EDMUND F. BRENNAN, Magistrate Judge.
Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying her application for a period of disability and Disability Insurance Benefits ("DIB") under Titles II of the Social Security Act. The parties have filed cross-motions for summary judgment. For the reasons discussed below, plaintiff's motion for summary judgment is granted, the Commissioner's motion is denied, and the matter is remanded for further proceedings.
Plaintiff filed an application for a period of disability and DIB, alleging that he had been disabled since June 30, 2005. Administrative Record ("AR") 148-155. Plaintiff's application was denied initially and upon reconsideration. Id. at 77-81, 83-88. On October 9, 2014, a hearing was held before administrative law judge ("ALJ") David M. Blume. Id. at 37-56. Plaintiff was represented by counsel at the hearing, at which she and a vocational expert testified. Id.
On December 29, 2014, the ALJ issued a decision finding that plaintiff was not disabled under sections 216(i) and 223(d) of the Act.
Id. at 24-32.
Plaintiff's request for Appeals Council review was denied on September 21, 2015, leaving the ALJ's decision as the final decision of the Commissioner. Id. at 1-7.
The Commissioner's decision that a claimant is not disabled will be upheld if the findings of fact are supported by substantial evidence in the record and the proper legal standards were applied. Schneider v. Comm'r of the Soc. Sec. Admin., 223 F.3d 968, 973 (9th Cir. 2000); Morgan v. Comm'r of the Soc. Sec. Admin., 169 F.3d 595, 599 (9th Cir. 1999); Tackett v. Apfel, 180 F.3d 1094, 1097 (9th Cir. 1999).
The findings of the Commissioner as to any fact, if supported by substantial evidence, are conclusive. See Miller v. Heckler, 770 F.2d 845, 847 (9th Cir. 1985). Substantial evidence is more than a mere scintilla, but less than a preponderance. Saelee v. Chater, 94 F.3d 520, 521 (9th Cir. 1996). "`It means such evidence as a reasonable mind might accept as adequate to support a conclusion.'" Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consol. Edison Co. v. N.L.R.B., 305 U.S. 197, 229 (1938)).
"The ALJ is responsible for determining credibility, resolving conflicts in medical testimony, and resolving ambiguities." Edlund v. Massanari, 253 F.3d 1152, 1156 (9th Cir. 2001) (citations omitted). "Where the evidence is susceptible to more than one rational interpretation, one of which supports the ALJ's decision, the ALJ's conclusion must be upheld." Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002).
Plaintiff argues that the ALJ erred in (1) assessing her severe impairments at step-two; (2) failing to provide sufficient reasons for rejecting the opinions of her treating physicians, and (3) discrediting her subjective complaints absent clear and convincing reasons. ECF No. 10 at 17-34.
Plaintiff first argues that the ALJ erred by finding that her only severe impairments were right knee internal derangement and depression.
First, plaintiff argues that the ALJ erroneously concluded that her left knee osteoarthritis was not a severe impairment. ECF No. 10 at 18-19. At step-two the ALJ found that plaintiff's severe impairments only included right knee internal derangement and depression. AR 24. The record, however, contains substantial medical evidence of a left knee impairment that has more than a slight or minimal effect on plaintiff's ability to perform basic physical activity. In May 2009, plaintiff presented "mainly with left knee pain," which was treated with injections. AR 489. An x-ray showed mild to moderate osteoarthritis, which was greatest at left patellofemoral joint. Id. at 578, 708. She received another left knee injection in June, at which time she reported that her "left knee really has not gotten any better at all". Id. at 490, 487. A September treatment note indicates that plaintiff received more knee injections, but that her left knee was "still very painful." Id. at 479. Similar complaints were also documented the following month. Id. at 473. While subsequent treatment notes indicate treatment primarily for other impairments, they also reflect that plaintiff has chronic arthritis in her knees, which were treated with narcotic pain medication. Id. at 419, 319. A treatment note from April 2012, also shows that plaintiff's physician recommended plaintiff undergo pool therapy to help with her knee pain caused by osteoarthritis in her knees, as her ability to exercise was likely to have orthopedic limitations. Id. at 319.
In light of that evidence, it is salient that the ALJ failed to provide any explanation for his finding that plaintiff's left knee osteoarthritis was non-severe. The ALJ's decision is devoid of any meaningful discussion of the medical evidence concerning plaintiff's left knee impairment. In assessing the limitations imposed by plaintiff' right knee impairment, the ALJ provided a summary of plaintiff's medical records, which included a reference to the May 2009 treatment note documenting plaintiff's complaints of left knee pain. AR 26. The ALJ also summarized the findings of the x-ray taken the same month, but failed to mention the radiologist impression finding mild to moderate osteoarthritis, greatest at the left joint. See id. at 29, 1004. The ALJ, however, cited to these two records in assessing plaintiff's right knee impairment, with no discussion relating to plaintiff's left knee osteoarthritis. Moreover, the ALJ failed to discuss evidence documenting that plaintiff's left knee impairment was treated with injections as well as narcotic pain medication. The failure to address this probative evidence regarding plaintiff's knee impairment constitutes error. Vincent v. Heckler, 739 F.2d 1391, 1394-95 (9th Cir. 1984) (the ALJ "must explain why significant probative evidence has been rejected.") (quotations omitted); see also Howard ex rel. Wolff v. Barnhart, 341 F.3d 1006, 1012 (9th Cir. 2003) (the ALJ need not discuss evidence that is neither significant nor probative).
The ALJ also failed to fully consider evidence documenting plaintiff's right arm impairment. At step-two, the ALJ concluded that plaintiff's carpel tunnel syndrome and cervical degenerative disc disease were not severe impairments. AR 24-25. In making this finding, the ALJ noted that one treatment record reflected plaintiff's reports of not feeling arm symptoms from carpal tunnel syndrome. AR 25. The ALJ also observed that plaintiff's treating physician noted that plaintiff's "arm pain from neck pain may be interrelated, but she also noted magnetic resonance imaging (MRI) scans of the cervical spine showed only mild disc/osteophytes complexes." Id.
These two records, viewed in isolation, fail to accurately depict plaintiff's right arm impairment. An August 2008 treatment note reflects that plaintiff experienced intermittent numbness in her fingertips and toes, but at that time she was only diagnosed with paresthesias. AR 499. In March 2009, plaintiff reported that her right shoulder started to ache. Id. at 492. An x-ray of plaintiff's neck "just show[ed] some arthritis, but a shoulder x-ray indicated that a tendon likely tore and pulled a bone fragment. Id.
In May 2009, plaintiff reported "developing some right shoulder pain that is associated with some numbness in her index and long finger[s]." Id. at 490. Her physician noted in regard to the shoulder pain there may be a component of cervical radiculopathy, and it was recommended that plaintiff restart rotator cuff exercises. Id. at 490. In September, plaintiff again complained of right arm pain. AR 479-480. Her shoulder had a fair range of motion but with general pain. Id. at 480.
An EMG study was performed in October 2009. The report indicated that plaintiff had a history of shoulder pain radiating to her elbow and forearm, but that an MRI of the cervical spine was not revealing. Id. at 709. However, the EMG study found signs of mild and chronic bilateral cervical radiculopathy, which was more prominent on the right, and moderate carpal tunnel syndrome. Id. at 711. The following month, plaintiff complained of neck and arm pain. AR 469-470. On examination, palpation of plaintiff's cervical spine caused shock sensations down the right arm. Id. at 470. Plaintiff had slightly less sensation on three fingers of her right hand, but no atrophy was noted. Id. Plaintiff, however, reported that it felt like the pain was not "coming from the wrist, but from the neck." Id. Plaintiff's physician noted that plaintiff "doesn't feel a large part of her arm symptoms," and that her carpal tunnel syndrome may be unrelated to her radiculopathy. Id. Treatment notes from March 2010 also show that plaintiff experienced a flare up in her neck and arm pain. Id. at 458.
The ALJ failed to reference or discuss most of these treatment records. Instead, in finding that plaintiff did not have a severe arm impairment, the ALJ focused solely on the minimal MRI findings and plaintiff's reports to her physician that she didn't feel arm symptoms from her carpel tunnel syndrome. Again, these isolated records fail to fully account for plaintiff's impairment. While the MRI results were devoid of significant findings, plaintiff's EMG study, which the ALJ ignored, confirmed cervical radiculopathy in plaintiff's right arm. As discussed above, plaintiff's treatment records consistently reflected complaints of pain and medical treatment for this impairment. Moreover, plaintiff's report of not feeling arm symptoms from carpal tunnel—a report that is relevant to assessing the severity of plaintiff's carpel tunnel syndrome—has no bearing on whether plaintiff's cervical radiculopathy (an impairment not even discussed by the ALJ) caused more no more than a minimal effect on the ability to work. See Webb, 433 F.3d at 686.
Moreover, the ALJ's failure to properly consider the severity of plaintiff's left knee and arm impairments at step-two was not harmless, as he failed to consider these impairments in assessing plaintiff's RFC.
Accordingly, the ALJ's step-two finding is not supported by substantial evidence. As the ALJ failed to consider significant medical records, the matter must be remanded for further proceedings to allow the ALJ consider and resolve any conflicts in the medical evidence. See Dominguez v. Colvin, 808 F.3d 403, 407 (9th Cir. 2015) ("Unless the district court concludes that further administrative proceedings would serve no useful purpose, it may not remand with a direction to provide benefits.") (internal quotes and citations omitted); Edlund v. Massanari, 253 F.3d at 1156 ("the ALJ is responsible for determining credibility, resolving conflicts in medical testimony, and resolving ambiguities."); see also Connett v. Barnhart, 340 F.3d 871, 874 (9th Cir. 2003) (holding that the appellate court "cannot rely on independent findings of the district court. We are constrained to review the reasons the ALJ asserts.").
Accordingly, it is hereby ORDERED that:
Lester v. Chater, 81 F.3d 821, 828 n.5 (9th Cir. 1995).
The claimant bears the burden of proof in the first four steps of the sequential evaluation process. Yuckert, 482 U.S. at 146 n.5. The Commissioner bears the burden if the sequential evaluation process proceeds to step five. Id.