Sanders v. Commissioner of Social Security
Filing
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ORDER GRANTING Plaintiff's Social Security Appeal and REMANDING Action for Further Administrative Proceedings signed by Magistrate Judge Sandra M. Snyder on 2/16/2015. CASE CLOSED. (Sant Agata, S)
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UNITED STATES DISTRICT COURT
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EASTERN DISTRICT OF CALIFORNIA
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SHEILA SANDERS,
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Plaintiff,
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CASE NO. 1:13-CV-1380-SMS
v.
CAROLYN W. COLVIN, Acting
Commissioner of Social Security,
ORDER GRANTING PLAINTIFF'S
SOCIAL SECURITY APPEAL AND
REMANDING ACTION FOR FURTHER
ADMINISTRATIVE PROCEEDINGS
Defendant.
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(Doc. 17)
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Plaintiff Sheila Sanders, by her attorneys, Dellert Baird Law Offices, PLLC, seeks judicial
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review of a final decision of the Commissioner of Social Security (“Commissioner”) denying her
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application for supplemental security income (“SSI”) pursuant to Title XVI of the Social Security
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Act (42 U.S.C. § 301 et seq.) (the “Act”). The matter is currently before the Court on the parties’
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cross-briefs, which were submitted, without oral argument, to the Honorable Sandra M. Snyder,
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United States Magistrate Judge. Following a review of the complete record and applicable law,
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this Court finds the decision of the Administrative Law Judge (“ALJ”) includes legal error and the
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record is not fully developed to provide substantial evidence to support the nondisability
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determination.
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I.
Background
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A. Procedural History
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On September 10, 2010, Plaintiff applied for supplemental security income. Plaintiff
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alleges onset of disability on June 20, 2006. The Commissioner initially denied the claims on
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March 17, 2011, and upon reconsideration again denied the claims on May 31, 2011. On July 1,
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2011, Plaintiff filed a timely request for a hearing.
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On January 31, 2012, and represented by counsel, Plaintiff appeared and testified at a
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video hearing presided over by Daniel Heely, Administrative Law Judge (“the ALJ”). See 20
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C.F.R. 416.14 29 et seq. An impartial vocational expert, George Meyers (“the VE”), also
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appeared and testified.
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On February 15, 2012, the ALJ denied Plaintiff’s application. The Appeals Council denied
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review on July 3, 2013. The ALJ’s decision thus became the Commissioner’s final decision. See
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42 U.S.C. § 405(h). On June 23, 2014, Plaintiff filed a complaint seeking this Court’s review
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pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3).
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B. Relevant Facts
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Plaintiff was born on May 1, 1954. At the administrative hearing, Plaintiff testified that she
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worked at a plant nursery as a cashier clerk in 2001, 2002, and 2003. She also worked with a temp
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agency in 2003. Plaintiff was incarcerated for approximately six years, during which time she
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worked in the corrections facility as a seamstress and firefighter.
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Plaintiff testified that there was no full-time job she thought she could handle, mostly
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because of physical pain in her ankles and low back. Her biggest concern was being able to make
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it through the day physically. Plaintiff constantly felt pain in her neck and low back, which was
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helped “some” by Vicodin. She testified that she could be on her feet for an hour at the longest,
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and had to lie down approximately two hours out of every eight or nine hours.
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Plaintiff was being treated for posttraumatic stress disorder (“PTSD”), depression, and
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bipolar disorder. Plaintiff initially testified that she would be able to focus at a job for eight hours
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a day with breaks. She then testified that her depression and anxiety would cause her to be angry,
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emotionally withdrawn, and unable to focus.
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Plaintiff lived with her disabled brother and did her own chores including preparing meals,
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washing dishes, and doing laundry. She was unable to mop because it hurt her back. Plaintiff liked
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to watch movies and sometimes watched TV. She did not own a computer but she occasionally
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would play solitaire on the computer or look up things online in order to help her nephew. Plaintiff
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had a driver’s license but did not own a car, so she got rides or took the bus to go grocery
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shopping.
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C. Relevant Medical Record
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In June 2006, Plaintiff suffered a fall, causing neck and back pain. She was prescribed
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medication and underwent physical therapy. In February 2007, an orthopedic surgeon diagnosed
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Plaintiff with having cervical disc degeneration with superimposed strain. In March and October
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2007, MRIs revealed foraminal stenosis and multi-level degenerative disc disease of the lumbar
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spine and a normal thoracic spine. No surgery was recommended. After 2007 and until 2011,
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Plaintiff did not receive any treatment for her axial spine.
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In 2011, Plaintiff continued to experience pain in her neck and back. In January 2011,
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consultative examiner Dr. Fariba Vesali performed an orthopedic examination and completed a
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functional assessment. AR 383-386. Dr. Vesali opined that Plaintiff could walk, stand, and sit six
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hours in an eight-hour workday with breaks every twenty minutes for stretching. She could lift or
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carry fifty pounds occasionally and twenty-five pounds frequently. He limited Plaintiff to
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occasional crouching and climbing and did not assess any manipulative limitations.
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In March 2011, Dr. W. Jackson reviewed Plaintiff’s file and completed a Physical Residual
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Capacity Assessment. His functional assessment was similar to Dr. Vesali’s in that he opined that
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Plaintiff could walk, stand, and sit approximately six hours in an eight-hour workday with breaks,
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limited Plaintiff to occasional crouching, climbing and other postural limitations, and did not
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assess any manipulative limitations. The main difference in the two opinions is that Dr. Jackson
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assessed that Plaintiff was only able to lift or carry twenty pounds occasionally and ten pounds
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frequently. Dr. Jackson’s assessment places Plaintiff functional capacity in the “light” range,
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whereas Dr. Vesali’s places her in the “medium” range.
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Also in 2011, Plaintiff began to complain of depression to physician assistant Leslie
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Halseth. This is the first time mental health issues appear in the record. Plaintiff was referred to
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social worker, C. Bitonti, in June 2011. She underwent her first psychiatric consultation with a
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psychiatrist, Dr. Naldony, in July 2011. Dr. Naldony diagnosed Plaintiff with depression, PTSD,
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and opioid dependence. He prescribed Zoloft and Lithium. In September 2011 Plaintiff reported to
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Ms. Halseth that she only took the medications for a few days and discontinued. In October 2011,
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Plaintiff returned for treatment with Ms. Bitonti after several months of absence. Plaintiff again
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indicated that she had stopped taking the medications prescribed by Dr. Naldony and expressed a
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desire to “just go to counseling.” She continued to refuse medication in December 2011. She also
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refused an appointment with Dr. Naldony. AR 452-461. Also in December 2011, Ms. Bitonti
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noted that an appointment was made with a new integrated behavioral health clinician. However,
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no there are no records from any further mental health treatment.
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D. Vocational Expert Testimony
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At the administrative hearing, the VE classified Plaintiff’s past full-time work as
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horticultural worker (DOT # 405.687-014, heavy, unskilled, SVP 2). For the first hypothetical
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question, the ALJ directed the VE to assume a hypothetical person of the same age, education, and
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work history as Plaintiff, who could sit for six hours but stand and/or walk for less than two hours
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in a workday; lift and/or carry less than ten pounds occasionally; never climb, balance, stoop,
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kneel, crouch, crawl, or work around hazards; would need numerous unscheduled rest breaks; and
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would not have sufficient concentration for simple, routine tasks. The VE opined that there were
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no full-time jobs for this hypothetical person.
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For the second hypothetical question, the ALJ directed the VE to assume a hypothetical
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person of the same age, education, and work history as Plaintiff, who could sit, stand, and walk six
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hours in an eight-hour workday with normal breaks, lift and/or carry fifty pounds occasionally and
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twenty-five pounds frequently, occasionally crouch and climb, and was limited to jobs involving
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simple, routine types of tasks with occasional public contact. The VE opined that this hypothetical
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person could not perform Plaintiff’s past job of horticultural worker, but could perform other work
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of hand packer (DOT # 920.587-018, medium, unskilled, SVP 2), cleaner (DOT # 919.687-014,
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medium, unskilled, SVP 1), and laundry worker (DOT # 361.685-018, medium, unskilled, SVP 2).
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For the third hypothetical question, the ALJ directed the VE to assume the same
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hypothetical person as described in the second hypothetical but without the limitation of
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occasional public contact. The VE opined that this hypothetical person could perform Plaintiff’s
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past work as horticultural worker as performed, and the jobs mentioned in the second hypothetical.
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Plaintiff’s attorney asked the VE to assume the same hypothetical person as described in
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the third hypothetical, but who would need to go away from the workplace and stretch for five
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minutes every twenty minutes. The VE opined that there would not be any jobs available for that
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person. There also would not be any jobs available for a person who needed to stretch for one
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minute off and on for twenty minutes, or for a person who needed to be seated for twenty minutes
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and then standing or walking for twenty minutes in shifts.
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E. Disability Determination
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After considering the evidence, the ALJ found that Plaintiff had not engaged in substantial
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gainful activity since the alleged onset date of disability. He found that Plaintiff had degenerative
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disc disease, anxiety, PTSD, and depression which significantly limited her ability to perform
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basic work activities. The ALJ found that Plaintiff did not have an impairment that met or
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medically equaled the severity of a listed impairment. He found that Plaintiff had the residual
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functional capacity (“RFC”) to perform “medium work” as defined in 20 C.F.R. 416.967(c), with
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the following limitations: only jobs involving simple routing types of tasks, sit/stand/walk for six
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hours in an eight-hour workday with normal breaks; lift and/or carry fifty pounds occasionally and
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twenty-five pounds frequently; and could occasionally crouch and climb. The ALJ concluded that
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Plaintiff was capable of performing her past relevant work as a horticultural worker. In the
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alternative, considering Plaintiff’s age, education, work experience, and RFC, there were jobs
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existing in significant numbers in the national economy that Plaintiff could perform. Hence, he
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determined that Plaintiff could make a successful adjustment to other work and was found “not
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disabled.”
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II.
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Discussion
Plaintiff raises two main issues for appeal. First, Plaintiff argues that the ALJ improperly
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assessed Plaintiff’s physical RFC because he failed to consider reviewing physician Dr. Jackson’s
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functional capacity opinion. Second, Plaintiff argues that the ALJ improperly assessed Plaintiff’s
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mental impairments and mental functional capacity because the record was incomplete and the
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ALJ’s conclusions were therefore unsubstantiated.
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A. The Five-Step Sequential Analysis
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An individual is considered disabled for purposes of disability benefits if she is unable to
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engage in any substantial, gainful activity by reason of any medically determinable physical or
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mental impairment that can be expected to result in death or that has lasted, or can be expected to
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last, for a continuous period of not less than twelve months. 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)
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(3)(A); see also Barnhart v. Thomas, 540 U.S. 20, 23 (2003). The impairment(s) must result from
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anatomical, physiological, or psychological abnormalities that are demonstrable by medically
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accepted clinical and laboratory diagnostic techniques and must be of such severity that the
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claimant is not only unable to do her previous work but cannot, considering her age, education,
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and work experience, engage in any other kind of substantial, gainful work that exists in the
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national economy. 42 U.S.C. §§ 423(d)(2)-(3), 1382c(a)(3)(B), (D).
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To encourage uniformity in decision making, the Commissioner has promulgated
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regulations prescribing a five-step sequential process for evaluating an alleged disability. 20
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C.F.R. §§ 404.1520 (a)-(f); 416.920 (a)-(f). In the five-step sequential review process, the burden
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of proof is on the claimant at steps one through four, but shifts to the Commissioner at step five.
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See Tackett v. Apfel, 180 F.3d 1094, 1099 (9th Cir. 1999). If a claimant is found to be disabled or
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not disabled at any step in the sequence, there is no need to consider subsequent steps. Id. at
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1098–99; 20 C.F.R. §§ 404.1520, 416.920.
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In the first step of the analysis, the ALJ must determine whether the claimant is currently
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engaged in substantial gainful activity. 20 C .F.R. §§ 404.1520(b), 416.920(b). If not, in the
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second step, the ALJ must determine whether the claimant has a severe impairment or a
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combination of impairments significantly limiting her from performing basic work activities. Id.
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§§ 404.1520(c), 416.920(c). If so, in the third step, the ALJ must determine whether the claimant
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has a severe impairment or combination of impairments that meets or equals the requirements of
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the Listing of Impairments, 20 C.F.R. 404, Subpart P, App. 1. Id. §§ 404.1520(d), 416.920(d). If
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not, in the fourth step, the ALJ must determine whether the claimant has sufficient RFC, despite
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the impairment or various limitations to perform his past work. Id. §§ 404.1520(f), 416.920(f). If
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not, in step five, the burden shifts to the Commissioner to show that the claimant can perform
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other work that exists in significant numbers in the national economy. Id. §§ 404.1520(g),
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416.920(g).
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B. Standard of Review
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Congress has provided a limited scope of judicial review of the Commissioner’s decision
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to deny benefits under the Act. The record as a whole must be considered, weighing both the
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evidence that supports and the evidence that detracts from the Commissioner’s decision.
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Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007) (citation and internal quotation marks
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omitted). In weighing the evidence and making findings, the Commissioner must apply the proper
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legal standards. See, e.g., Burkhart v. Bowen, 856 F.2d 1335, 1338 (9th Cir. 1988). If an ALJ
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applied the proper legal standards and the ALJ’s findings are supported by substantial evidence,
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this Court must uphold the ALJ’s determination that the claimant is not disabled. See, e.g., Ukolov
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v. Barnhart, 420 F.3d 1002, 104 (9th Cir. 2005); see also 42 U.S.C. § 405(g). Substantial
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evidence means “more than a mere scintilla but less than a preponderance.” Ryan v. Comm’r of
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Soc. Sec., 528 F.3d 1194, 1998 (9th Cir. 2008). It is “such relevant evidence as a reasonable mind
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might accept as adequate to support a conclusion.” Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir.
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2005). Where the evidence as a whole can support either outcome, the Court may not substitute its
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judgment for the ALJ’s; rather, the ALJ’s conclusion must be upheld. Id.
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C. Plaintiff’s Physical RFC
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Plaintiff contends that the ALJ’s physical RFC analysis was flawed because the ALJ
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adopted Dr. Vesali’s opinion regarding Plaintiff’s functional capacity without discussing Dr.
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Jackson’s conflicting opinion. The Commissioner responds that the ALJ implicitly rejected Dr.
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Jackson’s opinion in favor of Dr. Vesali’s, and that Dr. Vesali’s opinion was supported by
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substantial evidence and may be afforded greater weight as an examining source.
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Physicians render two types of opinions in disability cases: (1) clinical medical opinions
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regarding the nature of the claimant’s impairments and (2) opinions on the claimant’s ability to
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perform work. See Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998). “An ALJ is not bound
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by an expert medical opinion on the ultimate question of disability.” Tomasetti, 533 F.3d at 1041;
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S.S.R. 96-5p. Three types of physicians may offer opinions in social security cases: “(1) those
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who treat[ed] the claimant (treating physicians); (2) those who examine[d] but d[id] not treat the
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claimant (examining physicians); and (3) those who neither examine[d] not treat[ed] the claimant
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(nonexamining physicians).” Lester, 81 F.3d at 830. A treating physician’s opinion is generally
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entitled to more weight than the opinion of a doctor who examined but did not treat the claimant,
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and an examining physician’s opinion is generally entitled to more weight than that of a
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nontreating physician. Id.
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An ALJ is not required to discuss every piece of evidence in the record. Howard v.
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Barnhart, 341 F.3d 1006, 1012 (9th Cir. 2003); Vincent on Behalf of Vincent v. Heckler, 739 F.2d
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1393, 1394-95 (9th Cir. 1984). However, the ALJ must explain why “significant probative
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evidence has been rejected.” Vincent, 739 F.2d at 1395. “The RFC assessment must always
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consider and address medical source opinions. If the RFC assessment conflicts with an opinion
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from a medical source, the adjudicator must explain why the opinion was not adopted.” SSR 96-
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8p, 1996 SSR LEXIS 5 (SSR 1996); see also § 416.927(a)(2); Nixon v. Astrue, 2010 U.S. Dist.
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LEXIS 96218 (C.D. Cal. 2010)(“All opinions from acceptable medical sources must be
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considered.”) “Where an ALJ does not explicitly reject a medical opinion or set forth specific,
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legitimate reasons for crediting one medical opinion over another, he errs.” Garrison v. Colvin,
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759 F.3d 995, 1012 (9th Cir. 2014).
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Here, the record contained two medical opinions on Plaintiff’s ability to work. Dr. Vesali
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was an examining physician, and Dr. Jackson was a nonexamining, or reviewing, physician. The
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ALJ discussed Dr. Vesali’s opinion and gave it “significant weight” because they were the result
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of an in-person examination with testing and because Dr. Vesali was board certified in physical
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medicine and rehabilitation. The ALJ did not agree with Dr. Vesali’s opinion that Plaintiff
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required breaks every twenty minutes for stretching because of Plaintiff’s testimony that she could
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be on her feet for up to sixty minutes. Therefore, the ALJ’s RFC analysis adopted the physical
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functional capacity delineated by Dr. Vesali except without requiring breaks every twenty
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minutes. The ALJ’s decision contained no discussion of Dr. Jackson’s opinion, which came to
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almost all of the same conclusions as Dr. Vesali’s opinion regarding Plaintiff’s functional
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capacity, except that he felt that she could lift and carry significantly less than did Dr. Vesali.
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Dr. Jackson’s opinion is probative evidence from an acceptable medical source and must
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be considered. Because Dr. Jackson’s opinion is an acceptable medical source and conflicts with
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the RFC, the ALJ was required to explain why it was rejected. Had the ALJ considered this
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opinion, he may have reached a more restrictive physical RFC assessment, which would affect the
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availability of work that Plaintiff could perform. Therefore, the matter will be remanded in order
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for the ALJ to consider Dr. Jackson’s functional capacity opinion in the RFC assessment.
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D. Plaintiff’s Mental Impairments and Limitations
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Plaintiff contends that, because there was no medical opinion regarding Plaintiff’s mental
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limitations, the ALJ erred at step three of the sequential evaluation, in arriving at Plaintiff’s mental
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RFC, and in his duty to develop the record. The Commissioner responds that the ALJ properly
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analyzed Plaintiff’s mental health records, which did not establish any mental functional
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limitations, and properly accommodated mental functional limitations by limiting her to simple
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repetitive tasks.
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1. Applicable Law
The claimant bears the burden of demonstrating disability. Bowen v. Yuckert, 482 U.S.
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137, 146 n. 5, (1987). However, the ALJ has a duty to assist in developing the record when there
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is ambiguous evidence or when the record is inadequate to allow for proper evaluation of the
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evidence. Mayes v. Massanari, 276 F.3d 453, 459 (9th Cir. 2001); Armstrong v. Commissioner of
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Soc. Sec. Admin., 160 F.3d 587, 589 (9th Cir. 1998); 20 C.F.R. §§ 416.912(d)-(f); see also Sims v.
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Apfel, 530 U.S. 103, 110-11 (2000). The duty to develop the record is not triggered in the event of
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a silent record that does not support disability. Armstrong at 589. “ALJs are to seek additional
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evidence or ask the claimant to undergo further consultative examinations if there is consistent
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evidence of an impairment but the evidence is not sufficient for the ALJ to determine whether the
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claimant is disabled.” Rochin v. Barnhart, 204 Fed. Appx. 601, 603 (9th Cir. 2006)(citing 20
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C.F.R. 416.927(c)(3)). In particular, when there is evidence indicating the existence of a mental
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impairment, a determination of nondisability shall be made only if the Commissioner has made
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“every reasonable effort to ensure that a qualified psychiatrist or psychologist has completed the
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medical portion of the case review and any applicable residual functional capacity assessment.” 42
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U.S.C. 421(h).
Failure to order a consultative examination when such examination is necessary to make an
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informed decision is reversible error. Reed v. Massanari, 270 F.3d 838, 845 (9th Cir. 2001).
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Where the ALJ failed to develop the record, remand is appropriate so that the record may be
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developed. See 42 U.S.C. 405(g); Lewin v. Schweiker, 654 F.2d 631, 635 (9th Cir. 1981)(“If
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additional proceedings can remedy defects in the original administrative proceedings, a social
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security case should be remanded.”).
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2. Analysis
Here, the medical evidence covering Plaintiff’s mental impairments is rather sparse and
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spans approximately seven months in 2011. During these seven months, Plaintiff had three
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appointments with a social worker, one appointment with a psychiatrist, and several notes taken
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by a physician’s assistant. The psychiatrist prescribed medication for depression and PTSD, which
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Plaintiff only took for a few days. She indicated a desire to continue counseling, but there is no
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evidence that she continued. There is no mental functional capacity assessment in the record. In
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spite of this sparse record, the ALJ found that Plaintiff’s anxiety, PTSD, and depression were
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severe impairments at step two. At step three, the ALJ considered the “paragraph B” criteria in
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order to find that Plaintiff did not have an impairment that met a listing. First, the ALJ found that
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Plaintiff had moderate restriction in activities of daily living because she was able to watch TV
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and do some housework. Second, the ALJ found that Plaintiff had moderate difficulties in social
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functioning because she was able to live with others. Third, the ALJ found that Plaintiff had
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moderate difficulties in concentration, persistence, or pace because she could use a computer,
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watch a movie, and drive. Lastly, the ALJ found that Plaintiff had experienced no episodes of
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decompensation of extended duration.
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The ALJ then evaluated Plaintiff’s RFC. He noted that the RFC assessment requires an
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itemization of various functions contained in the paragraph B categories; however, he only
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discussed Plaintiff’s activities of daily living and her ability to focus. He did not discuss her
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capacity in social functioning. In addition, the ALJ did not rely on a mental functional capacity
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assessment from a medical source. The ALJ concluded, without discussion, that Plaintiff had the
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mental RFC to perform simple routine tasks.
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The ALJ’s mental impairment and limitations analysis is substantially lacking. The only
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mention of Plaintiff’s social functioning in the ALJ’s decision is that she lives with her brother,
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which indicates moderate ability in social functioning because she is able to live with others.
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However, the record also indicates that Plaintiff lived with her daughter and son-in-law upon
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release from incarceration, but her daughter “kicked her out,” and in October 2011 she was living
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with two people who were using drugs. AR 454. The ALJ resolved this by saying that her
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problems with her daughter “may be situational, and not medical, in nature.” Plaintiff testified that
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she does not engage in social activities outside the home, but also that she helped her nephew and
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“other people” drive her to the store.
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The record is insufficient to make proper conclusions regarding Plaintiff’s mental
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functioning. The evidence may more strongly support a finding that Plaintiff moves often and is
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unable to live with others. However, without a consultative examination, the evidence is
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insufficient to make proper findings. In this case, a consultative examination is necessary in order
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for the ALJ to make an informed disability determination. The ALJ was obligated to develop the
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record in order to make proper mental severity and functional capacity assessments. A qualified
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medical provider’s opinion is likely to have an effect the ALJ’s outcome at step three and the RFC
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assessment. Hence, the matter will be remanded for further proceedings in order that the ALJ may
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order a consultative examination and conduct a proper analysis at step three and Plaintiff’s mental
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RFC.
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III.
Conclusion and Order
Upon a careful review of the full record, the Court is unconvinced that Plaintiff is disabled.
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Yet, however reluctantly, the Court must remand because the ALJ’s nondisability determination
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includes legal error and the record is not fully developed to provide substantial evidence to support
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the nondisability determination. Accordingly,
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IT IS HEREBY ORDERED:
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1. that Plaintiff’s appeal from the administrative decision of the Commissioner of Social
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Security (Doc. 1) is GRANTED.
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2. pursuant to sentence four of 42 U.S.C. § 405(g), that the matter is REMANDED for
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further proceedings consistent with this decision; and,
3. the Clerk of Court is DIRECTED to enter judgment in favor of Plaintiff Sheila
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Sanders and against Defendant, Carolyn Colvin, Acting Commissioner of Social
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Security.
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IT IS SO ORDERED.
Dated:
February 16, 2015
/s/ Sandra M. Snyder
UNITED STATES MAGISTRATE JUDGE
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