Opinion
CV-23-00999-PHX-MTL
07-26-2024
Virginia Combest, Plaintiff, v. Commissioner of Social Security Administration, Defendant.
ORDER
MICHAEL T. LIBURDI UNITED STATES DISTRICT JUDGE.
At issue is the Social Security Administration's denial of Plaintiff Virginia Combest's application for Title II disability insurance benefits and Title XVI supplemental security income benefits under the Social Security Act. Plaintiff filed a complaint (Doc. 1) with the Court seeking review of her claim. The Court has reviewed the briefs (Docs. 17, 18, 20, 21), Plaintiff's notice of supplemental authority (Doc. 22), and the administrative record (Doc. 14 “A.R.”), and now affirms the Administrative Law Judge's (“ALJ”) decision.
Plaintiff filed a motion for summary judgment, which the Court will treat as an opening brief. (Doc. 17.)
I. BACKGROUND
Plaintiff filed an application for benefits on May 5, 2020 (A.R. at 268-81), for a period of disability beginning on December 30, 2015 (id. at 268, 275). Her claims were initially denied on January 13, 2021 (id. at 147, 149, 165, 181), and upon reconsideration on August 26, 2021 (id. at 183-84, 190, 196, 201, 206). Thereafter, she filed a request for a hearing which was held before the ALJ on May 26, 2022. (Id. at 124-46.) On July 15, 2022, the ALJ dismissed Plaintiff's claims. (Id. at 13-31.) She subsequently filed a request for review, which was denied on May 5, 2023. (Id. at 1-4.) She now seeks judicial review with this Court pursuant to 42 U.S.C. § 405(g).
On her application for disability insurance benefits, Plaintiff indicated that she became unable to work due to her disability on December 30, 2015. (A.R. at 268.) On her application for supplemental security income, she indicated that she became disabled on December 31, 2015. (Id. at 275.) The Court uses the earlier date, as did the ALJ. (Id. at 17.)
The Court has reviewed the record and will discuss the pertinent evidence in addressing the issues raised by the parties. Upon considering the medical evidence and opinions, the ALJ evaluated Plaintiff's disability claim based on the following medically determinable impairments: major depressive disorder, post-traumatic stress disorder, sepsis, left foot cellulitis, acute kidney failure, mild traumatic brain injury, fibromyalgia, hypertension, visual disturbance, cervical spine degenerative disc disease, obesity, cardiomegaly, migraines, insomnia, gastritis, prediabetes, and hypertriglyceridemia. (A.R. at 19.) The ALJ found that the impairments, considered singly and in combination, were not “severe.” (Id. at 13-31.) As a result, and without further analysis, the ALJ determined that Plaintiff was not disabled as defined in the Social Security Act during the relevant period. (Id.)
II. LEGAL STANDARD
In determining whether to reverse an ALJ's decision, the district court reviews only those issues raised by the party challenging the decision. See Lewis v. Apfel, 236 F.3d 503, 517 n.13 (9th Cir. 2001). The Court may set aside the Commissioner's determination only if it is not supported by substantial evidence or is based on legal error. Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007). Substantial evidence is relevant evidence that a reasonable person might accept as adequate to support a conclusion considering the entire record. Id. To determine whether substantial evidence supports a decision, the Court must consider the entire record and may not affirm simply by isolating a “specific quantum of supporting evidence.” Id. (internal marks and citation omitted). Generally, “[w]here 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) (citation omitted). The substantial evidence threshold “defers to the presiding ALJ, who has seen the hearing up close.” Biestek v. Berryhill, 587 U.S. 97, 108 (2019); see also Thomas v. CalPortland Co., 993 F.3d 1204, 1208 (9th Cir. 2021) (noting substantial evidence “is an extremely deferential standard”).
To determine whether a claimant is disabled, the ALJ follows a five-step process. 20 C.F.R. § 404.1520(a); § 416.920(a). The claimant bears the burden of proof on the first four steps, but the burden shifts to the Commissioner at step five. Tackett v. Apfel, 180 F.3d 1094, 1098-99 (9th Cir. 1999). At the first step, the ALJ determines whether the claimant is presently engaging in substantial gainful activity. 20 C.F.R. § 404.1520(a)(4)(i), (b); § 416.920(a)(i), (b). If so, the claimant is not disabled, and the inquiry ends. Id. At step two, the ALJ determines whether the claimant has a “severe” medically determinable physical or mental impairment. Id. § 404.1520 (a)(4)(ii), (c); § 416.920(a)(ii), (c). If not, the claimant is not disabled, and the inquiry ends. Id. At step three, the ALJ considers whether the claimant's impairment or combination of impairments meets or medically equals an impairment listed in Appendix 1 to Subpart P of 20 C.F.R. Part 404. 20 C.F.R. § 404.1520(a)(4)(iii), (d); § 416.920(a)(iii), (d). If so, the claimant is automatically found to be disabled. Id. At step four, the ALJ assesses the claimant's residual functional capacity and determines whether the claimant is still capable of performing past relevant work. Id. § 404.1520(a)(4)(iv), (e); § 416.920(a)(iv), (e). If so, the claimant is not disabled, and the inquiry ends. Id. If not, the ALJ proceeds to the fifth and final step, where the ALJ determines whether the claimant can perform any other work in the national economy based on the claimant's residual functional capacity, age, education, and work experience. 20 C.F.R. § 404.1520(a)(4)(v), (f); § 416.920(a)(v), (f). If not, the claimant is disabled. Id.
III. DISCUSSION
Plaintiff correctly notes that the ALJ's decision finding her not disabled at step two is atypical, as step two presents “a de minimis requirement that screens out only frivolous claims.” Glanden v. Kijakazi, 86 F.4th 838, 843 (9th Cir. 2023). The Ninth Circuit recently “reiterated the corollary principles that claimants need only make a de minimis showing for the analysis to proceed past this step and that properly denying a claim at step two requires an unambiguous record showing only minimal limitations.” Id. at 843-44.
In this Circuit, “an ALJ may find an impairment or combination of impairments not severe at step two only if the evidence establishes a slight abnormality that has no more than a minimal effect on an individual's ability to work.” Id. at 844 (cleaned up). “If a claimant has submitted evidence of a severe impairment, [the Court must] analyze [the] ALJ's step-two denial by asking whether the ALJ had substantial evidence to find that the medical evidence clearly established that the claimant did not have a medically severe impairment or combination of impairments.” Id. (cleaned up).
Plaintiff argues that she presented evidence of a medically severe impairment or combination of impairments and should have survived the low bar presented by step two. (Doc. 17 at 4, 11-19.) She asserts that the ALJ's decision to the contrary is not supported by substantial evidence, namely because the ALJ failed to fully consider evidence in the record that contradicted the ALJ's finding. (Id. at 11-19.) The Court considers her arguments in turn.
A. Traumatic Brain Injury
Plaintiff's first argument, though far from clear, appears to be that her traumatic brain injury constitutes a severe impairment and that the ALJ failed to consider relevant evidence in the record establishing that fact. (Id. at 12-16.)
She first points to records from her treatment at the Barrow Concussion and Brain Injury Center. (Id. at 13.) There, she was seen by Dr. Javier Cardenas, M.D. (A.R. at 492-96, 505-604.) The ALJ did not discuss Plaintiff's treatment at the Barrow Concussion and Brain Injury Center. (See generally id. at 13-31.) Plaintiff says that this was error because the records from that treatment conflict with the ALJ's finding. (Doc. 17 at 13.) But that argument is without merit. Dr. Cardenas's “findings,” as Plaintiff describes them, are no more than summaries of Plaintiff's self-reported symptoms. (See A.R. at 508-10, 513, 523-24, 526, 536.) As discussed later in this Order, the ALJ provided clear and convincing reasons for rejecting Plaintiff's symptom testimony. (See id. at 22.)
Next, Plaintiff objects to the ALJ's reference to her mini mental state examination (“MMSE”) test results. (Doc. 17 at 14.) When administered to her, Plaintiff scored a 29/30 on the MMSE, indicating that her cognition was normal. (A.R. at 476.) Plaintiff now contends that the ALJ should not have relied on this information because a few internet articles indicate that the MMSE “may under-detect cognitive impairment in acquired brain injury.” (Doc. 17 at 14 (internal marks omitted).) These sources insufficiently demonstrate that the ALJ's conclusion is unsupported by substantial evidence. Nor do they demonstrate that the medical record fails to clearly establish that her impairment is not severe.
Plaintiff also objects to the ALJ's statement that she “made no complaint concerning traumatic brain injury” as inconsistent with the record. (A.R. at 22; Doc. 17 at 14.) She notes that, during her hearing with the ALJ, she complained that she had chronic migraines, a flattened disc, and seizures because of her brain injury. (Doc. 17 at 14-15.) But the ALJ's observation did not relate to Plaintiff's statements at the hearing. Instead, the ALJ noted that Plaintiff did not complain about her traumatic brain injury at a particular medical evaluation. (See A.R. at 22.) Read in context, the ALJ's statement is consistent with the medical record. Plaintiff's argument otherwise is unavailing.
Fourth, Plaintiff argues that the evidence in the record demonstrates that she has a poor sense of direction, needs assistance from others, becomes confused doing simple tasks, and sometimes has trouble controlling her frustrations. (Doc. 17 at 15.) According to Plaintiff, this evidence is sufficient to survive step two. (Id.) But she again cites only to a record of her self-reported symptoms. (Id. (citing A.R. at 560).) As stated below, the ALJ provided clear and convincing reasons for rejecting Plaintiff's symptom testimony.
Plaintiff's final argument, that “where the ALJ finds impairments non severe and then finds no limitations to support step two denial he puts the cart before the horse,” is unclear. (Doc. 17 at 16 (cleaned up).) She references Dr. Cardenas's “findings” again, but that argument is unpersuasive for the reasons previously stated. (Id.) She also notes that “[psychotherapist Kati[e] Land[o]n similarly diagnose[d] limitations from [Plaintiff's] brain injury.” (Id.) The ALJ addressed Dr. Landon's statements and found them not persuasive. (A.R. at 29-30.) The ALJ carefully and convincingly explained that Dr. Landon's conclusions were inconsistent with the overall evidence. (Id.) Thus, the Court finds no “discrepancy in the record,” as Plaintiff argues. (Doc. 17 at 16.)
Plaintiff has, therefore, failed to demonstrate that the ALJ erred on this basis. The Court instead finds that substantial evidence supports the ALJ's conclusion that the medical record clearly establishes that Plaintiff's traumatic brain injury is not a severe impairment.
B. Combination of Impairments
Plaintiff next argues that her medically determinable impairments, when taken together, “limit [her] functioning.” (Id. at 17.) She contends that the ALJ failed to consider the combination of her impairments, and, therefore, the ALJ's decision is not supported by substantial evidence. (Id. at 17-18.)
Plaintiff correctly observes that the ALJ was required to consider the effect of her medically determinable impairments independently and together. See Mayes v. Massanari, 276 F.3d 453, 460 (9th Cir. 2001) (“A determination of whether an individual's impairments are of a sufficient medical severity to form the basis of eligibility for disability insurance benefits turns on the combined effect of all of the individual's impairments.”). But her assertion that the ALJ failed to do so is without merit. To the contrary, the ALJ frequently stated that it had considered Plaintiff's impairments “singly and in combination.” (A.R. 19, 21, 24, 30.) The Court further finds the ALJ's conclusion that the medical record clearly establishes that Plaintiff's medically determinable impairments are not severe even when considered in combination is supported by substantial evidence.
Plaintiff also appears to argue that the ALJ erred by failing to address the listing of impairments in § 6.00 of Appendix 1 to Subpart P of 20 C.F.R. Part 404. (Doc. 17 at 17-18.) That is not done until step three. 20 C.F.R. § 404.1520(a)(4)(iii), (d); § 416.920(a)(iii), (d). As the ALJ determined that Plaintiff was not disabled at step two, the ALJ was not required to proceed to step three. Id. § 404.1520 (a)(4)(ii), (c); § 416.920(a)(ii), (c).
C. Depression and PTSD
Plaintiff also objects that the ALJ “failed to . . . address [her] severe depression with PTSD.” (Doc. 17 at 18.) The ALJ, however, specifically found that Plaintiff's “mental ailments variously diagnosed to include major depressive disorder and post-traumatic stress disorder, considered singly and in combination, do not cause more than a minimal effect on [her] ability to do basic work activities and are therefore non-severe.” (A.R. at 24-26 (cleaned up).) Insofar as Plaintiff argues that the ALJ's conclusion is not supported by substantial evidence, the Court finds otherwise.
D. Plaintiff's Credibility
Plaintiff finally, and in conclusory fashion, argues that “[t]he ALJ did not provide clear and convincing reasons to not find [her] credible” and that “[t]he ALJ did not address the record as described above.” (Doc. 17 at 19.)
The ALJ was required to provide specific, clear, and convincing reasons for finding Plaintiff's symptom testimony not credible. See, e.g., Molina v. Astrue, 674 F.3d 1104, 1112 (9th Cir. 2012) (describing the analysis an ALJ is required to conduct when evaluating “a claimant's testimony regarding subjective pain or the intensity of symptoms”). And the ALJ did exactly that. The ALJ first addressed the record evidence of Plaintiff's physical impairments. (A.R. at 21-24.) Over three pages, the ALJ summarized the evidence in detail, noting mild impairments but explaining that Plaintiff's test results and evaluations did not support her claim that she was unable to do basic work activities due to severe symptoms. (Id.) The ALJ specifically indicated where Plaintiff's symptom testimony was directly contradicted by the record. (Id.) The Court finds the ALJ's analysis convincing.
The ALJ then explained that Plaintiff's lifestyle and activities were inconsistent with her symptom testimony. (Id. at 24.) The ALJ noted that she lived alone and was able to take care of herself, including by making her own meals, shopping in stores, walking outside, driving a vehicle, getting to appointments without difficulty, and planning activities such as moving and renting a room. (Id.) Such evidence of self-sufficiency has been held to contradict a claimant's symptom testimony. See Ahearn v. Saul, 988 F.3d 1111, 1117 (9th Cir. 2021). The Court again finds the ALJ's reasoning convincing.
Finally, the ALJ evaluated the record evidence of Plaintiff's mental impairments. (A.R. at 24-26.) Carefully summarizing that evidence, including treatment records in which Plaintiff reported progress and minimal symptoms, the ALJ determined that Plaintiff has a mild limitation in understanding, remembering, or applying information; a mild limitation in interacting with others; no limitation in concentrating, persisting, or maintaining pace; and a mild limitation in adapting or managing oneself. (Id.) The ALJ convincingly concluded that Plaintiff's mental impairments are, therefore, not severe. (A.R. at 26.)
The ALJ thus reviewed the record in detail and specifically, clearly, and convincingly explained how the evidence contradicted Plaintiff's symptom testimony. That is sufficient. Plaintiff's argument fails.
IV. CONCLUSION
The ALJ's decision finding Plaintiff not disabled at step two was not erroneous as the medical evidence clearly establishes that Plaintiff does not have a medically severe impairment or combination of impairments.
Accordingly, IT IS ORDERED affirming the July 25, 2022, decision by the Administrative Law Judge and the Commissioner of the Social Security Administration (A.R. at 13-31).
IT IS FURTHER ORDERED that Plaintiff's Motion for Summary Judgment (Doc. 17) is denied for the reasons stated in this Order.
IT IS FINALLY ORDERED directing the Clerk of Court to enter final judgment consistent with this Order and close this case.