Opinion
For Carl Gridley, Plaintiff: Bill LaTour, LEAD ATTORNEY, Bill LaTour Law Offices, Colton, CA.
For Carolyn W Colvin, Commissioner of Social Security, Defendant: Ann L Maley, LEAD ATTORNEY, SAUSA - Office of the U.S. Attorney, San Francisco, CA; Assistant U.S. Attorney LA-CV, LEAD ATTORNEY, AUSA - Office of U.S. Attorney, Civil Division, Los Angeles, CA; Assistant U.S. Attorney LA-SSA, LEAD ATTORNEY, Office of the General Counsel for Social Security Adm., San Francisco, CA.
ORDER VACATING DECISION OF ADMINISTRATIVE LAW JUDGE
HON. MICHAEL R. WILNER, UNITED STATES MAGISTRATE JUDGE.
I. SUMMARY OF RULING
Plaintiff Gridley challenges the denial of his application for disability insurance benefits. The Administrative Law Judge (ALJ) found that Plaintiff was capable of performing work in the national economy and denied benefits.
The Court concludes that the ALJ did not properly evaluate the opinion of Plaintiff's treating physician when establishing Plaintiff's residual functional capacity (RFC). As a result, the Court vacates the ALJ's decision and remands the matter for further proceedings.
II. PLAINTIFF'S CONDITIONS AND PROCEEDINGS BELOW
Plaintiff applied for disability benefits based on various ailments. Following an administrative hearing, the ALJ found that Plaintiff's back and shoulder conditions constituted " severe impairments" as that term is used under federal regulations. (AR 11.)
The ALJ determined that Plaintiff had the RFC to perform " light work" with additional nominal limitations. (AR 14.) However, in establishing the RFC, the ALJ expressly disregarded the opinion of Plaintiff's treating physician that Plaintiff be restricted to " no frequent or prolonged work overhead work." (AR 16, 802.)
A vocational expert testified that an individual with Plaintiff's RFC could perform several jobs in the economy. (AR 40-42.) From this, the ALJ concluded that Plaintiff was not disabled and denied benefits. (AR 18.)
III. DISCUSSION
A. Standard of Review
Under 42 U.S.C. § 405(g), a district court may review the agency's decision to deny benefits. The ALJ's findings and decision must be upheld if they are supported by substantial evidence and are free of legal error. Hill v. Astrue, 698 F.3d 1153, 1158 (9th Cir. 2012).
Error in a social security determination is subject to harmless error analysis. Ludwig v. Astrue, 681 F.3d 1047, 1054 (9th Cir. 2012). Reversal " is not automatic, but requires a determination of prejudice." Id. Among other things, a reviewing court must consider " the likelihood that the result would have been different" but for the error, and " the impact of the error on the public perception" of the proceeding. Shinseki v. Sanders, 556 U.S. 396, 411-12, 129 S.Ct. 1696, 173 L.Ed.2d 532 (2009). A federal court must conduct this harmless error analysis regardless of the parties' formulations of the claims on appeal: " in each case we look at the record as a whole to determine whether the error alters the outcome of the case." Molina v. Astrue, 674 F.3d 1104, 1115 (9th Cir. 2012).
B. Rejection of Treating Physician's Opinion (Issue 1)
Plaintiff contends that the ALJ improperly rejected the opinion and limitation recommended by his treating physician (Dr. Halbridge). (Docket # 17 at 3.)
Plaintiff confusingly weaves in aspects of distinct back and wrist conditions into his claim regarding the physician's specific shoulder-related limitations. (Docket # 17 at 5-7.) Plaintiff fails to explain how his carpal tunnel ailment relates in any way to the overhead work issue.
1. Facts and ALJ Decision
Plaintiff sustained an injury to his left shoulder while working in early 2009. He had an operation on the shoulder in early 2010. He had a similar operation on his right shoulder in 2005. (AR 801.)
Plaintiff continued to see Dr. Halbridge, a Board-certified orthopedic surgeon, on a regular basis through 2011 and 2012. (AR 796-900.) In addition to Plaintiff's back, neck, wrist, and headache conditions, Dr. Halbridge diagnosed Plaintiff with impairments to both shoulders: the left shoulder due to the recent operation, and the right shoulder due to " overuse [ ] because of opposite left shoulder injury." (AR 801.)
In what appear to be nearly monthly medical visits, the orthopedist examined and tested the range of motion of both of Plaintiff's shoulders. The range tests were generally uneven, although the reports do not explain a typical or acceptable range. (AR 799-800.) Significantly, in at least 13 periodic reports that Dr. Halbridge signed under penalty of perjury between October 2011 and August 2012, he recommended that Plaintiff could engage in " modified work" with the limitation of " no frequent or prolonged overhead work" because of his shoulder conditions. (AR 802, 810, 820, 828, 836, 844, 852, 858, 866, 874, 881, 888, 894.)
The ALJ gave " partial weight" to Dr. Halbridge's opinion and did not include the recommended overhead-work limitation in Plaintiff's RFC. (AR 16.) The ALJ determined that the restriction " overstate[ed Plaintiff's] limitations in light of his physical findings." The ALJ wrote that Plaintiff " consistently demonstrated normal results with his left shoulder and only a positive impingement sign with his right but with normal sensation, motor strength and range of motion." The ALJ also relied on the results of a 2009 MRI of Plaintiff's shoulder which was " a normal study." (Id.)
At page 16 of the written decision, the ALJ acknowledged the recommended limitation from Plaintiff's treating physician. However, at page 15, the ALJ erroneously stated that " [t]hroughout the claimant's treatment history, his doctors have assessed [ ] no significant functional restrictions" (citing AR 802, 852).
In addition, a consulting examining physician (whose opinion also warranted only " partial weight" from the ALJ (AR 16)) found uneven range of motion with Plaintiff's shoulders and diagnosed Plaintiff with identifiable conditions for each shoulder. (AR 653, 655.) However, the consultant concluded that Plaintiff did not require any restrictions on work-related postural movements. (AR 655.)
2. Relevant Law
" In determining a claimant's RFC, an ALJ must consider all relevant evidence in the record." Robbins v. Social Sec. Admin., 466 F.3d 880, 883 (9th Cir. 2006) (quotations omitted). In addition, an ALJ's findings " must be supported by specific, cogent reasons." Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998). " The ALJ must set out in the record his reasoning and the evidentiary support for his interpretation of the medical evidence." Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). If the ALJ rejects significant probative evidence, the ALJ must explain why. Vincent v. Heckler, 739 F.2d 1393, 1395 (9th Cir. 1984). " An ALJ may not render his own medical opinion or substitute his own diagnosis for that of a physician." Rubalcaba v. Colvin, No. CV 13-7068 PLA, 2015 WL 898371 at *10 (C.D. Cal. 2015) (citing Tackett, 180 F.3d at 1102-03).
An ALJ generally gives the most weight to medical evidence from a claimant's treating physician, and progressively less weight to the opinions of examining and nonexamining physicians. Under agency regulations, a treating physician's opinion as to the nature and severity of an impairment will be given controlling weight if it is " well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record." Orn v. Astrue, 495 F.3d 625, 631 (9th Cir. 2007) (quoting 20 C.F.R. § 404.1527).
When a treating physician's opinion is contradicted by another doctor's evaluation, the ALJ " must provide specific and legitimate reasons supported by substantial evidence" for rejecting the treating physician's opinion. Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995) (quotation marks omitted). The ALJ satisfies this burden by detailing and summarizing the facts and conflicting medical evidence and stating the ALJ's interpretations and findings. Tommasetti, 533 F.3d at 1041. Even when contradicted, " a treating or examining physician's opinion is still owed deference and will often be entitled to the greatest weight" in disability proceedings. Garrison v. Colvin, 759 F.3d 995, 1012 (9th Cir. 2014).
3. Analysis
The ALJ rejected the opinion and recommendation of Plaintiff's treating physician regarding the proposed overhead work limitation. Because this opinion was contradicted by a examining consultant's opinion, the ALJ was required to identify a specific and legitimate reason supported by substantial evidence to reject the opinion. Lester, 81 F.3d at 830. However, the ALJ failed to do so.
The ALJ stated that Plaintiff demonstrated " normal results" with his left shoulder and " normal [ ] range of motion" with his right shoulder. (AR 16.) Based on what? Plaintiff's doctor certainly did not conclude that the shoulder ailments presented dire circumstances. But the physician diagnosed legitimate medical conditions in both shoulders. Moreover, there is nothing in the records (or that the ALJ points to in the decision) to establish that Plaintiff's uneven range of motion test results were normal, abnormal, or anywhere in between. Rather, it appears that the ALJ -- not a trained physician -- unilaterally determined that a " flexion" result of 110 degrees or an " external rotation" of 60 degrees is a normal result. That's not the role of an ALJ. The ALJ's conclusion regarding the " normal" results and condition of Plaintiff's shoulders is devoid of the requisite reasoning and evidentiary support to constitute a legitimate reason to reject the treating physician's opinion. Tackett, 180 F.3d at 1098.
Also of dubious validity is the ALJ's reliance on Plaintiff's normal 2009 MRI results. That image predated: (a) Plaintiff's 2010 left shoulder operation; (b) Plaintiff's subsequently diagnosed right shoulder injury due to overuse; and (c) Dr. Halbridge's extensive examinations of Plaintiff in 2011 and 2012. By pointing to this old medical evidence from significantly before the doctor's recent opinion, the ALJ failed to identify a legitimate reason for rejecting the treating physician's recommendation. Lester, 81 F.3d at 830.
More broadly, though, the ALJ failed to demonstrate any level of deference to the opinion of the treating physician here. Garrison, 759 F.3d at 1012. Plaintiff presented an overwhelming record of treatment from a Board-certified specialist who examined Plaintiff regularly and in detail over a long period of time. On thirteen occasions, that expert recommended a fairly minimal restriction on Plaintiff's ability to work: not a total ban on all overhead work, just not too much of it. Yet, the ALJ brusquely stated that this opinion was " not well supported" nor worthy of consideration. That ignores the Ninth Circuit's recent observation that a treating doctor's evaluation " will often be entitled to the greatest weight" even if subject to dispute by another practitioner. Id. It wasn't here, and the ALJ failed to persuasively explain why.
Indeed, as noted above, the ALJ may well have misunderstood the nature of the orthopedist's opinion: he incorrectly stated that Dr. Halbridge recommended no functional limitations for Plaintiff. (AR 15.) Whether this was an inadvertent typo or a sloppy review of the evidence, it supports the conclusion that the ALJ was not deferential to the practitioner's evaluation here.
The Court concludes that the ALJ did not identify legitimate reasons supported by substantial evidence for rejecting the infrequent-overhead-work limitation. Further, the Court cannot say that the ALJ's error was harmless. Ludwig, 681 F.3d at 1054. The hypothetical RFCs that the ALJ gave to the vocational expert at the hearing did not include the additional overhead work limitation at issue here. (AR 40-42.) The Court therefore has no factual basis to conclude whether, if the limitation were to be included, Plaintiff could or could not perform the identified jobs or other work. Garrison, 759 F.3d at 1020 (explaining three-part " credit-as-true" analysis). The prudent result is to remand the case on " an open record." That is appropriate when the evidence may properly be developed further or when, as here, there is " serious doubt as to whether Claimant is, in fact, disabled" and unemployable under agency regulations. Burrell v. Colvin, 775 F.3d 1133, 1141 (9th Cir. 2014).
IV. CONCLUSION
The ALJ's decision is VACATED for the reasons stated above. The Court REMANDS the case to the Agency for further proceedings.
IT IS SO ORDERED.
JUDGMENT
IT is the judgment of the Court that the decision of the Administrative Law Judge is VACATED, and the matter is REMANDED to the Social Security Administration for further proceedings consistent with the Court's order.
Further, the Court finds no merit to his after-the-fact complaint that the ALJ should have developed the record further. Plaintiff was represented by a lawyer at the hearing, and can point to no ambiguous or incomplete medical issues that triggered the ALJ's duty to obtain more evidence. Ludwig, 681 F.3d at 1054 n.30.