Armando Barrera Aguilar v. Carolyn W. Colvin

Filing 23

MEMORANDUM DECISION AND ORDER by Magistrate Judge Suzanne H. Segal. IT IS ORDERED that Judgment be entered REVERSING the decision of the Commissioner and REMANDING this matter for further proceedings consistent with this decision. (See document for further details). (mr)

UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA

ARMANDO BARRERA AGUILAR,

No. CV 16-7565 SS

Plaintiff,
v.

MEMORANDUM DECISION AND ORDER

NANCY A. BERRYHILL,1
Acting Commissioner of the
Social Security Administration,
Defendant.

I.
INTRODUCTION

Armando Barrera Aguilar (“Plaintiff”) seeks review of the
final

decision

of

the

Commissioner

of

the

Social

Security

Administration (the “Commissioner” or the “Agency”) denying his
application

for

Disability

Insurance

Benefits

(“DIB”)

and

Nancy A. Berryhill is now the Acting Commissioner of Social
Security and is substituted for former Acting Commissioner
Carolyn W. Colvin in this case. See Fed. R. Civ. P. 25(d).
1

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Supplemental Security Income (“SSI”).
pursuant

to

28 U.S.C.

§ 636(c),

to

The parties consented,
the

jurisdiction

undersigned United States Magistrate Judge.

of

the

(Dkt. Nos. 11-12).

For the reasons stated below, the decision of the Commissioner is
REVERSED and this case is REMANDED for further administrative
proceedings consistent with this decision.

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II.

10

THE FIVE-STEP SEQUENTIAL EVALUATION PROCESS

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To

demonstrate

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a

for

disability

medically

benefits,

determinable

a

claimant

physical

or

must
mental

impairment that prevents him from engaging in substantial gainful
activity and that is expected to result in death or to last for a
continuous period of at least twelve months.
157

F.3d

715,

§ 423(d)(1)(A)).
incapable

of

721
The

performing

(9th

Cir.

1998)

impairment
the

work

must
he

Reddick v. Chater,
(citing

render

previously

42
the

U.S.C.
claimant

performed

and

incapable of performing any other substantial gainful employment
that exists in the national economy.

Tackett v. Apfel, 180 F.3d

1094, 1098 (9th Cir. 1999) (citing 42 U.S.C. § 423(d)(2)(A)).

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24

qualify

\\
\\

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3

To decide if a claimant is entitled to benefits, an ALJ
conducts a five-step inquiry.

20 C.F.R. §§ 404.1520, 416.920.

The steps are:

4
5

(1)

6

Is the claimant presently engaged in substantial
gainful activity?

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not disabled.

If so, the claimant is found

If not, proceed to step two.

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9

(2)

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Is the claimant’s impairment severe?
claimant is found not disabled.

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If not, the

If so, proceed

to step three.

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13

(3)

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Does the claimant’s impairment meet or equal one
of

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the

specific

impairments

described

C.F.R. Part 404, Subpart P, Appendix 1?

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the claimant is found disabled.

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in

20

If so,

If not, proceed

to step four.

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19

(4)

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Is the claimant capable of performing his past
work?

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If so, the claimant is found not disabled.

If not, proceed to step five.

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(5)

Is the claimant able to do any other work?
not, the claimant is found disabled.
claimant is found not disabled.

If

If so, the

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3

Tackett, 180 F.3d at 1098-99; see also Bustamante v. Massanari,
262 F.3d 949, 953-54 (9th Cir. 2001) (citations omitted); 20
C.F.R. §§ 404.1520(b)-(g)(1) & 416.920(b)-(g)(1).

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The claimant has the burden of proof at steps one through
four, and the Commissioner has the burden of proof at step five.
Bustamante, 262 F.3d at 953-54.

affirmative duty to assist the claimant in developing the record
at every step of the inquiry.

Id. at 954.

28

If, at step four, the

claimant meets his burden of establishing an inability to perform
past

work,

the

Commissioner

must

show

that

the

claimant

can

perform some other work that exists in “significant numbers” in
the national economy, taking into account the claimant’s residual
functional capacity (“RFC”), age, education, and work experience.
Tackett, 180 F.3d at 1098, 1100; Reddick, 157 F.3d at 721; 20
C.F.R. §§ 404.1520(g)(1), 416.920(g)(1).

The Commissioner may do

so by the testimony of a vocational expert or by reference to the
Medical-Vocational Guidelines appearing in 20 C.F.R. Part 404,
Subpart P, Appendix 2 (commonly known as “the Grids”).
v. Apfel, 240 F.3d 1157, 1162 (9th Cir. 2001).
has

both

exertional

(strength-related)

and

Osenbrock

When a claimant
non-exertional

limitations, the Grids are inapplicable and the ALJ must take the
testimony of a vocational expert.

Moore v. Apfel, 216 F.3d 864,

869 (9th Cir. 2000) (citing Burkhart v. Bowen, 856 F.2d 1335,
1340 (9th Cir. 1988)).

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Additionally, the ALJ has an

III.

1

THE ALJ’S DECISION

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The ALJ employed the five-step sequential evaluation process
in evaluating Plaintiff’s case.

At step one, the ALJ found that

Plaintiff met the insured status requirements of the Act through
June

30,

activity

2011,
since

and

had

October

not
30,

engaged
2008,

in

his

substantial
alleged

(Certified Administrative Record (“AR”) 31).

onset

gainful
date.

At step two, the

ALJ found that Plaintiff had the following severe impairments:

a

history of musculoligamentous strain of the lumbar spine, mild to
moderate lumbosacral disc disease, mild degenerative disc disease
of the cervical spine, mild degenerative disc disease of the
thoracic spine, a history of right inguinal hernia, status post
hernia

repair,

depressive

otherwise specified.

disorder

and

anxiety

disorder,

not

(AR 32).

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At step three, the ALJ found that Plaintiff did not have an
impairment or combination of impairments that met or medically
equaled one of the listed impairments in 20 C.F.R. Part 404,
Subpart P, Appendix 1. (AR 36).

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The ALJ then found that Plaintiff had the following residual
functioning capacity (“RFC”):

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[Plaintiff]
can
lift
and/or
carry
fifty
pounds
occasionally, twenty-five pounds frequently, stand and/or
walk six hours and sit six hours in an eight-hour
workday. [Plaintiff] can frequently climb ramps, stairs,
ladders, ropes and scaffolds, balance, stoop, kneel,
crouch and crawl.
[Plaintiff] is limited to the
performance of simple repetitive tasks.
[Plaintiff] can

1

have occasional supervision and he can occasionally
accept instructions and/or criticism from supervisors.
He can have occasional contact with coworkers and
incidental contact with the public. [Plaintiff] can have
occasional changes to a routine work setting.

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3
4
5

(AR 37).

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7

At step four, the ALJ determined that Plaintiff is unable to

8

perform any past relevant work.

9

found

that,

considering

(AR 42).

Plaintiff’s

At step five, the ALJ
age,

education,

work

10

experience, and RFC, there are jobs that exist in significant

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numbers in the national economy that the Plaintiff can perform.

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(AR 43).

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IV.

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STANDARD OF REVIEW

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Under 42 U.S.C. § 405(g), a district court may review the

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Commissioner’s decision to deny benefits.

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aside the Commissioner’s decision when the ALJ’s findings are

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based

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evidence” in the record as a whole.

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F.3d 1033, 1035 (9th Cir. 2001) (citing Tackett, 180 F.3d at

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1097); Smolen v. Chater, 80 F.3d 1273, 1279 (9th Cir. 1996)

24

(citing Fair v. Bowen, 885 F.2d 597, 601 (9th Cir. 1989)).

on

legal

error

or

are

not

The court may set

supported

by

“substantial

Aukland v. Massanari, 257

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26

“Substantial evidence is more than a scintilla, but less

27

than a preponderance.”

28

v. Chater, 112 F.3d 1064, 1066 (9th Cir. 1997)).

Reddick, 157 F.3d at 720 (citing Jamerson
It is “relevant

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evidence which a reasonable person might accept as adequate to
support a conclusion.” Id. (citing Jamerson, 112 F.3d at 1066;
Smolen,

80

F.3d

at

1279).

To

determine

whether

substantial

evidence supports a finding, the court must “‘consider the record
as a whole, weighing both evidence that supports and evidence
that detracts from the [Commissioner’s] conclusion.’”

Aukland,

257 F.3d at 1035 (quoting Penny v. Sullivan, 2 F.3d 953, 956 (9th
Cir.

1993)).

affirming

If

or

the

evidence

reversing

that

can

reasonably

conclusion,

the

support
court

substitute its judgment for that of the Commissioner.

either

may

not

Reddick,

157 F.3d at 720-21 (citing Flaten v. Sec’y, 44 F.3d 1453, 1457
(9th Cir. 1995)).

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V.

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DISCUSSION

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A. The ALJ Failed To Provide Specific And Legitimate Reasons
For Rejecting Dr. Fierro’s Opinion

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Plaintiff

contends

that

the

ALJ

failed

to

give

reasons

supported by substantial evidence for rejecting the opinion of
Plaintiff’s treating psychologist, Dr. Arturo Fierro, Ph.D.
MSO at 4).

(Pl.

The Court agrees.

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When

a

treating

or

examining

physician's

opinion

is

not

contradicted by another physician, it may be rejected only for

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“clear and convincing” reasons. Lester v. Chater, 81 F.3d 821,
830 (9th Cir. 1995).

When a treating or examining physician's

opinion is contradicted by another doctor, as is the case here,
it

may

only

legitimate”
record.

be

rejected

reasons

if

the

supported

by

ALJ

provides

substantial

“specific

evidence

in

and
the

Id. at 830–31; see also Ryan v. Comm'r of Soc. Sec., 528

F.3d 1194, 1198 (9th Cir. 2008).

The ALJ can meet this burden by

setting forth a detailed and thorough summary of the facts and
conflicting clinical evidence.

Magallanes v. Bowen, 881 F.2d

747, 751 (9th Cir. 1989).

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13

Dr. Fierro is a Ph.D. licensed clinical psychologist who

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treated Plaintiff weekly beginning in April of 2014.

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On March 15, 2016, Dr. Fierro listed his diagnostic impression of

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Plaintiff as: (1) Major Depressive Disorder severe with Psychotic

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Features,

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(AR 1120).

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maintain stability both as so far as medications and psychiatric

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treatment this patient does not appear able to return to more

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gainful

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functional impairments now appear chronically disabling.”

Recurrent;

and

and

(2)

Schizotype

Personality

(AR 1117).

Disorder.

He noted that “[d]espite [Plaintiff’s] efforts to

stable

living.

His

psychiatric

and

physical
(Id.).

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The ALJ gave little weight to Dr. Fierro’s opinion after

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determining that: (1) Dr. Fierro’s opinion was not supported by

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his own records; (2) despite the severity of the evaluations, Dr.

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Fierro did not seek to hospitalize Plaintiff or make a referral

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to “an actual psychiatrist”; (3) Dr. Fierro’s assessments suggest

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greater limitations than Plaintiff alleges and is contradicted by
Plaintiff’s daily activities; and (4) while Dr. Fierro offered
the impression of psychotic features and schizotype personality
disorder, there is no evidence that the Plaintiff was prescribed
medication for psychotic symptoms.

(AR 39-40).

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1. Dr. Fierro’s Records

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The ALJ argues that Dr. Fierro’s opinion is not supported by
his own records.

(AR 39).

The ALJ further argues that the

progress notes, specifically those regarding Plaintiff’s current
level of functioning, “appear primarily to be reiterations of the
claimant’s complaints.”

(Id.).

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The ALJ improperly rejected Dr. Fierro’s opinion.

First,

the ALJ found that Dr. Fierro’s progress notes are inconsistent
because they “indicate a waxing and waning.” (AR 41).
also

notes

that

medical

records

experienced “ups and downs.”

indicate

(AR 39).

that

The ALJ
Plaintiff

However, “waxing” and

“waning” do not necessarily contradict the existence of extreme
mental limitations.

Experiencing some “ups” and “fair days” does

not preclude the possibility of such mental limitations, either.
Therefore,

these

do

not

constitute

specific

and

legitimate

reasons for rejecting Dr. Fierro’s opinion.

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Additionally,

while

Dr.

Fierro

does

not

appear

to

have

conducted significant diagnostic testing, his opinion does not

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9

seem to rely exclusively on Plaintiff's subjective symptoms.

For

example, Dr. Fierro’s April 23, 2014 assessment includes clinical
observations

regarding

Plaintiff’s

appearance,

attitude,

psychomotor activity, speech, mood and affect, among others.
1051).

(AR

Likewise, his March 2016 report states that Plaintiff’s

“intellectual functioning and sensorium was established through
the mental status examination, which displays episodes of poor
memory and memory deficits for recent and remote recall, and poor
concentration.”

(AR 1118).

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2. Hospitalization

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The ALJ rejects Dr. Fierro’s opinion because, despite the
severity indicated in his evaluations, Dr. Fierro did not seek to
hospitalize

Plaintiff

psychiatrist”.
Plaintiff’s

(AR

symptoms

or

make

39).
is

a

First,
not

referral
Dr.

to

Fierro’s

inconsistent

an

“actual

assessment

with

a

lack

of
of

hospitalizations.

Not every individual with debilitating mental

illness

hospitalizations,

requires

nor

are

hospitalizations

appropriate in all instances.

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Second, Dr. Fierro’s decision not to refer Plaintiff to an
“actual psychiatrist” does not justify rejecting his professional
opinion without knowing and evaluating his reasons.

The ALJ’s

rejection of Dr. Fierro’s opinion on this basis is improper.

See

Smolen, 80 F.3d at 1288 (“If the ALJ thought he needed to know
the basis of [a doctor’s] opinions in order to evaluate them, he

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had a duty to conduct an appropriate inquiry, for example, by
supoenaing
them”

or

the

physicians

by

or

submitting

“continuing

the

further

hearing

to

questions
augment

to
the

record”)(citation omitted); see also Tonapetyan v. Halter, 242
F.3d 1144, 1150 (9th Cir. 2001)(the ALJ’s duty to develop the
record is triggered when there is “ambiguous evidence” or when
“the record is inadequate to allow for proper evaluation of the
evidence”);

Brown

v.

Heckler,

713

F.2d

441,

441

(9th

Cir.

1983)(“In Social Security cases the ALJ has a special duty to
fully

and

fairly

develop

the

record

and

to

assure

that

the

claimant’s interests are considered[,]” even when the claimant is
represented by counsel).

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On remand, the ALJ should develop the record to address any
ambiguity in the medical evidence.

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3. Daily Activities

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28

The

ALJ

contends

that

Dr.

Fierro’s

assessments

suggest

greater limitations than Plaintiff alleges and are contradicted
by Plaintiff’s daily activities.

(AR 40).

Plaintiff contends

that the “fact that [Plaintiff] can take public transportation;
goes to eat; takes care of his personal needs – does not mean
that Dr. Fierro’s opinion is inconsistent.”
Court agrees.

(Pl. MSO at 8).

The

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5
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7
8
9
10

Evidence

regarding

Plaintiff’s

daily

activities

does

not

contradict Dr. Fierro’s opinion that he has “extreme” limitations
in most areas of mental functioning.

A plaintiff does not need

to be completely incapacitated to be disabled.

Fair, 885 F.2d at

603;

(9th

Cooper

v.

Bowen,

815

F.2d

557,

561

Cir.

1987)

(“Disability does not mean that a claimant must vegetate in a
dark room excluded from all forms of human and social activity.”)
(citation

and

quotations

omitted);

Reddick,

157

F.3d

at

722

(“disability claimants should not be penalized for attempting to
lead normal lives in the face of their limitations.”).

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Instead,

a

plaintiff’s

daily

activities

are

inconsistent

with claimed disability where the plaintiff is able to spend a
substantial

part

of

the

day

engaged

transferable to a work setting.
the

record

does

not

show

in

activities

that

Fair, 885 F.2d at 603.

that

activities meet this requirement.

Plaintiff’s

are

Here,

limited

daily

The ALJ identified the fact

that Plaintiff goes to church, feels hopeful due to spiritual
support, is able to take public transportation, is able to care
for personal needs, eats at fast food restaurants, goes to the
park, and drives a motor vehicle as evidence contradicting Dr.
Fierro’s
These

opinion

activities

limitations.

of
are

“extreme”
not

mental

limitations.

inconsistent

with

(AR

extreme

40).

mental

Moreover, these activities do not demonstrate that

Plaintiff is able to spend a substantial part of his day engaged
in activities that are transferrable to a work setting.

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2
3
4
5
6
7

The ALJ therefore improperly relied upon Plaintiff’s daily
activities as a basis for rejecting Dr. Fierro’s opinion.
Gallant

v.

Heckler,

753

F.2d

1450,

1453-55

(9th

Cir.

See
1984)

(“Gallant”) (fact that claimant could cook for himself and family
members as well as wash dishes did not preclude a finding that
claimant was disabled due to constant back and leg pain).

Remand

is required.

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4. No Medication For Psychotic Symptoms

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12
13
14
15
16

The ALJ stated that, while Dr. Fierro offered the impression
of psychotic features and schizotype personality disorder, there
is no evidence that Plaintiff is prescribed medication for these
symptoms.

(AR 40).

Plaintiff contends that the ALJ found that

because Dr. Fierro did not prescribe medication, Dr. Fierro’s
opinion lacks substantial evidence.

(Pl. MSO at 8).

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22
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24
25

As a licensed psychologist, Dr. Fierro is likely unable to
prescribe any medications to Plaintiff.2

However, Dr. Fierro is

still a specialist, and the Social Security Agency gives more
“weight

to

the

opinion

of

a

specialist

about

medical

issues

related to his or her area of specialty than to the opinion of a
source who is not a specialist.” 20 C.F.R. § 404.1527(c)(5).
While

Plaintiff’s

primary

care

physicians

opted

to

prescribe

Zoloft and Elavil to Plaintiff, Dr. Fierro, as a psychologist,

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27
28

California
psychologists
cannot
legally
prescribe
medication.
See http://www.psychology.ca.gov/consumers/medicate.shtml.
2

1
2
3
4
5

was not permitted to prescribe medication.
could

not

direct

Plaintiff.

them

Thus,

to

Dr.

prescribe

Fierro

could

Moreover, Dr. Fierro

certain
not

medications

prescribe

to

medication

himself and did not have control over what other doctors chose to
prescribe.

Again, remand is required.

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7
8

B. The ALJ Failed To Properly Consider The
Examiner’s Limitations When Creating The RFC

Consultative

9
“A claimant's residual functional capacity is what he can

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11
12
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15
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still do despite his physical, mental, nonexertional, and other
limitations.” Cooper v. Sullivan, 880 F.2d 1152, 1155 n. 5 (9th
Cir.

1989)

(citing

20

C.F.R.

§

404.1545).

An

RFC

assessment

requires the ALJ to consider a claimant's impairments and any
related symptoms that may “cause physical and mental limitations
that affect what [he] can do in a work setting.” 20 C.F.R. §§
404.1545(a)(1), 416. 945(a)(1).
the

ALJ

considers

all

In determining a claimant's RFC,

relevant

evidence,

including

residual

functional capacity assessments made by consultative examiners,
State

Agency

physicians

404.1545(a)(3),

416.

and

medical

945(a)(3).

See

experts.
also

20
20

C.F.R.
C.F.R.

§§
§§

404.1513(c), 416. 913(c).

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24

Following

a

December

2,

2013

examination

of

Plaintiff,

25

consultative examining psychiatrist Dr. Rama Nadella opined on a

26

series

27

finding, the ALJ stated that he gave “greatest weight to the

28

opinion of the State Agency medical consultants and the reviewing

of

limitations.

(AR

841-845).

In

issuing

his

RFC

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5
6
7
8
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10

psychologist [], to find that the claimant is limited to the
range of unskilled work described in [the RFC].

Inasmuch as Dr.

Nadella’s opinion is consistent with those of the State Agency
medical consultants, I give it limited weight.”

(AR 39).

The

ALJ included four limitations similar to those proposed by Dr.
Nadella.

However,

limitations
performing
ability

he

stating
work

to

did

that

with

include

Plaintiff

activities

deal

not

on

the

a

two

is

Dr.

moderately

consistent

usual

of

basis

stressors

Nadella’s

limited
and

in

in

the

encountered

in

competitive work.

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12
Plaintiff contends that the ALJ never assessed any weight to

13
14

Dr. Nadella’s opinion.

15

it

16

Nadella’s opinion by the “similarities of Dr. Nadella’s opinion

17

to

18

But,

19

Nadella’s proposed limitations in the RFC.

20

Therefore,

21

requirement that he review the record as a whole.

can

the

be

inferred

ALJ’s

(Pl. MSO at 11).
that

assessed

Plaintiff

argues,

Plaintiff

the

ALJ

residual
the

claims,

ALJ

Plaintiff argues that

gave

great

weight

functional

capacity.”

failed

assess

the

ALJ

to

two

to

Dr.

(Id.).
of

Dr.

(Pl. MSO at 12).

failed

to

fulfill

the

(Id.).

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24
25
26
27
28

Defendant counters that the ALJ did assess weight to Dr.
Nadella’s opinion.

Specifically, the ALJ assigned Dr. Nadella’s

opinion “limited weight” before moving forward in determining an
appropriate RFC.

(Def. MSO at 9).

Defendant also argues that

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2

the ALJ “properly reviewed the record as a whole and articulated
a concrete RFC”.

(Id.).

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4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

The ALJ excluded two of Dr. Nadella’s proposed limitations.
Accordingly,

the

ALJ

legitimate

reasons,

implicitly

rejecting

erred

by

supported
portions

not
by

of

providing

specific

and

evidence,

for

opinion.

See

substantial

Dr.

Nadella’s

Jackson v. Colvin, 2014 WL 562240, at *2 (C.D. Cal. Feb. 11,
2014) (finding ALJ erred in failing to explain why RFC assessment
did

not

adopt

certain

moderate

limitations

opined

by

the

consultative examining psychiatrist); Jackson v. Colvin, 2013 WL
1873148, at *5 (C.D. Cal. May 2, 2013) (finding ALJ erred in
failing to proffer any reason for not explaining the rejection of
consultative psychiatrist's opinion that claimant would have mild
to moderate limitations with respect to handling normal stresses
at work); see also SSR 85-15, 1985 WL 56857, at *5-6 (Jan. 1,
1985)

(emphasizing

that

mentally

impaired

people

often

“have

difficulty accommodating to the demands of work and work-like
settings” and thus “[a]ny impairment-related limitations created
by

an

individual's

response

to

demands

of

work

...

must

be

reflected in the RFC assessment”).

22
23
24

On

remand,

the

ALJ

must

properly

assess

Dr.

Nadella’s

25

opinion and provide specific and legitimate reasons for rejecting

26

any portion of that opinion.

27
28

1

VI.

2

CONCLUSION

3
4
5
6
7
8

Accordingly,

IT

IS

ORDERED

that

Judgment

be

entered

REVERSING the decision of the Commissioner and REMANDING this
matter for further proceedings consistent with this decision.

IT

IS FURTHER ORDERED that the Clerk of the Court serve copies of
this Order and the Judgment on counsel for both parties.

9
10

DATED:

August 1, 2017

11
12
13

/S/
SUZANNE H. SEGAL
UNITED STATES MAGISTRATE JUDGE

14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

THIS

DECISION

IS

NOT

INTENDED

FOR

LEXIS/NEXIS, WESTLAW OR ANY OTHER LEGAL DATABASE.

PUBLICATION

IN