Cabrera v. Kijakazi
Filing
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ORDER by Judge Robert M. Illman granting 12 Motion for Summary Judgment; denying 16 Motion for Summary Judgment. (rmilc1) (Filed on 1/27/2025)
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UNITED STATES DISTRICT COURT
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NORTHERN DISTRICT OF CALIFORNIA
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EUREKA DIVISION
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ROGELIO C., 1
Plaintiff,
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v.
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United States District Court
Northern District of California
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MARTIN O'MALLEY,
Case No. 23-cv-05446-RMI
ORDER ON MOTIONS FOR
SUMMARY JUDGMENT
Re: Dkt. Nos. 12, 16
Defendant.
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Plaintiff seeks judicial review of an administrative law judge (“ALJ”) decision finding that
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Plaintiff’s disability had ceased under Titles II and VII of the Social Security Act. See Admin. Rec. at
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14. 2 The Appeals Council of the Social Security Administration declined to review the ALJ's decision.
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Id. at 4. As such, the ALJ's decision is a “final decision” of the Commissioner of Social Security,
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appropriately reviewable by this court. See 42 U.S.C. § 405(g), 1383(c)(3). Both parties have
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consented to the jurisdiction of a magistrate judge (Dkts. 6, 8) and both parties have filed briefs (Dkts.
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12, 16). For the reasons stated below, Plaintiff’s motion for summary judgment is GRANTED,
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Defendant’s motion is DENIED, and the case is REMANDED to the ALJ for further proceedings
consistent with this order.
I.
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Background
Plaintiff was born in 1994. AR at 47. He received an individualized education plan (IEP)
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Pursuant to the recommendation of the Committee on Court Administration and Case
Management of the Judicial Conference of the United States, Plaintiff's name is partially redacted.
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The Administrative Record (“AR”), which is independently paginated, has been filed in eight
attachments to Docket Entry #11. See Docs. 11-1 through 11-8.
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in school beginning in 2001. Id. at 1. On March 27, 2013, the Social Security Administration
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determined that Plaintiff had been disabled since June 1, 2002. Id. at 14. Only a small amount of
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medical evidence underlying the 2013 decision is included in the present record. That evidence is
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as follows:
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findings. AR at 361. Dr. Boyd assessed Plaintiff’s full-scale IQ at 73, in the “borderline
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low” range. Id. at 362. She opined that Plaintiff had two “[m]oderate impairment[s]”: in
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his ability to perform and sustain day-to-day work activities; and in his ability to maintain
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concentration, attention, persistence, and pace. Id. at 364.
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United States District Court
Northern District of California
An evaluation by Dr. Sara Boyd contained relatively normal mental status examination
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Dr. A. Garcia, a consultant for the SSA, completed a form indicating a number of
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moderate limitations as well as marked limitations in Plaintiff’s “ability to understand and
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remember detailed instructions[,]” “ability to carry out detailed instructions[,]” and
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“ability to complete a normal workday and workweek without interruptions from
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psychologically based symptoms and to perform at a consistent pace without an
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unreasonable number and length of rest periods.” AR at 368–69. Dr. Garcia concluded
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that Plaintiff was “[u]nable to perform simple repetitive tasks. Unable to maintain
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concentration, persistence or pace. Not able to relate well to supervisors, coworkers, or
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general public. Not able to adapt to work changes.” Id. at 370. On a second form, Dr.
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Garcia endorsed “marked” difficulties in concentrating, persisting, or maintaining pace
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and four or more extended episodes of decompensation. Id. at 379. Neither form
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elaborates on how Dr. Garcia reached these conclusions.
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Finally, Social Security records from the first decision indicate that Plaintiff was found to
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have moderate difficulties in understanding, remembering, or applying information and in
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interacting with others. AR at 79. The records reflect a finding of marked difficulties in
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concentrating, persisting, or maintaining pace and in adapting or managing oneself. Id.
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The ALJ in the current case gave Dr. Boyd’s opinion “little weight for the period to which
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is [sic] applies, as it is not consistent with the record as a whole, including prior hospitalizations.”
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AR at 22. However, the court has been unable to locate a reference to such hospitalizations in the
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United States District Court
Northern District of California
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record. The ALJ also describes the agency consultants’ opinions for this time period as
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“supported for the period during which they apply[,]” but does not reference what evidence
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“supported” them. Id. Again, the court has been unable to locate contemporaneous supporting
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evidence in the record.
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While receiving Social Security benefits, Plaintiff was sporadically employed as a car
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washer, security guard, retail worker, and shipper/receiver. AR at 49–50. However, Plaintiff
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testified that these jobs “didn’t last for long period[s] of time. I was let go.” Id. at 48. He
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elaborated that “I cannot understand what I have to do. I have to keep repeating myself. Like, I
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ask them the task over and over and, like, they get tired of me. . . . I have to read things over and
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over and stuff like that, you know, to comprehend.” Id. at 53. He said that he was let go from
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“[a]ll of” his jobs because he “wasn’t up to par, they said.” Id.
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In 2020, the Social Security Administration reviewed Plaintiff’s case. AR at 71. The
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Administration was unable to determine whether Plaintiff remained disabled based on the
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available medical records. Id. at 86. Although attempts were made to contact Plaintiff and
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arrange for a consultative examination, the Administration was apparently unable to reach
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Plaintiff. Id. at 76. Plaintiff did not present for a consultative examination despite Plaintiff and a
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third party receiving voicemails detailing the scheduled time and date of the examination. Id. As
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a result, the Administration had insufficient evidence to determine that Plaintiff remained disabled,
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and Plaintiff’s disability was deemed to have ceased in January of 2021. Id. at 86.
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Plaintiff contacted the Administration in May of 2021 objecting to the termination of his
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benefits. AR at 99. Plaintiff stated that he had not attended the consultative examination because
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Plaintiff never received a letter warning him that his benefits might end. Id. Plaintiff had some
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difficulty in his interactions with the Administration, as described by one Social Security
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employee:
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“Claimant would ramble on about needing his benefits reinstated. I
mailed forms for him to complete. I stated clearly to give me a call
when he receives the forms to help him complete it correctly. He
mailed the forms back blank. He has a hard time understanding and
following directions.”
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Id. at 280. The employee also noted that Plaintiff had difficulty concentrating. Id.
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United States District Court
Northern District of California
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The Administration scheduled a telephone hearing in Plaintiff’s case for October of 2021
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and sent him written notice thereof in September 2021. AR at 106. However, Plaintiff did not
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attend the hearing. Id. at 111. A second letter, noting that the hearing had taken place without
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Plaintiff and urging Plaintiff to contact the Administration immediately, was sent immediately
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after the hearing. Id. Plaintiff did not respond to that letter, either. Id. at 115. Later that month,
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the hearing officer determined that Plaintiff’s disability had ceased based on the lack of evidence
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and Plaintiff’s failure to cooperate. Id. In December of 2021, Plaintiff requested reconsideration
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of the hearing officer’s decision, objecting that he had not received a phone call about the
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upcoming hearing. Id. at 123. Later, when requesting a hearing before an ALJ, Plaintiff
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elaborated that he “never received a phone call or mail” regarding his claim and had “missed the
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phone call from SSI[.]” Id. at 135. Ultimately, an ALJ hearing was scheduled for November of
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2022. Id. at 173.
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At the hearing before the ALJ, Plaintiff repeatedly expressed confusion about the process,
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asking “what is this hearing for?” and noting that he “had trouble, like, understanding” documents
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he was sent about his right to counsel. AR at 37–38. Plaintiff testified that he had been homeless
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until a few months before the hearing and “was staying here and there, in my car” during that time.
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Id. at 55. At the end of the hearing, Plaintiff asked why “they try to, like question my Social
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Security[,]” even though the ALJ had explained the routine nature of the review to Plaintiff at the
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beginning of the hearing. Id. at 59. The ALJ arranged for Plaintiff to attend a psychological
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evaluation after the hearing. Id. at 46.
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Plaintiff was examined by Dr. Jacklyn Chandler in January of 2023. AR at 556. Dr.
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Chandler observed Plaintiff to be “immature for his age level” and described Plaintiff’s “insight
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and judgment [as] compromised, commensurate with his level of cognitive ability.” Id. at 557.
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Other than this, Plaintiff’s mental status examination findings were unremarkable. Id. Dr.
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Chandler assessed Plaintiff’s full-scale IQ to be 67, in the “extremely low range.” Id. at 557–58.
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She assessed his “overall intellectual ability within the borderline range[.]” Id. at 558. She opined
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that Plaintiff would have “moderate difficulty carrying out simple job instructions[,]” “moderate
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difficulty understanding and remembering . . . and moderate to marked difficulty carry[ing] out
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United States District Court
Northern District of California
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complex instructions[,]” “moderate difficulty adapting to changes in routine work
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settings[,]”“moderate difficulty maintaining attention and concentration[,]” and “moderate
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difficulty functioning under normal stress in a work setting.” Id. at 559. Elsewhere, Dr. Chandler
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opined that Plaintiff would have moderate to marked difficulty in “mak[ing] judgments on
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complex work-related decisions.” Id. at 560.
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The ALJ ultimately decided that Plaintiff’s disability had ended on January 1, 2021. AR at
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1). As relevant here, at step two of the Title II analysis and step one of the Title XVI analysis, the
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ALJ concluded that Plaintiff’s disabilities did not meet or equal the severity of the impairments
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listed in 20 CFR Part 404, Subpart P, Appendix 1. Id. at 17. The ALJ concluded that Plaintiff was
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moderately limited in understanding, remembering, or applying information; moderately limited in
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interacting with others; moderately limited in concentrating, persisting, or maintaining pace; and
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moderately limited in adapting and managing himself. Id. at 17–18. Moving on to step three of
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the Title II analysis and step two of the Title XVI analysis, the ALJ pointed out that Plaintiff had
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originally been found to have a marked limitation in concentration, persistence, and pace in
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addition to a finding of more than four extended episodes of decompensation. Id. at 19. Based on
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this, Plaintiff’s generally “minimal” mental status evaluation findings, no evidence of extended
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incidents of decompensation, and Plaintiff’s “inconsistently good” activities of daily living, the
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ALJ determined that Plaintiff had medically improved since he originally became eligible for
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Social Security benefits. Id.
Plaintiff appeals.
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II.
Standard
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The Social Security Act limits judicial review of the Commissioner’s decisions to final
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decisions made after a hearing. 42 U.S.C. § 405(g). The Commissioner’s findings “as to any fact,
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if supported by substantial evidence, shall be conclusive.” Id. A district court has limited scope
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of review and can only set aside a denial of benefits if it is not supported by substantial evidence
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or if it is based on legal error. Flaten v. Sec’y of Health & Human Servs., 44 F.3d 1453, 1457 (9th
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Cir. 1995). The phrase “substantial evidence” appears throughout administrative law and directs
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courts in their review of factual findings at the agency level. See Biestek v. Berryhill, 139 S. Ct.
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United States District Court
Northern District of California
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1148, 1154 (2019). Substantial evidence is defined as “such relevant evidence as a reasonable
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mind might accept as adequate to support a conclusion.” Id. at 1154 (quoting Consol. Edison Co.
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v. NLRB, 305 U.S. 197, 229 (1938)); see also Sandgathe v. Chater, 108 F.3d 978, 979 (9th Cir.
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1997). “In determining whether the Commissioner's findings are supported by substantial
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evidence,” a district court must review the administrative record as a whole, considering “both the
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evidence that supports and the evidence that detracts from the Commissioner’s conclusion.”
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Reddick v. Chater, 157 F.3d 715, 720 (9th Cir. 1998). The Commissioner’s conclusion is upheld
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where evidence is susceptible to more than one rational interpretation. Burch v. Barnhart, 400
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F.3d 676, 679 (9th Cir. 2005). However, courts “review only the reasons provided by the ALJ in
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the disability determination and may not affirm the ALJ on a ground upon which [s]he did not
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rely.” Garrison v. Colvin, 759 F.3d 995, 1010 (9th Cir. 2014).
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III.
Analysis
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20 C.F.R. § 404.1594(b)(1) states that a determination of medical improvement “must be
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based on improvement in the symptoms, signs, and/or laboratory findings associated with your
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impairment(s).” Here, however, the court is unable to determine whether the ALJ correctly
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applied this standard, because at least some of the “symptoms, signs, and/or laboratory findings”
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underlying Plaintiff’s original disability determination are missing from the record before this
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court. “In the absence of the early medical records, the administrative record lacks a foundation
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for a reasoned assessment of whether there is substantial evidence to support the Commissioner’s
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finding that [a claimant's current] condition represents an ‘improvement.’” Veino v. Barnhart, 312
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F.3d 578, 587 (2d Cir. 2002). Faced with an incomplete record, the court has no way to determine
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whether the ALJ’s finding of medical improvement is supported by substantial evidence in light of
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the record as a whole.
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Aside from the deficiencies in the record, this matter must be remanded because the ALJ
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has not compared Plaintiff’s current symptoms, signs, or laboratory results to his past ones, but
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rather to the broadly-stated impairment conclusions previously drawn by reviewing doctors. As
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other courts in this District have held, “it is not enough for the ALJ to simply compare the
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medically determinable impairments and RFC determination assessed at the time of the most
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United States District Court
Northern District of California
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recent favorable decision to those at present.” Keyes v. Saul, 2021 WL 2953232, at *6 (N.D. Cal.
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July 4, 2021); see also Zutphen v. Colvin, 2016 WL 5358589, at *6 (N.D. Cal. Sept. 26, 2016)
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(remanding where ALJ cited only original Step 2 listing, but not the underlying medical records,
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and then concluded that the plaintiff no longer met the listing). This is because “making reference
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to [a reviewing doctor’s or hearing officer’s] opinions cannot substitute for the ALJ’s own
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obligation set forth in 20 C.F.R. §§ 404.1594(b)(1) that the ALJ compare prior to current medical
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evidence.” Medina v. Colvin, 2015 WL 5448498, at *11 (N.D. Cal. Aug. 21, 2015); see also
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Veino, 312 F.3d at 587 (“The Commissioner also argues that the record before us is adequate
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because the 1982 medical evidence was summarized in the Hearing Officer's decision . . . . The
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difficulty with the Commissioner’s position is that these decisions are not evidence . . . . without
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any of the 1982 medical evidence in the record before us, this court cannot make a reasoned
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determination as to whether the DHO’s summary is accurate or adequate.”)
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Here, the ALJ’s decision rested on four factors: a comparison of Plaintiff’s categorical
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limitations, Plaintiff’s “minimal” mental status evaluation findings, no evidence of extended
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incidents of decompensation, and Plaintiff’s “inconsistently good” activities of daily living. As
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detailed above, a comparison of categorical limitations does not constitute the proper comparison
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of “symptoms, signs, or laboratory findings.” While Plaintiff’s mental status evaluations in recent
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years appear to have contained minimal negative findings, the only mental status evaluation in the
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record predating the first decision—conducted by Dr. Boyd during her examination—was also
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mostly normal. And while the ALJ determined that Plaintiff’s activities of daily living were
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inconsistent with Plaintiff’s previously adjudicated Step 2 impairments, the proper inquiry is
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instead whether Plaintiff’s activities of daily living, as evidence of his symptoms and signs of
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illness, are consistent with the “signs, symptoms, and laboratory findings” underlying Plaintiff’s
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past disability determination. The ALJ attempted no such inquiry. Because three of the four bases
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for the ALJ’s finding of medical improvement are legally faulty, the court cannot conclude that the
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ALJ’s errors were harmless.
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Accordingly, the ALJ’s decision is reversed and the case is remanded to the Commissioner
for further proceedings consistent with this order.
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IT IS SO ORDERED.
Dated: January 27, 2025
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ROBERT M. ILLMAN
United States Magistrate Judge
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United States District Court
Northern District of California
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