United States District Court, W.D. Washington, Seattle
A. TSUCHIDA CHIEF UNITED STATES MAGISTRATE JUDGE
Gabrielle S. seeks review of the denial of her application
for Supplemental Security Income. She contends the ALJ
misevaluated the medical opinion evidence and erred in
assessing her residual functional capacity. Dkt. 10. The
Court REVERSES the Commissioner's final
decision and REMANDS the matter for an
immediate award of benefits.
is currently 35 years old, completed the 8th grade, and has
no past relevant work. Tr. 35, 38-40. In June 2013, she
applied for benefits, alleging disability as of September
2004. Tr. 154. The Social Security Administration issued a
final decision finding her not disabled and denying her
application. Tr. 1, 10-20. Plaintiff sought review and this
court issued a decision reversing and remanding the case for
further administrative proceedings. Tr. 514-26. On remand,
the ALJ conducted another hearing and, on January 17, 2019,
issued a second decision finding plaintiff not disabled. Tr.
433-46. Plaintiff again seeks review by this court.
the five-step disability evaluation process,  the ALJ found
that plaintiff had not engaged in substantial gainful
activity since the application date; she had the following
severe impairments: obesity, affective disorder, anxiety
disorder, and posttraumatic stress disorder; and these
impairments did not meet or equal the requirements of a
listed impairment. Tr. 435-37. The ALJ found that plaintiff
had the residual functional capacity to perform light work
with additional postural and environmental limitations; she
had limitations on the complexity of the work, the amount and
nature of contact with others, and changes in the work
environment; and she would be off-task up to 10% of the
workday and may have 4 unexcused absences in a year. Tr. 438.
The ALJ found that plaintiff had no past relevant work but,
as there were jobs that exist in significant numbers in the
national economy that she could perform, she was not
disabled. Tr. 445-46.
argues that the ALJ erred by improperly rejecting all the
opinions from treating and examining providers in favor of
the opinions from nonexamining state agency psychologists.
Dkt. 10 at 5. The ALJ gave little weight to the opinions from
treating social worker Caitlin Cotter, LICSW, examining
psychologist Barbara Lui, Ph.D., examining psychologist
Kenneth Hapke, Ph.D., examining physician Kathleen Andersen,
M.D., examining psychologist Jan Kouzes, Ed.D., and treating
social worker Alana Honigman, LICSW; the ALJ gave significant
weight to the opinions of the state agency psychological
consultants, Dr. van Dam and Dr. Clifford. Tr. 441-42.
general, the ALJ should give more weight to the opinion of a
treating doctor than to that of a non-treating doctor, and
more weight to the opinion of an examining doctor than to
that of a non-examining doctor. 20 C.F.R. § 416.927;
Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1996).
The ALJ must give specific and legitimate reasons for
rejecting a treating or examining doctor's opinion that
is contradicted by another doctor, and clear and convincing
reasons for rejecting a treating or examining doctor's
uncontradicted opinion. Lester, 81 F.3d at 830-31. An ALJ
does this by setting out a detailed and thorough summary of
the facts and conflicting evidence, stating her
interpretation of the facts and evidence, and making
findings. Magallanes v. Bowen, 881 F.2d 747, 751
(9th Cir. 1989). The ALJ must do more than offer her
conclusions; she must also explain why her interpretation,
rather than the treating doctor's interpretation, is
correct. Orn v. Astrue, 495 F.3d 625, 632 (9th Cir.
2007) (citing Embrey v. Bowen, 849 F.2d 418, 421-22
(9th Cir. 1988)). The opinion of a non-examining doctor
cannot by itself constitute substantial evidence that
justifies the rejection of the opinion of either an examining
physician or a treating physician. Gallant v.
Heckler, 753 F.2d 1450, 1456 (9th Cir. 1984).
social workers are not acceptable medical sources who can
give medical opinions. The ALJ may evaluate opinions of other
medical sources using the same factors used to evaluate
medical opinions of acceptable medical sources. 20 C.F.R.
§ 419.927(f). The ALJ must give specific, germane
reasons for rejecting opinions from other sources that are
not acceptable medical sources. Dodrill v. Shalala,
12 F.3d 915, 919 (9th Cir. 1993).
found that the treating and examining providers' opinions
were inconsistent with the nature of plaintiff's
treatment, which the ALJ found appeared to be more focused on
methadone maintenance, situational stressors, parental
support, relapse prevention, life skills, and family support
rather than on addressing plaintiff's mood, anxiety, and
PTSD symptoms. Tr. 442. The ALJ found that if plaintiff's
mental condition was as severe as these providers assessed,
one would expect that her treatment would be tailored to deal
with that condition. Id. In making this finding, the
ALJ essentially takes on the role of a doctor, giving his
opinion about what type of treatment plaintiff should have
received. The ALJ does not cite to any evidence to support
this finding or explain how addressing the issues he
identifies was not appropriate treatment for plaintiff's
mental impairments or the symptoms she and her treating
providers identified. The ALJ may not substitute his own
interpretation of the medical evidence for the opinion of a
medical professional. See Tackett v. Apfel, 180 F.3d
1094, 1102-03 (9th Cir. 1999). This was not a valid reason to
reject these opinions.
also found these opinions to be inconsistent with the benign
mental status examination findings during appointments,
including findings of normal affect, cooperative behavior,
appropriate motor activity, appropriate speech, normal
thought processes, normal perceptual processes, full
orientation, intact memory, average intellectual functioning,
and normal judgment and insight. Tr. 443. The ALJ referred to
his discussion of mental status examinations in his
evaluation of plaintiff's subjective testimony, where he
identified four mental status examinations with normal
findings. Tr. 439 (citing Tr. 232, 253-54, 406, 654-55). Two
of these were notations made at appointments for
plaintiff's prediabetes that stated, in full:
“Appropriate affect, goal-directed thought.” Tr.
232, 406. One of them included the findings the ALJ
identified but also findings of unkempt appearance and poor
hygiene, flat affect, depressed and anxious mood. Tr. 654.
These were the only four mental status examinations the ALJ
relied on to discount six treating and examining opinions.
But four mental status examinations, two of which were
documented with only five words, do not constitute
substantial evidence sufficient to undermine the opinions of
four examining psychologists and psychiatrists and two
treating social workers. See Hill v. Astrue, 698
F.3d 1153, 1159 (9th Cir. 2012) (reviewing court must
consider the record as a whole and may not affirm by
isolating a specific quantum of supporting evidence). This
was not a valid reason to discount these opinions.
found that treatment notes from group counseling sessions did
not document significant problems with depression, anxiety,
or PTSD, and that the examining doctors were unaware of the
longitudinal evidence because they reviewed either minimal or
no evidence. Tr. 443. The ALJ again substituted his own
interpretation of the medical evidence when deciding what
information these notes should have contained. And the fact
that the examining doctors did not see the four mental status
exams the ALJ identified does not ...