Reyes v. Colvin
Filing
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ORDER denying 15 Motion for Summary Judgment; granting 16 Motion for Summary Judgment.In the attached order, the court denies Ms. Reyes's summary-judgment motion and grants the Commissioner's cross-motion. (Beeler, Laurel) (Filed on 9/28/2017)
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UNITED STATES DISTRICT COURT
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NORTHERN DISTRICT OF CALIFORNIA
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San Francisco Division
United States District Court
Northern District of California
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KIMBERLYDAWN BORJA REYES,
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Plaintiff,
v.
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NANCY A. BERRYHILL,
Defendant.
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Case No. 16-cv-06958-LB
ORDER DENYING PLAINTIFF’S
SUMMARY-JUDGMENT MOTION
AND GRANTING DEFENDANT’S
CROSS-MOTION FOR SUMMARY
JUDGEMENT
Re: ECF Nos. 15 & 16
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INTRODUCTION
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Plaintiff Kimberlydawn Reyes seeks judicial review of a final decision by the Commissioner
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of the Social Security Administration denying her claim for Supplemental Security Income
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(“SSI”) benefits under Title XVI of the Social Security Act.1 She moved for summary judgment;
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the Commissioner opposed the motion and filed a cross-motion.2 Under Civil Local Rule 16-5, the
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matter is deemed submitted for decision by this court without oral argument. All parties consented
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to magistrate-judge jurisdiction.3 The court denies Ms. Reyes’s summary-judgment motion and
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grants the Commissioner’s cross-motion for summary judgment.
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Cross-Motion – ECF No. 16.
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Consent Forms – ECF Nos. 6, 11.
Summary-Judgment Motion ̶ ECF No. 15. Record citations refer to material in the Electronic Case
File (“ECF”); pinpoint citations are to the ECF-generated page numbers at the top of documents.
ORDER – No. 16-cv-06958-LB
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STATEMENT
1. Procedural History
On February 28, 2013, Ms. Reyes, then age 38, filed a claim for SSI benefits based on
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depression, anxiety, right-hand weakness, back problems, arthritis, foot pain, hip problems, and
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head pain.4 Ms. Reyes’s alleged disability onset date is April 1, 2011.5 On March 14, 2013, R.
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Augello interviewed Ms. Reyes at a field office and completed a disability report, screening for
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prior claims.6 Her claim is similar to a previous claim she filed in February 2010,7 which the
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Commissioner and ultimately Administrative Law Judge Richard Laverdure denied in December
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2011.8
The Commissioner denied her current claim for SSI benefits initially and upon
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Northern District of California
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reconsideration.9 After the appointment of non-attorney advocate Dennis Contreras,10 Ms. Reyes
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timely appealed the Commissioner’s determination.11 On May 11, 2015, Administrative Law
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Judge Mary Parnow (the “ALJ”) held a hearing and heard testimony from Ms. Reyes and
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vocational expert Jo Ann Yoshioka.12 On August 14, 2015, the ALJ issued an unfavorable
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decision.13 The Appeals Council denied Ms. Reyes’s request for review of the decision.14 Ms.
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Reyes timely filed this action on December 2, 201615 and moved for summary judgment.16
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Administrative Record (“AR”) 14, 141, 158–59, 246.
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AR 160.
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AR 265–72.
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AR 119, 160.
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AR 116–34.
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AR 157, 172.
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AR 175–76.
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AR 191–96.
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AR 92–115.
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AR 11–28.
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AR 1–3.
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Compl. – ECF No. 1.
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Summary-Judgment Motion – ECF No. 15.
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ORDER – No. 16-cv-06958-LB
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The Commissioner opposed the motion and filed a cross-motion for summary judgment.17 Ms.
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Reyes elected not to file a response and submitted the matter.18
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2. Summary of Record and Administrative Findings
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2.1 Medical Records
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2.1.1
Dr. Nefissa Chambi: Primary-Care Physician – Treating
Ms. Reyes was treated by her primary-care physician Dr. Chambi and other healthcare
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providers at the Permanente Medical Group from April 2010 through July 2011 for a variety of
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aliments including hypertension, diabetes, common colds, and skin ailments.19 When Ms. Reyes
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complained about intermittent pain in her hip, knee, and hand (possibly related to an old injury
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and “retained metal in [her] pinky finger”),20 Dr. Chambi ordered hip and hand x-rays that showed
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no problems with her hips and no metal in her hand.21 Ms. Reyes felt she could not work and
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needed “documentation stating that her hand is not normal.”22 Dr. Chambi noted that Ms. Reyes
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was “[t]rying to get disability; reports that [she] cannot do her regular job (typing) due to old
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finger injury”23 and wrote that she discussed the finger issue with Ms. Reyes and said that it was
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“[n]ot a reason to get disability.”24 Ms. Reyes later said that she was having “serious issues” and
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thought that Dr. Chambi was “trying to keep her away from seeing the specialist [be]cause you are
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hidding [sic] something.”25 Dr. Chambi referred Ms. Reyes to an orthopedist, but advised her “that
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there is no[t] much that they can do for her finger.”26
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Cross-Motion – ECF No. 16.
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Notice of Submission – ECF No. 17.
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AR 390–563.
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AR 431.
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AR 434.
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Id.
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AR 439.
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AR 440–41.
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AR 443.
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AR 442.
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ORDER – No. 16-cv-06958-LB
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2.1.2
Joanne Ramos: Physician’s Assistant – Treating
In January 2011, Ms. Reyes saw P.A. Ramos about her pinky finger, hip pain, and lower back
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pain.27 P.A. Ramos performed a physical examination and determined that the right hip was
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“normal.”28 She ordered x-rays of the spine and knee.29 P.A. Ramos examined Ms. Reyes’s left
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knee in February 2011 and found there was a “slight lateral tilt of the left patella,” so she
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recommended a knee brace and exercises.30 When Ms. Reyes complained about her knee pain
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several weeks later, P.A. Ramos referred her to physical therapy.31
In November 2011, P.A. Ramos saw Ms. Reyes again and noted that the February 2011 x-ray
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showed “[e]arly degenerative disc disease at the L4-5 and L5-S1 levels.”32 P.A. Ramos concluded
that Ms. Reyes knees had “mild subchondral sclerosis,”33 but that she had “no swelling, no
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erythema, no tenderness to palpation, [and] full range of motion. . . .”34 P.A. Ramos wrote that she
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did not “see any orthopedic pathology other than patella alta on the left [and] mild degenerative
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changes in both knees [that] won’t explain the pressure-like pain radiating from the hip down the
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lateral aspect of the lower extremities.”35 P.A. Ramos referred Ms. Reyes to physical therapy.36
In November 2012, Ms. Reyes returned and reported lower back pain, knee pain, swelling in
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her leg and ankle, and chest pain.37 A November 2012 x-ray showed “some mild degenerative
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changes in her knees.”38 P.A. Ramos noted that Ms. Reyes was “not a very reliable historian” and
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AR 447–52.
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AR 450.
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AR 450–51.
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AR 476.
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AR 489.
32
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AR 612–13.
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AR 613.
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Id.
Id.
Id.
AR 903.
Id.
ORDER – No. 16-cv-06958-LB
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questioned whether her symptoms were “really true.”39 Ms. Reyes was given a cortisone injection
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for her left knee.40 In March 2013, when Ms. Reyes asked P.A. Ramos for a note stating that “she
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is unable to sit or stand due to her hip and knees [sic] problem,” P.A. Ramos stated she did not
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“see any reason to restrict her from sitting or standing.”41
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2.1.3
Dr. Binh Luu: Spine Specialist – Treating
Ms. Reyes saw Dr. Luu about her lower back pain in November 2011.42 Dr. Luu found she had
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early degenerative disc disease; he prescribed physical therapy and ordered an MRI.43 The MRI
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revealed “very mild degenerative changes.”44 “There is a mild BB disc bulge at L4-5 that may be
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leading to mild/subtle lateral recess narrowing.”45 Ms. Reyes received an epidural steroid injection
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in May 2012.46 At a follow-up visit, Ms. Reyes complained that the injection did not help, but Dr.
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Luu did “not recommend any repeat epidural steroid injection.”47
In March 2013, Ms. Reyes asked Dr. Luu for a note “stating that she is unable to sit and stand
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due to her back problem.”48 Dr. Luu declined because there were “[n]o restrictions from spine
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standpoint”; he stated “she only has very mild degenerative changes in her back but this does not
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prevent her from sitting or standing.”49
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Id.
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AR 903.
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AR 1085–86.
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AR 623–28.
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AR 626.
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AR 643.
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45
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Id.
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AR 644 (order), 789–808 (injection procedure).
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AR 822.
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AR 1086.
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49
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Id.
ORDER – No. 16-cv-06958-LB
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2.1.4
Dr. Jill Smith Forster: Orthopedic Surgeon – Treating
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Ms. Reyes had surgery on her flexor tendon twenty years ago,50 and she visited the same
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orthopedic surgeon (Dr. Smith Forster) again in February 2011 because she could not move her
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right pinky finger well and wanted a “note so she can be declared handicapped.”51 Ms. Reyes
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could not “state when the finger stopped working.”52 Dr. Smith Forster prescribed a splint and
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injection, which she found to be partially effective at a follow-up appointment in April 2011.53 In
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September 2011, Dr. Smith Forster declined to sign paperwork that Ms. Reyes brought in for her
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SSI claim because Ms. Reyes had full range of motion in her hand, with the exception of a slight
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deviation of her pinky that would not prevent her from using her hand, and said that she “see[s] no
reason from a hand point of view why this patient cannot be gainfully employed.”54 In March
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2013, when Ms. Reyes asked for a disability note, Dr. Smith Forster reported that she had “not
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seen this patient for several years,” but that “[s]he is not a candidate for ssi for her hand and can
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use it with no restrictions.”55
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2.1.5
Dr. Hyeon Choe: Primary-Care Physician – Treating
Ms. Reyes began seeing a new primary-care physician, Dr. Choe, in September 2011 for a
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“routine check up and exam [but ] . . . mainly to discuss about her SSI application.”56 Dr. Choe
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noted she had an appointment with orthopedics and did not complete her requested SSI
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paperwork.57
In December 2011, Ms. Reyes called Dr. Choe, reporting depression and anxiety and seeking
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AR 471.
Id.
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AR 471–72, 510.
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AR 585.
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AR 1086.
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AR 575.
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AR 581.
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Id.
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anti-depressant medication as recommended by her therapist.58 Dr. Choe also noted that Ms.
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Reyes filed for SSI and had been advised to contact her primary-care physician for her “depression
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issue.” 59 Dr. Choe diagnosed her with major depression, prescribed medication, and referred her
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for mental-health services.60 The next month, Ms. Reyes had another appointment, where Dr.
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Choe noted that the 5’ 2” Ms. Reyes had lost weight but still weighed 182 pounds and needed to
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control her diabetes.61 Throughout 2012, Dr. Choe, along with other staff at the Permanente
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Medical Group, continued to treat her for diabetes, common colds, and skin ailments.62
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In September 2012, Ms. Reyes reported experiencing arm pain.63 Dr. Choe diagnosed her with
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“lateral epicondylitis of elbow” (or “tennis elbow”) and prescribed rest, exercises, and ibuprofen.64
In November 2012, Ms. Reyes visited Dr. Choe about leg and ankle swelling, chest pain, and
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numb hands.65 Dr. Choe gradually lowered her dosage of a diabetes medication, and by April
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2013, the swelling had improved significantly.66 Dr. Choe continued to treat Ms. Reyes for
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diabetes, colds, and skin ailments through 2014.67
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2.1.6
In May 2014, Ms. Reyes had another MRI taken of her spine.68 The MRI showed “mild
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Dr. Preston-Hsu and Dr. Lau: Spine Specialists – Treating
discogenic disease of the cervical spine . . . .”69 Two physicians in the Spine Clinic at the
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AR 638.
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AR 638.
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Id.; see also AR 646 (noting Dr. Choe’s referral for “depression and stress”).
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AR 663–64.
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AR 668–73, 685–726, 731–43, 757–65, 768–88, 809–17, 842–45, 861–63, 913–19, 922–23, 926–
1008.
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AR 855.
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AR 854–60.
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AR 896.
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AR 896–97, 1107.
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AR 1166–69, 1202–08.
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AR 1178–81.
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AR 1178.
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ORDER – No. 16-cv-06958-LB
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Permanente Medical Group reviewed the MRI with Ms. Reyes.70 In May 2014, Dr. Preston-Hsu
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went over the imaging with Ms. Reyes and noted that she had “mild” degenerative disc disease.71
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In October 2014, Dr. Lau discharged Ms. Reyes from the spine clinic, stating, “there is no further
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management or diagnostic process that [the] spine clinic can offer.”72 Dr. Lau noted that there
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were “no signs of MRI findings to support [diagnosis] of cervical radic[ulopathy] or lumbar
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radic[ulopathy].”73
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2.1.7 Anneli Keller: Physical Therapist – Treating
Ms. Reyes had three physical therapy appointments with Anneli Keller to manage chronic pain
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in October and November 2014.74 The parties do not address these records, which do not
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otherwise contain information material to the issues presented, and so the court does not
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summarize them here.
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2.1.8
Dr. Daniel Dal Corso: Clinical Psychologist – Treating
In December 2011, Ms. Reyes began seeing psychologist Daniel Dal Corso, who diagnosed
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her with major depression and adjustment disorder with anxious mood based on her reports of
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“depression including depressed mood, anhedonia, significant appetite change, decreased energy
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and decreased concentration.”75 He recommended that she continue taking her antidepressants and
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going to therapy.76 He treated Ms. Reyes for depression and anxiety throughout the following
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year.77
In January 2012, Dr. Dal Corso observed that Ms. Reyes had a “hyperverbal rambling
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AR 1182–90, 1209–14.
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AR 1189.
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AR 1213.
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AR 1213.
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AR 1215–17, 1219–21, 1224–26.
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AR 645–47.
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76
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Id.
AR 679–82, 744–46, 818–20, 836–38, 845–47, 864–66, 869–70.
ORDER – No. 16-cv-06958-LB
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presentation,” possibly from being “overly caffeinated.”78 Dr. Dal Corso noted Ms. Reyes
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indicated that “she is currently disabled and not working but not able to answer what her disability
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is.”79 In March 2012, Ms. Reyes was “anxious about money” and “somewhat rambling,” making it
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“hard to track how she’s doing.”80 In May 2012, Dr. Dal Corso diagnosed her with “ADD/ADHD”
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and noted that Ms. Ramos reported being “calmer” on her medication and received an epidural
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three weeks earlier that helped “considerably with [her] pain.”81 In July 2012, Ms. Reyes reported
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that she was “feeling calmer” due to her medication but was stressed due to conflicts with
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neighbors and a perceived lack of family support.82 Dr. Dal Corso observed that her “line of
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thought [was] somewhat tangential.”83 Dr. Dal Corso “repeatedly encouraged [Ms. Reyes] to make
[an] appointment with [a] Medi-Cal psychiatrist for evaluation/treatment for attention deficit
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disorder.”84
In September 2012, Ms. Reyes reported that she had made an appointment with a Medi-Cal
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psychiatrist.85 She also noted that she was “feeling very nervous,” which she thought was “likely
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due to [her] kids starting back to school and having trouble coordinating and keeping up with
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everything.”86
In October 2012, she reported “ongoing anxiety about not being organized, forgetting things to
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AR 680.
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AR 745.
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AR 818–20.
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AR 837.
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Id.
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Id.
Id. The ALJ stated that while “the claimant’s treatment providers questioned that she might have had
ADHD, there was never a diagnosis or specific treatment.” (AR 16.) Dr. Dal Corso and therapist Amy
Walker did, however, list a diagnosis of ADD/ADHD. (AR 818, 1135.) But, as acknowledged by the
ALJ, Dr. Dal Corso recommended further evaluation, and the record does not reflect what (if any)
specific treatment Ms. Reyes received for ADD or ADHD. Because Ms. Reyes does not raise this
particular statement by the ALJ or the issue of ADD/ADHD, the court does not consider it as a
potential error here. See Sandgathe v. Chater, 108 F.3d 978, 980 (9th Cir. 1997) (declining to address
arguments not raised in the district court).
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AR 846, 865 (confirming appointment scheduled with Dr. Vallas).
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AR 846.
ORDER – No. 16-cv-06958-LB
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do, worry about [her] kids, [and] worry about other relatives saying negative things about her.”87
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She had experienced “numbness in the left side and [shortness of breath] for ‘about the past
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week.’”88 Dr. Dal Corso diagnosed her with “generalized anxiety disorder” and recommended that
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she call the advice nurse to see if she needed treatment for her physical symptoms.89
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2.1.9
Leslie Zuska: Marriage and Family Therapist – Treating
Ms. Reyes began seeing Ms. Zuska in October 201190 to treat her “anxiety, depression,
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suspiciousness and possibly paranoid ideation about her family members.”91 The record contains
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chart notes from two therapy sessions in July and September 2013.92 In July, Ms. Zuska observed
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that Ms. Reyes’s fear, tangential thinking, and incoherence seemed “to be resolving a bit.”93 Ms.
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Reyes reported that she was working on managing her diet and diabetes.94
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In September 2013, Ms. Zuska observed that Ms. Reyes was “a bit agitated” but otherwise
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very involved in her children’s education and on top of their homework and other issues.95 Ms.
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Zuska noted that Ms. Reyes had a “new level of self-awareness” and coherence, noting during the
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session that “she stopped herself mid-sentence to say ‘let me go back and finish one thought
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first.’”96 Ms. Zuska also observed that Ms. Reyes “continues to be unable to sit through a 45
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minute session without walking to relieve pain in hip and knee.”97
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AR 870.
Id.
Id.
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AR 375.
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AR 1114.
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AR 1113–18.
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AR 1118.
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Id.
Id.
Id.
Id.
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2.1.10 Dr. Melissa Vallas: Psychiatrist – Treating
In September 2012, Ms. Reyes saw Dr. Vallas for an initial assessment at Pathways to
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Wellness after her psychologist, Dr. Dal Corso, referred her to be evaluated for attention deficit
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hyperactivity disorder.98 Dr. Vallas found Ms. Reyes had “excessive anxiety affecting
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relationships” and moderate functional limitations of performing daily activities, maintaining
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social relationships, and maintaining concentration, persistence, and pace.99 She described Ms.
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Reyes as cooperative, euthymic in affect, okay in mood, and having a linear thought process
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without hallucinations or delusions.100
In February 2013, Ms. Reyes saw Dr. Vallas again and complained that her anxiety level was
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“7-8/10” and she was stressed about her finances.101 Dr. Vallas found Ms. Reyes had “residual
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[symptoms] of anxiety bordering on psychosis” and increased her dose of Risperidone.102 But she
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also found that Ms. Reyes was cooperative and had good judgment and a linear thought process
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without hallucinations or delusions.103
In March 2013, Ms. Reyes reported to Dr. Vallas that her anxiety was a “6-7/10” and she
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continued to suffer from panic episodes, excessive worry, and financial strain.104 Dr. Vallas
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concluded that Ms. Reyes had “chronic severe anxiety bordering on psychotic” and “residual sleep
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problems.”105 She prescribed Seroquel instead of Risperidone and kept her on Celexa.106
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In April 2013, Ms. Reyes reported that she was feeling calmer and less anxious, sleeping
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better, and having fewer headaches.107 She said that she was unemployed and applying for SSI.108
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98
AR 376–82.
99
AR 380.
100
AR 379.
101
AR 388–89.
102
AR 389.
103
AR 388–89.
104
AR 386.
105
AR 387.
106
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107
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108
Id.
AR 384.
Id.
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Dr. Vallas made no changes to Ms. Reyes’s medications and noted that she should continue to
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chart her moods and monitor any changes in symptoms.109
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2.1.11 Dr. Soleng Tom: Psychiatrist – Treating
On February 3, 2014, Ms. Reyes returned to Pathways to Wellness, reported a decreased
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appetite, but denied having panic attacks or insomnia.110 Dr. Tom examined Ms. Reyes and
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reported that she was oriented, verbal, polite, and articulate and clinically stable with intact
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memory, linear thought process and “fair” judgment and insight; he also noted that she was calm,
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cooperative with normal speech and appropriate affect and that her mood was “euthymic” (normal,
non-depressed) “on medication.”111 He recommended that she continue taking Seroquel, Prozac,
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and clonazepam at her current dosages.112
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2.1.12 Dr. Chris Esguerra: Psychiatrist – Treating
Ms. Reyes saw Dr. Esguerra at Pathways to Wellness from February 2014 to August 2014.113
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On February 20, 2014, Dr. Esguerra reported that she was “calm,” “cooperative,” and “adequately
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groomed” with a “normal gait and tone.”114 Ms. Reyes reported subjective symptoms of
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“debilitating anxiety with all day worry occurring 4–5 days out of the week” and an inability to
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leave the house due to “racing thoughts” and “feeling under pressure” with “low energy” and “ok”
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but “variable” sleep patterns.115 Dr. Esguerra found her speech to be “loud” but her affect to be
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appropriate, her thought process linear, her thought content to be within normal limits, her
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memory intact, her judgment good, her attention, concentration, and insight to be fair, and that she
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109
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AR 385.
110
AR 1128.
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111
AR 1128–29.
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112
Id.
113
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AR 1121–27, 1153–58.
114
AR 1126.
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115
Id.
ORDER – No. 16-cv-06958-LB
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presented no danger to herself or others.116 Dr. Esguerra did find that her “Generalized Anxiety
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Disorder [was] still minimally managed” and adjusted her dosages of Seroquel, Prozac, and
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clonazepam; he scheduled a follow-up visit in 3 to 6 weeks.117
At the follow-up visit on March 11, 2014, Ms. Reyes reported that her anxiety was “up and
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down” and that she worried a lot about her kids, who were struggling in school and with other
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issues.118 She noted that she had been hit recently in the arm by a female student at her son’s
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school and that she sometimes felt like people were against her or going to attack her when she
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went out in public.119 Dr. Esguerra found her appearance to be healthy and adequately groomed
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with a “steady” gait and “good” tone; she appeared “[t]ense,” and she was cooperative with
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normal (but loud) speech.120 Ms. Reyes’s affect was appropriate but she exhibited negative
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thoughts and had fragmented thought content.121 Dr. Esguerra found her memory to be intact and
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her attention, concentration, and judgment to be fair.122 Dr. Esguerra noted that Ms. Reyes was
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“struggling with coping with her anxiety, particularly around her kids” and that she needed to
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continue with therapy, breathing exercises, and her medication.123 Dr. Esguerra scheduled a
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follow-up visit in four weeks.124
On April 3, 2014, Ms. Reyes reported having two panic attacks a week and continued stress
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about her children.125 Ms. Reyes did state that she was doing the breathing exercises (albeit for
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shorter periods than prescribed) but found it helpful.126 She also noted that she was sleeping “ok”
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116
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AR 1126–27.
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AR 1127.
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118
AR 1124 (report signed by both Dr. Esguerra and a registered nurse).
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119
120
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121
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122
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123
124
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125
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126
Id.
Id.
AR 1125.
Id.
Id.
Id.
AR 1121.
Id.
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and eating less, and her energy was “ok.”127 Dr. Esguerra recommended that she continue her
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medication and therapy regimen and noted that she was cooperative and appropriate in dress, with
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normal speech and a normal, non-depressed “euthymic” mood and affect.128 He also noted that
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Ms. Reyes’s thought process was goal-directed with normal content, her memory, insight,
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judgment, attention, and concentration were all in intact, her gait, muscle strength and tone were
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all normal, and her fund of knowledge was “average.”129 Dr. Esguerra increased the interval for
7
Ms. Reyes’s next follow-up visit to six weeks.130
In May 2014, Dr. Esguerra filled out a check-the-box assessment for Ms. Reyes’s SSI claim.131
8
9
Dr. Esguerra found slight limitations of her ability to (1) remember locations and work-like
procedures, (2) maintain attention and concentration for simple tasks, (3) adhere to a schedule,
11
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10
(4) work close to others without being distracted, and (5) maintain socially appropriate behavior
12
and cleanliness.132 Ms. Reyes had moderate limitations of her ability to (1) understand and
13
remember both simple and detailed instructions, (2) maintain attention and concentration for
14
detailed tasks, (3) interact appropriately with the public, and (4) work with others without causing
15
distractions.133 Ms. Reyes had marked limitations of her ability to (1) perform at a consistent pace
16
without an unreasonable number or length of rest periods, (2) handle normal work stress, and (3)
17
accept instructions and criticism.134 Dr. Esguerra opined that he would expect Ms. Reyes to miss
18
12 days of work each month as a result of her conditions.135
In June 2014, Ms. Reyes saw Dr. Esguerra, reporting “some shortness of breath lately” and
19
20
21
22
23
127
128
129
Id.
AR 1122.
Id.
24
130
AR 1123.
25
131
AR 1139–41.
132
AR 1139–40.
26
133
Id.
27
134
AR 1140.
28
135
AR 1141.
ORDER – No. 16-cv-06958-LB
14
1
“two panic attacks.”136 She reported that the attacks were “due to worries about her house
2
hunting.”137 Dr. Esguerra noted that Ms. Reyes had “severe [Generalized Anxiety Disorder] with
3
appropriate stress due to housing and medical issues.”138 He recommended that she focus on
4
therapy and work with her primary-care physician to stabilize her shortness of breath and blood
5
sugar.139 Dr. Esguerra’s previous positive exam findings in April 2014 about her appearance,
6
behavior, speech, mood, affect, thought process, judgment, insight, memory, attention, et cetera
7
remained unchanged.140 Dr. Esguerra maintained the interval for Ms. Reyes’s next follow-up visit
8
at six weeks.141
In August 2014, Ms. Reyes reported she was “dealing with ups and downs” and sometimes
10
still felt overwhelmed “by social stressors,” including family and relationship issues, but also was
11
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9
more excited, energetic, and positive.142 Dr. Esguerra noted that her generalized anxiety disorder
12
was improving, she was “better handling her stressors,” therapy had proven “helpful,” and her
13
diabetes appeared to better controlled, but she was “not yet ready” to reduce her clonazepam
14
dosage.143 Dr. Esguerra’s previous positive exam findings in April and June 2014 about her
15
appearance, behavior, speech, mood, affect, thought process, judgment, insight, memory,
16
attention, et cetera remained unchanged.144 Dr. Esguerra also increased the interval for Ms.
17
Reyes’s next follow-up visit to eight weeks.145
There are no records of visits with Dr. Esguerra in 2015, but a letter “created per the request of
18
19
the addressee,” Ms. Reyes, and signed by “Elizabeth Mole, MSN, RN, PMHNP” on January 28,
20
21
136
22
137
23
138
139
AR 1156.
Id.
AR 1157.
Id.
24
140
25
141
AR 1158.
142
AR 1153.
143
AR 1154.
26
27
144
28
145
Id.
Id.
AR 1155.
ORDER – No. 16-cv-06958-LB
15
1
2015 states that Ms. Reyes has been a patient at Pathways to Wellness since September 10, 2012,
2
and is “currently diagnosed with Generalized Anxiety Disorder.”146
3
4
2.1.13 Amy Walker: Marriage and Family Therapist – Treating
5
Ms. Reyes had four therapy sessions with Ms. Walker between March 2014 and May 2014 to
6
treat anxiety, depression, and symptoms of attention-deficit hyperactivity disorder.147 Ms. Walker
7
found Ms. Reyes had “tangential and disorganized” speech.148 Ms. Reyes consistently expressed
8
worries and concerns about her family and finances.149 Ms. Reyes noted that she was not
9
managing her diabetes very well; at one session, she reported that she could not discern whether
10
she was experiencing high blood sugar or anxiety.150
In May 2014, Ms. Walker completed a check-the-box report for Ms. Reyes.151 She found slight
United States District Court
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11
12
limitations of Ms. Reyes’s ability to (1) accept instructions and criticism from supervisors and
13
(2) maintain socially acceptable behavior.152 She found moderate limitations of Ms. Reyes’s
14
ability to (1) remember locations and work-like procedures and (2) understand and remember
15
simple and detailed instructions.153 Ms. Reyes had marked limitations of her ability to (1) handle
16
normal work stress, (2) interact appropriately with the public, and (3) work without distracting
17
others.154 Ms. Walker identified extreme limitations of Ms. Reyes’s ability to (1) maintain
18
attention and concentration for simple and detailed tasks, (2) adhere to a schedule, (3) work close
19
to others without being distracted, and (4) perform at a consistent pace without an unreasonable
20
21
22
23
146
AR 1227.
147
AR 1134–35.
148
Id.
24
149
25
150
AR 1135.
151
AR 1131–32.
152
27
AR 1132.
153
AR 1131.
28
154
AR 1132.
26
Id.
ORDER – No. 16-cv-06958-LB
16
1
number or length of rest periods.155
2
2.1.14 Dr. Carmen Roman: Psychiatrist – Treating
In October 2014, Ms. Reyes saw Dr. Roman at Pathways to Wellness.156 Ms. Reyes reported
3
still feeling overwhelmed by “social stressors,” including mild stress due to “family and
5
relationship concerns,” but said that she had more excitement and better energy.157 Dr. Roman
6
diagnosed her with generalized anxiety disorder but noted that she had been “stable on [her]
7
current medications” and that her “[m]ain issues are related to family stress.”158 Dr. Roman noted
8
that she presented as anxious with rapid/pressured speech and that she was otherwise cooperative,
9
goal-directed, alert, with intact judgment, memory, attention, concentration, and language, with an
10
average fund of knowledge and a normal gait and muscle strength and tone — though Ms. Reyes
11
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4
did report a history of “chronic pain.”159
12
13
2.1.15 Mary Ann Vigilanti: State Agency Psychologist – Examining
14
Dr. Vigilanti evaluated Ms. Reyes’s mental status on May 11 and 21, 2010.160 Dr. Vigilanti
15
conducted the examination in two separate visits “because of the length of time it took to complete
16
one test.”161 Dr. Vigilanti described Ms. Reyes as “hyper verbal with excessive details” and
17
“present[ing] as anxious, almost manic.”162 Dr. Vigilanti noted that Ms. Reyes’s “thinking became
18
tangential when responding to some questions, becoming incoherent.”163 Dr. Vigilanti listed
19
diagnoses of anxiety disorder, unknown substance-related disorder (based on prescribed
20
21
22
23
155
AR 1131–32.
156
AR 1150.
157
Id.
24
158
AR 1152.
25
159
AR 1150–51.
160
AR 354.
161
AR 355.
26
27
162
28
163
Id.
Id.
ORDER – No. 16-cv-06958-LB
17
1
medications), and cognitive disorder.164
Dr. Vigilanti administered the WAIS-111, Wechsler Memory-111, and Bender-Gestalt
2
3
Tests.165 The tests showed Ms. Reyes has a full scale IQ of 78.166 Dr. Vigilanti found Ms. Reyes
4
could follow simple instructions but might struggle with following through due to confusion.167
5
Dr. Vigilanti found that Ms. Reyes would struggle to maintain attendance, work consistently, and
6
maintain concentration.168 Dr. Vigilanti recommended that Ms. Reyes receive “special and
7
additional supervision” and work “in low stress environments, that are predictable and structured
8
[and] that do not involve decision making or judgment.”169
9
10
2.1.16 Dr. Sandra Battis and Dr. J.R. Saphir – Reviewing Physicians
On July 30, 2013, Dr. Sandra Battis, a reviewing physician, found that the evidence supported
United States District Court
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11
12
adopting Ms. Reyes’s residual functional capacity as determined by ALJ Laverdure in 2011.170
13
She highlighted that Ms. Reyes was limited in handling and fingering with her right hand based on
14
the problem with her right pinkie.171 On March 10, 2014, Dr. J.R. Saphir reached the same
15
conclusion, noting that there was no additional medical evidence “showing worsening.”172
16
17
2.2 Function Report
18
Louisa Reyes, Ms. Reyes’s mother, completed a third-party function report on May 22,
19
2013.173 Louisa Reyes described her daughter’s routine and daily activities as follows; Ms. Reyes
20
21
164
AR 357–58.
22
165
AR 355–56.
23
166
167
24
168
25
169
Id.
AR 357.
Id.
Id.
170
AR 151–53.
171
27
AR 153.
172
AR 168–69.
28
173
AR 292–99.
26
ORDER – No. 16-cv-06958-LB
18
1
gets up in the morning and takes her medication before waking up her children and getting them
2
ready for school; sometimes, Ms. Reyes’s children wake her up in the morning.174 Ms. Reyes
3
makes sure that her children are showered, fed, and ready for school and activities (such as
4
church) but sometimes her mother helps out.175 She is nervous while her children are at school,
5
and “[d]epending on her stress level[,] she may watch TV.”176 When Ms. Reyes is in pain, she
6
sleeps, showers, and “sometimes [ ] forces herself to get up to eat.”177
Ms. Reyes needs some help with “getting up on the tub” and personal care, but can eat and use
7
8
the restroom independently.178 Sometimes she needs to be reminded to take her medicine on
9
time;179 she needs to take her anxiety and pain medicine to sleep.180 Ms. Reyes does some chores,
but her mother and children help out too by carrying the laundry, sweeping and mopping, and
11
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10
preparing some meals.181 Ms. Reyes drives and goes to the store, but her mother and children
12
usually accompany her to help unload the groceries; she does not have her own bank account.182
13
Ms. Reyes can walk five minutes before taking a 15-minute break.183 Ms. Reyes spends time with
14
her immediate family, briefly visits with other relatives, goes to church, and meets with her
15
psychiatrist, but she is less outgoing and social than she used to be; she gets nervous and
16
“panicky.”184 Her ability to concentrate and follow instructions “varies” and “depends on her
17
stress level.”185
Ms. Reyes filled out a function report the same day as her mother, and it is nearly (word-for-
18
19
174
AR 292.
175
21
AR 293–94.
176
AR 292, 296.
22
177
AR 292.
178
AR 293.
179
24
AR 294.
180
AR 293.
25
181
AR 294.
182
AR 295.
183
27
AR 297.
184
AR 296–98.
28
185
AR 297.
20
23
26
ORDER – No. 16-cv-06958-LB
19
1
word) identical, and so the court does not summarize it here.186
2
3
2.3 Ms. Reyes’s Testimony
4
At the hearing, Ms. Reyes testified that she was a single, high-school graduate who lived with
5
her mother, brother, sister-in-law, two adult nephews, and four teenage children.187 Her only
6
income sources were “food stamps and cash aid.”188 She had “problems standing, sitting, and
7
walking” that required shifting every ten minutes to alleviate pain in her back, feet, arm, hip, and
8
leg.189 She suffered from numbness and imbalance due to diabetes.190 Ms. Reyes said that she did
9
not have “full control of [her] right hand” because she “cut a tendon muscle.”191
She suffers from severe depression four to five days a week, and her antidepressants make her
11
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10
tired and disoriented such that she would “lie down a lot, four to six times a day.”192 She has panic
12
attacks five to six days a week that last from one to four hours; during that time, she is short of
13
breath and disoriented.193 She has difficulty sleeping and addresses it by taking “Tylenol, Codeine
14
3[,] and Seroquel.”194
Ms. Reyes’s mother and children help her with dressing, laundry, and household chores.195
15
16
When she has severe pain, her mother prepares meals for her children and transports them.196
17
18
19
20
186
21
AR 300–07.
187
AR 97–98.
22
188
AR 98.
23
189
Id.
190
24
AR 98–100.
191
AR 101.
25
192
AR 103.
193
AR 103–04.
194
27
AR 107–08.
195
AR 106–07.
28
196
26
Id.
ORDER – No. 16-cv-06958-LB
20
1
2.4 Vocational Expert Testimony
2
Vocational expert (“VE”) Jo Ann Yoshioka testified at the hearing.197 Because Ms. Reyes
3
lacked any recent past relevant work experience, the VE testified based only on hypotheticals.198
4
The VE testified that an individual of Ms. Reyes’s age, education, and experience could work as a
5
classifier, laundry folder, or housekeeper/cleaner based on the following functional limitations:
6
occasionally lift twenty pounds; frequently lift ten pounds; walk, sit, or stand for six hours in an
7
eight-hour day; occasionally climb, stoop, crouch or crawl; frequently kneel and balance;
8
frequently handle and occasionally finger and push/pull with the non-dominant hand; and rare
9
public interaction.199
When Ms. Reyes’s advocate asked whether Ms. Reyes could work if she needed to stand or sit
10
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Northern District of California
11
“at will,” the VE excluded the housekeeper/cleaner job.200 The VE testified that an individual
12
could not perform any of the three jobs she identified if he or she was limited to simple tasks with
13
additional supervision, was off task 15 percent of the time, or needed to take unscheduled rest
14
breaks throughout the day.201
15
16
2.5 Previous Determination of Nondisability
17
On February 1, 2010, Ms. Reyes filed an earlier claim for SSI benefits (as distinct from the
18
claim now at issue), which the Commissioner denied initially and upon reconsideration.202
19
Administrative Law Judge Richard Laverdure rendered an unfavorable decision that the present
20
ALJ, Mary Parnow, gave great weight in the decision presently under review.203
Following the five-step sequential evaluation process, ALJ Laverdure first found Ms. Reyes
21
22
23
197
AR 110–14.
24
198
25
199
AR 110–11.
200
AR 114.
201
27
AR 113–14.
202
AR 119.
28
203
AR 21 (relying on AR 119–30).
26
Id.
ORDER – No. 16-cv-06958-LB
21
1
had severe impairments including: “mild degenerative disc disease; obesity; right small finger
2
flexion deformity; anxiety; and depression.”204 He concluded these impairments did not meet the
3
applicable listings, and so he evaluated Ms. Reyes’s residual functional capacity (“RFC”).205 ALJ
4
Laverdure found that Ms. Reyes had the RFC to perform light work involving frequent handling,
5
occasional fingering, and occasional pushing or pulling (except with her right upper extremity)
6
with rare public interaction.206 Because Ms. Reyes could work as a housekeeper/cleaner based on
7
her RFC, ALJ Laverdure concluded that she was not disabled.207 The Appeals Council denied Ms.
8
Reyes’s request for review,208 and the record does not reflect that she sought judicial review.
9
2.6 Administrative Findings
11
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Northern District of California
10
The ALJ followed the five-step sequential evaluation process and concluded Ms. Reyes was
12
not disabled.209
At step one, the ALJ found that Ms. Reyes had not engaged in substantial gainful activity since
13
14
she filed her application for SSI benefits on February 28, 2013.210
At step two, the ALJ found that Ms. Reyes had the following severe impairments:
15
16
“degenerative disc disease of the lumbar spine, obesity, right small finger flexion deformity,
17
generalized anxiety disorder, [and] depressive disorder.”211 The ALJ found that Ms. Reyes’s
18
diabetes and hypertension were non-severe impairments because medication compliance
19
controlled her symptoms.212 The ALJ found attention deficit hyperactivity disorder was not one of
20
21
204
AR 121.
205
AR 121–23.
206
24
AR 123.
207
AR 129–30.
25
208
AR 135–37.
209
AR 14–23.
210
AR 16.
22
23
26
27
211
28
212
Id.
Id.
ORDER – No. 16-cv-06958-LB
22
1
Ms. Reyes’s impairments because “there was never a diagnosis or specific treatment.”213
2
At step three, the ALJ found that Ms. Reyes did not have an impairment or combination of
3
impairments that met or medically equaled the severity of a listed impairment.214 Specifically, the
4
ALJ found that Ms. Reyes’s hand and back impairments did not meet Listings 1.02 and 1.04.215
5
Although the ALJ considered obesity as an aggravating factor, she found no evidence that obesity
6
caused any other severe impairments to meet the listings.216 The ALJ found that Ms. Reyes’s
7
mental impairments — both individually and combined — did not meet Listings 12.04 and 12.06
8
because Ms. Reyes did not have marked limitations of daily living, social functioning, or
9
concentration, persistence or pace.217 The ALJ found mild restrictions of daily living, moderate
difficulties with social functioning, and moderate difficulties with concentration because Ms.
11
United States District Court
Northern District of California
10
Reyes could prepare meals, drive a car, shop for groceries, attend medical appointments, and help
12
her children with homework.218
13
At step four, to determine Ms. Reyes’s RFC, the ALJ followed a two-step process. First, she
14
determined whether Ms. Reyes suffered from an underlying medically determinable physical or
15
mental impairment (i.e. an impairment that could be shown by medically acceptable clinical and
16
laboratory diagnostic techniques) that could reasonably be expected to produce her pain or other
17
symptoms.219 The ALJ then evaluated the intensity, persistence, and limiting effects of Ms.
18
Reyes’s symptoms to determine the extent to which they limited her functioning.220 The ALJ
19
found that Ms. Reyes’s medically determinable impairments could reasonably be expected to
20
cause her symptoms, but that her statements about their intensity, persistence, and limiting effects
21
22
23
213
214
24
215
25
216
26
217
Id.
AR 17.
Id.
Id.
Id.
218
27
AR 17–18.
219
AR 18.
28
220
AR 19.
ORDER – No. 16-cv-06958-LB
23
1
were not entirely credible.221 The ALJ found that Ms. Reyes’s treating physicians directly
2
contradicted her allegations about her physical ailments,222 and that Ms. Reyes’s claims about the
3
severity of her mental ailments were not supported by the medical records, including her “normal
4
mental status examinations” and the absence of records showing hospitalization.223 The ALJ
5
concluded that Ms. Reyes had the RFC to perform light work involving frequent handling,
6
occasional fingering, and occasional pushing or pulling (except with her right upper extremity)
7
with rare public interaction.224
At step five, the ALJ determined that Ms. Reyes could perform work as a classifier, laundry
8
9
folder, or housekeeper/cleaner.225 The ALJ concluded that Ms. Reyes was not disabled.226
10
United States District Court
Northern District of California
11
12
ANALYSIS
1. Standard of Review
Under 42 U.S.C. § 405(g), district courts have jurisdiction to review any final decision of the
13
14
Commissioner if the claimant initiates a suit within sixty days of the decision. A court may set
15
aside the Commissioner’s denial of benefits only if the ALJ’s “findings are based on legal error or
16
are not supported by substantial evidence in the record as a whole.” Vasquez v. Astrue, 572 F.3d
17
586, 591 (9th Cir. 2009) (internal citation and quotation marks omitted); 42 U.S.C. § 405(g).
18
“Substantial evidence means more than a mere scintilla but less than a preponderance; it is such
19
relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
20
Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995). The reviewing court should uphold “such
21
inferences and conclusions as the [Commissioner] may reasonably draw from the evidence.” Mark
22
v. Celebrezze, 348 F.2d 289, 293 (9th Cir. 1965). If the evidence in the administrative record
23
24
221
25
222
AR 19–20.
223
AR 20–21.
224
27
AR 18.
225
AR 22.
28
226
AR 23.
26
Id.
ORDER – No. 16-cv-06958-LB
24
1
supports the ALJ’s decision and a different outcome, the court must defer to the ALJ’s decision
2
and may not substitute its own decision. Tackett v. Apfel, 180 F.3d 1094, 1097–98 (9th Cir. 1999).
3
“Finally, [a court] may not reverse an ALJ’s decision on account of an error that is harmless.”
4
Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012).
5
6
2. Applicable Law
7
A claimant is considered disabled if (1) he or she suffers from a “medically determinable
8
physical or mental impairment which can be expected to result in death or which has lasted or can
9
be expected to last for a continuous period of not less than twelve months,” and (2) the
“impairment or impairments are of such severity that he or she is not only unable to do his
11
United States District Court
Northern District of California
10
previous work but cannot, considering his age, education, and work experience, engage in any
12
other kind of substantial gainful work which exists in the national economy. . . .” 42 U.S.C.
13
§ 1382c(a)(3)(A) & (B). The five-step analysis for determining whether a claimant is disabled
14
within the meaning of the Social Security Act is as follows. Tackett, 180 F.3d at 1098 (citing
15
20 C.F.R. § 404.1520).
16
17
18
19
20
21
22
23
24
25
26
27
28
Step One. Is the claimant presently working in a substantially gainful activity? If
so, then the claimant is “not disabled” and is not entitled to benefits. If the claimant
is not working in a substantially gainful activity, then the claimant case cannot be
resolved at step one, and the evaluation proceeds to step two. See 20 C.F.R.
§ 404.1520(a)(4)(i).
Step Two. Is the claimant’s impairment (or combination of impairments) severe? If
not, the claimant is not disabled. If so, the evaluation proceeds to step three. See 20
C.F.R. § 404.1520(a)(4)(ii).
Step Three. Does the impairment “meet or equal” one of a list of specified
impairments described in the regulations? If so, the claimant is disabled and is
entitled to benefits. If the claimant’s impairment does not meet or equal one of the
impairments listed in the regulations, then the case cannot be resolved at step three,
and the evaluation proceeds to step four. See 20 C.F.R. § 404.1520(a)(4)(iii).
Step Four. Considering the claimant’s RFC, is the claimant able to do any work
that he or she has done in the past? If so, then the claimant is not disabled and is not
entitled to benefits. If the claimant cannot do any work he or she did in the past,
then the case cannot be resolved at step four, and the case proceeds to the fifth and
final step. See 20 C.F.R. § 404.1520(a)(4)(iv).
Step Five. Considering the claimant’s RFC, age, education, and work experience,
is the claimant able to “make an adjustment to other work?” If not, then the
ORDER – No. 16-cv-06958-LB
25
claimant is disabled and entitled to benefits. See 20 C.F.R. § 404.1520(a)(4)(v). If
the claimant is able to do other work, the Commissioner must establish that there
are a significant number of jobs in the national economy that the claimant can do.
There are two ways for the Commissioner to show other jobs in significant
numbers in the national economy: (1) by the testimony of a vocational expert or
(2) by reference to the Medical-Vocational Guidelines at 20 C.F.R., part 404,
subpart P, app. 2.
1
2
3
4
5
6
7
For steps one through four, the burden of proof is on the claimant. At step five, the burden
shifts to the Commissioner. Gonzales v. Sec’y of Health & Human Servs., 784 F.2d 1417, 1419
(9th Cir. 1986).
8
9
3. Application
10
United States District Court
Northern District of California
11
12
13
14
15
16
Ms. Reyes does not challenge the ALJ’s determination of her impairments at step two or the
conclusion at step three that these impairments do not meet the applicable listings. Instead, Ms.
Reyes contends that substantial evidence does not support the ALJ’s conclusion at step four that
she had the RFC to perform light work with certain limitations.227 Specifically, Ms. Reyes argues
that the ALJ improperly weighed (1) the previous finding of nondisability made by ALJ Richard
Laverdure and (2) the opinion of treating psychiatrist Dr. Esguerra in his May 16, 2014 assessment
(“Esguerra Assessment”).228
17
18
3.1 The ALJ Properly Considered the Prior ALJ’s Determination of Nondisability
19
20
21
22
23
In giving great weight to the prior decision of ALJ Laverdure (finding that Ms. Reyes was not
disabled), the ALJ held that Ms. Reyes was not disabled because the “evidence of record did not
support any worsening of symptoms of previously found severe impairments and did not support
the finding of any new severe impairment in the interim between the prior decision and the instant
one.”229 Ms. Reyes argues ALJ Parnow erred because her circumstances in fact changed.
24
25
26
227
27
AR 18.
228
Summary-Judgment Motion – ECF No. 15 at 5–11.
28
229
AR 21.
ORDER – No. 16-cv-06958-LB
26
“The principals of res judicata apply to administrative decisions, although the doctrine is
1
2
applied less rigidly to administrative proceedings than to judicial proceedings.” Chavez v. Bowen,
3
844 F.2d 691, 693 (9th Cir. 1988). “The claimant, in order to overcome the presumption of
4
continuing nondisability arising from the first administrative law judge’s findings of nondisability,
5
must prove ‘changed circumstances’ indicating a greater disability.” Id. (internal citation omitted).
6
Changed circumstances include a new impairment or a change in the severity of an existing
7
impairment. Id.; see also Lester v. Chater, 81 F.3d 821, 827 (9th Cir. 1995). Even if the plaintiff
8
can overcome the presumption of nondisability, prior determinations such as the RFC “are res
9
judicata in the subsequent proceeding absent ‘new and material’ evidence on those issues.”
Stephens v. Colvin, No. 14-CV-02484-YGR, 2015 WL 3430586, at *6 (N.D. Cal. May 28, 2015)
11
United States District Court
Northern District of California
10
(quoting Chavez, 844 F.2d at 694).
Ms. Reyes identifies two changed circumstances: (1) mild degenerative disc disease and
12
13
(2) pain on the right side of her head.230
Ms. Reyes argues that her previously diagnosed mild degenerative disc disease is different
14
15
from her subsequently diagnosed degenerative disc disease.231 Ms. Reyes does not cite any
16
authority or evidence to support her argument. The Commissioner’s disability Listing 1.04 for
17
spine disorders simply references “degenerative disc disease,” not “mild degenerative disc
18
disease.” See 20 C.F.R. Pt. 404, Subpt. P, App. 1. Ms. Reyes does not have a new impairment
19
based upon these terminology differences.
To the extent Ms. Reyes alleges that she experienced a change in the severity of her
20
21
degenerative disc disease, the record does not support her position. In her summary-judgment
22
motion, Ms. Reyes relies on a new MRI performed in May 2014 as evidence of her “new
23
impairment,” but this imaging does not show her condition worsened.232 A previous 2011 MRI
24
revealed only “mild multi-level degenerative changes,”233 and the 2014 MRI showed only “mild
25
26
230
231
Summary-Judgment Motion – ECF No. 15 at 11.
Id.
27
232
Id. (citing AR 640, 1177–78).
28
233
AR 640.
ORDER – No. 16-cv-06958-LB
27
1
discogenic disease of the cervical spine . . . .”234 In 2011 and 2012, Dr. Luu (a spine specialist)
2
noted Ms. Reyes had “very mild degenerative changes”235 and “very minimal age expected
3
findings . . . .”236 In 2013, Dr. Luu declined to provide Ms. Reyes with a note she requested; Ms.
4
Reyes stated that “she is unable to sit and stand due to her back problem.”237 Dr. Luu stated that
5
there were “[n]o restrictions from spine standpoint,” and that Ms. Reyes “only has very mild
6
degenerative changes in her back” that do “not prevent her from sitting or standing.”238 Dr.
7
Preston-Hsu, another spine specialist, reviewed the 2014 MRI and described Ms. Reyes’s
8
degenerative disc disease as “mild”239 before Dr. Lau discharged her from the spine clinic several
9
months later.240 In sum, the record does not show the severity of her degenerative disc disease
worsened, resulting in changed circumstances for res judicata purposes. See Chavez, 844 F.2d at
11
United States District Court
Northern District of California
10
693.
Ms. Reyes also states that in her “second application[,] [she] claim[s] pain on the right side of
12
13
the head.”241 She does not elaborate. ALJ Parnow acknowledged that Ms. Reyes “alleged
14
disability due to . . . pain in the right side of the head”242 but found this was not one of Ms.
15
Reyes’s severe impairments at step two of the sequential evaluation.243 Ms. Reyes does not argue
16
the ALJ erred at step two or identify any evidence of pain on the right side of her head. Moreover,
17
in April 2013, Ms. Reyes told Dr. Vallas she had been experiencing fewer headaches.244 But while
18
there is one note about headaches, there is little other evidence of head pain generally (inclusive of
19
20
234
21
AR 1178.
235
AR 643.
22
236
AR 822.
237
AR 1086.
23
238
Id.
24
239
AR 1189.
25
240
AR 1213.
241
Summary-Judgment Motion – ECF No. 15 at 11.
242
27
AR 19 (citing AR 274; see also AR 141).
243
AR 16.
28
244
AR 384.
26
ORDER – No. 16-cv-06958-LB
28
1
headaches) or pain on the right side of the head specifically in the medical record. Given these
2
circumstances, Ms. Reyes does not show that her circumstances changed based on pain on the
3
right side of the head. See id.
4
Because Ms. Reyes does not show her circumstances changed and identifies no new and
5
material evidence, she fails to demonstrate that ALJ Parnow erred by giving great weight to the
6
findings and determination of nondisability made previously by ALJ Laverdure. See id.
7
8
3.2 Substantial Evidence Supports the ALJ’s Weighing of Dr. Esguerra’s Opinion
9
Although the ALJ “gave some weight to the opinion of [Ms. Reyes’s] treating psychiatrist,
Chris Esguerra, M.D,”245 Ms. Reyes argues the ALJ improperly rejected the “more restrictive
11
United States District Court
Northern District of California
10
limitations” in the Esguerra Assessment246 — including his finding of “marked limitations in her
12
ability to perform at a consistent pace, handle normal stress, and accept criticism from
13
supervisors.” 247 The ALJ found that these aspects of the Esguerra Assessment were unsupported
14
“by the evidence of record including the normal mental status examination, and the claimant’s
15
ability to drive, shop, and help her children with their homework.”248
The ALJ is responsible for “‘resolving conflicts in medical testimony, and for resolving
16
17
ambiguities.’” Garrison v. Colvin, 759 F.3d 995, 1010 (9th Cir. 2014) (quoting Andrews, 53 F.3d
18
at 1039). In weighing and evaluating the evidence, the ALJ must consider the entire case record,
19
including each medical opinion in the record, together with the rest of the relevant evidence.
20
20 C.F.R. § 416.927(b); see also Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007) (“[A] reviewing
21
court [also] must consider the entire record as a whole and may not affirm simply by isolating a
22
specific quantum of supporting evidence.”) (internal quotation marks and citation omitted).
“In conjunction with the relevant regulations, [the Ninth Circuit has] developed standards that
23
24
guide [the] analysis of an ALJ’s weighing of medical evidence.” Ryan v. Comm’r of Soc. Sec., 528
25
245
AR 21.
246
27
AR 1139–41.
247
AR 21.
28
248
26
Id.
ORDER – No. 16-cv-06958-LB
29
1
F.3d 1194, 1198 (9th Cir. 2008) (citing 20 C.F.R. § 404.1527). Social Security regulations and
2
case law distinguish among three types of physicians (or other “acceptable medical sources”):
3
(1) treating physicians; (2) examining physicians; and (3) non-examining physicians. 20 C.F.R.
4
§ 416.927(c), (e); Lester, 81 F.3d at 830. “Generally, a treating physician’s opinion carries more
5
weight than an examining physician’s, and an examining physician’s opinion carries more weight
6
than a reviewing [non-examining] physician’s.” Holohan v. Massanari, 246 F.3d 1195, 1202 (9th
7
Cir. 2001) (citing Lester, 81 F.3d at 830); Smolen v. Chater, 80 F.3d 1273, 1285 (9th Cir. 1996).
8
9
An ALJ, however, may disregard the opinion of a treating physician, whether or not
controverted. Andrews, 53 F.3d at 1041. “To reject [the] uncontradicted opinion of a treating or
examining doctor, an ALJ must state clear and convincing reasons that are supported by
11
United States District Court
Northern District of California
10
substantial evidence.” Ryan, 528 F.3d at 1198 (alteration in original) (internal quotation marks and
12
citation omitted). By contrast, if the ALJ finds that the opinion of a treating physician is
13
contradicted, a reviewing court will only require that the ALJ provide “specific and legitimate
14
reasons supported by substantial evidence in the record.” Reddick v. Chater, 157 F.3d 715, 725
15
(9th Cir. 1998) (internal quotation marks and citation omitted); see also Garrison, 759 F.3d at
16
1012 (“If a treating or examining doctor’s opinion is contradicted by another doctor’s opinion, an
17
ALJ may only reject it by providing specific and legitimate reasons that are supported by
18
substantial evidence.”) (internal quotation marks and citation omitted).
19
The Ninth Circuit has “held that the ALJ may ‘permissibly reject[ ] . . . check-off reports that
20
[do] not contain any explanation of the bases of their conclusions.’” Molina, 674 F.3d at 1111
21
(quoting Crane v. Shalala, 76 F.3d 251, 253 (9th Cir. 1996)) (alteration in original). This is
22
because “the regulations give more weight to opinions that are explained than to those that are
23
not.” Holohan, 246 F.3d at 1202; but see Popa v. Berryhill, No. 15-16848, 2017 WL 4160041, at
24
*5 (9th Cir. Sept. 20, 2017) (holding that under the circumstances of that case, a “check-box form”
25
was not a germane reason to reject “other source” evidence).
26
“If a treating physician’s opinion is not given ‘controlling weight’ because it is not ‘well-
27
supported’ or because it is inconsistent with other substantial evidence in the record, the [Social
28
Security] Administration considers specified factors in determining the weight it will be given.”
ORDER – No. 16-cv-06958-LB
30
1
Orn, 495 F.3d at 631. “Those factors include the ‘[l]ength of the treatment relationship and the
2
frequency of examination’ by the treating physician; and the ‘nature and extent of the treatment
3
relationship’ between the patient and the treating physician.” Id. (quoting 20 C.F.R.
4
§ 404.1527(d)(2)(i)–(ii)) (alteration in original). “Additional factors relevant to evaluating any
5
medical opinion, not limited to the opinion of the treating physician, include the amount of
6
relevant evidence that supports the opinion and the quality of the explanation provided[,] the
7
consistency of the medical opinion with the record as a whole[, and] the specialty of the physician
8
providing the opinion . . . .” Id. (citing 20 C.F.R. § 404.1527(d)(3)–(6)); see also Magallanes v.
9
Bowen, 881 F.2d 747, 753 (9th Cir. 1989) (ALJ need not agree with everything contained in the
10
medical opinion and can consider some portions less significant than others).
United States District Court
Northern District of California
11
In addition to the medical opinions of the “acceptable medical sources” outlined above, the
12
ALJ must also consider the opinions of other “medical sources who are not acceptable medical
13
sources and [the testimony] from nonmedical sources.” See 20 C.F.R. § 416.927(f)(1). An “ALJ
14
may discount the testimony” or opinion “from these other sources if the ALJ gives … germane
15
[reasons] … for doing so.” Molina, 674 F.3d at 1111 (internal quotations and citations omitted).
16
Here, the ALJ properly assigned little or no weight to the marked limitations in the Esguerra
17
Assessment because they were (1) not supported by Dr. Esguerra’s own examination notes (and
18
lacked any explanation reconciling this assessment with his notes), (2) inconsistent with the
19
examination notes from other treating or examining acceptable medical source providers, and
20
(3) inconsistent with Ms. Reyes’s level of daily activities and the relatively conservative treatment
21
she has received. The court addresses each reason in turn.
First, the ALJ found that Dr. Esguerra’s own treatment notes and clinical records do not
22
23
support the extent of Ms. Reyes’s limitations found in the Esguerra Assessment.249 While Dr.
24
Esguerra’s treatment notes and clinical records do reflect that Ms. Reyes suffers from anxiety and
25
stress, they also show that Dr. Esguerra repeatedly assessed her as cooperative with an average
26
fund of knowledge, appropriate in affect and appearance, with intact memory, euthymic mood
27
28
249
AR 21, 1121–27, 1139–41, 1153–58.
ORDER – No. 16-cv-06958-LB
31
1
(normal, non-depressed), and fair judgment, insight, attention, and concentration.250 Dr. Esguerra’s
2
clinical notes reflect that Ms. Reyes’s therapy with her new therapist was going well,251 her
3
medication adequately managed her symptoms,252 and she was “better handling her stressors.”253
4
Dr. Esguerra’s clinical notes also reflect Ms. Reyes’s subjective reports of feeling overwhelmed
5
by family and financial stressors, but in general, Dr. Esguerra’s mental-status examinations
6
remained unremarkable over the course of the treatment relationship.254 Moreover, in completing
7
the Esguerra Assessment, Dr. Esguerra did not provide any detailed explanation for his check-the-
8
box assessment or attempt to reconcile it with his examination notes.255 Given these
9
circumstances, the ALJ did not err by giving the Esguerra Assessment less than controlling
weight. See Molina, 674 F.3d at 1111 (ALJ properly rejected check-the-box report that lacked a
11
United States District Court
Northern District of California
10
supporting explanation and clinical findings); see also Bayliss v. Barnhart, 427 F.3d 1211, 1216
12
(9th Cir. 2005) (holding that even under the heightened “clear and convincing” standard, the ALJ
13
properly discredited a treating physician’s opinion when it was not supported by the physician’s
14
own clinical notes); Meanel v. Apfel, 172 F.3d 1111, 1113–14 (9th Cir. 1999) (affirming an ALJ’s
15
discrediting of a treating physician’s conclusory and minimally supported medical opinion).
Second, the severity of Ms. Reyes’s mental limitations set forth in the Esguerra Assessment is
16
17
not supported by the treatment notes and clinical records of Drs. Dal Corso, Vallas, Tom, and
18
Roman, who also treated Ms. Reyes. In addition, the ALJ gave great weight to the State agency
19
examining psychologist.256
Dr. Dal Corso’s notes from visits in 2012, two years before the Esguerra Assessment, reflect
20
21
250
AR 1122, 1124–27, 1154, 1157.
251
AR 1124; see also AR 1154 (“therapy helpful”).
252
24
AR 1124, 1126.
253
AR 1154.
25
254
AR 1122, 1127, 1154, 1157.
255
AR 1140.
22
23
26
27
28
256
AR 21 (ALJ noted that the State examining psychologist, Dr. Vigilanti, had “opined that [Ms.
Reyes] could perform routine one or two step assignments with limited interactions with the general
public.”) Ms. Reyes does not argue that Dr. Vigilanti’s findings support the Esguerra Assessment,
which in any event, predated the Esguerra Assessment by four years. See AR 354–58.
ORDER – No. 16-cv-06958-LB
32
1
that Ms. Reyes felt stressed and anxious about relationships with her family and neighbors but also
2
felt calmer on her medication.257 That same year, Dr. Vallas described Ms. Reyes as excessively
3
anxious but also cooperative, euthymic in affect, okay in mood, and having a linear thought
4
process (without any hallucinations or delusions); Dr. Vallas’s assessment did note moderate
5
limitations of Ms. Reyes’s daily life, social functioning, concentration and persistence, and
6
undetailed “[e]pisodes of decomposition.”258 Dr. Vallas’s subsequent progress notes from 2013,
7
however, reflect that Ms. Reyes continued to have normal mental-status assessments and was
8
improving, noting that she slept better and had fewer headaches and less anxiety.259
In February 2014, a few months before Dr. Esguerra completed his assessment, Dr. Tom
9
described Ms. Reyes as oriented, verbal, polite, and articulate and clinically stable with intact
11
United States District Court
Northern District of California
10
memory, linear thought process and “fair” judgment and insight; he also noted that she was calm,
12
cooperative with normal speech and appropriate affect, and her mood was “euthymic on
13
medication.”260
14
In October 2014, several months after Dr. Esguerra’s assessment, Dr. Roman noted that Ms.
15
Reyes had mild stress due to “family and relationship concerns,” but that she had more excitement
16
and better energy.261 In January 2015, Elizabeth Mole, a nurse at Pathways to Wellness, signed
17
what appears to be a stand-alone form letter stating that Ms. Reyes has generalized anxiety
18
disorder; the letter is not accompanied by an explanation or clinical findings.262
19
In sum, the notes and medical records from Ms. Reyes’s treating psychologists and
20
psychiatrists show Ms. Reyes had anxiety and felt stressed, particularly with respect to her
21
children and family relationships. They do not, however, support the severity of the limitations in
22
the Esguerra Assessment because they reflect that Ms. Reyes was managing her anxiety,
23
24
257
AR 818–20, 837, 870.
25
258
AR 379–80.
259
AR 384–87.
260
27
AR 1128–29.
261
AR 1150.
28
262
AR 1227.
26
ORDER – No. 16-cv-06958-LB
33
1
continuously improving, and otherwise presenting with normal mental status.
With respect to the consistency of the Esguerra Assessment and other evidence in the record,
2
3
Ms. Reyes’s therapist, Amy Walker, provided an “other source” medical opinion via a check-the-
4
box report in May 2014.263 Ms. Walker’s report is not wholly consistent with the Esguerra
5
Assessment or with the medical assessments of Ms. Reyes’s other “acceptable medical source”
6
treatment providers. While she indicated, like Dr. Esguerra, that Ms. Reyes had a marked
7
limitation of her ability to handle normal work stress, she found that Ms. Reyes had extreme
8
limitations in the area of attention and concentration whereas Dr. Esguerra found those areas to be
9
only slightly or moderately impaired in the Esguerra Assessment264 (or intact or normal in his
clinical examination findings265 and in the findings of other “acceptable source” treatment
11
United States District Court
Northern District of California
10
providers266). Ultimately, the ALJ gave little weight to Ms. Walker’s opinion because of its
12
inconsistency with the record and because she is not an acceptable medical source.267 Although
13
Ms. Reyes points to the cover letter for Ms. Walker’s check-the-box report as evidence that Ms.
14
Reyes is disorganized, forgetful, and tangential in her thinking, she does not argue or identify any
15
basis for finding that the ALJ erroneously discounted Ms. Walker’s opinion for non-germane
16
reasons. See Molina, 674 F.3d at 1111.268 Moreover, the cover letter does not clearly show what
17
18
263
AR 1131–32.
19
264
Compare AR 1131–32 with AR 1139–40.
265
AR 1122, 1125, 1127, 1154, 1157.
266
AR 379, 1129, 1151.
20
21
22
23
24
25
26
27
28
267
AR 21–22. As previously discussed, an ALJ must consider the opinions of medical sources who are
not “acceptable medical sources,” but may discount or disregard those opinions for “germane” reasons.
See Molina, 674 F.3d at 1111. As such, the fact that Ms. Walker may not be an acceptable medical
source by itself is not a basis to disregard her opinion. While licensed psychologists qualify as
acceptable medical sources, the record does not reflect that Ms. Walker is a licensed psychologist. See
Gomez v. Chater, 74 F.3d 967, 971 (9th Cir. 1996), superseded on other grounds as stated in Boyd v.
Colvin, 524 F. App’x 334, 336 (9th Cir. 2013) (mem.). She signed her report (AR 1130–32), not as an
“LFMT” or licensed marriage and family therapist, but as an “IFMT.” See Jager v. Barnhart, 192 F.
App’x 589, 591(9th Cir. 2006) (therapists opinion entitled to less weight as an “other source” than
opinion from an acceptable medical source). Regardless of whether Ms. Walker is an “acceptable
medical source,” the ALJ’s other reasons for discounting her opinion (e.g., the inconsistency of her
opinion with the rest of the medical record, et cetera) are “specific and legitimate” and “supported by
substantial evidence in the record” and thus are sufficient. Reddick, 157 F.3d at 725.
268
Summary-Judgment Motion – ECF No. 15 at 8.
ORDER – No. 16-cv-06958-LB
34
1
Ms. Reyes asserts that it does. In actuality, Ms. Walker stated that Ms. Reyes’s “attendance has
2
been good for the most part” and that she only “occasionally forgets about her appointments.”269
3
Ms. Walker stated that Ms. Reyes reported forgetfulness and disorganization but also stated that
4
“Ms. Reyes is a delightful and kind client” who “consistently shares examples of how she places
5
the needs of her children above her own . . . .”270
Accordingly, the court finds that ALJ’s determination — that the medical record, as a whole,
6
7
is not consistent with the severity of the limitations opined in the Esguerra Assessment — is
8
supported by “specific and legitimate” reasons based on “substantial evidence.” See Reddick, 157
9
F.3d at 725.
Finally, the ALJ also gave little or no weight to the Esguerra Assessment because she found
10
United States District Court
Northern District of California
11
the severity of those purported limitations to be inconsistent with Ms. Reyes’s daily activities,
12
including her “ability to drive, shop, and help her children with their homework.”271 Ms. Reyes
13
contends that these activities are not necessarily inconsistent with the marked limitations of her
14
ability to perform at a consistent pace, handle normal stress, and accept criticism from supervisors
15
as noted in the Esguerra Assessment.272
An ALJ may discredit or discount evidence of disability “when the claimant reports
16
17
participation in everyday activities indicating capacities that are transferrable to a work setting.”
18
Molina, 674 F.3d at 1112–13. “Even where those activities suggest some difficulty functioning,
19
they may be grounds for discrediting” evidence in the record. Id. at 1113; see Rollins v.
20
Massanari, 261 F.3d 853, 857 (9th Cir. 2001).
21
Here, it is undisputed that Ms. Reyes participates in day-to-day activities such as shopping,
22
driving, and caring for her children.273 Ms. Reyes told Dr. Esguerra that she picked her children up
23
24
25
26
269
270
AR 1130.
Id.
271
27
AR 21.
272
Summary-Judgment Motion – ECF No. 15 at 8–9.
28
273
AR 292–95, 1118.
ORDER – No. 16-cv-06958-LB
35
1
from school and was “focusing on her younger son to help him get through high school.”274 Ms.
2
Reyes’s mother wrote that she makes “sure [the children are] fed, showered and ready for
3
school/church or other activities.”275 In September 2013, therapist Leslie Zuska noted that Ms.
4
Reyes “is trying to track each kid’s curriculum and homework” and appeared to be “doing better
5
with school LOOP and [ ] to be more on top of her children’s issues than in previous years.”276
6
The court does not doubt parenting can be a challenging and stressful endeavor, but substantial
7
evidence in the record reflects that Ms. Reyes cared for herself and her children.277 The record also
8
indicates that Ms. Reyes is able to drive, shop, and appropriately interact with family, treatment
9
providers, school personnel, and others.278 Here, the inconsistency between the alleged severity of
Ms. Reyes’s impairments and her daily activities constitutes an additional, “specific and
11
United States District Court
Northern District of California
10
legitimate” reason for discounting the weight given to the Esguerra Assessment. As such, the ALJ
12
did not err by finding these daily activities to be inconsistent with the purported severity of Ms.
13
Reyes’s mental limitations as set forth in the Esguerra Assessment. 279
14
274
AR 1153.
275
16
AR 293.
276
AR 1118.
17
277
AR 292–95, 1118, 1153.
278
AR 293–95, 1132.
15
18
19
20
21
22
23
24
25
26
27
28
279
The ALJ also noted that Ms. Reyes’s alleged severe mental limitations were not supported by her
“fairly conservative treatment with only medication management and therapy” and because Ms. Reyes
had not been hospitalized or visited an ER because of her mental-health issues. See AR 21. The Ninth
Circuit has held that “evidence of ‘conservative treatment’ is sufficient to discount a claimant’s
testimony regarding severity of an impairment.” Parra v. Astrue, 481 F.3d 742, 751 (9th Cir. 2007)
(citing Johnson v. Shalala, 60 F.3d 1428, 1434 (9th Cir.1995)). Whether “medication management and
therapy” are sufficiently “conservative” treatments for undermining the severity of a claimant’s
mental-health impairment does not appear to have been decided by the Ninth Circuit, but it is
questionable. See Goodwin v. Comm’r of Soc. Sec. Admin., No. 09-CV-00469-LEK, 2011 WL
4498962, at *5 (D. Haw. Sept. 26, 2011) (finding that ALJ’s characterization of mental-health
treatment of medication and therapy as “conservative” was inconsistent with the record as a whole);
Merker v. Astrue, No. 10-CV-4058-JCG, 2011 WL 2039628, at *7 (C.D. Cal. May 25, 2011) (based on
“Plaintiff’s treatment history of having weekly therapy sessions and using medication, the Court
cannot conclude that Plaintiff’s treatment was conservative when viewed holistically, and on this
record.”); Garcia v. Colvin, No. 14-CV-00092-AS, 2015 WL 4450901, at *3 (C.D. Cal. July 20, 2015)
(court held that ALJ erred in finding Plaintiff’s treatment conservative because the court considered
biofeedback therapy and Xanax prescriptions as non-conservative treatment) (citing Parra, 481 F.3d at
751 (finding “conservative treatment” as “treat[ment] with an over-the-counter pain medication.”)).
Nevertheless, because the court finds that the ALJ’s determination is supported by substantial evidence
based on other specific and legitimate reasons, it does not need to make that determination here.
ORDER – No. 16-cv-06958-LB
36
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