Kerns v. Commissioner of Social Security

1 2 3 4 5 6 7 UNITED STATES DISTRICT COURT 8 WESTERN DISTRICT OF WASHINGTON AT TACOMA 9 10 MARY A. K., CASE NO. 3:25-CV-5802-DWC 11 Plaintiff, v. ORDER REVERSING AND 12 REMANDING DEFENDANT’S COMMISSIONER OF SOCIAL DECISION TO DENY BENEFITS 13 SECURITY, 14 Defendant. 15 Plaintiff filed this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of 16 Defendant’s denial of her applications for supplemental security income (“SSI”) and disability 17 insurance benefits (“DIB”).1 The Court concludes that the Administrative Law Judge (“ALJ”) 18 erred in evaluating the medical opinion evidence. Had the ALJ properly considered the medical 19 opinions, the residual functional capacity (“RFC”) may have included additional limitations, or 20 the ultimate determination of disability may have changed. The ALJ’s error, therefore, is not 21 harmless, and this matter is reversed and remanded pursuant to sentence four of 42 U.S.C. § 22 23 1 Pursuant to 28 U.S.C. § 636(c), Federal Rule of Civil Procedure 73, and Local Rule MJR 13, the parties 24 have consented to have this matter heard by the undersigned Magistrate Judge. See Dkt. 3. 1 405(g), to the Commissioner of the Social Security Administration for further proceedings 2 consistent with this order. 3 I. Procedural History 4 Plaintiff filed her applications for SSI and DIB on March 5, 2019, alleging disability as of 5 May 19, 2016. Dkt. 8, Administrative Record (“AR”) 247–48. Plaintiff’s claims were denied 6 initially on May 30, 2019, and upon reconsideration on October 5, 2020. AR 247–48, 287–88. A 7 hearing was held before ALJ Gerard W. Langan on June 24, 2021, AR 185, who issued a 8 decision denying Plaintiff’s claim on September 14, 2021. AR 2037. 9 The Appeals Council denied Plaintiff’s request for review on September 23, 2022, 10 making the ALJ’s decision the Commissioner’s final decision subject to judicial review. AR 11 2043. Plaintiff filed a complaint in the Western District of Washington on November 28, 2022, 12 seeking judicial review of the September 14, 2021, decision. AR 2050. On November 30, 2023, 13 United States Magistrate Judge Theresa L. Fricke entered an order reversing and remanding the 14 September 14, 2021, decision. AR 2074–88. 15 Pursuant to a remand from the Appeals Council, AR 2089, the matter came on for a 16 second hearing on October 9, 2024, before ALJ Mark Triplett (“the ALJ”). AR 1985. On April 4, 17 2025, the ALJ entered an order, once again, concluding that Plaintiff was not disabled. AR 18 1953–73. Plaintiff filed a second complaint with this Court on September 10, 2025, seeking 19 judicial review of the ALJ’s April 4, 2025, decision. Dkt. 6. 20 II. Standard of Review 21 Pursuant to 42 U.S.C. § 405(g), this Court may set aside the Commissioner’s denial of 22 social security benefits if the ALJ’s findings are based on legal error or are not supported by 23 substantial evidence in the record as a whole. Bayliss v. Barnhart, 427 F.3d 1211, 1214 n.1 (9th 24 1 Cir. 2005) (citing Tidwell v. Apfel, 161 F.3d 599, 601 (9th Cir. 1999)). Substantial evidence is 2 “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” 3 Biestek v. Berryhill, 587 U.S. 97, 103 (2019) (citation omitted). “We review only the reasons 4 provided by the ALJ in the disability determination and may not affirm the ALJ on a ground 5 upon which [they] did not rely.” Garrison v. Colvin, 759 F.3d 995, 1010 (9th Cir. 2014). 6 “[H]armless error principles apply in the Social Security Act context.” Molina v. Astrue, 7 674 F.3d 1104, 1115 (9th Cir. 2012), superseded on other grounds by 20 C.F.R. § 404.1502(a). 8 Generally, an error is harmless if it is not prejudicial to the claimant and is “inconsequential to 9 the ultimate nondisability determination.” Stout v. Comm’r, Soc. Sec. Admin., 454 F.3d 1050, 10 1055 (9th Cir. 2006); see also Molina, 674 F.3d at 1115. 11 III. Discussion 12 Plaintiff argues that the ALJ erred in: (1) evaluating certain medical opinion evidence; (2) 13 evaluating Plaintiff’s subjective symptom testimony; and (3) making Step Five findings that 14 were based upon an erroneous RFC assessment. Dkt. 18 at 2. 15 Plaintiff argues that the ALJ erred in evaluating the medical opinions of: (1) Dr. Ruddell; 16 (2) Dr. Wilkinson; and (3) Nurse Practitioner Gizatu. Dkt. 18 at 3–7. 17 For applications filed after March 27, 2017, in evaluating medical opinion evidence, 18 ALJ’s “will not defer or give any specific evidentiary weight, including controlling weight, to 19 any medical opinion(s) or prior administrative medical finding(s)[.]” 20 C.F.R. §§ 404.1520c(a), 20 416.920c(a).2 Rather, ALJ’s must consider every medical opinion or prior administrative medical 21 finding in the record and evaluate the persuasiveness of each one using specific factors. Id. The 22 2 The regulations regarding the evaluation of medical opinion evidence have been amended for claims filed 23 on or after March 27, 2017. See Revisions to Rules Regarding the Evaluation of Medical Evidence, 82 Fed. Reg. 5844, 5867–68, 5878–79 (Jan. 18, 2017). Because Plaintiff’s application was filed after that date, the new regulations apply. 24 See 20 C.F.R. §§ 404.1520c, 416.920c. 1 critical factors in an ALJ’s determination of persuasiveness are the “supportability” and 2 “consistency” of each opinion. Id. §§ 404.1520c(b)(2), 416.920c(b)(2). 3 “Supportability means the extent to which a medical source supports the medical opinion 4 by explaining the ‘relevant . . . objective medical evidence.’” Woods v. Kijakazi, 32 F.4th 785, 5 791–92 (9th Cir. 2022) (quoting 20 C.F.R. § 404.1520c(c)(1)); see also 20 C.F.R. § 6 416.920c(c)(1). A medical opinion is more “supportable,” and therefore more persuasive, when 7 the sources provide ample relevant “objective medical evidence and supporting explanations” for 8 their medical opinion. Id. “Consistency means the extent to which a medical opinion is 9 ‘consistent . . . with the evidence from other medical sources and nonmedical sources in the 10 claim.’” Woods, 32 F.4th at 792 (quoting 20 C.F.R. § 404.1520c(c)(2)); see also 20 C.F.R. § 11 416.920c(c)(2). 12 Critically, an ALJ must articulate “how [they] considered the supportability and 13 consistency factors for a medical source’s medical opinions” when making their decision. 20 14 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2). “Even under the new regulations, an ALJ cannot 15 reject an examining or treating doctor’s opinion as unsupported or inconsistent without providing 16 an explanation supported by substantial evidence.” Woods, 32 F.4th at 792. 17 Plaintiff argues that the ALJ erred in evaluating the medical opinion of Dr. Wilkinson. 18 Dkt. 18 at 4. The Court agrees. 19 Dr. Wilkinson conducted a mental status exam of Plaintiff on February 8, 2019, opining, 20 inter alia, that Plaintiff had marked limitations in her ability to: perform activities within a 21 schedule, maintain regular attendance, and be punctual within customary tolerances without 22 special supervision; maintain appropriate behavior in a work setting; complete a normal work 23 24 1 day and work week without interruptions from psychologically based symptoms; and that 2 Plaintiff’s overall severity level was “marked.” AR 634–35. 3 The ALJ found that Dr. Wilkinson’s February 2019 opinion was not persuasive, noting 4 that it was “poorly supported as the narrative section of the opinion did not show this level of 5 dysfunction” and “woefully contradictive as Dr. Wilkinson noted the claimant had a moderate 6 limitation in making simple decisions, but he also noted [Plaintiff] would not need a payee for 7 benefits.” AR 1969. As for consistency, the ALJ found that the opinion was inconsistent with the 8 opinion of Drs. Fitterer and Underwood, who opined moderate limitations in these areas. AR 9 224, 229, 238, 257, 263, 277, 282. The ALJ also observed that the opinion was inconsistent with 10 Plaintiff’s “normal mental status examinations and her modest treatment history” as well as her 11 “robust activities of daily living[.]” AR 1969. 12 Nonetheless, as Plaintiff argues, “the ALJ failed to evaluate the two new evaluations 13 from Dr. Wilkinson and the new evaluation from NP Gizatu[.]” Dkt. 18 at 4. Indeed, the ALJ 14 explicitly noted in the decision that he had “considered the February 2019 opinion of [Dr.] 15 Wilkinson[,]” but Dr. Wilkinson also conducted psychological evaluations of Plaintiff on 16 December 27, 2021, and again on January 4, 2023. AR 2388–95. 17 In 2021, Dr. Wilkinson opined that Plaintiff’s condition had worsened since his initial 18 evaluation, opining that Plaintiff had severe limitations in her ability to: perform activities within 19 a schedule, maintain regular attendance, and be punctual within customary tolerances without 20 special supervision; and to maintain appropriate behavior in a work setting. AR 2390. Dr. 21 Wilkinson concluded that Plaintiff maintained an overall “marked” severity rating. Id. 22 On January 4, 2023, Dr. Wilkinson conducted his third evaluation of Plaintiff. AR 3207. 23 In that report, Dr. Wilkinson opined that Plaintiff still experienced the severe limitations that Dr. 24 1 Wilkinson had opined in 2021, but Plaintiff’s ability to complete a normal workday and work 2 week without interruptions from her symptoms had also worsened from marked to severe. AR 3 3209. In this opinion, for the first time, Dr. Wilkinson concluded that Plaintiff had an overall 4 severity of “severe.” AR 3210. 5 Again, the Court observes that, in discounting Dr. Wilkinson’s medical opinion evidence, 6 the ALJ specifically indicated that he had considered the “February 2019” opinion of Dr. 7 Wilkinson, Exhibit 5F—but does not cite to, reference, or acknowledge Dr. Wilkinson’s 8 subsequent evaluations or opinions, Exhibits 27F and 38F, when evaluating Dr. Wilkinson’s 9 opinion—or elsewhere in the decision. AR 1953–69. While an ALJ is “not required to articulate 10 how [they] considered each medical opinion or prior administrative medical finding from one 11 medical source individually[,]” 20 C.F.R. §§ 404.1520c(b)(1), 416.920c(b)(1), an ALJ, 12 nonetheless, “may not reject significant probative evidence without explanation.” Flores v. 13 Shalala, 49 F.3d 562, 571 (9th Cir. 1995) (internal quotation marks and citation omitted).3 14 Moreover, an ALJ has a duty to “set forth” their reasoning “in a way that allows for 15 meaningful review[,]” Brown-Hunter v. Colvin, 806 F.3d 487, 492 (9th Cir. 2015), which 16 requires an ALJ to “build an accurate and logical bridge from the evidence to her conclusions so 17 that we may afford the claimant meaningful review of the SSA’s ultimate findings.” Blakes v. 18 Barnhart, 331 F.3d 565, 569 (7th Cir. 2003).4 Here, the ALJ failed to do so absent discussion of 19 3 The regulations require that when a medical source offers “multiple medical opinion(s) or prior 20 administrative medical findings, [the ALJ] will articulate how [they] considered the medical opinions or prior administrative medical findings from that medical source together in a single analysis using the factors listed in 21 paragraphs (c)(1) through (c)(5) of this section, as appropriate.” 20 C.F.R. §§ 404.1520c(b)(1), 416.920c(b)(1). Here, as the AJL did not reference Dr. Wilkinson’s opinion 2021 and 2023 opinions and only referenced Dr. Wilkinson’s 22 singular February 2019 opinion, the record does not show the AJL made the single analysis required by the regulations. AR 1969. 23 4 As Plaintiff notes, the ALJ also failed to discuss the medical opinion evidence of Nurse Practitioner Gizatu. Dkt. 18 at 7; AR 1953–73. On remand, the ALJ must reconsider all medical opinion evidence, including the opinion 24 of Nurse Practitioner Gizatu. 1 these opinions, and for this reason, the Court concludes that the ALJ erred in evaluating the 2 medical opinion evidence of Dr. Wilkinson. 3 Applying the harmless error analysis, the Court notes that Dr. Wilkinson opined Plaintiff 4 has “severe” functional limitations due to her mental conditions. AR 3210. The Court concludes 5 that, had the ALJ properly considered Dr. Wilkinson’s subsequent medical opinions, Plaintiff’s 6 RFC, or the ultimate determination of disability may have changed based upon this opinion. The 7 ALJ’s error, therefore, is not harmless, and the proper disposition is to reverse and remand the 8 matter for consideration of this medical opinion evidence. See Stout, 454 F.3d at 1055; see also 9 Molina, 674 F.3d at 1115. 10 In light of this disposition, the Court need not consider Plaintiff’s remaining arguments, 11 because, on remand, the ALJ is instructed to reconsider the entire sequential process, including 12 Plaintiff’s subjective symptom testimony, and the medical opinion evidence, including Dr. 13 Wilkinson’s 2021 and 2023 medical opinions. See Social Security Ruling 96-8p, 1996 WL 14 374184 (1996) (an RFC “must always consider and address medical source opinions”); Valentine 15 v. Comm’r of Soc. Sec. Admin., 574 F.3d 685, 690 (9th Cir. 2009) (“[A]n RFC that fails to take 16 into account a claimant’s limitations is defective.”); Watson v. Astrue, No. ED-CV-09-1447- 17 PLA, 2010 WL 4269545, at *5 (C.D. Cal. Oct. 22, 2010) (concluding the RFC and hypothetical 18 questions posed to the vocational expert at Step Five were defective when the ALJ did not 19 properly consider physicians’ findings). 20 // 21 // 22 // 23 24 1 IV. Conclusion 2 Based on the foregoing reasons and the relevant record, the Court ORDERS that this 3 matter be REVERSED and REMANDED for further administrative proceedings, consistent 4 with this order. 5 Dated this 10th day of June, 2026. 6 A 7 David W. Christel United States Magistrate Judge 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24