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William A. v. Commissioner of Social Security

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

June 24, 2019

WILLIAM A., Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          ORDER REVERSING AND REMANDING DEFENDANT'S DECISION TO DENY BENEFITS

          David W. Christel United States Magistrate Judge.

         Plaintiff 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”). 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. 2.

         After considering the record, the Court concludes the Administrative Law Judge (“ALJ”) erred when she failed to provide specific, legitimate reasons, supported by substantial evidence, to discount opinion evidence from Dr. William D. Weiss, Ph.D.; Dr. Holly Petaja, Ph.D.; and Dr. David T. Morgan, Ph.D. Had the ALJ properly considered this medical opinion evidence, the residual functional capacity (“RFC”) may have included additional limitations. The ALJ's errors are therefore not harmless, and this matter is reversed and remanded pursuant to sentence four of 42 U.S.C. § 405(g) to the Social Security Commissioner (“Commissioner”) for further proceedings consistent with this Order.

         FACTUAL AND PROCEDURAL HISTORY

         On July 15, 2015, Plaintiff filed an application for SSI, alleging disability as of September 5, 2008. See Dkt. 9, Administrative Record (“AR”) 15. The application was denied upon initial administrative review and on reconsideration. See AR 15. ALJ S. Pines held a hearing on April 12, 2017. AR 29-44. In a decision dated August 10, 2017, the ALJ determined Plaintiff to be not disabled. AR 12-28. Plaintiff's request for review of the ALJ's decision was denied by the Appeals Council, making the ALJ's decision the final decision of the Commissioner. See AR 1-6; 20 C.F.R. § 416.1481.

         In Plaintiff's Opening Brief, Plaintiff maintains the ALJ erred by failing to: (1) properly consider medical opinion evidence from Drs. Weiss, Petaja, and Morgan, as well as treatment notes from Dr. Jennifer McDonald, M.D., and other treating sources; (2) state clear and convincing reasons to discount Plaintiff's subjective symptom testimony and germane reasons to discount lay witness testimony from Plaintiff's case manager, Pam Hunt; and (3) provide an RFC assessment and Step Five findings supported by substantial evidence. Dkt. 13, pp. 3-18. Plaintiff requests the Court remand this matter for an award benefits. Id. at pp. 18-19.

         STANDARD OF REVIEW

         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)).

         DISCUSSION

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

         Plaintiff challenges the ALJ's consideration of medical opinion evidence from Drs. Weiss, Petaja, Morgan, McDonald, and treatment notes from several treating sources. Dkt. 13, pp. 3-12.

         In assessing an acceptable medical source, an 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 [her] 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. Drs. Weiss and Petaja

         Plaintiff first asserts the ALJ improperly considered medical opinion evidence from Drs. Weiss and Petaja. Dkt. 13, pp. 3-6.

         On July 20, 2014, Dr. Weiss conducted a psychological/psychiatric evaluation of Plaintiff. AR 241-45. Dr. Weiss's evaluation included reviewing social service case notes on Plaintiff and conducting a clinical interview and mental status examination. See AR 241-45. Dr. Weiss described several clinical findings in his report, such as about Plaintiff's manic episodes and depression. See AR 242. Dr. Weiss diagnosed Plaintiff with Bipolar I Disorder, “severe, with psychotic features, ”; polysubstance dependence; and borderline personality disorder. See AR 243.

         Dr. Weiss opined Plaintiff is moderately limited in his ability to perform routine tasks without special supervision, make simple work-related decisions, be aware of normal hazards and take appropriate precautions, and set realistic goals and plan independently. AR 244. Further, Dr. Weiss determined Plaintiff has marked limitations in several areas of basic work activities, such as in his ability to understand, remember, and persist in tasks by following very short and simple instructions; learn new tasks; adapt to changes in a routine work setting; and ask simple questions or request assistance. AR 243-44. Dr. Weiss found Plaintiff markedly impaired in his ability to communicate and perform effectively in a work setting, maintain appropriate behavior in a work setting, and complete a normal workday and workweek without interruptions from psychologically based symptoms. AR 244. Lastly, Dr. Weiss opined Plaintiff is severely limited in two areas of basic work activities: the ability to understand, remember, and persist in tasks by following detailed instructions; and the ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances without special supervision. AR 244.

         On November 17, 2014, Dr. Petaja conducted a review of the record in this matter. AR 353-55. Dr. Petaja determined Plaintiff has diagnoses of bipolar disorder and borderline personality disorder. AR 355. Dr. Petaja opined Plaintiff is significantly limited in his ability to learn new tasks, adapt to changes in a routine work setting, make simple work-related decisions, and set realistic goals and plan independently. AR 354. Dr. Petaja found Plaintiff has several marked limitations, including in his ability to understand, remember, and persist in tasks by following very short and simple instructions; perform activities within a schedule, maintain regular attendance and be punctual within customary tolerances; and perform routine tasks without special supervision. AR 354. Additionally, Dr. Petaja found Plaintiff markedly limited in his ability to be aware of normal hazards and take appropriate precautions, ask simple questions, or request assistance, and communicate and perform effectively in a work setting. AR 354. Dr. Petaja also determined Plaintiff has marked limitations in his ability to maintain appropriate ...


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