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Olivieri v. Berryhill

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

July 3, 2018

NANCY A BERRYHILL, Deputy Commissioner of Social Security for Operations, Defendant.



         Plaintiff Elisabeth Olivieri filed this action, pursuant to 42 U.S.C. § 405(g), for judicial review of Defendant's denial of Plaintiff's applications for supplemental security income (“SSI”) and 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.

         After considering the record, the Court concludes the Administrative Law Judge (“ALJ”) erred when she failed to properly discount medical opinion evidence from Dr. Mark Magdaleno, M.D. Had the ALJ properly considered Dr. Magdaleno's opinion, the residual functional capacity (“RFC”) may have included additional limitations. The ALJ may have also changed the weight she gave to medical opinion evidence from Dr. Albert Hattem, M.D., with proper consideration of Dr. Magdaleno's opinion. 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 Deputy Commissioner of Social Security (“Commissioner”) for further proceedings consistent with this Order.


         On March 21, 2014, Plaintiff filed applications for SSI and DIB, alleging disability as of June 21, 2011. See Dkt. 8, Administrative Record (“AR”) 18. The applications were denied upon initial administrative review and on reconsideration. See AR 18. ALJ Stephanie Martz held a hearing on December 15, 2015. AR 38-79. In a decision dated April 21, 2016, the ALJ found Plaintiff to be not disabled. AR 15-37. 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, § 416.1481.

         In Plaintiff's Opening Brief, Plaintiff maintains the ALJ erred by: (1) improperly assessing medical opinion evidence, thereby resulting in an inaccurate RFC; and (2) finding Plaintiff had a severe impairment of substance abuse disorder at Step Two of the sequential evaluation process. Dkt. 10, pp. 3-11. Plaintiff requests the Court remand for an award of benefits as a result of these errors. Id. at 11.


         Pursuant 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 Cir. 1999)).


         I. Whether the ALJ properly assessed the medical opinion evidence.

         Plaintiff argues the ALJ improperly assessed her RFC in light of medical opinion evidence from Drs. Wayne Dees, Psy.D., Xandra Rarden, M.D., Mark Magdaleno, M.D., and Albert Hattem, M.D. Dkt. 10, pp. 5-11.

         The ALJ must provide “clear and convincing” reasons for rejecting the uncontradicted opinion of either a treating or examining physician. Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995) (citing Pitzer v. Sullivan, 908 F.2d 502, 506 (9th Cir. 1990)); Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir. 1988)). When a treating or examining physician's opinion is contradicted, the opinion can be rejected “for specific and legitimate reasons that are supported by substantial evidence in the record.” Lester, 81 F.3d at 830-31 (citing Andrews v. Shalala, 53 F.3d 1035, 1043 (9th Cir. 1995); Murray v. Heckler, 722 F.2d 499, 502 (9th Cir. 1983)). The ALJ can accomplish this by “setting out a detailed and thorough summary of the facts and conflicting clinical evidence, stating his interpretation thereof, and making findings.” Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998) (citing Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989)).

         A. Mental Limitations

         Plaintiff first argues the RFC should contain greater mental limitations due to opinion evidence from Drs. Dees and Rarden. Dkt. 10, pp. 5-9.

         1. Dr. Dees

         On January 8, 2014, Dr. Dees conducted a psychological/psychiatric evaluation of Plaintiff. AR 387-96. As part of his evaluation, Dr. Dees conducted a clinical interview and mental status examination of Plaintiff. AR 387-88, 390-91. Dr. Dees found Plaintiff moderately limited in her ability to adapt to changes in a routine work setting, communicate and perform effectively in a work setting, and set realistic goals and plan independently. AR 389-90. In addition, Dr. Dees opined Plaintiff was markedly limited in her ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances without special supervision. AR 389. Dr. Dees also determined Plaintiff had a marked limitation in her ability to maintain appropriate behavior in a work setting. AR 390. Lastly, Dr. Dees found Plaintiff severely limited in her ability to complete a normal work day and work week without interruptions from psychologically based symptoms. AR 390.

         The ALJ discussed Dr. Dees' findings and gave his opinion “little weight, ” stating:

Such extreme limitations are not supported by the record or Dr. Dee's [sic] own mental status examinations. Indeed, during such an examination, the claimant's appearance was within normal limits, her thoughts were logical and linear, she was friendly and cooperative, and she was fully oriented with memory within normal limits. Dr. Dees did note that the claimant was depressed, but this observation alone does not explain the ratings he assessed, especially given all of his other observations.

AR 29 (internal citations omitted).

         One reason the ALJ gave for discounting Dr. Dees' opinion was because Dr. Dees' “extreme limitations” were not supported by his own mental status examination. AR 29. An ALJ may reject an opinion that is “inadequately supported by clinical findings.” Bayliss, 427 F.3d at 1216 (citing Tonapetyan v. Halter, 242 F.3d 1144, 1149 (9th Cir. 2001)). Here, the ALJ accurately summarized the findings from the mental status examination and explained how these findings - which were largely normal - did not support Dr. Dees' opined limitations. See AR 29; see also AR 390-91 (mental status examination). As such, the ALJ reasonably determined Dr. Dees' opinion was not supported by his own mental status examination, and this was a specific, legitimate reason to discount this opinion. See Bayliss, 427 F.3d at 1216 (upholding an ALJ's rejection of a physician's findings where the physician's “other recorded observations and opinions” contradicted his opinion about Plaintiff's abilities); see also Allen v. Heckler, 749 F.2d 577, 579 (9th Cir. 1984) (citation omitted) (“If the evidence admits of more than one rational interpretation, ” the court must uphold the ALJ's decision).

         While the ALJ also discounted Dr. Dees' opinion for being unsupported by the medical record as a whole, the Court need not assess whether this reason was proper, as any error would be harmless. See Presley-Carrillo v. Berryhill, 692 Fed.Appx. 941, 944-45 (9th Cir. 2017) (citing Carmickle v. Comm'r of Soc. Sec. Admin., 533 F.3d 1155, 1162) (noting that although an ALJ erred with regard to one reason he gave to discount a medical opinion, “this error was harmless because the ALJ gave a reason supported by the record” to discount the opinion). Accordingly, the ALJ need not re-evaluate Dr. Dees' opinion on remand.

         2. Dr. ...

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