Court Opinion

ID: 4672960
Source: CourtListenerOpinion
Date Created: 2021-03-30 20:00:31.498009+00
Date Added: 2024-06-11T08:03:10.092600
License: Public Domain

NOT FOR PUBLICATION                           FILED
                    UNITED STATES COURT OF APPEALS                       MAR 30 2021
                                                                     MOLLY C. DWYER, CLERK
                                                                       U.S. COURT OF APPEALS
                           FOR THE NINTH CIRCUIT

DIONNE MARIE NADON,                             No.   19-35712

                Plaintiff-Appellant,            D.C. No. 9:18-cv-00140-JCL

 v.
                                                MEMORANDUM*
ANDREW M. SAUL, Commissioner of
Social Security,

                Defendant-Appellee.

                    Appeal from the United States District Court
                            for the District of Montana
                  Jeremiah C. Lynch, Magistrate Judge, Presiding

                       Argued and Submitted March 8, 2021
                            San Francisco, California

Before: WALLACE, GOULD, and FRIEDLAND, Circuit Judges.

      Dionne Nadon appeals from the district court’s judgment affirming the Social

Security Administration (SSA)’s denial of her application for Title II disability

insurance benefits, as well as her application for Title XVI supplemental security

income. The parties are familiar with the facts, so we do not recount them here

except as necessary to provide context for our ruling. We have jurisdiction pursuant

      *
             This disposition is not appropriate for publication and is not precedent
except as provided by Ninth Circuit Rule 36-3.
to 28 U.S.C. § 1291. We review the district court’s judgment affirming an ALJ’s

denial of benefits de novo. Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005).

We VACATE the district court’s affirmance of the denial and REMAND Nadon’s

application to the ALJ for proper consideration of Nadon’s post-traumatic stress

disorder (PTSD) diagnosis and Dr. Newman’s treatment notes.

      Nadon applied for Title II period disability insurance benefits in April 2015,

and she applied for Title XVI supplemental security income on May 31, 2016. She

has alleged her disability began on March 27, 2015. Her alleged disability stems

from a bulging disc in her back, fibromyalgia, other chronic pain, anxiety,

depression, and PTSD. The claims were initially denied in August 2015, and they

were denied again upon reconsideration in January 2016. The basis for the denials

was the determination that Nadon’s conditions are not severe and do not cause

marked limitations. The ALJ held a video hearing in November 2016, and Nadon

was represented by counsel.

      The record submitted to the ALJ included treatment notes by psychiatrist Dr.

Michael Newman, which reflect two sessions he had with Nadon in May 2016 and

July 2016. Dr. Newman diagnosed Nadon with depression and PTSD after the May

2016 session. Dr. Newman elaborated in his notes after their July 2016 session that

Nadon suffers from major depression, “severe and recurrent,” and PTSD. Dr.

Newman wrote that Nadon “reports that she is experiencing emotional and physical

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pain,” “[s]he is sleeping poorly,” and “[s]he is isolating.” He concluded that Nadon

“has thoughts of suicide, but has no plan,” and that “[s]he keeps herself alive because

of her children.”

      In January 2017, the ALJ denied Nadon’s application. The ALJ conducted

the five-step evaluation process, pursuant to 20 C.F.R. §§ 404.1520(a) and

416.920(a), and determined that Nadon was not disabled at steps four and five. The

ALJ ultimately held that Nadon is not entitled to benefits because she has sufficient

residual functional capacity to return to her past relevant work. The ALJ found that

Nadon’s “medically determinable mental impairments of depression and anxiety,

considered singly and in combination, do not cause more than minimal limitation in

the claimant’s ability to perform basic mental work activities and are therefore

nonsevere.” The ALJ did not discuss Nadon’s PTSD diagnosis or Dr. Newman’s

treatment notes relating to Nadon’s PTSD.

      The ALJ cited Dr. Newman’s notes only once to support her finding that “the

claimant demonstrated good concentration, and good insight and judgment during

other examinations.” The ALJ referenced PTSD only in the context of Nadon’s

subjective complaints. Instead, the ALJ relied, in part, on the opinions of two

nonexamining state agency consultants: Mary Bogumill, Ph.D., and Lisa Renner,

M.D. Their respective conclusions were that Nadon’s “mental conditions were

nonsevere.”    Both opinions address “12.04-Affective Disorders” and “12.06-

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Anxiety-Related Disorders.” Neither opinion discussed the PTSD diagnosis nor the

resulting limitations. PTSD is included under section 12.15 relating to “Trauma-

and stress-related disorders.”

       The Social Security Appeals Council denied Nadon’s appeal in March 2018.

In her appeal submission to the Appeals Council, Nadon included a mental

assessment by Dr. Newman dated March 27, 2017. In the 2017 mental assessment,

Dr. Newman wrote that he had started seeing Nadon on May 23, 2016. He wrote

that he had seen Nadon “every few months,” he had diagnosed Nadon with “major

depression; PTSD,” and he opined that Nadon on average is likely to be absent from

work because of those impairments “more than three times per month.” Dr. Newman

stated that the assessment related back to March 27, 2015. In rejecting Nadon’s

appeal, the Council found that Dr. Newman’s assessment did not relate to the period

at issue.

       In July 2019, the district court upheld the ALJ’s decision. The district court’s

order addressed Dr. Newman’s treatment notes; however, it did not discuss the

PTSD diagnosis. The district court, instead, stated that the “ALJ relied on Dr.

Newman’s progress notes from a May 2016 visit in finding that Plaintiff’s medically

determinable mental impairments of depression and anxiety did not cause more than

minimal limitations.” The district court ignored the July 2016 notes and asserted

that “[a]t the time of the ALJ’s decision, there were no other progress notes from Dr.

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Newman in the record.” The district court discounted Dr. Newman’s 2017 mental

assessment and stated that “it was not part of the record at the time of [the] ALJ’s

decision,” and “it did not relate to the period at issue.” The district court also

discounted the retrospective diagnosis in mental assessment and reasoned that

“although Dr. Newman check-marked a box stating that Plaintiff’s symptoms and

limitations would have been present in March 2015, he did not begin treating her

until May 2016.”

      “A decision to deny benefits will only be disturbed if it is not supported by

‘substantial evidence or it is based on legal error.’” Burch, 400 F.3d at 679 (citation

omitted).   Therefore, we review an agency’s factual findings for substantial

evidence. Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019). “[T]he ALJ may reject

an uncontroverted opinion of a treating physician only for clear and convincing

reasons.” Andrews v. Shalala, 53 F.3d 1035, 1041 (9th Cir. 1995) (emphasis

omitted). If the ALJ ignores a medical opinion, we review that omission for

harmless error. Marsh v. Colvin, 792 F.3d 1170, 1172–73 (9th Cir. 2015); see also

Burch, 400 F.3d at 679 (holding that the agency’s conclusion will not be reversed

for errors that are harmless). “In reviewing the agency’s determination, a reviewing

court considers the evidence in its entirety, weighing both the evidence that supports

and that detracts from the ALJ’s conclusion.” Luther v. Berryhill, 891 F.3d 872, 875

(9th Cir. 2018) (citation omitted).

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      First, it is not clear whether the ALJ, the district court, and the SSA in its brief

on appeal have mistakenly overlooked the PTSD diagnosis or have conflated it with

depression. Nadon’s benefits application, the May 2016 and July 2016 treatment

notes, the 2017 mental assessment, and Nadon’s brief on appeal all discuss PTSD.

The ALJ cited “Exh. 16F/3” in her order, which is the first page of the May 2016

notes; however, the list of exhibits for the ALJ’s decision describes the dates for

Newman’s notes as “7/26/2016 to 7/26/2016.” In the ALJ’s failure to discuss Dr.

Newman’s uncontroverted PTSD diagnosis, she also did not provide clear and

convincing reasons to reject the diagnosis. Even if the ALJ, the district court, and

the SSA conflated PTSD with depression, our court has recognized PTSD as a

condition distinct from depression in the context of Social Security benefits appeals.

See Ghanim v. Colvin, 763 F.3d 1154, 1160, 1164 (9th Cir. 2014).

      Second, it is also noteworthy that the Appeals Council, the district court, and

the government have confused the record relating to Dr. Newman’s treatment notes

to discount Nadon’s diagnosis at various points in the proceedings. The record

available to the ALJ clearly reflects that Nadon visited Dr. Newman in May 2016

and July 2016. Yet the district court held that only the May 2016 notes were

available, whereas the government on appeal asserts that only the July 2016 notes

were available. The Appeals Council also erroneously believed that Dr. Newman’s

March 2017 opinion “d[id] not relate to the time period at issue” in Nadon’s benefits

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application. Misunderstanding the temporal scope of a medical opinion is error.

Taylor v. Comm’r of Soc. Sec. Admin., 659 F.3d 1228, 1232 (9th Cir. 2011).

      Nonetheless, the district court highlighted that “although Dr. Newman check-

marked a box stating that Plaintiff’s symptoms and limitations would have been

present in March 2015, he did not begin treating her until May 2016.” Similarly, the

government argues that “[a]lthough Dr. Newman . . . check-marked a box indicating

that Nadon’s symptoms and limitations would have been present in March 2015, the

record contained no indication that he saw or treated Nadon prior to July 2016.” The

government has argued, and the district court agreed, that Dr. Newman’s 2017

mental assessment, therefore, fails to “provide[] any basis for changing the ALJ’s

decision.” This is not the law. We have previously held that a “claimant may

establish such continuous disabling severity by means of a retrospective diagnosis.”

Flaten v. Sec’y of Health & Human Servs., 44 F.3d 1453, 1461 (9th Cir. 1995). It is

well-established that rejecting a medical opinion because it was rendered

retrospectively is not a legitimate basis. See, e.g., Morgan v. Comm’r of Soc. Sec.

Admin., 169 F.3d 595, 601 (9th Cir. 1999); Lester v. Chater, 81 F.3d 821, 832 &

n.10 (9th Cir. 1995).

      Third, the ALJ picked portions of Dr. Newman’s treatment notes to discount

Nadon’s subjective testimony regarding her activities of daily living and how her

mental conditions interfered with her life. On remand, we instruct the ALJ to

                                         7
consider Nadon’s subjective evidence indicating Nadon’s difficulties due to her

PTSD and depression. The ALJ cited the May 2016 notes only to support her finding

that Nadon “demonstrated good concentration, and good insight and judgment[.]”

Yet the ALJ omitted Dr. Newman’s notes that Nadon had reported suicidal thoughts

and isolation.

      Our court’s decision in Diedrich v. Berryhill is instructive. 874 F.3d 634 (9th

Cir. 2017); see also Ghanim, 763 F.3d at 1164. In Diedrich, the ALJ found that

Diedrich was able to engage in a wide range of daily living activities, citing her

abilities to bathe, cook, shop, do chores, and other tasks. However, we held that “the

ALJ ignored other evidence showing the difficulties Diedrich faced in everyday

life,” and we cited Gallant v. Heckler, 753 F.2d 1450, 1456 (9th Cir. 1984), for the

proposition that an “ALJ may not justify a credibility finding by ignoring competent

evidence in the record that suggests an opposite result.” Diedrich, 874 F.3d at 643

(quotation marks omitted). We listed, among other things, Diedrich’s periodic

sleeplessness, bouts of depression, and promiscuousness during manic periods. Id.

We concluded “[t]hat Diedrich could participate in some daily activities does not

contradict the evidence of otherwise severe problems that she encountered in her

daily life during the relevant period.” Id. The ALJ failed to consider similar

evidence from Nadon’s testimony and Dr. Newman’s treatment notes. We direct the

ALJ to conduct this analysis on remand.

                                          8
      Ultimately, the ALJ’s failure to address Dr. Newman’s medical opinion

generally, and specifically with respect to the PTSD diagnosis, was legal error that

was not harmless. See Garrison v. Colvin, 759 F.3d 995, 1012 (9th Cir. 2014)

(“Where an ALJ does not explicitly reject a medical opinion or set forth specific,

legitimate reasons for crediting one medical opinion over another, he errs”). The

ALJ did not simply reject Dr. Newman’s medical opinion without providing reasons

for crediting another opinion; she completely overlooked the PTSD diagnosis or

conflated it with depression and anxiety. In addition, the record does not include

another medical opinion that addressed a potential PTSD diagnosis or its severity,

which might controvert Dr. Newman’s assessment. The ALJ’s error in ignoring this

evidence is not harmless because we cannot “confidently conclude that no

reasonable ALJ, when fully crediting the testimony, could have reached a different

disability determination.” Marsh, 792 F.3d at 1173 (quoting Stout v. Comm’r, Soc.

Sec. Admin., 454 F.3d 1050, 1056 (9th Cir. 2006)).

      On remand, the ALJ is directed to consider Nadon’s PTSD diagnosis and Dr.

Newman’s treatment notes. We also direct the ALJ to consider the PTSD diagnosis

as distinct from that of depression, and the disability analysis should reflect as much.

      VACATED and REMANDED.

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