United States District Court, W.D. Washington, Tacoma
ORDER REVERSING AND REMANDING DEFENDANT'S
DECISION TO DENY BENEFITS
W. Christel, United States Magistrate Judge
Tracy Edwin Oyler filed this action, pursuant to 42 U.S.C.
§ 405(g), for judicial review of Defendant's denial
of Plaintiff's application for disability insurance
benefits (“DIB”). Pursuant to 28 U.S.C. §
636(c), Federal Rule of Civil Procedure 73, and Local Rule
MJR 13, the parties have consented to have this matter heard
by the undersigned Magistrate Judge. See Dkt. 5.
considering the record, the Court concludes the
Administrative Law Judge (“ALJ”) erred by failing
to adequately address medical opinion evidence from Dr.
Patricia Sylwester, M.D. Had the ALJ properly considered Dr.
Sylwester's opinion, the residual functional capacity
(“RFC”) may have included additional limitations.
The ALJ's error is therefore not harmless, and this
matter is reversed and remanded pursuant to sentence four of
42 U.S.C. § 405(g) to the Acting Commissioner of Social
Security (“Commissioner”) for further proceedings
consistent with this Order.
AND PROCEDURAL HISTORY
August 4, 2014, Plaintiff filed an application for DIB,
alleging disability as of September 9, 2013. See
Dkt. 8, Administrative Record (“AR”) 25. The
application was denied upon initial administrative review and
on reconsideration. See AR 25. ALJ David Johnson
held a hearing on May 10, 2016. AR 42-90. In a decision dated
June 10, 2016, the ALJ determined Plaintiff to be not
disabled. AR 22-41. The Appeals Council denied
Plaintiff's request for review of the ALJ's decision,
making the ALJ's decision the final decision of the
Commissioner. See AR 1-6; 20 C.F.R. § 404.981,
Plaintiff's Opening Brief, Plaintiff maintains the ALJ
erred by: (1) failing to properly consider medical opinion
evidence from Dr. Sylwester; and (2) failing to respond to
Plaintiff's post-hearing objections. See Dkt.
10. As a result of these errors, Plaintiff requests the Court
remand his claim for further administrative proceedings.
Id. at 17.
to 42 U.S.C. § 405(g), this Court may set aside the
Commissioner's denial of social security benefits if the
ALJ's findings are based on legal error or not supported
by substantial evidence in the record as a whole. Bayliss
v. Barnhart, 427 F.3d 1211, 1214 n.1 (9th Cir. 2005)
(citing Tidwell v. Apfel, 161 F.3d 599, 601 (9th
Whether the ALJ properly considered the medical opinion
asserts the ALJ erred by failing to give adequate reasons to
reject medical opinion evidence from examining physician Dr.
Sylwester. Dkt. 10, pp. 10-17.
March 27, 2016, Dr. Sylwester conducted a physical
examination of Plaintiff. See AR 596-600. Dr.
Sylwester's examination included a record review, a
discussion with Plaintiff regarding his complaints and
medical history, and a physical examination. See AR
595-600. Based on her physical examination, Dr. Sylwester
noted Plaintiff could “change position with
difficulty.” AR 598. Dr. Sylwester further determined
Plaintiff had an unsteady, wide-based gait in the absence of
his brace and cane. AR 598. Similarly, Dr. Sylwester found
Plaintiff “very unbalanced, ” with an unsteady
walk, unable to perform a toe walk, unsteady on a heel walk,
and unable to stand or hop on either leg independently. AR
598. Dr. Sylwester diagnosed Plaintiff with right knee
arthritis, and noted he was “tender to palpation over
the medial joint line of his right knee.” AR 599.
Plaintiff's heart conditions, Dr. Sylwester noted
Plaintiff had existing diagnoses of atrial fibrillation,
congestive heart failure, and dilated cardiomyopathy. AR
596-97, 599. Dr. Sylwester's examination revealed
Plaintiff's heart had irregular rhythm with normal
ventricular response, and Plaintiff displayed
“shortness of breath with minimal exertion.” AR
599. In all, Dr. Sylwester wrote she did not expect any of
Plaintiff's conditions - his right knee arthritis, heart
conditions, or unsteady gait - to improve over time. AR 599.
her examination, Dr. Sylwester provided a functional
assessment of Plaintiff's abilities. See AR
599-600. She opined Plaintiff had a maximum ability to stand
or walk with normal breaks for less than two hours due to his
arthritis, heart condition, and unsteady gait. AR 599.
Furthermore, she determined that although Plaintiff was not
limited in his ability to sit with normal breaks, he
“may need to change positions as needed.” AR 600.
Dr. Sylwester opined it was “medically necessary”
for Plaintiff to use his right knee brace and cane “for
all distances and all terrain.” AR 600. She also wrote
Plaintiff had a maximum lifting and carrying capacity of less
than ten pounds occasionally and frequently in light of his
heart condition and unsteady gait. AR 600. In addition, she
opined Plaintiff “should never climb, balance, stoop,
kneel, crouch or crawl due to his heart condition, arthritis,
and unsteady gait.” AR 600. Dr. Sylwester determined
Plaintiff was not limited in his ability to reach, ...