ANDREW J. WISTRICH, Magistrate Judge.
Plaintiff filed this action seeking reversal of the decision of defendant, the Commissioner of the Social Security Administration (the "Commissioner"), denying plaintiff's application for disability insurance benefits. The parties have filed a Joint Stipulation ("JS") setting forth their contentions with respect to the disputed issues.
The parties are familiar with the procedural facts, which are summarized in the Joint Stipulation. [
The Commissioner's denial of benefits should be disturbed only if it is not supported by substantial evidence or is based on legal error.
Plaintiff contends that the ALJ failed properly to evaluate the medical opinion evidence regarding plaintiff's mental and physical impairments.
In general, "[t]he opinions of treating doctors should be given more weight than the opinions of doctors who do not treat the claimant."
Even when not entitled to controlling weight, "treating source medical opinions are still entitled to deference and must be weighed" in light of (1) the length of the treatment relationship; (2) the frequency of examination; (3) the nature and extent of the treatment relationship; (4) the supportability of the diagnosis; (5) consistency with other evidence in the record; and (6) the area of specialization.
If a treating source opinion is uncontroverted, the ALJ must provide clear and convincing reasons, supported by substantial evidence in the record, for rejecting it. If contradicted by that of another doctor, a treating or examining source opinion may be rejected for specific and legitimate reasons that are based on substantial evidence in the record.
Plaintiff underwent a consultative psychiatric examination at the Commissioner's request in April 2013. Ijeoma Ijeaku, M.D. interviewed plaintiff and conducted a mental status examination. [AR 677-682]. Plaintiff, who appeared to be a "good and reliable historian," reported that her symptoms started when she was diagnosed with thyroid cancer and experienced post-surgical complications that caused "drastic changes to her life." [AR 678]. She reported seeking psychiatric care in March 2013 and receiving a referral to a psychiatrist. [AR 678]. Plaintiff endorsed symptoms of depressed mood, crying spells, feelings of hopelessness and helplessness, difficulty concentrating, memory problems, insomnia, low energy, lack of motivation, decreased appetite but recent weight gain, and anhedonia. Plaintiff denied suicidal ideation, auditory or visual hallucinations. Mental status examination revealed depressed mood, dysphoric and tearful affect, intact memory and concentration, limited understanding of abstractions, poor insight, and good judgment. Dr. Ijeaku diagnosed major depressive disorder without psychotic features, rule out depression due to general medical conditions. [AR 681]. Dr. Ijeaku assessed moderate impairments in plaintiff's ability to understand, remember, and carry out complex instructions; perform activities within a schedule and maintain regular attendance; complete a normal workday or workweek without interruptions from psychiatric symptoms; and respond appropriately to changes in a work setting. He assessed "no impairment" in her ability to understand, remember, and carry out simple instructions and to maintain concentration, persistence, and pace. [AR 681]. Dr. Ijeaku gave plaintiff a Global Assessment of Functioning ("GAF") score of 60, signifying moderate symptoms or any moderate difficulty in social, occupational, or school functioning.
In August 2013, plaintiff presented to Upland Community Counseling ("UCC"), a San Bernardino County clinic, for a psychiatric evaluation on referral by her primary care physician. [AR 880-884]. Julie C. Myers, Ph.D. assessed plaintiff by interviewing her and conducting a mental status examination. Plaintiff reported that she experienced depressed mood, forgetfulness, poor concentration, racing thoughts, constant worrying, insomnia, decreased appetite, loss of interest in personal grooming, suicidal ideation about twice a month, and auditory hallucinations. Plaintiff said that her symptoms began in September 2012, after she underwent surgery for thyroid cancer, and had worsened over the past three months. [AR 880, 882]. She reported that since her diagnosis she had lived rent-free, bartering for housing by assisting her housemate with her business by performing tasks such as filing and making copies. Plaintiff had no family or friends in California and was "very isolated." [AR 880]. Plaintiff was taking the anti-depressant fluoxetine (Prozac) recently prescribed by her primary care doctor. [AR 881]. Mental status examination findings included fair hygiene, "somber" and depressed mood; sad, blunted affect; depressed thought process; reports of memory problems and auditory hallucinations. Plaintiff's insight and judgment were good. [AR 883].
Dr. Myers diagnosed major depressive disorder, single episode, severe, with psychotic features. [AR 887]. She assessed a GAF score of 50, signifying serious symptoms or any serious impairment in social, occupational, or school functioning. [AR 887]. Dr. Myers referred plaintiff to a staff psychiatrist and provided her with information regarding group therapy and supportive services. [AR 883].
Plaintiff began treatment with Sushma Sachdev-Wali, M.D., a UCC psychiatrist, in October 2013.
During medication management visits in November 2013 and January 2014, Dr. Wali noted that plaintiff's mood was "less depressed," and that her sleep had improved. Plaintiff's compliance with medication was "good." Plaintiff's diagnosis was unchanged. [AR 889-890]. Her Prozac and trazodone dosages were both increased. [AR 888].
In March 2014, Dr. Wali completed a Mental Disorder Questionnaire Form containing narrative responses to a series of questions regarding plaintiff's clinical presentation, symptoms, history, current mental status, current functioning, medications, diagnosis, and prognosis. [AR 891-895]. Dr. Wali reported plaintiff's subjective symptoms, including depressed mood, difficulty sleeping, isolating herself in her room about half of the day, making mistakes while performing tasks for her housemate, needing reminders, lack of energy, forgetfulness, trouble concentrating and staying on task, difficulty and delay in completing chores, decreased energy, and anhedonia. [AR 893-894]. Mental status examination findings included lethargic and depressed mood, tearfulness, and impaired delayed recall. Plaintiff was taking Prozac and trazodone. She said that her psychiatric medications had reduced her mood swings. Plaintiff's diagnosis remained the same, and her prognosis was "guarded." Dr. Wali recommended that plaintiff continue to receive mental health services and opined that plaintiff was not competent to manage funds on her own behalf. [AR 894].
In August 2014, Dr. Wali completed a Mental Impairment Questionnaire stating that she had seeing plaintiff every four to eight weeks for about a year. [AR 1021-1025]. Dr. Wali gave plaintiff a diagnosis of major depressive disorder, severe, with psychotic features, and assigned her a GAF score of 50, signifying serious symptoms or any serious impairment in social, occupational, or school functioning. In addition to Prozac and trazodone, Dr. Wali had prescribed Risperdal (risperidone), which is used to treat symptoms of schizophrenia.
In restricting plaintiff to no more than simple, repetitive tasks involving only occasional contact with the general public, coworkers, or supervisors, the ALJ said that he gave "significant weight" to Dr. Ijeaku's examining source opinion "because it is consistent with the medical evidence," and "little weight to Dr. Wali's opinion because it is inconsistent with the substantial evidence, including the claimant's activities of daily living." [AR 52].
The ALJ's rationale for his rejection of Dr. Wali's opinion is legally insufficient. Saying that a medical opinion is "inconsistent with the substantial evidence" is not a specific reason for rejecting the opinion; it is nothing more than boilerplate. The ALJ identified only one specific inconsistency, the purported conflict between Dr. Wali's opinion and plaintiff's daily activities. An inconsistency between treating physician's opinion and a claimant's daily activities can be a specific, legitimate reason for rejecting a treating physician's opinion, but "this principle has no application [where] a holistic review of the record does not reveal an inconsistency between the treating providers' opinions and [the claimant's] daily activities."
During the September 2014 hearing, plaintiff testified that she had no income and received food stamps. She lived with her friend and her friend's daughter. [AR 71]. She was able manage her personal grooming, but she was dependent on her housemates for help with household chores. [AR 80]. Plaintiff helped her friend for "an hour or two" by filling out invoices, usually on Wednesdays and Thursdays. [AR 71-72, 79]. Plaintiff said that she made "a lot of mistakes" in filling out the invoices. [AR 72, 85]. Plaintiff had a driver's license but testified that she no longer drove because she did not feel safe doing so due to dizziness and lack of concentration. [AR 72, 83].
"[A] holistic review of the record does not reveal an inconsistency" between Dr. Wali's opinion and plaintiff's daily activities that is sufficient, standing alone, to justify rejecting the treating psychiatrist's opinion.
In finding that plaintiff retains the RFC for a restricted range of light work, the ALJ rejected the August 2014 opinion of a workers' compensation internal medicine Agreed Medical Examiner, Jens Dimmick, M.D., except that the ALJ credited Dr. Dimmick's conclusion that plaintiff could sit for six hours in an eight-hour day. The ALJ otherwise rejected Dr. Dimmick's functional assessment and gave "significant weight" to the April 2013 opinion of the Commissioner's consultative examining internist, Bryan To, M.D. The ALJ did not, however, accept Dr. To's opinion that plaintiff could perform medium work; instead, the ALJ found that plaintiff could perform a range of light work. [AR 52-53, 668-674, 1000-1013].
The ALJ rejected Dr. Dimmick's opinion because it was "inconsistent with the objective evidence and the medical record as a whole. [Dr. Dimmick's] own examination of the claimant revealed unremarkable findings." [AR 53]. The ALJ said that he gave weight to Dr. To's opinion because it was "consistent with the medical evidence, including his own objective examination findings." [AR 51].
The ALJ's reasons for rejecting most of Dr. Dimmick's opinion and giving more weight to Dr. To's opinion are not specific and legitimate. Both Dr. Dimmick and Dr. To performed physical examinations that resulted in unremarkable findings. [
A district court may "revers[e] the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing[.]"
Those "rare circumstances" compelling a remand for an award of benefits are not present. The ALJ committed reversible legal error in evaluating the medical opinion evidence. However, the record is not free from conflicts and ambiguities within and between the medical opinion evidence and plaintiff's testimony, which the ALJ found less than fully credible (a finding that plaintiff does not challenge). [
On remand, the Commissioner shall direct the ALJ to conduct a supplemental hearing, fully and fairly develop the record, reevaluate the record as a whole, and to issue a new decision containing appropriate findings.
For the reasons stated above, the Commissioner's decision is