of inducible myocardial ischemia and that plaintiff

seemed motivated to make a lifestyle readjustment and planned to

join a gym. AR 401.

Five months later, plaintiff’s treating internal medicine

physician Dr Jiang, in a “cardiac medical source statement

questionnaire” dated August 12, 2003, opined that plaintiff was

incapable of even low stress jobs, was unable to sit or stand for

more than two hours, incapable of lifting more than twenty pounds,

and must avoid all exposure to extreme cold, heat, wetness,

humidity, noise, fumes, odors and hazards. He noted, moreover,

that plaintiff was not a malingerer. AR 495-98. 

Plaintiff testified that he saw a psychologist for his

depression “for a little while.” AR 39. Treating psychologist Dr

Wendy Sinclair-Brown, PhD, responded to a medical records request

for the period during which she treated plaintiff for depression

with the statement that “patient has no psychological problems that

prevent him from participating in ADL’s or the workforce.” AR 369. 

She provided no other records. Id. 

The record also contains reports from consulting

examinations ordered by the SSA in connection with plaintiff’s

claim for benefits. On November 2, 2002, psychiatrist Arthur

Floreza, MD, examined plaintiff and diagnosed him with a

“depressive disorder not otherwise specified,” noting that “[h]e is

now currently spending a good deal of time isolating himself from

the public and so he would likewise have difficulty maintaining

regular attendance in a workplace.” AR 363-67. Dr Floreza further

noted that plaintiff’s depression was likely secondary to his

medical condition, and that due to “the chronicity of his medical

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condition [h]is prognosis is quite poor and [] he will [be]

unlikely [to] improve within the next 12 months.” AR 366. Dr

Floreza concluded: “[h]e would be capable of completing simple and

repetitive tasks if his medical condition allows * * *[and] the

claimant would not have difficulty with complex tasks, again,

medical condition permitting.” AR 367. On December 19, 2002,

psychiatrist Donald Walk, MD, completed a “Mental Residual

Functional Capacity Assessment,” indicating that he found plaintiff

to be moderately limited in the areas of “the ability to complete a

normal workday and workweek without interruptions from

psychologically based symptoms and to perform at a consistent pace

without an unreasonable number and length of rest periods” and ”the

ability to interact appropriately with the general public.” AR at

371. Dr Walk concluded that plaintiff has a “depressive feature

[that] may reduce public interaction/persistence: [but] he can

adapt to competitive employment.” AR 372.

B

On June 24, 2002, plaintiff filed an application for

social security disability benefits. AR 68. In his initial

application, plaintiff stated that he was disabled due to his heart

condition; in his reconsideration disability report he stated that

his injury had worsened and he was suffering from severe

depression, fatigue, sleep deprivation, shortness of breath and

dizziness. AR 75, 100. Both initially and on reconsideration, the

SSA denied Plaintiff’s request for benefits finding that plaintiff

was not disabled within the meaning of Title Two of the Social

Security Act (Act). AR 55, 60. 

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Plaintiff filed a timely request for an administrative

hearing, which took place on August 28, 2003. At the hearing,

plaintiff testified that he was unable to work due to depression

and extreme fatigue resulting from his heart condition. AR at 37,

39. The vocational expert (VE) testified that a hypothetical

fifty-five-year-old individual with plaintiff’s past relevant work

experience, level of education, and a residual functional capacity

(RFC) for light work would be able to work as a lab technician. AR

43. The VE also testified that if an individual was limited in the

manner described by Dr Jiang (unable to sit or stand for more than

four hours in a day or to be exposed to extreme environmental

conditions and needing to miss work more than four times a month)

that individual would not be able to work in any job which exists

in substantial numbers in the economy on a full-time basis. AR 48.

On October 21, 2003, the administrative law judge (ALJ)

denied benefits based on the evidence presented at the hearing,

including the testimony of plaintiff and the VE, the reports of Drs

Starksen, Jiang, Bress, and Schwartz and other medical records. AR

14-20. The ALJ’s decision set forth the five-step sequential

evaluation of disability required by 20 CFR § 404.1520, which

considered the following: 1) whether plaintiff was currently

engaged in substantial gainful activity; 2) whether plaintiff had a

severe impairment or combination of impairments; 3) if plaintiff

had a severe impairment, whether plaintiff had a condition that met

or equaled the conditions outlined in the Listing of Impairments,

20 CFR § 404, Pt 404, Subpt P, App 1; 4) if plaintiff did not have

such a condition, whether plaintiff was capable of performing his

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past work; and 5) if not, whether plaintiff had the RFC to do other

available work. 

Applying this five-step sequential evaluation to

plaintiff, the ALJ found that: 1) plaintiff met the Act’s insured

status requirements through December 2006 and had not been engaged

in substantial gainful activity during the relevant period; 2)

plaintiff had a history of coronary artery disease, status post

mitral valve replacement and double bypass, and mild depression; 3)

plaintiff did not have an impairment that met or equaled any listed

impairment; 4) ”the claimant’s subjective complaints of shortness

of breath, frequent fatigue, reduced stamina and stress were

uncorroborated by objective clinical signs and findings showing the

existence of medically determinable impairments that could

reasonably cause the degree of incapacity alleged”; 5) the

conclusions of the functional assessment form submitted by Dr Jiang

were not supported by the clinical signs and findings and were

contrary to the doctor’s progress notes — “[f]or example, Dr Jiang

provided no explanation why an individual who was ready to join a

gym in March 2002 was incapable of more than very restricted

activities in August 2002"; 6) plaintiff retained the RFC for an

essentially full range of light work; 7) plaintiff’s past relevant

work as a lab technician was skilled light work and his past

relevant work as a truck/van driver was medium semi-skilled work;

8) plaintiff retained the RFC for his previous employment as a lab

technician and also had the capacity to perform other jobs that

exist in significant numbers in the national economy; 9) the

claimant had not been under a disability as defined by the Act at

any time through the date of the decision. AR 16, 19. 

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The ALJ also reasoned that the fact that plaintiff had

undergone surgery and was taking medication “does not render him

disabled,” and commented that “given the nature of the surgery his

functional nature may have improved.” AR 17. Further, the ALJ

found that plaintiff’s depressive disorder was not severe,

reasoning that “[t]he claimant’s minimal treatment does not support

the presence of a severe mental impairment.” Id. The ALJ

concluded that plaintiff was not disabled because he was capable of

performing his former light work as a lab technician, or,

alternatively, was able to perform other jobs per the VE’s

testimony. Id. 

Plaintiff appealed the ALJ’s decision to the SSA’s

Appeals Council, which denied review. On April 28, 2004, plaintiff

timely filed the instant action for judicial review of the ALJ’s

decision. 

II

The court’s jurisdiction is limited to reviewing the

administrative record to determine whether the ALJ’s decision is

supported by substantial evidence and whether the SSA complied with

the requirements of the Constitution, the Act and its

administrative regulations in reaching the decision reviewed. 42

USC § 405(g). A district court may overturn a decision to deny

benefits only if the decision is not supported by substantial

evidence or if the decision is based on legal error. See Andrews v

Shalala, 53 F3d 1035, 1039 (9th Cir 1995); Magallanes v Bowen, 881

F2d 747, 750 (9th Cir 1989). “Substantial evidence” is defined as

“more than a mere scintilla but less than a preponderance; it is

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such relevant evidence as a reasonable mind might accept as

adequate to support a conclusion.” Andrews, 53 F3d at 1039. 

III

A

The Act provides that certain individuals who are “under

a disability” shall receive disability benefits. 42 USC §

423(a)(1)(D). Disability is the “inability to engage in any

substantial gainful activity by reason of any medically

determinable physical or mental impairment which can be expected to

result in death or which has lasted or can be expected to last for

a continuous period of not less than 12 months.” 42 USC §

423(d)(1)(A). An individual will be found disabled if his

impairments are such “that he is not only unable to do his previous

work but cannot, considering his age, education, and work

experience engage in any other kind of substantial gainful work

which exists in the national economy * * *.” 42 USC §

423(d)(2)(A). 

To evaluate a claim of disability based on mental

impairment, the ALJ is required to employ a “special technique” at

the administrative hearing level to assist in 1) identifying the

need for additional evidence, 2) considering and evaluating the

functional consequences of the mental disorder on the claimant’s

ability to work and 3) organizing and presenting the facts. See 20

CFR § 404.1520a(b). The regulation provides: 

(b)(1) Under the special technique, we must

first evaluate your pertinent symptoms, signs, and

laboratory findings to determine whether you have a

medically determinable mental impairment(s). [] If we

determine that you have a medically determinable mental

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impairment(s), we must specify the symptoms, signs, and

laboratory findings that substantiate the presence of

the impairment(s) and document our findings in

accordance with paragraph (e) of this section. * * *

(c)(1) * * * We will consider all relevant

and available clinical signs and laboratory findings,

the effects of your symptoms, and how your functioning

may be affected by factors including, but not limited

to, chronic mental disorders, structured settings,

medication, and other treatment. * * * (3) We have

identified four broad functional areas in which we

will rate the degree of your functional limitation:

Activities of daily living; social functioning;

concentration, persistence, or pace; and episodes of

decompensation. [] (4) When we rate the degree of

limitation in the first of three functional areas []

we will use the following five-point scale: None,

mild, moderate, marked, and extreme. When we rate the

degree of limitation in the fourth functional area

(episodes of decompensation) we will use the following

four-point scale: None, one or two, three, four or

more. The last point on each scale represents a

degree of limitation that is incompatible with the

ability to do any gainful activity.

(d) * * * After we rate the degree of

functional limitation resulting from your

impairment(s), we will determine the severity of your

mental impairment(s). * * *

(e) Documenting application of the

technique. * * * At the administrative law judge

hearing and Appeals Council levels[], we will document

application of the technique in the decision. * * *

(2) At the administrative law judge hearing and

Appeals Council levels, the written decision issued by

the administrative law judge or Appeals Council must

incorporate the pertinent findings and conclusions

based on the technique. The decision must show the

significant history, including examination and

laboratory findings, and the functional limitations

that were considered in reaching a conclusion about

the severity of the mental impairment(s). The

decision must include a specific finding as to the

degree of limitation in each of the functional areas

described in paragraph (c) of this section.

20 CFR § 404.1520a (emphasis added). 

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B

Plaintiff makes two major contentions in support of his

motion. First, he contends that the ALJ erred by applying the

wrong legal standard when determining whether plaintiff has a

mental impairment; specifically, plaintiff argues that the ALJ did

not follow § 1520a’s requirement that she enumerate her findings as

to the degree of limitation in each of the four functional areas. 

Pl Mot (Doc #13 at 4-5). Second, plaintiff contends that the ALJ

further erred by failing to incorporate all of plaintiff’s alleged

impairments into the questions the ALJ posed to the VE. Id. The

court agrees with these contentions and finds on that basis that

remand to the agency is warranted.

1

Here, the ALJ did not, at any point in her decision,

“include a specific finding as to the degree of limitation in each

of the four functional areas,” nor did the ALJ “incorporate

pertinent findings and conclusions” regarding plaintiff’s alleged

mental impairment as required by § 1520a. Failure to do so requires

this court to remand if the plaintiff has a “colorable claim of

mental impairment.” See Guiterrez v Apfel, 199 F3d 1048, 1051 (9th

Cir 2000). Guiterrez construed an earlier version of § 1520a which

required the ALJ to complete a Psychiatric Review Technique Form

(PRTF). An amended section 404.1520a became effective on September

20, 2000, and was therefore applicable to the ALJ’s decision in this

matter. 65 Fed Reg 507746-01. Prior to its amendment, the

regulation merely required the ALJ to complete a PRTF in order to

comply with the statute. Guiterrez, 199 F3d at 1049-1050. The new

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regulation abolished the use of the PRTF in favor of requiring the

ALJ to set forth detailed findings and conclusions into his or her

decision. See 20 CFR § 404.1520a(e)(2), quoted in part III A above. 

A plaintiff’s claim of mental impairment is “colorable” if

it is one which is not “wholly insubstantial, immaterial, or

frivolous.” McBride Cotton & Cattle Corp v Veneman, 290 F3d 973,

981 (9th Cir 2002) (quoting Cassim v Bowen, 824 F2d 791, 795 (9th

Cir 1987)). Dr Floreza, a consulting physician, concluded that

plaintiff had a depressive disorder; Dr Starksen, one of plaintiff’s

treating physicians, noted that plaintiff might suffer from

depression; and Dr Jiang, another treating physician, concluded that

plaintiff’s physical symptoms and limitations caused depression. AR

at 339, 396, 495. This evidence gives rise to a colorable claim of

mental impairment. Accordingly, the ALJ was required to follow the

procedures set forth in § 1520a. 

The ALJ’s noncompliance with § 1520a was not harmless

because it resulted in her failure adequately to consider

plaintiff’s alleged mental impairment as a possible basis for his

claim of disability. Specifically, the ALJ did not consider

whether, based on plaintiff’s degree of limitation in each of the

four functional areas, plaintiff’s mental impairment was severe at

step two, met or equaled a listed impairment at step three, impacted

his RFC at step four, or should have been included in her

hypothetical questions to the VE at step five. See 20 CFR §

404.1520. 

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2

The ALJ’s failure to apply the special technique for

mental impairments at 20 CFR § 404.1520a makes it impossible for the

court to determine whether substantial evidence supported

plaintiff’s alleged mental impairment and whether the ALJ thus erred

in failing to include this alleged impairment in the hypothetical

questions posed to the VE. “An ALJ must propound a hypothetical to

a VE that is based on medical assumptions supported by substantial

evidence in the record that reflects all the claimant’s

limitations.” Osenbrock v Apfel, 240 F3d 1157, 1165 (9th Cir

2001)(citing Roberts v Shalala, 66 F3d 179, 184 (9th Cir 1985)). 

 On remand, the ALJ must evaluate plaintiff’s mental

impairment using the procedure set out at § 1520a and must then

repeat the remaining steps of the sequential evaluation in light of

the properly-conducted mental impairment evaluation. If the ALJ

determines that under the § 1520a analysis there is substantial

evidence of a mental impairment the ALJ must propound hypothetical

questions to the VE that reflect this limitation. If the evidence

in the record is insufficient to determine the extent of plaintiff’s

mental impairment under § 1520a, a new psychiatric evaluation may be

required. See 20 CFR §§ 404.1519(a)(b)(4), 416.919a(b)(4); see also

Smolen v Charter, 80 F3d 1273, 1288 (9th Cir 1996) (holding that

“[i]n Social Security cases, the ALJ has a special duty to fully and

fairly develop the record and to assure that the claimant’s

interests are considered”). 

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IV

For the reasons stated herein, this matter is remanded to

the SSA for re-evaluation of the evidence consistent with this

order. The clerk shall enter judgment in accordance with this order

and close the file and terminate all pending motions.

IT IS SO ORDERED.

 

VAUGHN R WALKER

United States District Chief Judge

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