Opinion ID: 1449891
Heading Depth: 1
Heading Rank: 6

Heading: Evidence Vasquez was Severely Impaired

Text: In the five-step sequential process used to evaluate an applicant's disability status, step two consists of determining whether a claimant has a medically severe impairment or combination of impairments. Bowen v. Yuckert, 482 U.S. 137, 140-41, 107 S.Ct. 2287, 96 L.Ed.2d 119 (1987). Vasquez argues that the ALJ's finding of no mental impairment was improper and not supported by substantial evidence. We hold that the ALJ should have been afforded an opportunity to consider additional evidence generated between the ALJ's decision and the Appeals Council hearing, and remand for that purpose. The medical evidence confirms at least some degree of cognitive impairment. In February 2004, Owen Lum, M.D. (Dr. Lum) interviewed and evaluated Vasquez without administering any tests. Dr. Lum diagnosed Vasquez as having adjustment disorder with mixed moods and assessed a Global Assessment of Functioning (GAF) Level of 67. This number indicates an assessment of mild symptoms and some difficulty functioning. [6] Assessing her functional capacity, Dr. Lum wrote that Vasquez is able to perform simple and repetitive tasks, and in the absence of major psychiatric problems, could perform detailed tasks. He stated that she is able to accept instructions from supervisors and interact with coworker[s] and the public, and further, that she could work on a consistent basis and attend a regular work situation[,] secondary to the absence[ ] of major cognitive deterioration. The month after Dr. Lum's interview, Vasquez was interviewed and tested by psychologist Ute Kollath, Ph.D. (Dr. Kollath). Dr. Kollath administered WMS-III, WAIS-III and Bender-Gestalt examinations. She reported that Vasquez's IQ score was a 62, placing her in the mildly mentally retarded range; however, Dr. Kollath further stated that this appears to be an underestimate of her intellectual level of functioning and variable motivation might account for this. Her clinical impression was that Vasquez placed in at least the borderline range. Her Global Measure of Impairment (GMI) score was less than 50, which demonstrates a memory in the impaired range; however, Dr. Kollath reported that this score appears to be an underestimate of her memory functioning because she was able to recall some, detailed autobiographical information. Dr. Kollath stated that her overall impression was of an individual who could well have cognitive impairment, but stated that Vasquez's limited engagement towards the testing process interfered with a full assessment. Dr. Kollath diagnosed an Adjustment Disorder with Depressed Mood, Learning Disorder NOS, and a GAF of 60. This GAF score indicates moderate symptoms or moderate difficulty in social, occupational, or school functioning. DSM IV-TR, p. 34. She specifically noted that Vasquez appeared to be able to maintain concentration, persistence, and pace, was able to relate well in the interview and would be able to appropriately interact with supervisors and co-workers in a job setting. She found her able to perform simple repetitive tasks, but unable to perform detailed and complex tasks. The ALJ referenced the findings of Drs. Lum and Kollath in her decision, though she made no specific findings regarding Vasquez's mental health. In assessing the objective evidence of impairment obtained from Dr. Kollath's testing, the ALJ noted Dr. Kollath's observations that the scores were likely underestimates of her true abilities. After the ALJ issued her decision denying benefits, Vasquez was seen by Dr. Sanchez for further psychological evaluation and testing. Vasquez argues that this additional evidence, which she submitted to the Appeals Council, clearly demonstrates that she did suffer from a mental impairment during the relevant time period. [7] Dr. Sanchez reviewed Vasquez's records and administered the following examinations: WAIS-III adult intelligence scale; WMS-III memory scale; 3(WRAT3) wide range achievement test; Reyes 15 Items; and a mental status examination. His report noted that she put forth full effort during the evaluation, demonstrated no indication of malingering during the Reyes 15 Items test, and appeared as a credible claimant. Dr. Sanchez's report indicates that Vasquez's Full Scale IQ score is a 65, which indicates that she is currently functioning in the mentally retarded range of measured intelligence. It further states that, all of her scores fall within the borderline and mentally retarded range indicating limited general verbal intelligence; conceptual thinking; numeric manipulation; immediate auditory recollection; general knowledge; social judgment, common sense, reality awareness, judgment in practical situation; limited ability to differentiate between essential and non-essential details; limited capacity for sustained effort, attention, concentration and mental efficiency ... Her scores on the memory examination demonstrated significantly below average memory skills. Dr. Sanchez assessed that Vasquez could read at a third grade level, spell at a fourth grade level, and perform arithmetic at a first grade level. He diagnosed Major Depressive Disorder, Pain Disorder, Reading Disorder, Disorder of Written Expression, Mathematics Disorder, and Borderline Intellectual Functioning, with an overall GAF of 49. The GAF score indicates an assessment that Sanchez suffered from serious symptoms or a serious impairment in social, occupation, or school functioning. DSM IV-TR, p. 34. Dr. Sanchez further stated that while Vasquez would not have any difficulty being socially appropriate, [s]he would have moderate difficulty in concentrating, focusing and keeping up with the pace of a working environment given [her] preoccupation with pain and her current level of emotional functioning. He stated that she was viewed as being able to perform simple and repetitive tasks, but was not able to determine whether she would be able to tolerate the stress of an 8-hour day, 40-hour week on a consistent basis. Dr. Sanchez's report suggests that Vasquez may suffer from cognitive impairments. While Dr. Kollath reported Vasquez's IQ score at 62, she noted that the score appear[ed] to be an underestimate of her intellectual level of functioning. She further stated that while Vasquez appeared to be an individual who could well have cognitive impairment, her limited engagement towards the testing process interfered with a full assessment. In comparison, Dr. Sanchez reported that Vasquez was a credible claimant and found that Vasquez's IQ was slightly higher (a Full Scale score of 65) but still within the mentally retarded range of measured intelligence. If credited, Dr. Sanchez's statements could certainly support a finding of mental impairment. His report plainly states that Vasquez has significantly below average memory skills, and test scores indicating limited social judgment, common sense, capacity for sustained effort, attention and mental efficiency. Further, his GAF assessment indicates serious symptoms or a serious impairment in social, occupation, or school functioning. See DSM IV-TR, p. 34. The Commissioner argues that Dr. Sanchez's findings are contrary to the evidence presented to the ALJ ( e.g., the testimony of Drs. Lum and Kollath), and therefore, should not be credited. However, if the Appeals Council had remanded the case for additional review, Dr. Sanchez's findings would have enhanced the information available to the ALJ and provided additional, rather than contradictory, evidence of Vasquez's condition. Though the ALJ expressed some hesitancy regarding the credibility of Dr. Kollath's findings, as explained above, Dr. Sanchez arrived at a similar diagnosis. Because Dr. Sanchez's findings are based on objective clinical tests, and buttressed by his statement that Vasquez appeared to be a credible claimant, they could be sufficient to show a mental impairment. See Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir.1989) (quoting Miller v. Heckler, 770 F.2d 845, 849 (9th Cir.1985) (where a nontreating physician's opinion rests on objective clinical tests, it must be viewed as substantial evidence)). Moreover, to the extent Drs. Kollath and Sanchez's testimony supports a finding of mental impairment that would not have been supported by Dr. Lum's testimony, the Court may conclude that the evidence is not actually contradictory, because Dr. Lum did not perform any of the clinical tests on which Drs. Kollath and Sanchez based their opinions. When viewed as a whole, the medical reports suggest that Vasquez may suffer from a cognitive impairment. Because the ALJ did not have access to Dr. Sanchez's reports in deciding otherwise, she also did not account for Vasquez's mental impairments in determining her residual functioning capacity at step four of the disability determination. See § 404.1523 (noting that where a claimant has a combination of impairments, the combined impact of the impairments will be considered throughout the disability determination process); § 404.1545 (noting that where a claimant has more than one impairment, the SSA will consider all of them, even those that are not severe, in determining the claimants residual functioning capacity). Neither party has presented any argument regarding how Vasquez's impairments would affect a determination of her residual functioning capacity under the guidelines. [8] Thus, there are no facts presented that clearly indicate the proper outcome of steps four and five of the disability determination evaluation. For this reason, the Court cannot find Vasquez disabled and order an immediate payment of benefits. See Harman v. Apfel, 211 F.3d 1172, 1178-79 (9th Cir.2000) (allowing an immediate award of benefits directed when, among other things, it is clear from the record that the ALJ would be required to find the claimant disabled if the evidence is credited). Rather, in cases such as these, where the testimony of the vocational expert has failed to address a claimant's limitations as established by improperly discredited evidence, this Circuit has consistently ... remanded for further proceedings rather than payment of benefits. Id. Accordingly, we remand to allow the ALJ to consider Dr. Sanchez's reports in determining whether Vasquez suffers from a mental impairment, and to consider how these limitations affect her residual functioning capacity and ability to perform other work at steps four and five of the disability determination sequence.