Padilla v. Commissioner of Social Security Administration
Filing
21
ORDER - IT IS ORDERED that the Commissioner's decision is REVERSED and this matter is remanded for a determination of benefits. IT IS FURTHER ORDERED that the Clerk of Court shall enter judgment in favor of Plaintiff and terminate this case. (See document for complete details). Signed by Magistrate Judge Bridget S Bade on 10/3/18. (SLQ)
1
WO
2
3
4
5
6
IN THE UNITED STATES DISTRICT COURT
7
FOR THE DISTRICT OF ARIZONA
8
9
Dorothy Padilla,
No. CV-17-02737-PHX-BSB
Plaintiff,
10
11
v.
12
Commissioner
Administration,
ORDER
13
of
Social
Security
Defendant.
14
15
Plaintiff Dorothy Padilla seeks judicial review of the decision of the
16
Commissioner of Social Security (the “Commissioner”) denying her application for
17
benefits under the Social Security Act (the “Act”). The parties have consented to proceed
18
before a United States Magistrate Judge pursuant to 28 U.S.C. § 636(b), and have filed
19
briefs in accordance with Local Rule of Civil Procedure 16.1. For the following reasons,
20
the Court reverses the Commissioner’s decision and remands for a determination of
21
benefits.
22
I.
Procedural Background
23
On June 24, 2013, Plaintiff applied for social security disability income (“SSDI”)
24
for a period of disability and disability insurance benefits under Title II of the Act.
25
(Tr. 29.)1 On December 11, 2013, she also applied for supplemental security income
26
(SSI) under Title XVI of the Act. (Id.) After the Social Security Administration (“SSA”)
27
denied Plaintiff’s initial application and her request for reconsideration, she requested a
28
1
Citations to “Tr.” are to the certified administrative record. (Doc. 13.)
1
hearing before an administrative law judge (“ALJ”). (Id.) After conducting a hearing, on
2
February 5, 2016 the ALJ issued a decision finding Plaintiff not disabled under the Act.2
3
(Tr. 29-41.) On June 15, 2017, the Social Security Administration Appeals Council
4
denied Plaintiff’s request for review. (Tr. 1-6.) Plaintiff now seeks judicial review of the
5
ALJ’s decision pursuant to 42 U.S.C. § 405(g).
6
II.
Administrative Record
7
The record before the Court establishes the following history of diagnoses and
8
treatment related to Plaintiff’s physical impairments.3 The record also includes medical
9
opinions.
10
A.
11
Plaintiff received treatment from Steven Sumpter, D.O., at Integrated Medical
12
Services (“IMS”) beginning in October 2011 and continuing through 2015. (Doc. 16 at
13
6-7 (citing (Tr. 399-403 (Oct. 11, 2011); Tr. 702-05 (Dec. 5, 2011); Tr. 396-99 (Dec. 18,
14
2012); Tr. 504-06 (May 1, 2013); Tr. 500-03 (Aug. 21, 2013); Tr. 496-99 (Nov. 5, 2013);
15
Tr. 493-95 (Dec. 20, 2013); Tr. 552-55 (Jan. 30, 2014); Tr. 673-76 (March 11, 2014;
16
Tr. 669-72 (March 28, 2014); Tr. 664-68 (April 22, 2014); Tr. 569-63 (May 22, 2014);
17
Tr. 655-58 (June 30, 2014); Tr. 651-54 (July 15, 2014); Tr. 860-64 (Mar. 23, 2015)).)
Relevant Treatment History
18
In November 2013, Dr. Sumpter referred Plaintiff to the orthopedic clinic at IMS,
19
where she was evaluated by Navtej Tung, M.D. (Tr. 518-22.) Plaintiff reported that she
20
had chronic low back pain that radiated into her legs. (Tr. 518.) Plaintiff reported that
21
she could sit for about an hour, she could stand for thirty minutes, and she had difficulty
22
walking any distance.
23
tenderness at L4, L5, S1 that was “worse with forward flexion of the lumbar spine” and
24
with extension. (Tr. 521.) A straight-leg raising test was positive on the left side. (Id.)
(Id.)
On examination, Dr. Tung observed that Plaintiff had
25
2
26
27
Plaintiff had been previously found not disabled in February 2012. (Tr. 29.) That
decision was not given res judicata effect in the ALJ’s 2016 decision and it is not at issue
before this Court. (See Tr. 29-30.)
3
28
Plaintiff states that her appeal to this Court focuses on her orthopedic impairments.
(Doc. 16 at 3-4.) Therefore, the Court also focuses on those impairments.
-2-
1
An MRI of Plaintiff’s lumbar spine showed “bilateral pars defect” at L5-S1
2
“resulting in grade 1 anterolisthesis.” (Tr. 522.) The MRI also showed “some facet
3
degenerative changes . . . a disc bulge, and foraminal narrowing.”
4
concluded that Plaintiff was “a good candidate for interventional procedures.” (Tr. 522.)
5
Therefore, Plaintiff had lumbar epidural steroid injections on November 21, 2013
6
(Tr. 536), January 3, 2014 (Tr. 528 (noting chronic back pain with radiation the legs)),
7
and January 21, 2014 (Tr. 526, 598 (noting chronic back pain with radiation to the legs)).
8
She had an L4-S1 bilateral medial branch nerve block on August 7, 2014 for “chronic
9
low back pain.” (Tr. 590-91.) Plaintiff had lumbar radiofrequency ablation procedures
10
on June 15 and 24, 2015. (Tr. 756, 749.) The June 2015 treatment notes state that
11
Plaintiff’s lumbar sacral spine exhibited tenderness on palpation, muscle spasms, and
12
pain on motion. (Tr. 750, 757.) Straight-leg raising tests were positive. (Id.)
(Id.)
Dr. Tung
13
On referral from IMS, Plaintiff received physical therapy for her back pain.
14
(Tr. 612-14, 620.) During her initial visit on March 12, 2014, Plaintiff reported that she
15
had back pain that “fluctuate[d] but [was] constant.” (Id.) Plaintiff’s pain disturbed her
16
sleep and was worse with sitting longer than thirty minutes, bending, lifting or carrying
17
groceries. (Id.) On examination, Plaintiff had increased pain on forward bending, side
18
bending, and reported that pain travelled down both legs. (Tr. 613.) During a March
19
2014 appointment, Plaintiff reported that her pain fluctuated and she did not have any
20
pain at that time. (Tr. 610.) However, on examination, Plaintiff reported that “STM” to
21
the back was painful. (Id.) On June 8, 2014, Plaintiff was discharged from physical
22
therapy for “non-compliance.” (Tr. 609.)
23
B.
24
1.
25
26
Opinion Evidence
Treating Physician Steven Sumpter, D.O.
Treating physician Dr. Sumpter completed three assessments of Plaintiff’s ability
to perform work-related physical activities.4
On December 20, 2013, Dr. Sumpter
27
4
28
The Court considers the opinions rendered after the alleged disability onset date of
February 14, 2012. (See Tr. 37 (noting that medical opinions made in 2011 had no
probative value because there were rendered prior to the 2012 onset date).)
-3-
1
assessed Plaintiff and opined that she could not work eight hours a days, five days a week
2
on a regular basis due to her “lumbar radiculopathy, facet syndrome, bulging disc,
3
spondylolisthesis of the lumbar spine, and morbid obesity.” (Tr. 489.) He opined that, in
4
an eight-hour day, Plaintiff could sit for two hours, stand or walk for two hours, and lift
5
or carry less than ten pounds. (Id.) Dr. Sumpter stated that it was “medically necessary”
6
for Plaintiff to change position every twenty-one to forty-five minutes. (Id.) Dr. Sumpter
7
also opined that due to pain and fatigue, Plaintiff would be “[o]ff task 16-20% of an 8-
8
hour work day.” (Tr. 490.) Dr. Sumpter confirmed that his opinions were based on
9
treatment notes, medical records, radiographic records, and Plaintiff’s responses to
10
treatment. (Id.)
11
On January 19, 2015, Dr. Sumpter completed another assessment of Plaintiff’s
12
ability to perform work-related physical activities. (Tr. 621.) Dr. Sumpter opined that
13
Plaintiff could not work on a regular and consistent basis due to “severe, constant low
14
back pain radiating into legs.” (Id.) Dr. Sumpter assessed the same exertional limitations
15
that he assessed in December 2013. (Compare Tr. 489 with Tr. 621.) Dr. Sumpter again
16
opined that Plaintiff needed to change positions every twenty-one to forty-five minutes.
17
(Id.) Dr. Sumpter also opined that pain would cause severe limitations, defined as being
18
“[o]ff task greater than 21% of an 8-hour work day.” (Tr. 622.)
19
On August 25, 2015, Dr. Sumpter completed another assessment of Plaintiff’s
20
ability to perform work-related physical activities.
21
Plaintiff’s “chronic back pain, myalgia, headaches, chest pain, and difficulty breathing”
22
affected her ability to function and precluded an eight-hour work day. (Tr. 740.) He
23
assessed the same exertional limitations he had assessed in December 2013 and January
24
2019. (Compare Tr. 621 with Tr. 740.) He also opined that Plaintiff needed to change
25
position every twenty-one to forty-five minutes. (Tr. 740.) Dr. Sumpter opined that
26
Plaintiff’s pain, fatigue, dizziness, and headaches resulted in “moderately severe”
27
limitations that would cause Plaintiff to be “[o]ff task 16-20% of an 8-hour work day.”
28
(Tr. 741.)
-4-
(Tr. 740-41.)
He found that
1
2.
2
On March 19, 2014, Dr. Maria Pons, a state agency physician, reviewed the
3
medical record and completed a residual functional capacity assessment (“RFC”).
4
(Tr. 160.) Dr. Pons opined that Plaintiff could sit, stand, and walk about six hours in an
5
eight-hour day. (Tr. 161.) She opined that Plaintiff could occasionally lift or carry up to
6
twenty pounds, and could frequently lift or carry up to ten pounds. (Id.) Dr. Pons found
7
that Plaintiff could frequently climb ramps and stairs, occasionally climb ladders, ropes,
8
or scaffolds, frequently stoop, kneel, crouch, and crawl, and frequently handle. (Tr. 161-
9
62.)
10
III.
State Agency Physician Maria Pons, M.D.
Administrative Hearing Testimony
11
During the October 16, 2015 administrative hearing, Plaintiff testified that she was
12
unable to work due to “discomfort” caused by “a slipped disc in [her] back.” (Tr. 86.)
13
She also complained of fibromyalgia, depression, and anxiety. (Id.) Plaintiff testified
14
that she had received treatment from her primary care physician Dr. Sumpter for the
15
previous three years, and he had referred her to pain management. (Tr. 87.) Plaintiff
16
testified that she was taking prescribed pain medications, including Percocet and
17
cyclobenzaprine, which helped but did not eliminate her pain.
18
Plaintiff testified that medications “subdue[d] the throbbing pain,” but she was never pain
19
free. (Tr. 90-91, 94-95.) Plaintiff stated that she had received injections and physical
20
therapy for back pain, but that she did not experience substantial benefit from those
21
treatments. (Tr. 91.)
(Tr. 87-88, 95-96.)
22
Plaintiff also testified that she could stand for twenty minutes and walk for about
23
an hour. (Tr. 90, 92.) Plaintiff testified that she could sit for about forty-five minutes and
24
then she either had to “take a pill and ice [her] back” or “heat [her] back.” (Id.) Plaintiff
25
testified that “pain management” had instructed her not to lift anything heavier than a
26
gallon of milk. (Tr. 93.) Plaintiff testified that she napped every day from 11:00 to 2:30,
27
due to pain, fatigue, and depression. (Tr. 99.) Plaintiff testified that she could take out
28
-5-
1
the trash, do laundry, and prepare meals. (Tr. 93-94.) However, Plaintiff was “instructed
2
not to sweep or mop” because it was “one of the worst things for [her] back.” (Id.)
3
A vocational expert also testified at the administrative hearing. (Tr. 104-113
4
(testifying telephonically).)
5
assessment by Dr. Pons (see Tr. 160-62), the vocational expert testified that Plaintiff
6
could perform her past work as a photocopy machine operator. (Tr. 108-09.) The
7
vocational expert also testified that sustained work would be precluded for an individual
8
with the limitations that Dr. Sumpter assessed. (Tr. 110-12; see Tr. 489, 621, 740.) The
9
vocational expert further testified that sustained work would be precluded for a person
10
who had to nap for “longer than usual breaks” during the day, as Plaintiff had testified.
11
(Tr. 112.)
12
IV.
In response to a question from the ALJ based on the
The ALJ’s Decision
13
A claimant is considered disabled under the Social Security Act if she is unable
14
“to engage in any substantial gainful activity by reason of any medically determinable
15
physical or mental impairment which can be expected to result in death or which has
16
lasted or can be expected to last for a continuous period of not less than 12 months.” 42
17
U.S.C. § 423(d)(1)(A); see also 42 U.S.C. § 1382c(a)(3)(A) (nearly identical standard for
18
SSI benefits).5 To determine whether a claimant is disabled, the ALJ uses a five-step
19
sequential evaluation process. See 20 C.F.R. §§ 404.1520, 416.920.
20
A.
21
In the first two steps, a claimant seeking disability benefits must initially
22
demonstrate (1) that she is not presently engaged in a substantial gainful activity, and
23
(2) that her medically impairment or combination of impairments is severe. 20 C.F.R.
24
§§ 404.1520(b) and (c), 416.920(b) and (c). If a claimant meets steps one and two, there
25
are two ways in which she may be found disabled at steps three through five. At step
26
three, she may prove that her impairment or combination of impairments meets or equals
27
5
28
The Five-Step Sequential Evaluation Process
The definition of disability is the same for SSDI and SSI benefits. See Diedrich v.
Berryhill, 874 F.3d 634, 637 (9th Cir. 2017). Therefore, the Court does not always
include parallel citations when citing the relevant regulations. See e.g., 20 C.F.R.
§§ 404.1520 (SSDI), id. § 416.920 (SSI).
-6-
1
an impairment in the Listing of Impairments found in Appendix 1 to Subpart P of 20
2
C.F.R. Part 404. 20 C.F.R. § 404.1520(a)(4)(iii). 20 C.F.R. §§ 404.1520(d), 416.920(d).
3
If so, the claimant is presumptively disabled. If not, the ALJ determines the claimant’s
4
RFC. 20 C.F.R. §§ 404.1520(e), 416.920(e). At step four, the ALJ determines whether a
5
claimant’s RFC precludes her from performing her past relevant work.
6
C.F.R. §§ 404.1520(f); 416.920(f). If the claimant establishes this prima facie case, the
7
burden shifts to the government at step five to establish that the claimant can perform
8
other jobs that exist in significant numbers in the national economy, considering the
9
claimant’s RFC, age, work experience, and education.
20
20 C.F.R. §§ 404.1520(g),
10
416.920(g). If the government does not meet this burden, then the claimant is considered
11
disabled within the meaning of the Act.
12
B.
13
Applying the five-step sequential evaluation process, the ALJ found that Plaintiff
14
had not engaged in substantial gainful activity since the alleged disability onset date,
15
February 14, 2012. (Tr. 32.) At step two, the ALJ found that Plaintiff had the following
16
severe impairments: “morbid obesity, fibromyalgia, migraine headaches, degenerative
17
disc disease, bilateral pars defect, anterolisthesis, vitamin D deficiency, bipolar disorder,
18
and obsessive-compulsive disorder (20 CFR 404.1520(c) and 416.920(c)).” (Id.) The
19
ALJ found Plaintiff did not have an impairment or combination of impairments and that
20
met or medically equaled the severity of a listed impairment. (Tr. 33.)
21
The ALJ’s Application of the Five-Step Evaluation Process
The ALJ found that Plaintiff had the RFC to “perform light work as defined in 20
22
CFR 404.1567(b) and 416.967(b).” (Tr. 34.)
23
“frequently climb ladders, ropes, or scaffolds[,] frequently stoop, kneel, crouch and
24
crawl[,] and frequently handle.” (Id.) The ALJ also found Plaintiff “could perform
25
simple routine and repetitive work tasks involving simple work-related decisions and
26
simple instructions.” (Id.) The ALJ concluded that Plaintiff “should not perform work
27
requiring public contact” other than “[i]ncidental public contact.” (Id.)
28
-7-
The ALJ clarified that Plaintiff could
1
The ALJ concluded that Plaintiff could perform her past relevant work as a
2
photocopying machine operator. (Tr. 39.) The ALJ alternatively found that, based on
3
Plaintiff’s age, education, and RFC, she could perform other jobs that existed in
4
significant numbers in the national economy. (Tr. 39-41.) Therefore, the ALJ concluded
5
that Plaintiff was not under a disability as defined in the Act from the alleged onset date,
6
February 14, 2012, through the date of her decision. (Tr. 41.) Therefore, the ALJ denied
7
Plaintiff’s applications for benefits. (Id.)
8
V.
Standard of Review
9
The district court has the “power to enter, upon the pleadings and transcript of
10
record, a judgment affirming, modifying, or reversing the decision of the Commissioner,
11
with or without remanding the cause for a rehearing.” 42 U.S.C. § 405(g). The district
12
court reviews the Commissioner’s decision under the substantial evidence standard and
13
must affirm the Commissioner’s decision if it is supported by substantial evidence and it
14
is free from legal error. Smolen v. Chater, 80 F.3d 1273, 1279 (9th Cir. 1996); Ryan v.
15
Comm’r of Soc. Sec. Admin., 528 F.3d 1194, 1198 (9th Cir. 2008).
16
means more than a mere scintilla, but less than a preponderance; it is “such relevant
17
evidence as a reasonable mind might accept as adequate to support a conclusion.”
18
Richardson v. Perales, 402 U.S. 389, 401 (1971) (citations omitted); see also Webb v
19
Barnhart, 433 F.3d 683, 686 (9th Cir. 2005).
Substantial evidence
20
In determining whether substantial evidence supports a decision, the court
21
considers the record as a whole and “may not affirm simply by isolating a specific
22
quantum of supporting evidence.” Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007)
23
(internal quotation and citation omitted). The ALJ is responsible for resolving conflicts
24
in testimony, determining credibility, and resolving ambiguities. See Andrews v. Shalala,
25
53 F.3d 1035, 1039 (9th Cir. 1995). “When the evidence before the ALJ is subject to
26
more than one rational interpretation, [the court] must defer to the ALJ’s conclusion.”
27
Batson v. Comm’r of Soc. Sec. Admin., 359 F.3d 1190, 1198 (9th Cir. 2004) (citing
28
Andrews, 53 F.3d at 1041).
-8-
1
The court applies the harmless error doctrine when reviewing an ALJ’s decision.
2
Thus, even if the ALJ erred, the decision will not be reversed if the error is
3
“inconsequential to the ultimate nondisability determination.” Tommasetti v. Astrue, 533
4
F.3d 1035, 1038 (9th Cir. 2008) (citations omitted); see also Molina v. Astrue, 674 F.3d
5
1104, 1115 (9th Cir. 2012) (an error is harmless so long as there remains substantial
6
evidence supporting the ALJ’s decision and the error “does not negate the validity of the
7
ALJ’s ultimate conclusion”); Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005)
8
(stating that “[a] decision of the ALJ will not be reversed for errors that are harmless.”).
9
VI.
Plaintiff’s Claims
10
Plaintiff asserts that the ALJ erred by (1) rejecting Dr. Sumpter’s opinions related
11
to Plaintiff’s ability to perform work-related physical activities, and (2) rejecting
12
Plaintiff’s symptom testimony without providing clear and convincing reasons supported
13
by substantial evidence in the record. (Doc. 16 at 1-2.) Plaintiff asserts that these errors
14
were harmful because the vocational expert testified that work would be precluded based
15
on Dr. Sumpter’s opinions or based on Plaintiff’s symptom testimony.
16
Commissioner asserts that the ALJ’s decision is free of harmful error. (Doc. 17.)
(Id.)
The
17
A.
18
In weighing medical source opinion evidence, the Ninth Circuit distinguishes
19
between three types of physicians: (1) treating physicians, who treat the claimant;
20
(2) examining physicians, who examine but do not treat the claimant; and (3) non-
21
examining physicians, who neither treat nor examine the claimant. Lester v. Chater, 81
22
F.3d 821, 830 (9th Cir. 1995). Generally, more weight is given to a treating physician’s
23
opinion.
24
substantial evidence for rejecting a treating or an examining physician’s uncontradicted
25
opinion. Id.; see also Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998). An ALJ may
26
reject the controverted opinion of a treating or an examining physician by providing
27
specific and legitimate reasons that are supported by substantial evidence in the record.
28
Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th Cir. 2005); Reddick, 157 F.3d at 725.
Medical Source Opinion Evidence
Id.
The ALJ must provide clear and convincing reasons supported by
-9-
1
Opinions from non-examining medical sources are entitled to less weight than
2
opinions from treating or examining physicians. Lester, 81 F.3d at 831. Although an
3
ALJ generally gives more weight to an examining physician’s opinion than to a non-
4
examining physician’s opinion, a non-examining physician’s opinion may nonetheless
5
constitute substantial evidence if it is consistent with other independent evidence in the
6
record. Thomas v. Barnhart, 278 F.3d 947, 957 (9th Cir. 2002).
7
medical opinion evidence, the ALJ may consider “the amount of relevant evidence that
8
supports the opinion and the quality of the explanation provided; the consistency of the
9
medical opinion with the record as a whole; [and] the specialty of the physician providing
10
When evaluating
the opinion . . . .” Orn, 495 F.3d at 631.
11
B.
12
The ALJ considered three opinions from Plaintiff’s treating physician Dr. Sumpter
13
and assigned those opinions “little weight.” (Tr. 37; see Tr. 489-90, 621-22, 740-41.)
14
The parties agree that the ALJ could reject Dr. Sumpter’s opinions by providing specific
15
and legitimate reasons supported by substantial evidence in the record. (Doc. 16 at 12
16
n. 17; Doc. 17 at 13-14); see Moore v. Comm’r of Soc. Sec. Admin., 278 F.3d 920, 924
17
(9th Cir. 2002) (“The ALJ could reject the opinions of Moore’s examining physicians,
18
contradicted by a nonexamining physician, only for specific and legitimate reasons that
19
are supported by substantial evidence in the record.”). However, they disagree about
20
whether the ALJ provided sufficient reasons for discounting Dr. Sumpter’s opinions.
The ALJ Erred by Discounting Dr. Sumpter’s Opinions
21
The ALJ discounted Dr. Sumpter’s opinions because she concluded that (1) the
22
“extreme limitations” that Dr. Sumpter assessed would render Plaintiff “bedridden,” and
23
they lacked “substantial support from the objective clinical and diagnostic findings” and
24
the treatment record; and (2) the limitations that Dr. Sumpter assessed were inconsistent
25
with Plaintiff’s conservative treatment history, her activities of daily living, and her
26
inconsistent compliance with treatment. (Tr. 37.)
27
///
28
///
- 10 -
1
1.
Lack of Support in the Medical Record for Opinions
2
The ALJ discounted Dr. Sumpter’s opinions because she believed that the
3
“extreme limitations” that he assessed would render Plaintiff “bedridden,” and that they
4
were not supported by objective clinical and diagnostic findings or the treatment record.6
5
(Tr. 37.) The ALJ stated that she assigned Dr. Sumpter’s opinions “little weight,” but did
6
not specifically identify which of the limitations Dr. Sumpter assessed that she was
7
discounting. (Id.) Additionally, in her discussion of Dr. Sumpter’s opinions, the ALJ did
8
not identify the evidence in the record that detracted from those opinions. (Id.) The
9
ALJ’s conclusory assertion that the diagnostic and treatment record did not support the
10
“extreme limitations” that Dr. Sumpter assessed does not satisfy the standard required for
11
rejecting a treating physician’s opinion.7 See 20 C.F.R. §§ 404.1527, 416.927; Swanson
12
v. Sec’y of Health and Human Servs, 763 F.2d 1061, 1065 (9th Cir.1985) (stating that an
13
ALJ properly rejects a treating physician’s opinion if he sets out a detailed and thorough
14
summary of the facts and conflicting clinical evidence, states his interpretation of the
15
facts and conflicting evidence, and makes findings.).
16
The ALJ must do more than offer her conclusions. “[Sh]e must set forth [her] own
17
interpretations and explain why they, rather than the doctors’, are correct.” Embrey v.
18
Bowen, 849 F.2d 418, 421–22 (9th Cir. 1988); see also Widmark v. Barnhart, 454 F.3d
19
1063, 1069 (9th Cir. 2006). The ALJ did not satisfy this burden in concluding, without
20
explanation, that Dr. Sumpter’s opinions in 2013 and 2015 lacked support in the
21
objective medical evidence and treatment record. (Tr. 37.) Even if the record includes
22
6
23
24
25
26
In defense of the ALJ’s decision, the Commissioner states that the ALJ permissibly
rejected Dr. Sumpter’s opinions because they were provided on check-box forms.
(Doc. 17 at 14.) The ALJ did not include this rationale in support of her rejection of
Dr. Sumpter’s opinions. (Tr. 37.) This court’s review is limited to “reasoning and
factual findings offered by the ALJ—not post hoc rationalizations that attempt to intuit
what the adjudicator may have been thinking.” Bray v. Comm’r Soc. Sec. Admin., 554
F.3d 1219, 1225-26 (9th Cir. 2009). Accordingly, the Court considers the rationale and
facts upon which the ALJ relied in determining that Plaintiff was not disabled.
7
27
28
The agency has amended regulations for evaluating medical evidence, but the amended
regulations (in pertinent part) only apply to claims filed on or after March 27, 2017, and
therefore are not relevant to this case. See 20 C.F.R. § 404.1527 (applicable to claims
filed before March 27, 2017); § 404.1520c (applicable to claims filed after March 27,
2017).
- 11 -
1
limited objective evidence and treatment evidence, the ALJ still failed to connect that
2
evidence, or lack of evidence, to her rejection of any particular limitation that
3
Dr. Sumpter identified in his 2013 and 2015 opinions. See Trevizo v. Berryhill, 871 F.3d
4
664, 682 n. 10 (9th Cir. 2017) (finding “the absence of medical records regarding alleged
5
symptoms is not itself enough to discredit a claimant’s testimony.”) Therefore, the ALJ’s
6
conclusory assertion does not constitute a legally sufficient reason for discounting
7
Dr. Sumpter’s opinions.
8
9
2.
Conservative Treatment
The ALJ also discounted Dr. Sumpter’s opinions because she found them
10
inconsistent with Plaintiff’s “conservative treatment history.”
11
challenges this rationale, and the Commissioner’s response does not discuss or defend it.
12
(Doc. 17 at 14-16.) As set forth below, the ALJ’s characterization of Plaintiff’s treatment
13
as conservative was not a legally sufficient reason for discounting Dr. Sumpter’s
14
opinions.
(Tr. 37.)
Plaintiff
15
“Any evaluation of the aggressiveness of a treatment regimen must take into
16
account the condition being treated.” Revels v. Berryhill, 874 F.3d 648, 667 (9th Cir.
17
2017). In Revels, the Ninth Circuit concluded that the ALJ erred by rejecting a plaintiff’s
18
symptom testimony based on the plaintiff’s “supposedly ‘conservative’ treatment,”
19
including facet and epidural injections, and prescription pain medications. Id. at 667. In
20
Garrison v. Colvin, 759 F.3d at 995, 1015 n.20 (9th Cir. 2014), the Ninth Circuit stated
21
that it “doubt[ed] that epidural steroid shots to the neck and lower back qualify as
22
‘conservative’ medical treatment.” Id.
23
Here, Plaintiff received “interventional procedures” for her back pain. (Tr. 522.)
24
Specifically, Plaintiff had lumbar epidural steroid injections (Tr. 526, 528, 536), an L4-
25
S1 bilateral medial branch nerve block (Tr. 590-91), and lumbar radiofrequency ablation
26
procedures. (Tr. 749, 756.) She was also prescribed medications for her pain, including
27
Percocet and cyclobenzaprine. (Tr. 87-88.) The ALJ did not explain why she considered
28
this treatment “conservative” for back pain. (Tr. 37.) “Moreover, the failure of a treating
- 12 -
1
physician to recommend a more aggressive course of treatment, absent more, is not a
2
legitimate reason to discount the physician’s subsequent medical opinion about the extent
3
of disability.” Trevizo, 871 F.3d at 677. The Court concludes that the ALJ erred by
4
discounting Dr. Sumpter’s opinions based on the ALJ’s characterization of Plaintiff’s
5
treatment for her back pain as conservative.
6
3.
Daily Activities
7
The ALJ also discounted Dr. Sumpter’s opinions because she found them
8
inconsistent with Plaintiff’s “activities of daily living.” (Tr. 37.) A claimant’s ability to
9
engage in daily activities that are incompatible with the severity of symptoms described
10
by a treating physician may support the rejection of that opinion. Ghanim v. Colvin, 763
11
F.3d 1154, 1162 (9th Cir. 2014); see Morgan v. Comm’r of Soc. Sec. Admin., 169 F.3d
12
595, 600-02 (9th Cir. 1999) (stating that an inconsistency between a treating physician’s
13
opinion and a claimant’s daily activities is a specific and legitimate reason to discount the
14
treating physician’s opinion). However, as discussed below, the ALJ did not provide
15
specific and legitimate reasons for rejecting Dr. Sumpter’s opinions based on Plaintiff’s
16
activities of daily living.
17
In her decision, the ALJ noted that Plaintiff’s daily activities included performing
18
self-care, preparing meals, using a computer, shopping, driving, caring for pets, and
19
handling money. (Tr. 36.) However, the ALJ did not discuss the frequency or duration
20
of these activities. (Id.); see Trevizo, 871 F.3d at 676 (concluding that ALJ erred by
21
relying on the claimant’s activities to discount her treating physician’s opinion where
22
there were no details about the what the activities involved or the extent of those
23
activities). Additionally, in her discussion of the weight she assigned to Dr. Sumpter’s
24
opinions, the ALJ did not identify which of Plaintiff’s activities exceeded the physical
25
limitations that Dr. Sumpter identified. (Tr. 37.)
26
Further, Dr. Sumpter’s assessments of Plaintiff’s work-related physical abilities
27
addressed limitations on sustained and continuous activities in a work setting (Tr. 489-90,
28
621-22, 740-41), not her ability to perform physical activities in a non-work setting.
- 13 -
1
Garrison v. Colvin, 759 F.3d 995, 1016 (9th Cir. 2014 (citing Bjornson v. Astrue, 671
2
F.3d 640, 647 (7th Cir. 2012) (“The critical difference between activities of daily living
3
and activities in a full-time job are that a person has more flexibility in scheduling the
4
former than the latter, can get help from other persons . . . , and is not held to a minimum
5
standard of performance, as she would be by an employer. The failure to recognize these
6
differences is a recurrent, and deplorable, feature of opinions by administrative law
7
judges in social security disability cases.”) (citations omitted in original)).
8
The Court concludes that the asserted inconsistency between Plaintiff’s activities
9
of daily living and the physical limitations that Dr. Sumpter identified do not satisfy the
10
requirement that the ALJ provide specific and legitimate reasons that are supported by
11
substantial evidence in the record for discounting a treating physician’s contradicted
12
opinion. See Bayliss, 427 F.3d at 1216.
13
4.
Inconsistent Compliance with Treatment
14
The ALJ also rejected Dr. Sumpter’s opinions because she concluded that the
15
limitations he identified were inconsistent with Plaintiff’s “inconsistent compliance with
16
treatment.” (Tr. 37.) The ALJ noted that Plaintiff stopped physical therapy. (Tr. 36, 91.)
17
The ALJ also noted that Plaintiff was prescribed Oxycodone for pain, but a July 28, 2015
18
treatment note indicated that a drug screen was positive for THC but negative for
19
Plaintiff’s medications, and that Plaintiff was warned to take her medications as
20
prescribed. (Tr. 747.)
21
Unexplained or inadequately explained failure to seek treatment or to follow a
22
prescribed course of treatment can be a legitimate basis for doubting the severity of a
23
claimant’s symptoms. Smolen v. Chater, 80 F.3d 1273, 1284 (9th Cir. 1996). However,
24
here, the ALJ did not explain how Plaintiff’s poor compliance with physical therapy in
25
2014 affects the validity of Dr. Sumpter’s opinions that were rendered in January and
26
August 2015. (Tr. 621-22, 740-41.) Additionally, while the ALJ noted the positive drug
27
screen that was mentioned in the July 2015 treatment note, she did not discuss the related
28
examination findings, which indicate that “palpation of the lumbosacral spine revealed
- 14 -
1
abnormalities,” tenderness, and muscle spasms. (Tr. 746.) Additionally, lumbosacral
2
spine motion was “abnormal,” and “spine pain was elicited by motion.” (Id.) A straight-
3
leg raising test was positive. (Id.)
4
In summary, because the ALJ did not provide specific and legitimate reasons for
5
discounting Dr. Sumpter’s opinions that are supported by substantial evidence in the
6
record, the ALJ erred in discounting Dr. Sumpter’s opinions. See Bayliss, 427 F.3d at
7
1216. Because the Court concludes that the ALJ erred by discounting Dr. Sumpter’s
8
opinions, it does not reach Plaintiff’s other asserted error. (Doc. 16 at 1-2.)
9
VII.
Remand for an Award of Benefits
10
Under the Ninth Circuit’s credit-as-true standard, courts may credit as true
11
improperly rejected medical opinions or claimant testimony and remand for an award of
12
benefits if each of the following is satisfied: “(1) the record has been fully developed and
13
further administrative proceedings would serve no useful purpose; (2) the ALJ has failed
14
to provide legally sufficient reasons for rejecting evidence, whether claimant testimony or
15
medical opinion; and (3) if the improperly discredited evidence were credited as true, the
16
ALJ would be required to find the claimant disabled on remand.” Garrison, 759 F.3d at
17
1020 (citing Ryan, 528 F.3d at 1202). If the “credit-as-true rule” is satisfied, the court
18
may remand for further proceedings, instead of for an award of benefits, “when the
19
record as a whole creates serious doubt as to whether the claimant is, in fact, disabled
20
within the meaning of the Social Security Act.” Garrison, 759 F.3d at 1021.
21
Here, the Court finds that the record has been fully developed and further
22
administrative proceedings would serve no useful purpose. Further, as detailed above,
23
the Court finds that the ALJ has failed to provide legally sufficient reasons for rejecting
24
Dr. Sumpter’s opinions. According to the vocational expert’s testimony, if Dr. Sumpter’s
25
opinions are credited as true, Plaintiff would be disabled under the Act. (Tr. 110-12.)
26
The record does not create serious doubt as to whether Plaintiff is disabled under the Act.
27
See Garrison, 759 F.3d at 1021.
28
Accordingly,
- 15 -
1
2
3
4
5
IT IS ORDERED that the Commissioner’s decision is REVERSED and this
matter is remanded for a determination of benefits.
IT IS FURTHER ORDERED that the Clerk of Court shall enter judgment in
favor of Plaintiff and terminate this case.
Dated this 3rd day of October, 2018.
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
- 16 -
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?