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Houston v. Berryhill

United States District Court, W.D. Washington, Seattle

September 21, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Susan Houston appeals the ALJ's decision finding her not disabled. The ALJ found Ms. Houston's obesity, cervical and lumbar degenerative disc disease, osteoarthritis, diabetes, affective disorder, anxiety, posttraumatic stress disorder, substance abuse, left knee medical meniscus tear, chrondromalacia, are severe impairments; that with these impairments she has the Residual Functional Capacity (RFC) to lift/carry 20 pounds occasionally and 10 pounds frequently, and stand/walk and sit for six hours, with normal breaks subject to additional physical, postural, environmental, and non-exertional limitations; that Ms. Houston cannot perform her past work but can perform other jobs that exist in significant numbers in the national economy. Tr. 23-37.

         Ms. Houston contends the ALJ erred in assessing the medical opinions of her treating and examining providers. Dkt. 11 at 1. As discussed below, the Court REVERSES the Commissioner's final decision and REMANDS the matter for further administrative proceedings under sentence four of 42 U.S.C. § 405(g).


         A. James Czysz, Psy.D.

         Dr. Czysz performed a psychological evaluation of Ms. Houston and opined she has several moderate and marked limitations in her ability to perform work activities. Tr. 462-68. Ms. Houston argues, and the Court agrees, the ALJ erred by failing to provide specific and legitimate reasons to reject Dr. Czysz's opinion. See Lester v. Chater, 81 F.3d 821, 830-31 (9th Cir. 1996).

         The ALJ found Dr. Czysz's opinions lacked sufficient rationale and support, and relied instead upon Ms. Houston's non-credible statements. An ALJ may not reject an examining physician's opinion by questioning the credibility of the patient's complaints where the doctor does not discredit those complaints and supports his ultimate opinion with his own observations. Edlund v. Massanari, 253 F.3d 1152, 1159 (9th Cir. 2001). Dr. Czysz did not question Ms. Houston's claims. While he considered her statements, he also supported his conclusions by performing a clinical examination and mental status exam, and by administering standardized testing. Additionally, in the clinical findings section, Dr. Czysz described Ms. Houston's symptoms, their severity, and the impact on her ability to perform work. Substantial evidence does not support the ALJ's conclusion that the doctor failed to provide a rationale or any support for his opinions.

         The ALJ also found the difficulties Ms. Houston displayed during Dr. Czysz's cognitive exam were inconsistent with her treatment record which the ALJ indicated showed she had normal attention span, concentration and memory. Tr. 32. Substantial evidence does not support this finding. First the records the ALJ relies upon were created by other sources, not a medical doctor. Many of the records the ALJ referenced were prepared by Megan Merritt, PA-C. The ALJ rejected Ms. Merritt's opinions about the severity of Ms. Houston's limitations, Tr. 34. It is thus unreasonable for the ALJ to rely on discredited Ms. Merritt's records to reject Dr. Czyz's opinions. Second, only one record indicated normal attention, concentration and memory. Tr. 522. The others were limited to memory only. One record indicated intact attention and memory but also noted poor concentration and severe anxiety. Tr. 474-75. None of the records indicate any testing was performed and if so what the results were. An ALJ may gave more weight to the opinion of an “other source” who is not an “acceptable medical source” if the other source provides better supporting evidence and a better explanation for his or her opinion. See SSR 06- 03p, 2006 WL 2329939, *5 (Aug. 9, 2006). But here, the other sources did not consistently find Ms. Houston more functional in all cognitive spheres as the ALJ found, and provided no supporting evidence or explanation in support of their notations regarding memory, concentration or attention. The ALJ's determination is thus not supported by substantial evidence.

         Finally, the ALJ rejected Dr. Czysz's opinion regarding depressive symptoms as inconsistent with findings from another exam. Substantial evidence does not support this finding because Dr. Czysz's opinion is based upon psychological testing he performed regarding Ms. Houston's depression, but the exam relied upon by the ALJ to contradict the doctor's depression opinions pertains to an appointment addressing Ms. Houston's physical symptoms. See Tr. 544. That it mentions “no . . . evidence of depression” during that appointment does not constitute a meaningful contrast to Dr. Czysz's findings.

         B. Joanne Gartenberg, M.D., and Suzanne Oelke, M.A.

         Dr. Gartenberg and Ms. Oelke co-signed a May 2015 medical source statement rating Ms. Houston's limitations in a variety of areas and describing her diagnoses. Tr. 599-01. The ALJ rejected the statement on the grounds it does not cite to any objective signs or provide a significant rational to support the limitations found; is inconsistent with treatment records showing “normal concentration, attention span, memory, mood and affect”; and because the statement was completed only a week after Ms. Houston started treatment with the doctor and Ms. Oelke. Id. Tr. 33.

         The ALJ erred in rejecting the statement as inconsistent with the treatment record. This is a conclusory statement and legal error. See Regennitter v. Comm'r Soc. Sec. Admin., 166 F.3d 1294, 1299 (9th Cir.1999) (Conclusory reasons will not justify an ALJ's rejection of a medical opinion.).

         The ALJ may give less weight to a doctor's opinion that is brief, conclusory, and inadequately supported by medical records. Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th Cir. 2005). The Court cannot say it was unreasonable for the ALJ to discount the statement on the grounds it lacks “significant rationale.” The statement states Ms. Houston's diagnoses, how “she has trouble functioning, ” and how she has been homeless five years. Tr. 601. But there is no explanation for how these statements support a finding that Ms. Houston is markedly and moderately impaired in virtually every functional category. The marked and moderate limitations are thus essentially unexplained.

         Although the ALJ reasonably found the statement should be discounted because it lacks significant rationale, Ms. Houston argues, the ALJ erred because Dr. Gartenberg's treatment notes support the findings contained in the statement. Dkt. 11 at 4-5. However, at the time Dr. Gartenberg signed the statement, she had examined Ms. Houston once; her treatment notes from that examination does not contain findings indicating Ms. Houston has multiple marked and moderate cognitive or social functional limitations. See Tr. 686-87. After completing the statement, Dr. Gartenberg examined Ms. Houston a number of times. But most of the mental status examination findings are within normal limits. See Tr. 677-87. The doctor noted Ms. Houston had depressed and anxious mood but those notes provides no more information than the statement which also indicated Ms. Houston suffered from depression and PTSD. Some of the doctor's post-statement examination findings are also inconsistent with the statement. For example, Dr. Gartenberg found Ms. Houston's memory was intact after signing the statement, in contrast to the statements findings that Ms. Houston has moderate and marked limitations in her ability to remember instructions. Compare Tr. 599-600 wi ...

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