EDMUND F. BRENNAN, Magistrate Judge.
Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying her application for Supplemental Security Income ("SSI") under XVI of the Social Security Act. The parties have filed cross-motions for summary judgment. ECF Nos. 16 & 17. For the reasons discussed below, plaintiff's motion is granted, the Commissioner's motion is denied, and the matter is remanded for further proceedings.
Plaintiff filed an application for SSI, alleging that she had been disabled since November 1, 2000. Administrative Record ("AR") at 206-27. Her application was denied initially and upon reconsideration. Id. at 105-10, 114-19. Thereafter, a hearing was held before administrative law judge ("ALJ") Timothy S. Snelling. Id. at 50-82. Plaintiff was represented by counsel at the hearing, at which she testified. Id.
On June 27, 2016, the ALJ issued a decision finding that plaintiff was not disabled under section 1614(a)(3)(A) of the Act.
AR at 41-45.
Plaintiff's request for Appeals Council review was denied on January 12, 2018, leaving the ALJ's decision as Commissioner's final decision. 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 by failing to provide clear and convincing reasons for rejecting her subjective complaints. ECF No. 16 at 6-9.
In evaluating a plaintiff's testimony regarding subjective pain or symptoms, an ALJ must follow a two-step analysis. First, they must determine whether the plaintiff has presented objective medical evidence of an underlying impairment "which could reasonably be expected to produce the pain or other symptoms alleged." Lingenfelter v. Astrue, 504 F.3d 1028, 1036 (9th Cir. 2007). At the first step, "the claimant is not required to show that her impairment could reasonably be expected to cause the severity of the symptom she has alleged; she need only show that it could reasonably have caused some degree of the symptom." Vasquez v. Astrue, 572 F.3d 586, 591 (9th Cir. 2009) (quoting Smolen v. Chater, 80 F.3d 1273, 1282 (9th Cir. 1996)). "If the claimant meets the first test and there is no evidence of malingering, the ALJ can only reject the claimant's testimony about the severity of the symptoms if she gives specific, clear and convincing reasons for the rejection." Id. "[F]or the ALJ to reject the claimant's complaints, the ALJ must provide specific, cogent reasons for the disbelief." Berry v. Astrue, 622 F.3d 1228, 1234 (9th Cir. 2010) (internal quotations and quotation marks omitted); see Diedrich v. Berryhill, 874 F.3d 634, 641 (9th Cir. 2017) (once a plaintiff submits medical evidence of an impairment that could reasonably be expected to produce the alleged symptoms, "the ALJ must give specific, clear and convincing reasons in order to reject the claimant's testimony about the severity of the symptoms.").
Plaintiff testified that she experiences backpain between her shoulder blades that constantly radiates down her right arm and occasionally down her left arm. AR 56-57. She also reported having no feeling on the right side of her body, which limits her ability to use her right upper extremity. Id. at 58, 69-70. She stated that she did not exercise because she feels fatigued "all the time." Id. at 59. She also stated that she could only walk about half a city block before getting tired. Id. at 64. In an exertion questionnaire, plaintiff reported that she could lift and carry no more than five to ten pounds but could only lift that amount of weight two times per day. Id. at 246.
In his decision, the ALJ concluded plaintiff's impairments could reasonably be expected to cause her alleged symptoms. Id. at 44. But he ultimately concluded that the alleged intensity and limiting effect was not entirely consistent with evidence in the record. Id. With respect to plaintiff's diabetes, hypertension, and hypothyroidism, the ALJ observed that treatment records reflected that these impairments were controlled with medication and were uncomplicated. Id. As for complaints of right shoulder pain, the ALJ found that plaintiff's allegations were inconsistent with the medical evidence of record. Id. Specifically, the ALJ noted that plaintiff's "physical examinations showed generally normal findings with full motor strength in all extremities" and that treatment records did not reflect complaints of right shoulder pain until February 2016. Id.
The ALJ's finding that plaintiff's diabetes, hypertension, and hypothyroidism were controlled by medication, when taken, is supported by the medical evidence of record. Id. at 288 (plaintiff reported symptoms are fairly controlled), 331 ("dm/htn/thyroid — stable with meds"), 340 (same), 352-53 (diabetes controlled with diet and oral medication; blood pressure "not at goal," but plaintiff was not taking medication), 355-59 (diabetes is uncomplicated and controlled with diet and medication; hypothyroidism uncontrolled but plaintiff not compliant with medication); 361-65 (hypertension and diabetes stable). Accordingly, it was permissible for the ALJ to discount plaintiff's allegations regarding the limiting effect of these impairments. See Warre v. Comm'r Soc. Sec. Admin., 439 F.3d 1001, 1006 (9th Cir. 2006) ("Impairments that can be controlled effectively with medication are not disabling for the purpose of determining eligibility for SSI benefits.").
However, the ALJ's sole reason for discounting plaintiff's allegation of severe shoulder pain—that it was not supported by medical evidence—was not a sufficient basis for rejecting plaintiff's allegations. As a threshold matter, "an ALJ may not reject a claimant's subjective complaints based solely on a lack of objective medical evidence to fully corroborate the alleged severity of pain." Moisa v. Barnhart, 367 F.3d 882, 885 (9th Cir. 2004); see Bunnell v. Sullivan, 947 F.2d 341, 346-47 (9th Cir. 1991) (The ALJ "may not discredit a claimant's testimony of pain and deny disability benefits solely because the degree of pain alleged by the claimant is not supported by objective medical evidence.").
But more significantly, the purported inconsistency is based on the ALJ's lay interpretation of the medical evidence. The ALJ correctly noted that treatment records prior to 2016 failed to document issues with plaintiff's right shoulder. But treatment records from February 2016 document complaints of right shoulder pain and examination revealed tenderness and moderately reduced range of motion. AR 384-88. As observed by the ALJ, plaintiff's physician ordered an MRI, which showed marked deformity to the right shoulder with absence of the humeral head, flattening of the glenoid, marked joint effusion with multiple intra-articular loose bodies of various soft tissues, abnormal signal within remnant humeral shaft, and diffuse atrophy of all rotator cuff muscles. Id. at 392.
The MRI results were not reviewed by the two physicians who provided opinions regarding plaintiff's functional limitations.
Accordingly, the matter must be remanded to allow for proper consideration of the medical evidence. Dominguez v. Colvin, 808 F.3d 403, 407 (9th Cir. 2015) ("A district court may reverse the decision of the Commissioner of Social Security, with or without remanding the case for a rehearing, but the proper course, except in rare circumstances, is to remand to the agency for additional investigation or explanation.") (internal quotes and citations omitted).
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.