McGuire v. Commissioner of Social Security
Filing
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ORDER REVERSING THE COMMISSIONER'S DECISION signed by Hon. Brian A Tsuchida. The Commissioner's final decision is REVERSED and this case is REMANDED for further administrative proceedings. (TF)
Case 3:22-cv-05693-BAT Document 17 Filed 05/22/23 Page 1 of 8
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UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF WASHINGTON
AT SEATTLE
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CHRISTOPHER M.,
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CASE NO. C22-5693-BAT
Plaintiff,
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ORDER REVERSING THE
COMMISSIONER’S DECISION
v.
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
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Plaintiff appeals the ALJ’s decision finding him not disabled. He contends the ALJ
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misevaluated the medical evidence, his testimony, and the lay evidence. 1 Dkt. 11 at 2. For the
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reasons below, the Court REVERSES the Commissioner’s final decision and REMANDS the
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matter for further administrative proceedings under sentence four of 42 U.S.C. § 405(g).
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BACKGROUND
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Plaintiff is currently 47 years old, has an 8th-grade education, and worked as a cement
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mason. Tr. 212, 1418. In September 2017, he applied for benefits, alleging disability as of
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December 9, 2016. Tr. 190-97. His applications were denied initially and on reconsideration.
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Plaintiff also argues the ALJ’s errors resulted in an incorrect residual functional capacity
(“RFC”) determination and step-five findings, Dkt. 11 at 17-18; the Court need not address these
derivative errors separately.
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Tr. 118-21, 125-38. The ALJ conducted a hearing in March 2019, Tr. 30-65, and issued a
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decision finding Plaintiff not disabled. Tr. 15-22.
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The Appeals Council denied review, Tr. 1-6, and Plaintiff sought judicial review. The
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United States District Court for the Western District of Washington granted the parties’
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stipulation to reverse the ALJ’s decision and remand the case for further administrative
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proceedings. Tr. 1509-10. On remand, a different ALJ held a hearing in April 2022, Tr. 1428-81,
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and issued a decision finding Plaintiff not disabled. Tr. 1405-20. The Appeals Council did not
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assume jurisdiction, making the ALJ’s April 2022 decision the Commissioner’s final decision.
DISCUSSION
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A.
Plaintiff’s Testimony
Absent evidence of malingering, an ALJ must provide clear and convincing reasons to
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discount a claimant’s testimony. See Burrell v. Colvin, 775 F.3d 1133, 1136-37 (9th Cir. 2014).
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The discounted Plaintiff’s testimony on the grounds they were not entirely consistent with the
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objective medical evidence. Tr. 1411-14. However, the ALJ failed to identify any inconsistencies
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and instead simply summarized the medical records as the evidence he relied upon in
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determining RFC. See id. This type of summary does not constitute the clear and convincing
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reasons required to discount a claimant’s testimony. See Brown-Hunter v. Colvin, 806 F.3d 487,
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493-94 (9th Cir. 2015) (ALJ failed to provide specific reasons, allowing for meaningful review
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where “she simply stated her non-credibility conclusion and then summarized the medical
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evidence supporting her RFC determination”).
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Although the Commissioner contends the ALJ properly cited evidence contradicting
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Plaintiff’s allegations, Dkt. 15 at 4-5, no such contrast is evident in the ALJ’s discussion. See Tr.
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1411-14. The Commissioner also contends the ALJ relied on Plaintiff’s improvement with
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treatment as a basis for discounting his testimony, Dkt. 15 at 4, but the ALJ did not find this
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explicitly. The ALJ noted Plaintiff reported improvement immediately after a steroid injection in
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April 2018, but the ALJ then cited evidence showing just a few months later, Plaintiff’s pain
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returned. See Tr. 1413. Thus there is no reasonable basis to conclude the ALJ intended to find the
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short-lived improvement Plaintiff experienced undermined his testimony he suffers from
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persistent pain.
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Because the ALJ failed to provide a legally sufficient reason to discount Plaintiff’s
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allegations, the ALJ erred and must reconsider Plaintiff’s testimony on remand. 2
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B.
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Lay Evidence
The ALJ acknowledged evidence provided by Deloris Strauser, Plaintiff’s significant
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other, and stated he considered it “to the extent that it was consistent with the claimant’s
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subjective complaints.” Tr. 1412 (citing Tr. 266, 1655-56). Because the ALJ linked Ms.
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Strauser’s statements to Plaintiff’s allegations, and erred in assessing Plaintiff’s allegations, the
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ALJ similarly erred and must also reconsider Ms. Strauser’s statements and hearing testimony,
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Tr. 52-56, on remand.
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C.
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Medical Opinion Evidence
The applicable regulations require the ALJ to articulate the persuasiveness of each
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medical opinion, specifically regarding whether the opinions are supported and consistent with
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the record. 20 C.F.R. §§ 404.1520c(a)-(c), 416.920c(a)-(c). An ALJ’s consistency and
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Plaintiff requests remand for further proceedings or alternatively, remand for a finding of
disability, Dkt. 11 at 18-19. Plaintiff fails to show a finding of disability is appropriate here. See
Leon v. Berryhill, 880 F.3d 1044, 1045 (9th Cir. 2017) (“An automatic award of benefits in a
disability benefits case is a rare and prophylactic exception to the well-established ordinary remand
rule.”). Thus, the Court finds remand for further administrative proceedings is appropriate.
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supportability findings must be supported by substantial evidence. See Woods v. Kijakazi, 32
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F.4th 785, 792 (9th Cir. 2022). Plaintiff contends the ALJ misevaluated the following medical
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opinions.
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Dr. Tsoi examined Plaintiff in November 2017 and completed a DSHS form opinion
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finding Plaintiff has severe low back pain with radiculopathy on the right that is moderately
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severe, which is defined as it causes significant workplace limitations. Tr. 477-80. Dr. Tsoi’s
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accompanying examination notes indicate he believed Plaintiff was not physically capable of
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working “at the moment[,]” and should be found eligible for financial assistance for up to six
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months. Tr. 482. Dr. Lein, a DSHS non-examining physician, reviewed unspecified evidence
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from July 2017 and opined in December 2017 that for 12 months, Plaintiff was limited to
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performing sedentary work with marked restrictions in his ability to perform postural activities
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and to perform activities within a schedule, maintain regular attendance and be punctual within
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customary tolerances. Tr. 485-87.
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Andrew Tsoi, M.D. & Arild Lein, M.D.
The ALJ referred to the opinions of Drs. Tsoi and Lein collectively as the opinions of Dr.
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Tsoi, and found them persuasive because they were supported by Plaintiff’s diagnoses and
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generally consistent with Plaintiff’s treatment records. Tr. 1415-15. The ALJ noted although the
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“moderate” and “marked” ratings are “too vague for inclusion in the [RFC assessment], the
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undersigned is persuaded [that] the claimant [is] limited to sedentary work.” Tr. 1415.
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Plaintiff contends, Dkt. 11 at 3, the ALJ erred in purporting to find the opinions of Drs.
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Tsoi and Lein well-supported and consistent with the record and therefore persuasive, and yet
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failing to include any limitations in the RFC assessment that account for the marked postural and
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schedule/attendance/punctuality limitations on vagueness grounds. Dr. Tsoi’s opinion is indeed
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vague as to which functional areas were moderately limited by Plaintiff’s condition, Tr. 477, but
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Dr. Lein identified marked limitations in specific functional areas: postural activities and the
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ability to maintain a schedule, attendance, and punctuality. See Tr. 485. The ALJ’s finding of
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vagueness is thus not reasonable with respect to Dr. Lein’s opinion. Accordingly, on remand, the
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ALJ shall reconsider the opinions of Drs. Tsoi and Lein and separately assess the persuasiveness
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of each opinion.
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2.
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Ms. Martin, Plaintiff’s treating nurse, completed a form opinion in October 2018
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Ellen Martin, ARNP
describing Plaintiff’s workplace limitations for purposes of his worker’s compensation claim.
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Tr. 577. Ms. Martin opined Plaintiff was unable to work until at least April 2019 and identified
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many specific functional limitations in Plaintiff’s ability to inter alia sit, reach, stand, walk, and
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lift. Id.
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The ALJ found Ms. Martin’s opinion unpersuasive, noting it was supported by Plaintiff’s
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inability to bend as well as his inability to sit for more than 10 minutes, and by his decreased
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range of motion and pain with ambulation. Tr. 1416. The ALJ found the opinion was inconsistent
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with the record, however, which showed Plaintiff had decreased cervical range of motion,
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tenderness with deep palpation, decreased sensation in his legs, spinal tenderness, and positive
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straight leg raising, but also indicated that at other times, Plaintiff had normal strength, tone, and
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sensation in his arms, no trigger points in the spine, and normal walking. Id. The ALJ also found
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Ms. Martin’s opinion inconsistent with an independent medical evaluation finding no cervical or
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lumbar radiculopathy or stenosis. Tr. 1416-17.
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The ALJ’s supportability and consistency findings are unclear and appear to be internally
inconsistent with the ALJ’s decision as a whole. The ALJ found Ms. Martin’s opinion to be
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supported by Plaintiff’s inability to bend as well as his inability to sit for more than 10 minutes,
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and also supported by his decreased range of motion and pain with ambulation, Tr. 1416, but the
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ALJ did not find Plaintiff to be so limited. The ALJ found Plaintiff could perform sedentary
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work, which would be inconsistent with an inability to sit for more than 10 minutes. The ALJ
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thus found Ms. Martin’s opinion to be supported by evidence he rejected, which is internally
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inconsistent, that was not resolved.
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Moreover, the ALJ referenced evidence supporting Ms. Martin’s opinion in his summary
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of the evidence that is purportedly inconsistent with Ms. Martin’s opinion. See Tr. 1416-17. As
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the ALJ himself acknowledged, Plaintiff demonstrated decreased range of motion, tenderness
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with palpation, decreased sensation, and positive straight leg raising. See id. And although the
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ALJ referenced an independent medical evaluation as inconsistent with Ms. Martin’s opinion, the
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ALJ found that independent medical evaluation to be unpersuasive because it was inconsistent
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with treatment records showing that Plaintiff had tenderness and decreased range of motion of
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the cervical and lumbar spine and a slow and antalgic gait. See Tr. 1417.
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Because the ALJ’s supportability and consistency findings with respect to Ms. Martin’s
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opinion create internal inconsistencies within the ALJ’s decision and analysis and are not
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supported by substantial evidence, the ALJ must reconsider the persuasiveness of Ms. Martin’s
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opinion on remand.
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3.
James Garrity, D.O.
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The ALJ found persuasive Dr. Garrity’s opinion Plaintiff is limited to sedentary work.
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Tr. 1415 (citing Tr. 714-23). Plaintiff suggests the ALJ erred in failing to acknowledge Dr.
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Garrity’s findings are consistent with Plaintiff’s testimony. See Dkt. 11 at 5. As noted supra,
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however, the ALJ must reconsider Plaintiff’s testimony on remand. Plaintiff has not identified
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any particular error in the ALJ’s assessment of Dr. Garrity’s opinion that warrants
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reconsideration on remand.
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4.
Mario Alinea, M.D.
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Dr. Alinea indicated in December 2021 Plaintiff had carpal tunnel syndrome and
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suggested additional testing to confirm this. Tr. 1974-75. The doctor noted Plaintiff was not
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currently working and opined (for purposes of Plaintiff’s worker’s compensation claim) this
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condition was work-related but indicated there were “[n]o limitations for this claim for now.” Id.
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The ALJ found persuasive Dr. Alinea’s opinion Plaintiff’s carpal tunnel syndrome
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resulted in no limitations. Tr. 1415. The ALJ found although Dr. Alinea’s conclusion was not
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fully supported by examination findings, which show positive Tinel’s and Phalen’s testing and
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decreased grip strength, it was consistent with evidence showing “moderate median entrapment
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neuropathy at the wrists with abnormalities on sensory nerve testing on both hands, but no
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evidence for localized ulnar neuropathy[.]” Tr. 1415.
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The ALJ’s consistency and supportability findings are confusing and create internal
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inconsistencies. The ALJ found Dr. Alinea’s opinion was not fully supported in light of evidence
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(decreased grip strength and abnormal test results) that would suggest that Plaintiff does have
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limitations related to carpal tunnel syndrome and found the opinion consistent with evidence of
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neuropathy and sensory abnormalities. Tr. 1415. The ALJ’s findings do not explain why Dr.
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Alinea’s opinion is persuasive; instead, they undermine the probative value of Dr. Alinea’s
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opinion. On remand, the ALJ shall reconsider the persuasiveness of Dr. Alinea’s opinion.
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5.
Miscellaneous Medical Evidence
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Plaintiff’s opening contains a lengthy summary of various medical findings he contends
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the ALJ should have discussed. Dkt. 11 at 6-14. Plaintiff fails to tether these findings to any
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particular part of the ALJ’s decision. The Court accordingly rejects this conclusory approach
CONCLUSION
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For the foregoing reasons, the Court finds the ALJ harmfully erred. The Court finds the
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ALJ’s errors do not compel an award of benefits. There are numerous opinions and other
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evidence that must be reevaluated, and this is a task the Commissioner should undertake, not the
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Court. Further administrative proceedings are thus necessary and appropriate.
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The Court accordingly ORDERS: The Commissioner’s final decision is REVERSED,
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and this case is REMANDED for further administrative proceedings under sentence four of 42
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U.S.C. § 405(g). On remand, the ALJ shall reassess the testimony of Plaintiff and the lay
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witnesses; reassess the opinions of Drs. Tsoi and Lein, Ms. Martin, and Dr. Alinea, and develop
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the record and redetermine RFC as needed, and proceed to the remaining steps of the disability
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determination process as appropriate.
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DATED this 22nd day of May, 2023.
A
BRIAN A. TSUCHIDA
United States Magistrate Judge
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ORDER REVERSING THE COMMISSIONER’S DECISION - 8
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