United States District Court, W.D. Washington, Seattle
REPORT AND RECOMMENDATION
BRIAN A. TSUCHIDA, Magistrate Judge.
Cheyonna Lewis appeals the ALJ's written decision finding her not disabled. She contends the ALJ harmfully misevaluated her credibility and the medical evidence, and that the Court should therefore reverse the Commissioner's final decision for an award of benefits. Dkt. 14 at 2, 17. As discussed below, the ALJ gave at least one clear and convincing reason, supported by substantial evidence to discount Ms. Lewis's testimony. However, the ALJ harmfully erred in determining Ms. Lewis's Residual Functional Capacity ("RFC") by failing to account for all limitations assessed by Amanda Ragonesi, Psy.D. Because the record does not establish a clear entitlement to benefits, the Court recommends REVERSING the Commissioner's final decision and REMANDING the case for further administrative proceedings under sentence four of 42 U.S.C. § 405(g).
Ms. Lewis is currently 36 years old, has a high school degree, and some community college credits. Tr. 31. She worked as a sales associate, barista, and home attendant caregiver. Tr. 69, 275. In October 2010, she applied for benefits, alleging disability as of January 2010. Tr. 21, 78. Her applications were denied initially and on reconsideration. Tr. 82, 89, 102, 115. The ALJ conducted a hearing on August 22, 2012, and subsequently issued a written decision finding Ms. Lewis not disabled. Tr. 21-36, 43-74.
THE ALJ'S DECISION
Utilizing the five-step disability evaluation process,  the ALJ found at steps one through three that Ms. Lewis last worked in January 2010; that major depressive disorder, posttraumatic stress disorder, attention deficit hyperactivity disorder, morbid obesity, back pain, and cervical degenerative disc disease were severe impairments; and that none of these impairments met the requirements of a Listing. With these impairments, the ALJ found Ms. Lewis had the RFC to perform light work subject to the following additional limitations: she could lift or carry twenty pounds occasionally and ten pounds frequently; she could climb only stairs or ramps; she could only occasionally kneel, crouch, or crawl; and she would work best in a simple, routine work environment and should have no more than occasional public contact. Tr. 26. Based on this RFC, a Vocational Expert ("VE") testified that Ms. Lewis could not perform her past relevant work but that there were jobs in the national economy that she could perform. Tr. 35, 69-71. The ALJ accordingly found Ms. Lewis not disabled at step five. As the Appeals Council denied review, the ALJ's decision is the Commissioner's final decision. Tr. 1.
A. Ms. Lewis's Credibility
Ms. Lewis argues the ALJ committed reversible error by failing to provide clear and convincing reasons to discount her testimony about her mental limitations. Dkt. 12 at 5-6. In specific she contends the ALJ erroneously discounted "the severity of her mental limitations, " by relying on her academic activities and lack of mental health treatment. Dkt. 12 at 6. This argument fails.
The ALJ discounted Ms. Lewis's credibility for several reasons, some of which Ms. Lewis has not contested. First, the ALJ found that her testimony was inconsistent with the minimal amount of mental health treatment she received. The Commissioner concedes this ground is invalid. Dkt 15 at 7. However, even accepting this concession, the ALJ gave the following valid reasons to discount Ms. Lewis's credibility: the level of treatment Ms. Lewis sought for her physical problems was inconsistent with her testimony about the severity of her physical limits; the objective medical evidence regarding her physical limitations was inconsistent with her testimony; and Ms. Lewis's activities were inconsistent with her testimony about the severity of both her physical and mental limitations. Tr. 27-30.
Turning first to the ALJ's finding that Ms. Lewis sought little treatment for her allegedly debilitating back problems, an ALJ may properly discount a claimant's statements if the level or frequency of treatment is inconsistent with the level of complaints. Molina v. Astrue, 674 F.3d 1104, 1113 (9th Cir. 2012). The ALJ found Ms. Lewis "testified that she stopped working as an at home care giver in 2009 due to pain in her back and knees. However, the medical record indicates that she sought little, if any, treatment for back and knee pain in all of 2010." Tr. 28. The ALJ's finding that Ms. Lewis's "minimal pursuit of treatment for her physical condition indicates that her pain was not as extreme or limiting as she has alleged, " is thus properly supported by substantial evidence of record. Tr. 28.
The record also shows Ms. Lewis's testimony about the severity of her limitations is inconsistent with the medical record. The record shows that although Ms. Lewis saw her primary care physician numerous times between 2009 and 2010, there is no mention in her medical records about back pain and no indication that she received medical treatment for back pain. Tr. 659-63. The ALJ also noted that in 2011, Ms. Lewis sought treatment for back and knee pain, and that the objective medical evidence was "not consistent with the degree of limitations alleged." Tr. 28. The record supports this finding. The record shows that in March 2011, Dr. Peter Pfeiffer conducted a physical disability evaluation which showed normal coordination, station, and gait. Tr. 689-692. The doctor noted that Ms. Lewis could easily get up and down off the examination table, tie her shoe laces, and dress herself. Tr. 691. Dr. Pfeiffer diagnosed chronic lumbar strain and low back pain. Id. He opined the condition was "mildly limiting, " would improve with exercise, weight loss, physical therapy, and massage, and " no further intervention beyond this is necessary." Tr. 691. The doctor also diagnosed "left knee pain" but stated that "her condition should remain stable and is not a limiting complaint." Id.
Similarly, an October 2011 examination upon complaint of increased back pain revealed lumbar tenderness and spasm but full range of motion, normal straight leg raises, and normal stability and strength. Tr. 760-61. A short time later, Ms. Lewis presented with intermittent numbness in her left arm and both legs. Tr. 763, 765, 772, 782-5. However, an assessment by a neurologist proved "unremarkable" and "without clear physiologic changes seen on examination." Tr. 790. Nerve conductions studies were "essentially normal." Tr. 801. In short, substantial evidence thus supports the ALJ's finding that Ms, Lewis's testimony about the severity of her physical and pain limitations is inconsistent with the medical record.
The ALJ also properly found Ms. Lewis's activities of daily living were inconsistent with her testimony about the severity of both her physical and mental impairments. Activities of daily living "may be grounds for discrediting the claimant's testimony to the extent that they contradict claims of a totally debilitating impairment." Molina v. Astrue, 673 F.3d at 1113. Here, the ALJ found Ms. Lewis's activities "indicate that she would be able to perform in a simple, routine work environment." Tr. 29-31. The ALJ arrived at this conclusion by observing that Ms. Lewis provided total care for her disabled son including dressing, feeding, bathing, and toileting, and that she organized his medical appointments and transported him as needed. Tr. 47-48. The ALJ further found Ms. Lewis was able to attend community college on a part-time basis, go to the library and church, grocery shop, cook, and clean her house. Tr. 29-31. And, although she struggled with school, the ALJ observed that Ms. Lewis was also able to earn several A's and B's and carried a ...