Carpenter v. Bisignano

1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 SOUTHERN DISTRICT OF CALIFORNIA 10 11 RYAN C., Case No.: 3:25-cv-01816-AHG 12 Plaintiff, ORDER RESOLVING JOINT MOTION FOR JUDICIAL REVIEW 13 v. OF THE FINAL DECISION OF THE 14 FRANK BISIGNANO, Commissioner of COMMISSIONER OF SOCIAL Social Security, SECURITY 15 Defendant. 16 [ECF No. 19] 17 18 On March 24, 2026, Ryan C. (“Plaintiff”) and the Commissioner of Social Security 19 (“Commissioner” or “Defendant”) filed a Joint Motion for Judicial Review of the Final 20 Decision of the Commissioner of Social Security (“Joint Motion”) pursuant to 42 U.S.C. § 21 405(g), regarding Plaintiff’s request for judicial review of a decision by the Commissioner 22 denying Plaintiff’s application for supplemental security income. ECF No. 19. 23 For the reasons set forth below, the Court resolves the Joint Motion in Plaintiff’s 24 favor, GRANTS Plaintiff’s motion to remand, and REMANDS this action for calculation 25 of benefits to be awarded to Plaintiff. 26 I. BACKGROUND 27 Plaintiff filed an application for supplemental security income under Title XVI of 28 the Social Security Act on November 17, 2022, alleging a disability onset date of 1 August 5, 2021. Certified Administrative Record (“AR”) 56, 506–522. The Commissioner 2 denied Plaintiff’s claim initially on February 6, 2023, and denied reconsideration on 3 November 16, 2023. AR 393–98; 400–02. Plaintiff requested a hearing before an 4 Administrative Law Judge (“ALJ”), which was held on June 20, 2024. AR 80–112. 5 On August 19, 2024, the ALJ issued an unfavorable decision denying Plaintiff’s 6 application. AR 53–70. The ALJ found that Plaintiff has no past relevant work. AR 68. 7 The ALJ also found that Plaintiff could perform jobs that exist in significant numbers in 8 the national economy and therefore had not been under a disability since 9 November 17, 2022, the date his application was filed. AR 69–70. 10 Plaintiff requested review of the ALJ’s decision by the Appeals Council, which 11 denied review on June 11, 2025. AR 1–7. Plaintiff timely filed this action on July 17, 2025. 12 ECF No. 1; 42 U.S.C. § 405(g). 13 II. STANDARD OF REVIEW 14 Pursuant to 42 U.S.C. § 405(g), this Court has authority to review the 15 Commissioner’s decision to deny benefits. The Court may set aside the Commissioner’s 16 denial of benefits only if it is not supported by substantial evidence or is based on legal 17 error. Berry v. Astrue, 622 F.3d 1228, 1231 (9th Cir. 2010). 18 Substantial evidence is “such relevant evidence as a reasonable mind might accept 19 as adequate to support a conclusion.” Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019) 20 (quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)). The standard 21 requires “more than a mere scintilla” of evidence, “but less than a preponderance.” Revels 22 v. Berryhill, 874 F.3d 648, 654 (9th Cir. 2017) (citation omitted). The standard is “highly 23 deferential.” Valentine v. Comm'r Soc. Sec. Admin., 574 F.3d 685, 690 (9th Cir. 2009). 24 Thus, “‘[w]here evidence is susceptible to more than one rational interpretation,’ the ALJ’s 25 decision should be upheld.” Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007) (quoting 26 Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005)). 27 However, the Court “must consider the entire record as a whole, weighing both the 28 evidence that supports and the evidence that detracts from the Commissioner’s conclusion, 1 and may not affirm simply by isolating a specific quantum of supporting evidence.” 2 Garrison v. Colvin, 759 F.3d 995, 1009 (9th Cir. 2014) (internal quotation marks omitted). 3 The ALJ is responsible for resolving conflicts in the medical evidence and ambiguities in 4 the record. Magallanes v. Bowen, 881 F.2d 747, 750 (9th Cir. 1989). Further, “[t]he 5 grounds upon which an administrative order must be judged are those upon which the 6 record discloses that its action was based.” SEC v. Chenery Corp., 318 U.S. 80, 87 (1943). 7 Even where the ALJ commits legal error, the Court may not reverse if the error is 8 harmless—that is, where it is inconsequential to the ultimate nondisability determination. 9 Garcia v. Comm’r of Soc. Sec., 768 F.3d 925, 929 (9th Cir. 2014); see also Burch, 400 10 F.3d at 679 (citation omitted). 11 III. SUMMARY OF ALJ’S FINDINGS 12 A. The Five-Step Evaluation Process 13 The ALJ follows a five-step sequential evaluation process in assessing whether a 14 claimant is disabled. 20 C.F.R. § 416.920;1 Tackett v. Apfel, 180 F.3d 1094, 1098–99 (9th 15 Cir. 1999). In the first step, the Commissioner must determine whether the claimant is 16 currently engaged in substantial gainful activity; if so, the claimant is not disabled, and the 17 claim is denied. Lounsburry v. Barnhart, 468 F.3d 1111, 1114 (9th Cir. 2006). 18 If the claimant is not currently engaged in substantial gainful activity, the second 19 step requires the ALJ to determine whether the claimant has a “severe” impairment or 20 combination of impairments significantly limiting his ability to do basic work activities, 21 22 23 1 Unless otherwise noted, all references to the agency regulations herein are to the regulations in effect at the time of the ALJ’s decision. See, e.g., SSR 16-3, 2016 SSR 24 LEXIS 4 n.27 (S.S.A. 2016) (“When a Federal court reviews our final decision in a claim, 25 we expect the court will review the final decision using the rules that were in effect at the time we issued the decision under review.”); Anne B. v. Comm’r, Soc. Sec. Admin., No. 26 1:18-CV-02146-HZ, 2019 WL 6976034, at *8 (D. Or. Dec. 20, 2019) (collecting cases for 27 the proposition that “[t]he applicable regulations are those in effect at the time the ALJ issued his decision”). The regulations governing Title XVI supplemental security income 28 1 and which has lasted or is expected to last for a continuous period of at least 12 months; if 2 not, a finding of nondisability is made and the claim is denied. Id. See also 20 C.F.R. 3 § 416.909 (setting forth the 12-month duration requirement). If the claimant has a “severe” 4 impairment or combination of impairments, the third step requires the ALJ to determine 5 whether the impairment or combination of impairments meets or equals an impairment in 6 the Listing of Impairments (“Listing”) set forth at 20 C.F.R. Part 404, Subpart P, Appendix 7 1; if so, disability is conclusively presumed, and benefits are awarded. Lounsburry, 468 8 F.3d at 1114. 9 If the claimant’s impairment or combination of impairments does not meet or equal 10 an impairment in the Listing, the ALJ proceeds to the fourth step of the disability evaluation 11 process. The fourth step requires the ALJ to determine whether the claimant has sufficient 12 residual functional capacity (“RFC”) to perform his past work. Id. Therefore, the ALJ must 13 determine the claimant’s RFC before moving to step four. 14 An RFC is “an assessment of an individual’s ability to do sustained work-related 15 physical and mental activities in a work setting on a regular and continuing basis.” SSR 16 96-8p, 1996 WL 374184, at *1 (July 2, 1996). It reflects the most a claimant can do despite 17 his limitations. 20 C.F.R. § 416.945(a)(1). An RFC assessment must include an 18 individual’s functional limitations or restrictions as a result of all of his impairments—even 19 those that are not severe (see 20 C.F.R. § 416.945(a)(1)–(2), (e))—and must assess his 20 “work-related abilities on a function-by-function basis.” SSR 96-8p, 1996 WL 374184, at 21 *1; see also Valentine, 574 F.3d at 690 (“an RFC that fails to take into account a claimant’s 22 limitations is defective”). An ALJ errs when he provides an incomplete RFC that ignores 23 or discounts “significant and probative evidence” favorable to a claimant’s position. Hill 24 v. Astrue, 698 F.3d 1153, 1161–62 (9th Cir. 2012). 25 An RFC determination must be based on all relevant evidence, including the 26 diagnoses, treatment, observations, and opinions of medical sources, such as treating and 27 examining physicians. 20 C.F.R. § 416.945. A court must uphold an ALJ’s RFC 28 assessment when the ALJ has applied the proper legal standards and substantial evidence 1 in the record as a whole supports the decision. See Bayliss v. Barnhart, 427 F.3d 1211, 2 1217 (9th Cir. 2005). At step four of the disability analysis, if the ALJ determines a 3 claimant has sufficient RFC to perform past relevant work, the claimant is not disabled, 4 and the claim is denied. Drouin v. Sullivan, 966 F.2d 1255, 1257 (9th Cir. 1992). The 5 claimant has the burden of proving that he is unable to perform past relevant work at step 6 four. Id. If the claimant meets this burden, a prima facie case of disability is established. 7 Id. 8 At step five, the burden then shifts to the Commissioner to establish that the claimant 9 is not disabled because there is other work existing in “significant numbers” in the national 10 or regional economy the claimant can do, considering the claimant’s RFC, age, education, 11 and work experience. 20 C.F.R. § 416.960(c)(1), (c)(2); see also 20 C.F.R. 12 § 416.920(g)(1). The determination of this issue comprises the fifth and final step in the 13 sequential analysis. 20 C.F.R. § 416.920; Tackett, 180 F.3d at 1099. 14 B. The ALJ’s Application of the Five-Step Process in This Case 15 At step one, the ALJ determined that Plaintiff had not engaged in substantial gainful 16 activity since November 17, 2022, the application date. AR 59. At step two, the ALJ 17 determined that Plaintiff has the following severe impairments: autism spectrum disorder, 18 history of attention deficit hyperactivity disorder (ADHD), depression, anxiety, tic 19 disorder, and panic disorder. AR 59. 20 At step three, the ALJ determined that Plaintiff did not have an impairment or 21 combination of impairments that met or medically equaled the severity of one of the 22 impairments in the Listing, noting that he had considered Listings 12.04, 12.06, and 12.11. 23 AR 60. The ALJ determined that Plaintiff has moderate limitations in understanding, 24 remembering, or applying information, as well as in interacting with others. AR 60. The 25 ALJ also determined that Plaintiff has moderate limitations in concentrating, persisting, or 26 maintaining pace, and in adapting or managing oneself. AR 61. 27 Between steps three and four, the ALJ determined that Plaintiff had the residual 28 functional capacity (“RFC”) to perform a full range of work at all exertional levels with 1 certain nonexertional limitations. AR 61–62. Specifically, the ALJ determined that 2 Plaintiff: 3 . . . can understand, remember, and carry out simple, routine, repetitive tasks, with breaks every two hours; have no interaction with the general public; and 4 have only occasional work-related, non-personal, non-social interaction with 5 co-workers and supervisors involving no more than a brief exchange of information or hand-off of product. He could not perform highly time- 6 pressured tasks and would be limited to generally goal-oriented work without 7 time-sensitive strict production quotas, and to a low-stress environment in which he would not have to switch from task to task and would have minimal 8 decision-making capability. 9 AR 61–62. 10 At step four, the ALJ concluded that Plaintiff has no past relevant work. AR 68. At 11 step five, the ALJ considered that Plaintiff was a “younger individual” as of the date the 12 application was filed and that he has at least a high school education. AR 69. Based on the 13 vocational expert’s testimony, the ALJ determined that Plaintiff was “capable of making a 14 successful adjustment to other work that exists in significant numbers in the national 15 economy.” AR 70. Specifically, the ALJ found that Plaintiff could perform the medium- 16 exertion jobs of Cleaner, Hand Packager, and Day Worker. AR 69. The ALJ concluded 17 that Plaintiff had not been under a disability since November 17, 2022, the date his 18 application was filed. AR 70. 19 IV. DISCUSSION 20 Plaintiff brings two claims of error in the Joint Motion: 1) the ALJ failed to properly 21 consider the psychiatric medical opinion of Dr. Gregory Nicholson, and 2) the ALJ failed 22 to properly consider Plaintiff’s testimony. ECF No. 19 at 4. 23 A. The ALJ Erred in Evaluating Dr. Nicholson’s Opinion 24 As his first claim of error, Plaintiff argues that the ALJ failed to properly evaluate 25 the opinion of consultative examiner Dr. Gregory Nicholson. ECF No. 19 at 4–18. Plaintiff 26 contends that although the ALJ found Dr. Nicholson’s opinion partially persuasive, the 27 ALJ failed to adequately address Dr. Nicholson’s finding that Plaintiff was moderately 28 1 limited in performing work activities without special or additional supervision. Id. 2 Defendant responds that the ALJ reasonably found Dr. Nicholson’s opinion only partially 3 persuasive and adequately accounted for the supported limitations in the RFC. Id. at 15– 4 18. 5 1. Legal Standard 6 With respect to the ALJ’s consideration of medical opinion evidence, the Social 7 Security Administration’s revised regulations for considering medical opinions and prior 8 administrative findings, found at 20 C.F.R. § 416.920c(c)(1)–(c)(5), apply because 9 Plaintiff filed his SSI application after March 27, 2017. AR 56 (application filed 10 November 17, 2022). The Ninth Circuit has recognized that these new regulations upend 11 the longstanding treating physician rule. Woods v. Kijakazi, 32 F.4th 785, 789 (9th Cir. 12 2022). Rather than attributing deference to a medical opinion based on the nature of the 13 relationship between the physician and the claimant, an ALJ must evaluate the 14 “persuasiveness” of any medical opinions. Id. at 792. 15 In evaluating persuasiveness, an ALJ must consider the medical source opinion’s 16 supportability, its consistency, the relationship between the source and the claimant, the 17 source’s specialization, and other factors such as the source’s knowledge of other evidence, 18 social security requirements, and whether there was subsequently submitted evidence. Id.; 19 20 C.F.R. § 416.920c(c)(1)–(c)(5). Though an ALJ may discuss each of the factors to be 20 considered in his opinion, the regulations only require the ALJ to explain how he 21 considered the most important factors—supportability and consistency. 22 20 C.F.R. § 416.920c(b)(2). Supportability examines the relevant objective medical 23 evidence and supporting explanations presented by the source. 20 C.F.R. § 416.920c(c)(1). 24 Consistency examines the evidence from other medical and nonmedical sources. 20 C.F.R. 25 § 416.920c(c)(2). 26 Under the revised regulations, “an ALJ’s decision, including the decision to discredit 27 any medical opinion, must simply be supported by substantial evidence.” Woods, 32 F.4th 28 at 787; see also Kitchen v. Kijakazi, 82 F.4th 732, 739 (9th Cir. 2023) (explaining how an 1 ALJ weighing a medical opinion must provide an explanation supported by substantial 2 evidence, which articulates how the ALJ considered supportability and consistency); 3 Sloane S. v. Kijakazi, No. 21cv1043-MMA-MSB, 2023 WL 2017284, at *4 (S.D. Cal. Feb. 4 15, 2023). ALJs must address how they considered the consistency and supportability 5 factors in sufficient detail to allow a reviewing court to determine whether that reasoning 6 is supported by substantial evidence. Titus L.S. v. Saul, No. 20cv04825-AFM, 2021 WL 7 275927, at *7 (C.D. Cal. Jan. 26, 2021) (citing Ford v. Saul, 950 F.3d 1141, 1154 (9th Cir. 8 2020)). 9 Ultimately, “an ALJ errs when he rejects a medical opinion or assigns it little weight 10 while doing nothing more than ignoring it, asserting without explanation that another 11 medical opinion is more persuasive, or criticizing it with boilerplate language that fails to 12 offer a substantive basis for his conclusion.” Massey v. Kijakazi, No. 21-35986, 2022 WL 13 16916366, at *1 (9th Cir. Nov. 14, 2022) (quoting Garrison, 759 F.3d at 1012–13); see 14 also Labryssa v. Kijakazi, No. 21cv04233-BLF, 2022 WL 2833981, at *7 (N.D. Cal. 15 July 20, 2022) (finding a lack of substantial evidence where the ALJ failed to engage with 16 the medical opinion “in any meaningful sense” and “made only a passing assessment” of 17 the supportability and consistency factors). 18 2. Analysis 19 The medical opinion at issue is the December 22, 2022 psychiatric consultative 20 examination performed by Dr. Gregory Nicholson. AR 4669–75. During the examination, 21 Plaintiff reported difficulty concentrating, forgetfulness, losing and misplacing things, 22 difficulty staying organized, restlessness, panic attacks, depressed mood, irritability, 23 insomnia, decreased energy, and decreased interest in activities. AR 4670. Plaintiff also 24 reported multiple prior suicide attempts. AR 4670. He had never worked and was living 25 with his parents. AR 4671. Dr. Nicholson diagnosed unspecified tic disorder, unspecified 26 ADHD, panic disorder, and unspecified depressive disorder. AR 4673. In his functional 27 assessment, Dr. Nicholson opined that Plaintiff was moderately limited in his ability to 28 relate and interact with coworkers and the public; mildly limited in maintaining 1 concentration, attention, persistence, and pace; mildly limited in accepting instructions 2 from supervisors; mildly limited in maintaining regular attendance and performing work 3 activities on a consistent basis; and moderately limited in performing work activities 4 without special or additional supervision. AR 4674. 5 The ALJ discussed Dr. Nicholson’s examination and found his opinion partially 6 persuasive. AR 66–67. The ALJ found that Dr. Nicholson’s opinion was supported by his 7 examination findings and also found portions of the opinion consistent with the treatment 8 record. AR 66–67. The ALJ incorporated several mental limitations into the RFC, 9 including restrictions to simple, routine, repetitive tasks; no interaction with the general 10 public; only occasional work-related interaction with coworkers and supervisors; and a 11 low-stress work environment with minimal decision-making. AR 61–62. Additionally, the 12 ALJ found Dr. Nicholson’s use of terms such as “mild” and “moderate” to be “vague” and 13 “non-policy compliant,” explaining that those terms did not describe specific work-related 14 restrictions. AR 66–67. 15 The Court recognizes that the ALJ was not required to adopt every limitation 16 assessed by Dr. Nicholson. However, the ALJ did not adequately explain his treatment of 17 Dr. Nicholson’s finding that Plaintiff was moderately limited in performing work activities 18 without special or additional supervision. AR 4674. The RFC does not contain an express 19 restriction addressing Plaintiff’s ability to perform work activities without special or 20 additional supervision. AR 61–62. This omission matters because the supervision 21 limitation is different from the restrictions the ALJ included in the RFC. Limiting Plaintiff 22 to simple, routine, repetitive tasks addresses the type of work Plaintiff can perform, while 23 limiting his interaction with the public, coworkers, and supervisors addresses contact with 24 other people. AR 61–62. These restrictions do not address whether Plaintiff can perform 25 his work without special or additional supervision. Because the RFC does not include that 26 limitation, the ALJ was required to explain why it was not adopted. See SSR 96-8p, 1996 27 WL 374184, at *7 (requiring an ALJ to explain why a medical opinion conflicting with the 28 RFC was not adopted). 1 The ALJ’s characterization of Dr. Nicholson’s use of the term “moderate” as 2 “vague” does not adequately explain why the supervision limitation was discounted. 3 Although “moderate” does not itself specify a concrete work restriction, Dr. Nicholson 4 identified the particular ability affected—Plaintiff’s ability to perform work activities 5 without special or additional supervision. Courts have rejected similar attempts to discount 6 medical opinions merely because the physician used terms such as “mild” or “moderate” 7 to describe functional limitations. See Vincent L.P. v. Saul, No. 2:20-CV-05716-JC, 2021 8 WL 2209674, at *4 (C.D. Cal. May 31, 2021) (finding that the ALJ’s characterization of 9 the physician’s use of “moderate” as “vague” was not a sufficient reason for discounting 10 the opinion); see also Lisardo S. v. Berryhill, No. 5:18-CV-00480-AFM, 2019 WL 773686, 11 at *6 (C.D. Cal. Feb. 20, 2019) (finding error where the ALJ discounted an examining 12 physician’s opinion as “vague and unclear” because the physician assessed “moderate 13 limitations”); Vasquez v. Berryhill, No. 1:16-CV-00448-GSA, 2017 WL 2633413, at *6 14 (E.D. Cal. June 19, 2017) (finding that the ALJ could not reject an examining physician’s 15 moderate limitations as “vague and ambiguous”). 16 Defendant also argues that the ALJ reasonably found Dr. Nicholson’s opinion 17 inconsistent with Plaintiff’s “intact mental status and effective treatment.” ECF No. 19 at 18 17. In support, Defendant points to the treatment records cited by the ALJ, which 19 Defendant contends reflect intact mental-status findings and improvement with treatment. 20 Id.; AR 67. The Court does not question that these records contain generally intact mental- 21 status findings and evidence of some improvement with treatment. The question, however, 22 is whether that evidence contradicts Dr. Nicholson’s specific supervision limitation. The 23 records include findings such as cooperative behavior, normal speech, coherent or linear 24 thought processes, good judgment, and fair or good insight. ECF No. 19 at 17; AR 4741, 25 4745, 4752, 4756, 4762, 4770, 4822, 4826–27, 4840–41, 4869, 4882. But these findings 26 do not directly address Plaintiff’s ability to perform work activities without special or 27 additional supervision. Moreover, some of the same records reflect continuing psychiatric 28 symptoms and functional limitations. A March 28, 2023 progress note reflects a linear 1 thought process and good judgment, but also documents Plaintiff’s continued reports of 2 significant depression and anxiety. AR 4766–71. A November 20, 2023 progress note 3 reflects normal and cooperative behavior, alert cognition, and coherent thought processes, 4 while also diagnosing Plaintiff with severe, recurrent major depressive disorder. 5 AR 4824–27. Although a February 2024 appointment reflected generally normal mental- 6 status findings, Plaintiff’s provider increased Cymbalta to 40 mg and added hydroxyzine 7 for anxiety and insomnia. AR 4836–41. Thus, the ALJ could properly consider these 8 mental-status findings in evaluating the consistency of Dr. Nicholson’s opinion, but the 9 decision does not explain how they undermine the particular finding that Plaintiff was 10 moderately limited in performing work activities without special or additional supervision. 11 AR 4674. 12 The record also contains evidence supporting Dr. Nicholson’s supervision 13 limitation. In his Function Report, Plaintiff stated that he can pay attention for only a “small 14 period of time” before losing concentration. AR 821. When asked about spoken 15 instructions, Plaintiff explained, “Sometimes I am told to do something, and I have to be 16 reminded.” AR 821. A January 31, 2023 progress note similarly documented that Plaintiff 17 was “easily overwhelmed and loses focus.” AR 4689. Plaintiff later testified that he had 18 never obtained a driver’s license because his doctor advised against driving due to his 19 inability to focus and concern that Plaintiff “could be a danger to the road.” AR 86. 20 Plaintiff’s mother testified that she reminds him to take medication, get dressed, and 21 complete basic daily activities, and attends his medical appointments because he does not 22 always pay attention when medication changes and treatment are discussed. AR 103–05. 23 Plaintiff’s experience in community college provides additional context. Although Plaintiff 24 has attended community college since approximately 2019, he testified that he takes only 25 one class per semester. AR 87–90. An April 7, 2023 progress note also reflects that Plaintiff 26 reported being able to manage only one class per semester because he became easily 27 overwhelmed. AR 4757–58. Viewed together, Plaintiff’s reports, his mother’s testimony, 28 and the treatment records are consistent with Dr. Nicholson’s assessment that Plaintiff was 1 moderately limited in performing work activities without special or additional supervision. 2 AR 4674. 3 Defendant relies on Rounds v. Commissioner of Social Security Administration, 807 4 F.3d 996, 1006 (9th Cir. 2015). ECF No. 19 at 16. Specifically, Defendant notes that “[t]he 5 Ninth Circuit has long recognized that the RFC determination rests with the ALJ and 6 includes the responsibility to translate and incorporate clinical findings into a succinct 7 residual functional capacity.” Id. The Court does not disagree with that general proposition. 8 However, Defendant’s reliance on Rounds does not resolve the issue here. The relevant 9 question is not whether the ALJ had authority to translate Dr. Nicholson’s findings into 10 concrete work restrictions, but whether the ALJ adequately explained his treatment of 11 Dr. Nicholson’s supervision limitation. 12 The Social Security Administration’s own Program Operations Manual System 13 (“POMS”) further supports treating the supervision limitation separately. Under the 14 heading “Mental Abilities Critical for Performing Unskilled Work,” the POMS separately 15 identifies the ability to “sustain an ordinary routine without special supervision” as an 16 ability needed for unskilled work. POMS DI 25020.010(B)(2)(a)–(c), (3)(f). The POMS 17 lists this ability separately from other mental abilities, including maintaining concentration 18 and attention, maintaining regular attendance, and carrying out instructions and responding 19 appropriately to criticism from supervisors. Id. Thus, the POMS further supports treating 20 the ability to work without special supervision as a distinct functional ability rather than 21 one necessarily encompassed by limitations involving simple work or interaction with 22 supervisors. 23 Having found that the ALJ did not adequately address Dr. Nicholson’s supervision 24 limitation, the Court next considers whether the error was harmless. An ALJ’s error does 25 not warrant reversal if it is harmless. See Buck v. Berryhill, 869 F.3d 1040, 1048 (9th Cir. 26 2017). An error is harmless only if it is “inconsequential to the ultimate nondisability 27 determination.” Brown-Hunter, 806 F.3d at 494 (quotations omitted). When “the ALJ did 28 not provide enough ‘reasoning in order for us to meaningfully determine whether the ALJ’s 1 conclusions were supported by substantial evidence,’ we cannot treat the error as 2 harmless.” Lambert, 980 F.3d at 1278 (quoting Treichler, 775 F.3d at 1103). 3 The ALJ’s error was not harmless. During the administrative hearing, Plaintiff’s 4 counsel asked the vocational expert to consider an individual requiring frequent 5 supervision, defined as supervisory intervention approximately once an hour to keep an 6 individual “on task, on track.” AR 110–11. The vocational expert testified that such 7 frequent supervision would not be consistent with competitive employment. AR 111. Thus, 8 the supervision limitation could affect the ultimate disability determination. Because the 9 ALJ did not adequately explain his treatment of Dr. Nicholson’s supervision limitation, the 10 Court cannot conclude that the error was harmless. 11 For these reasons, the Court finds that the ALJ failed to properly evaluate 12 Dr. Nicholson’s medical opinion, and that the error was not harmless. 13 B. The ALJ Erred in Discrediting Plaintiff’s Testimony 14 Plaintiff contends that the ALJ failed to provide legally sufficient reasons for 15 discounting Plaintiff’s testimony regarding the severity of his psychiatric symptoms and 16 resulting limitations. ECF No. 19 at 18–34. Plaintiff argues that the ALJ failed to identify 17 the specific testimony he discounted and link that testimony to particular evidence in the 18 record, and that the objective medical evidence alone was insufficient to support the ALJ’s 19 evaluation of Plaintiff’s testimony. Id. at 21–25. Defendant contends that the ALJ properly 20 evaluated Plaintiff’s testimony and reasonably found that Plaintiff’s allegations were 21 inconsistent with the objective medical evidence, his response to treatment, his attendance 22 at community college, and generally normal mental status examinations. Id. at 28–33. 23 1. Legal Standard 24 An ALJ evaluating a claimant’s testimony regarding the extent of his symptoms and 25 impairments must follow a two-step inquiry. Ghanim v. Colvin, 763 F.3d 1154, 1163 (9th 26 Cir. 2014). First, the ALJ must determine whether there is objective medical evidence to 27 support the testimony. Id. If so, and there is no evidence of malingering, “the ALJ can only 28 reject the claimant’s testimony about the severity of the symptoms if he gives ‘specific, 1 clear and convincing reasons’ for the rejection.” Id. (quoting Vasquez v. Astrue, 572 F.3d 2 586, 591 (9th Cir. 2009)). An ALJ must “specifically identify the testimony [he] finds not 3 to be credible ... and explain what evidence undermines that testimony.” Lambert v. Saul, 4 980 F.3d 1266, 1277 (9th Cir. 2020) (quoting Treichler v. Comm’r of Soc. Sec. Admin., 5 775 F.3d 1090, 1102 (9th Cir. 2014)). An ALJ’s decision must be “sufficiently specific to 6 allow a reviewing court to conclude the adjudicator rejected the claimant’s testimony on 7 permissible grounds and did not ‘arbitrarily discredit a claimant’s testimony.’” Bunnell v. 8 Sullivan, 947 F.2d 341, 345–46 (9th Cir. 1991).2 “[A]n ALJ may not reject a claimant’s 9 subjective complaints based solely on a lack of medical evidence to fully corroborate the 10 alleged severity of pain.” Burch, 400 F.3d at 680. 11 If the ALJ fails to meet these requirements for specificity, the Court may not fill in 12 the gaps. Lambert, 980 F.3d at 1278. A reviewing court is therefore “constrained to review 13 the reasons the ALJ asserts.” Id. (quoting Brown-Hunter v. Colvin, 806 F.3d 487, 494 (9th 14 Cir. 2015)); Burrell v. Colvin, 775 F.3d 1133, 1138 (9th Cir. 2014). 15 2. Plaintiff’s Testimony 16 In his Function Report, Plaintiff described significant limitations arising from his 17 autism spectrum disorder, ADHD, anxiety, panic disorder, depression, and tic disorder. 18 19 20 2 The Social Security Administration published new guidance regarding how to evaluate a 21 claimant’s subjective symptom testimony. See SSR 16-3p, 2016 WL 1119029 (Mar. 16, 2016); 2017 WL 5180304 (Oct. 25, 2017) (clarifying SSR 16-3p). Additionally, effective 22 March 27, 2017, the Social Security Administration updated the relevant agency 23 regulations regarding how a claimant’s symptoms are evaluated. See 20 C.F.R. § 416.929. Although the ALJ’s opinion was issued after these changes, the jurisprudence governing 24 the applicable two-step inquiry remains good law. See, e.g., Campbell v. Saul, 848 F. App’x 25 718, 721 (9th Cir. 2021) (applying the two-step inquiry in a recent case appealing an ALJ’s decision from 2018, in which the newer regulations were applied); Vooge v. Saul, 840 F. 26 App’x 253, 254 (9th Cir. 2021) (same, in case involving an ALJ’s opinion issued in January 27 2019). See also Trevizo v. Berryhill, 871 F.3d 664, 678 n.5 (9th Cir. 2017) (noting SSR 16- 3p is consistent with existing Ninth Circuit precedent regarding the ALJ’s assessments of 28 1 Plaintiff reported difficulty completing tasks, understanding, and following written and 2 spoken instructions, and stated that he can only pay attention for small periods of time 3 before losing concentration. AR 821. Plaintiff also reported that stress and changes in 4 routine are difficult for him to handle. AR 822. Regarding his ability to function 5 independently, Plaintiff reported that he mostly stays home and that his “anxiety takes 6 over” when he leaves home. AR 820, 823. He further reported that his mother supports him 7 with daily activities including washing his hair and shaving. AR 817. 8 At the hearing held on June 20, 2024, Plaintiff provided testimony regarding the 9 severity and persistence of his symptoms. Plaintiff explained that he did not believe he 10 could “hold down a job” due to his difficulty processing information and anxiety in public 11 settings. AR 90. Plaintiff testified that other people “process things faster and can tend to 12 understand things better than I do,” and that it “takes me time to really understand 13 something.” AR 90. He further testified that he rarely goes out and that, when he does, his 14 parents generally drive him. AR 86–87. Plaintiff testified that he has never obtained a 15 driver’s license because his doctor advised against driving due to his inability to focus and 16 concern that Plaintiff “could be a danger to the road.” AR 86. Plaintiff also testified that he 17 has never attempted to use public transportation because it is “too weird of a setting” for 18 him to feel comfortable in. AR 90–91. Plaintiff further testified that his parents 19 “constantly” remind him to take his medication and remind him to eat several times a week. 20 AR 102. 21 Plaintiff additionally testified regarding his limited course load in community 22 college. Although Plaintiff has attended community college since approximately 2019, he 23 testified that he takes only one class per semester because of his difficulty focusing and the 24 amount of time it takes him to complete assignments. AR 87–88, 90. Despite years of 25 attendance, Plaintiff had not obtained a degree by the time of the hearing. AR 88–90. 26 3. The ALJ’s Reasons for Rejecting Plaintiff’s Testimony 27 The ALJ found that Plaintiff has the severe impairments of autism spectrum 28 disorder, history of attention deficit hyperactivity disorder (ADHD), depression, anxiety, 1 tic disorder, and panic disorder. AR 59. The ALJ found that Plaintiff’s medically 2 determinable impairments could reasonably be expected to cause the alleged symptoms, 3 satisfying the first step of the inquiry. AR 65. The ALJ did not make a finding of 4 malingering. Therefore, the ALJ was required to provide specific, clear and convincing 5 reasons, supported by substantial evidence, for discounting Plaintiff’s testimony. See 6 Ghanim, 763 F.3d at 1163. 7 a. Failure to Adequately Identify and Link Plaintiff’s Discounted Testimony 8 9 An ALJ must “specifically identify the testimony ... he finds not to be credible and 10 ... explain what evidence undermines the testimony.” Holohan v. Massanari, 246 F.3d 11 1195, 1208 (9th Cir. 2001). Here, in evaluating Plaintiff’s testimony, the ALJ included the 12 following boilerplate language: 13 After careful consideration of the evidence, the undersigned finds that the claimant’s medically determinable impairments could reasonably be expected 14 to cause the alleged symptoms; however, the claimant’s statements 15 concerning the intensity, persistence and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the 16 record for the reasons explained in this decision. 17 AR 65. Courts have repeatedly found this language to be too general and boilerplate to 18 satisfy the requirement that an ALJ specifically identify the testimony being discounted. In 19 Lambert, for example, the Ninth Circuit found that identical language was insufficient to 20 meet the ALJ’s burden: 21 The ALJ’s decision does not meet the requirements set forth in our cases and 22 does not permit meaningful review. The ALJ noted generically that “the claimant’s statements concerning the intensity, persistence and limiting 23 effects of [her] symptoms are not entirely consistent with the objective 24 medical and other evidence for the reasons explained in the decision.” But this “boilerplate statement” by way of “introductory remark,” which is “routinely 25 include[d]” in ALJ decisions denying benefits, did not “identify what parts of 26 the claimant’s testimony were not credible and why.” 27 Lambert, 980 F.3d at 1277; Burrell, 775 F.3d at 1138 (general statement that testimony is 28 “inconsistent in some unspecified way” is insufficient); Treichler, 775 F.3d at 1103 (noting 1 that identical boilerplate statement was insufficient because the “ALJ must identify the 2 testimony that was not credible”). 3 The problem with this boilerplate language is that “statements concerning the 4 intensity, persistence and limiting effects” is too general a description for the Court to 5 understand precisely what portions of Plaintiff’s testimony are claimed to be inconsistent 6 with other evidence in the record. Isis A. v. Saul, No. 18cv01728-W-MSB, 2019 WL 7 3554969, at *4 (S.D. Cal. Aug. 5, 2019) (“When an ALJ fails to specify the rejected 8 testimony and how the evidence provides clear and convincing reasons to reject it, the 9 reviewing court cannot proceed without ‘substitut[ing its own] conclusions for the ALJs, 10 or speculat[ing] as to the grounds for the ALJ’s decision.”) (quoting Treichler, 775 F.3d at 11 1103). 12 Plaintiff’s testimony reflects several distinct functional limitations, including 13 difficulty focusing and processing information, inability to drive because of problems 14 maintaining attention, reliance on his parents for transportation and reminders, difficulty 15 functioning independently, and an inability to manage more than one college course per 16 semester. These symptoms and their resulting limitations are varied and cannot be treated 17 as a unitary complaint. See Lambert, 980 F.3d at 1278. 18 The ALJ acknowledged that Plaintiff’s impairments could reasonably produce his 19 symptoms but concluded that Plaintiff’s statements were “not entirely consistent with the 20 medical evidence and other evidence in the record.” AR 65. The ALJ thereafter cited 21 Plaintiff’s treatment history, socialization, absence of inpatient psychiatric treatment, and 22 objective medical findings. AR 65. Although the ALJ summarized portions of Plaintiff’s 23 testimony and the medical evidence, he did not adequately identify which portions of 24 Plaintiff’s testimony he discounted and link that testimony to the evidence he found 25 contradictory. AR 62–65; see Brown-Hunter, 806 F.3d at 489 (holding that failure to 26 identify specific testimony and link it to evidence constitutes reversible error). Without that 27 connection, the Court would be required to determine for itself which evidence the ALJ 28 believed contradicted which portions of Plaintiff’s testimony. The Court may not supply 1 reasoning that the ALJ did not provide. See Lambert, 980 F.3d at 1278; Treichler, 775 F.3d 2 at 1103. 3 b. Lack of Substantial Evidence Supporting the ALJ’s Reasons for Discounting Plaintiff’s Testimony 4 5 The ALJ repeatedly relied on findings that Plaintiff had coherent thought processes, 6 intact memory, average intelligence, normal concentration during office visits, cooperative 7 interactions with providers, and good eye contact. AR 63–65. Objective medical evidence 8 is relevant to the evaluation of a claimant’s testimony. However, an ALJ may not reject a 9 claimant’s subjective complaints solely because the objective medical evidence does not 10 fully corroborate the alleged severity of the symptoms. Burch, 400 F.3d at 680. 11 The ALJ did not adequately explain how those findings contradicted Plaintiff’s 12 particular functional complaints. Plaintiff testified that he has never obtained a driver’s 13 license because his doctor advised against driving due to his inability to focus. AR 86. He 14 does not go out often and, when he does, his parents generally drive him. AR 86–87. He 15 has never attempted to use public transportation because he is uncomfortable in that setting. 16 AR 90–91. Plaintiff’s mother testified that she continues to remind Plaintiff to take 17 medication, get dressed, and complete basic daily activities. AR 105. She also testified that 18 Plaintiff has become more isolated and “just stays at home in his room.” AR 106. She 19 further testified that she attends Plaintiff’s appointments because Plaintiff does not always 20 pay attention during discussions regarding medication changes and treatment. AR 104–05. 21 The ALJ did not explain how isolated findings of normal concentration during office visits 22 contradicted Plaintiff’s reported difficulties maintaining attention and functioning 23 independently. 24 The ALJ’s reliance on Plaintiff’s cooperative interactions and good eye contact with 25 providers is similarly insufficient. Plaintiff’s ability to participate appropriately during 26 brief office visits does not necessarily conflict with his testimony that he struggles to 27 maintain focus, function independently, and tolerate social interactions outside structured 28 settings. Plaintiff’s mother reported, for example, that Plaintiff “can’t wait to get back 1 home” when placed in public settings, and that he sleeps all day and is up all night. 2 AR 799. The ALJ did not explain how Plaintiff’s presentation during medical appointments 3 contradicted these reported difficulties. 4 The ALJ also relied on Plaintiff’s attendance at community college, but did not 5 address the circumstances under which Plaintiff attended school. Plaintiff testified that he 6 has attended community college since approximately 2019 but has only been able to take 7 one class per semester because of his difficulty focusing and the amount of time it takes 8 him to complete assignments. AR 87–88, 90. The record further reflects that Plaintiff was 9 eligible for disability-related accommodations at community college, including 100% 10 extended time on quizzes and examinations. AR 854. Despite years of attendance, Plaintiff 11 had not obtained a degree by the time of the hearing. AR 88–90. The ALJ did not explain 12 how this limited and highly accommodated school attendance was inconsistent with 13 Plaintiff’s claimed limitations or translated into an ability to perform full-time competitive 14 work. 15 Defendant also relies on evidence that Plaintiff experienced some improvement with 16 treatment. ECF No. 19 at 30–31. The record reflects periods of improvement, including a 17 report that Plaintiff was managing his coursework well and that Adderall helped him with 18 homework. AR 4739, 4867. However, as the Ninth Circuit has explained, “it is error to 19 reject a claimant’s testimony merely because symptoms wax and wane in the course of 20 treatment” as “[c]ycles of improvement and debilitating symptoms are a common 21 occurrence,” and an ALJ may not “pick out a few isolated instances of improvement . . . 22 and treat them as a basis for concluding a claimant is capable of working.” Garrison, 759 23 F.3d at 1017. Plaintiff continued receiving psychiatric treatment and medication 24 management, and in February 2024, his provider increased his Cymbalta dosage despite 25 generally normal mental-status findings. AR 4836–41. The ALJ did not explain how 26 Plaintiff’s periods of improvement or response to medication contradicted his particular 27 testimony regarding difficulty maintaining attention, functioning independently, and 28 completing tasks. 1 Finally, the ALJ characterized Plaintiff’s condition as relatively controlled based in 2 part on the absence of “invasive treatment such as inpatient psychiatric treatment.” AR 65. 3 This reasoning is flawed. The absence of psychiatric hospitalization does not necessarily 4 undermine a claimant’s allegations of disabling mental health symptoms, particularly 5 where the record reflects ongoing psychiatric treatment, continued medication adjustments, 6 and persistent functional complaints. See Quiroz v. Berryhill, No. 8:16-CV-02127-GJS, 7 2018 WL 922130, at *7 (C.D. Cal. Feb. 14, 2018) (“Nothing in Social Security 8 jurisprudence requires mentally impaired claimants to be subjected to harsh treatments— 9 whether involuntary psychiatric hospitalizations . . . or other non-routine care—before they 10 can be found to be disabled.”) (internal quotations omitted); Matthews v. Astrue, No. 11 EDCV 11–01075–JEM, 2012 WL 1144423, at *9 (C.D. Cal. April 4, 2012) (“Claimant 12 does not have to undergo inpatient hospitalization to be disabled.”). 13 The Ninth Circuit has also cautioned that an ALJ may not place undue weight on a 14 handful of normal findings while overlooking the broader record. Attmore v. Colvin, 827 15 F.3d 872, 877 (9th Cir. 2016) (requiring consideration of the overall diagnostic picture). 16 Here, the ALJ was entitled to consider Plaintiff’s normal mental-status findings, response 17 to treatment, college attendance, and level of treatment. But those facts had to be 18 considered in the context of the broader record, which reflects continuing difficulty 19 functioning independently, maintaining focus, and handling social interactions. 20 Taken together, the ALJ’s reliance on generally normal mental-status findings, 21 Plaintiff’s college attendance, periods of improvement with treatment, and the absence of 22 inpatient psychiatric treatment does not provide specific, clear and convincing reasons, 23 supported by substantial evidence, for discounting Plaintiff’s testimony. 24 The ALJ’s error was also not harmless. Plaintiff’s testimony described limitations 25 directly relevant to his ability to sustain competitive employment, including difficulty 26 maintaining attention, following instructions, completing tasks, processing information, 27 and functioning independently. AR 85–102, 816–23. The RFC did not expressly account 28 for the full extent of these alleged limitations. AR 61–62. Because proper consideration of 1 Plaintiff’s testimony could have resulted in additional limitations in the RFC and affected 2 the ultimate disability determination, the Court cannot conclude that the error was 3 harmless. 4 For these reasons, the Court finds that the ALJ erred in evaluating Plaintiff’s 5 testimony and that the error was not harmless. 6 V. THE APPROPRIATE REMEDY 7 The remaining question is whether this case should be remanded for further 8 administrative proceedings or for the immediate calculation and award of benefits. To 9 make this determination, the Court applies the “credit-as-true” rule. Trevizo, 871 F.3d at 10 682. Under that rule, the Court considers whether: (1) the record has been fully developed 11 and further proceedings would serve a useful purpose; (2) the ALJ did not provide legally 12 sufficient reasons for rejecting evidence; and (3) if the improperly discredited evidence 13 were credited as true, the claimant would be found disabled. Id. at 682–83 (quoting 14 Garrison, 759 F.3d at 1020). When these factors are met, remand for an award of benefits 15 may be appropriate. Burrell, 775 F.3d at 1141. 16 All three factors are satisfied here. First, to determine whether further administrative 17 proceedings would be useful, courts consider “whether the record as a whole is free from 18 conflicts, ambiguities, or gaps, whether all factual issues have been resolved, and whether 19 the claimant’s entitlement to benefits is clear under the applicable legal standard.” 20 Treichler, 775 F.3d at 1103–04. “[T]he key consideration is whether remanding for further 21 administrative proceedings would serve a useful purpose or would instead unnecessarily 22 extend a claimant[’s] long wait for benefits.” Norris v. Colvin, 160 F. Supp. 3d 1251, 1284 23 (E.D. Wash. 2016) (citing Benecke v. Barnhart, 379 F.3d 587, 595 (9th Cir. 2004)). Here, 24 the record has been fully developed. It includes years of psychiatric treatment records, 25 Dr. Nicholson’s consultative examination and medical opinion, Plaintiff’s Function Report 26 and testimony, Plaintiff’s mother’s report and testimony, and vocational expert testimony. 27 The vocational expert was specifically questioned about whether an individual requiring 28 frequent supervisory intervention could sustain competitive employment. AR 110–11. 1 Second, as discussed above, the ALJ did not adequately evaluate Dr. Nicholson’s 2 supervision limitation and did not provide legally sufficient reasons for discounting 3 Plaintiff’s testimony. The decision did not explain whether Dr. Nicholson’s finding that 4 Plaintiff was moderately limited in performing work activities without special or additional 5 supervision was accepted, rejected, or incorporated into the RFC. The ALJ also failed to 6 provide specific, clear and convincing reasons, supported by substantial evidence, for 7 discounting Plaintiff’s testimony. Thus, the second factor is satisfied. 8 Third, if the improperly rejected evidence is credited as true, Plaintiff would be 9 found disabled. Dr. Nicholson specifically found that Plaintiff was moderately limited in 10 his ability to perform work activities without special or additional supervision. 11 Dr. Nicholson separately assessed other areas of mental functioning, finding only mild 12 limitations in Plaintiff’s ability to maintain concentration, attention, persistence, and pace; 13 accept instructions from supervisors; and maintain regular attendance and perform work 14 activities on a consistent basis. AR 4674. 15 Plaintiff’s testimony and his mother’s testimony provide further evidence regarding 16 the extent of Plaintiff’s need for reminders and redirection. Plaintiff testified that his 17 parents constantly remind him to take his medication and remind him to eat several times 18 a week. AR 102. Plaintiff’s mother similarly testified that Plaintiff needs reminders or 19 redirection “all the time.” AR 105. She described reminding Plaintiff to take medication, 20 get dressed for appointments, clean his room, pick up after himself, brush his teeth, and 21 comb his hair, and summarized that Plaintiff requires “[a] lot of reminders.” AR 105. She 22 also testified that she attends Plaintiff’s medical appointments because Plaintiff often does 23 not pay attention to discussions concerning medication changes and treatment. AR 104– 24 05. 25 Plaintiff’s counsel asked the vocational expert to consider an individual who needed 26 “frequent supervision,” meaning that a supervisor would need to intervene approximately 27 once an hour during the workday “in order to keep them on task, on track.” AR 110–11. 28 The vocational expert testified that such supervisory intervention “would not be consistent 1 |} with competitive employment.” AR 111. When asked what level of supervision would 2 ordinarily be expected, the vocational expert explained that the amount of supervision 3 ||depends on the tasks and duties involved, but that an individual generally receives the 4 || greatest amount of supervision during orientation to ensure an understanding of the tasks 5 duties and “beyond that, there’s really no need other than an annual performance 6 appraisal.” AR 111. Although Dr. Nicholson’s use of the term “moderate” does not 7 || establish a specific frequency of workplace supervision, the Court considers his assessment 8 ||together with the testimony describing the nature and frequency of Plaintiff's need for 9 ||reminders and redirection. If the improperly rejected evidence is credited as true, Plaintiff 10 || would therefore be found disabled. 11 Accordingly, remand for the immediate calculation and award of benefits is 12 || appropriate. See Benecke, 379 F.3d at 595. 13 || VI. CONCLUSION 14 For the reasons discussed above, the Court finds that the ALJ failed to properly 15 ||evaluate Dr. Nicholson’s medical opinion and failed to provide specific, clear, and 16 || convincing reasons for discounting Plaintiffs testimony. 17 The Court therefore resolves the Joint Motion in Plaintiff's favor, REVERSES the 18 || Commissioner’s decision pursuant to sentence four of 42 U.S.C. § 405(g), and REMANDS 19 || this action for calculation and award of benefits to Plaintiff. 20 IT IS SO ORDERED. 21 Dated: September 14, 2026 Metucrern H. Xyvolant 23 Honorable Allison H. Goddard 24 United States Magistrate Judge 25 26 27 28