Mayewski 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 AMANDA L. M., CASE NO. 3:25-cv-05814-GJL 11 Plaintiff, v. SOCIAL SECURITY DISABILITY 12 APPEAL ORDER COMMISSIONER OF SOCIAL 13 SECURITY, 14 Defendant. 15 This Court has jurisdiction pursuant to 28 U.S.C. § 636(c), Fed. R. Civ. P. 73 and Local 16 Magistrate Judge Rule 13. See also Consent to Proceed Before a United States Magistrate Judge, 17 Dkt. 2. This matter has been fully briefed. See Dkts. 10, 12, 13. 18 Having considered the Administrative Record (AR) and all memoranda, the Court 19 concludes that the Administrative Law Judge (ALJ) committed harmful error when she failed to 20 properly consider Plaintiff’s mental impairments at Step Two of the Social Security sequential 21 process. Therefore, this matter is REVERSED and REMANDED pursuant to sentence four of 22 42 U.S.C. § 405(g) to the Commissioner of the Social Security Administration for further 23 proceedings consistent with this Order. 24 1 I. PROCEDURAL HISTORY 2 On April 24, 2023, Plaintiff filed a claim for Supplemental Security Income (SSI). AR 3 95. Her claim was denied initially on September 19, 2023, and upon reconsideration on February 4 26, 2024. AR 95, 114. On November 7, 2024, the ALJ entered a decision concluding that 5 Plaintiff was not disabled. AR 17–26. On July 31, 2025, Appeals Council denied Plaintiff’s 6 request for review, making the ALJ’s decision the Commissioner’s final decision subject to 7 judicial review. AR 1. On September 15, 2025, Plaintiff filed a complaint with this Court seeking 8 judicial review of the ALJ’s decision. Dkt. 4. Defendant filed the sealed Administrative Record 9 in this matter on November 14, 2025. Dkt. 7. 10 II. BACKGROUND 11 Plaintiff was born on January 19, 1982, and was forty years old on February 23, 2022, her 12 alleged date of disability onset. AR 95. Plaintiff has a limited (tenth grade) education. AR 264, 13 730. In her decision, the ALJ found that Plaintiff suffers from the severe impairments of obesity 14 and migraines. AR 19. The ALJ found that Plaintiff was not disabled prior to her Date Last 15 Insured (DLI) because she had the following Residual Functional Capacity (RFC): 16 [T]o perform light work as defined in 20 CFR 416.967(b) except she can stand and/or walk up to 5 hours and sit for up to 6 hours. She can frequently climb ramps 17 or stairs. She can frequently balance, stoop, kneel, and crouch. She can occasionally crawl. She cannot climb ladders, ropes, or scaffolds. She should avoid concentrated 18 exposure to industrial levels of vibration, respiratory irritants, and hazards. 19 AR 21–22. III. DISCUSSION 20 Pursuant to 42 U.S.C. § 405(g), this Court may set aside the Commissioner’s denial of 21 benefits if the ALJ’s findings are based upon legal error or are not supported by substantial 22 evidence in the record as a whole. Bayliss v. Barnhart, 427 F.3d 1211, 1214 n.1 (9th Cir. 2005) 23 (citing Tidwell v. Apfel, 161 F.3d 599, 601 (9th Cir. 1999)). Substantial evidence is “such 24 1 relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” 2 Biestek v. Berryhill, 587 U.S. 97, 103 (2019) (citation omitted). “We review only the reasons 3 provided by the ALJ in the disability determination and may not affirm the ALJ on a ground 4 upon which [they] did not rely.” Garrison v. Colvin, 759 F.3d 995, 1010 (9th Cir. 2014). 5 First, Plaintiff argues that the ALJ erred in finding that her medically determinable 6 mental impairments were not severe impairments at Step Two. Dkt. 10 at 3. Specifically, she 7 contends that the “ALJ’s analysis of the medical opinion evidence addressing Plaintiff’s mental 8 impairments is brief, conclusory, not supported by substantial evidence, and is not sufficient to 9 allow for meaningful review.” Id. at 6. 10 At Step Two, the ALJ must determine “whether the claimant has a medically severe 11 impairment or combination of impairments.” Smolen v. Chater, 80 F.3d 1273, 1290 (9th Cir. 12 1996); 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). An impairment is not “severe” if it 13 does not “significantly limit” the ability to conduct basic work activities. Id. §§ 404.1522(a), 14 416.922(a). Basic work activities are defined as the “abilities and aptitudes necessary to do most 15 jobs.” Id. §§ 404.1522(b), 416.922(b). In considering whether a claimant’s mental impairments 16 are severe, the ALJ considers four broad functional areas: understand, remember, or apply 17 information; interact with others; concentrate, persist, or maintain pace; and adapt or manage 18 oneself. Id. §§ 404.1520a(c)(3), 416.920a(c)(3). The ALJ then rates the degree of the claimant’s 19 limitation in these areas on a five-point scale, “[n]one, mild, moderate, marked, [or] extreme.” 20 Id. §§ 404.1520a(c)(4), 416.920a(c)(4). If the ALJ rates the degree of limitation as “none” or 21 “mild” in all four areas of functioning, then the mental impairment is not “severe, unless the 22 evidence otherwise indicates that there is more than a minimal limitation in [the claimant’s] 23 ability to do basic work activities.” Id. §§ 404.1520a(d)(1), 416.920a(d)(1). 24 1 Plaintiff underwent a psychological evaluation by Dr. Cunningham on October 10, 2023, 2 AR 729–39, wherein Dr. Cunningham conducted the Beck Anxiety Inventory (BAI) and the 3 Beck Depression Inventory-II (BDI-II) tests on Plaintiff. AR 731, 736–38. First, Dr. 4 Cunningham opined that Plaintiff “meets [the] criteria for PTSD as defined by the DSM-5” due 5 to childhood abuse, and that Plaintiff “is hypervigilant with feelings of paranoia[,]” she has 6 “flashbacks and recurrent and intense intrusive thoughts[,]” as well as “nightmares and night 7 terrors . . . memory gaps about [her] traumas[,]” and “feels disconnected from others.” AR 730– 8 31. 9 Next, Dr. Cunningham opined that Plaintiff “meets [the] criteria for depression as defined 10 by the DSM-5” in that “[s]he gets little enjoyment in life[,] [s]he feels sad most of the time[,] 11 [s]he feels hopeless and discouraged about her future[,] [s]he isolates[,] [s]he cannot sleep[,] 12 feels tired all the time[,]” she “has no energy” and “scored a 42 on the BDI-II.” AR 731. 13 Finally, Dr. Cunningham determined that Plaintiff “meets [the] criteria for anxiety, 14 agoraphobia, and panic disorder as defined by the DSM-5” because she “experiences anxiety and 15 apprehension more days than not[,] [s]he finds it difficult to control [her] feelings[,] [s]he feels 16 restless, is easily fatigued[,] irritable[,] and has trouble concentrating.” Id. Dr. Cunningham 17 observed that Plaintiff’s “symptoms cause clinically significant impairment in her personal, 18 social and occupational life” and that Plaintiff’s “feelings of anxiety increase when she is in 19 public places.” Id. 20 Dr. Cunningham’s evaluation also opined that Plaintiff had “marked” limitations in 21 Plaintiff’s ability to: understand, remember, and persist in tasks by following detailed 22 instructions; to perform activities within a schedule, maintain regular attendance, and be punctual 23 within customary tolerances without special supervision; to learn new tasks; to adapt to changes 24 1 in a routine work setting; to communicate and perform effectively in a work setting; to maintain 2 appropriate behavior in a work setting; and to complete a normal work day and work week 3 without interruptions from psychologically based symptoms. AR 732. Finally, Dr. Cunningham 4 observed Plaintiff’s affect at the psychological evaluation “was blunted[,]” she “exhibited very 5 low energy[,]” AR 733, that Plaintiff “did not know the name of the first president[,]” could not 6 “count backward by 3 or spell a word backward” and “has thoughts of suicide but would not act 7 on them ‘because of people who love [her].’” AR 734. 8 The ALJ concluded that Plaintiff only had “mild limitation” in the four functional areas 9 and her medically determinable impairments of anxiety, depression, and PTSD were 10 “nonsevere.” AR 20. Later in the decision, the ALJ found Dr. Cunningham’s opinion that 11 Plaintiff had “marked overall impairment [wa]s not persuasive.” AR 24. The ALJ found that 12 “[t]hese limitations are not entirely supported by [Dr. Cunningham’s] exam findings which noted 13 some impairment but indicate that they were in part based on [Plaintiff]’s self-reports[.]” Id. The 14 ALJ also found that “the degree of impairment noted in [Dr. Cunningham’s] opinion [wa]s 15 inconsistent with the lack of engagement in mental health treatment, [Plaintiff]’s own statements 16 primar[ily] complaining of an inability to work due to physical symptoms, and with the largely 17 unremarkable mental status evaluations noted throughout the record.” Id. 18 For SSI applications filed after March 27, 2017, in evaluating medical opinion evidence, 19 ALJ’s “will not defer or give any specific evidentiary weight, including controlling weight, to 20 any medical opinion(s) or prior administrative medical finding(s)[.]” 20 C.F.R. §§ 404.1520c(a), 21 416.920c(a).1 Rather, ALJ’s must consider every medical opinion or prior administrative medical 22 1 The regulations regarding the evaluation of medical opinion evidence have been amended for claims filed on or after 23 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. See 20 24 C.F.R. §§ 404.1520c, 416.920c. 1 finding in the record and evaluate the persuasiveness of each one using specific factors. Id. The 2 critical factors in an ALJ’s determination of persuasiveness are the “supportability” and 3 “consistency” of each opinion. Id. §§ 404.1520c(b)(2), 416.920c(b)(2). 4 “Supportability means the extent to which a medical source supports the medical opinion 5 by explaining the ‘relevant . . . objective medical evidence.’” Woods v. Kijakazi, 32 F.4th 785, 6 791–92 (9th Cir. 2022) (quoting 20 C.F.R. § 404.1520c(c)(1)); see also id. at § 416.920c(c)(1). A 7 medical opinion is more “supportable,” and therefore more persuasive, when the sources provide 8 ample relevant “objective medical evidence and supporting explanations” for their medical 9 opinion. Id. “Consistency means the extent to which a medical opinion is ‘consistent . . . with the 10 evidence from other medical sources and nonmedical sources in the claim.’” Woods, 32 F.4th at 11 792 (quoting 20 C.F.R. § 404.1520c(c)(2)); see also id. at § 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. Id. §§ 14 404.1520c(b)(2), 416.920c(b)(2). “Even under the new regulations, an ALJ cannot reject an 15 examining or treating doctor’s opinion as unsupported or inconsistent without providing an 16 explanation supported by substantial evidence.” Woods, 32 F.4th at 792. Indeed, “[i]f a claimant 17 has submitted evidence of a severe impairment, we analyze an ALJ’s step-two denial by asking 18 ‘whether the ALJ had substantial evidence to find that the medical evidence clearly establish [the 19 claimant] did not have a medically severe impairment or combination of impairments.’” Glanden 20 v. Kijakazi, 86 F.4th 838, 844 (9th Cir. 2023) (citation omitted). 21 First, the ALJ found Dr. Cunningham’s opinion was “not entirely supported” because her 22 exam findings were “in part based on [Plaintiff]’s self-reports[,]” despite the ALJ previously 23 acknowledging that Plaintiff had at least “some impairment” due to her medically determinable 24 1 impairments of depression, anxiety, and PTSD. AR 20, 24. As an initial matter, the Court 2 observes that the medical opinion was also “in part based” upon Dr. Cunningham’s own clinical 3 observations of Plaintiff, including Plaintiff’s “blunted” affect, her “very low energy[,]” and the 4 BAI and BDI-II tests conducted on Plaintiff, not merely upon Plaintiff’s self-reports. AR 733, 5 736–37. 6 It is well-established, however, that “the rule allowing an ALJ to reject opinions based on 7 self-reports does not apply in the same manner to opinions regarding mental illness.” Buck v. 8 Berryhill, 869 F.3d 1040, 1049 (9th Cir. 2017). “Psychiatric evaluations may appear subjective, 9 especially compared to evaluation in other medical fields[,] [therefore,] [d]iagnoses will always 10 depend in part on the patient’s self-report, as well as on the clinician’s observations of the 11 patient.” Id. For these reasons, “the report of a psychiatrist should not be rejected simply because 12 of the relative imprecision of psychiatric methodology.” Id. (brackets and ellipses omitted). In 13 fact, a medical opinion’s “partial reliance on [the claimant]’s self-reported symptoms is thus not 14 a reason to reject [the physician’s] opinion.” Id. For this reason, the Court concludes the ALJ’s 15 decision to discount Dr. Cunningham’s medical opinion because it was “in part based on 16 [Plaintiff]’s self-reports” was erroneous. 17 The ALJ also observed that “the degree of impairment noted in [Dr. Cunningham’s] 18 opinion is inconsistent with the lack of engagement in mental health treatment[.]” AR 24. 19 Nonetheless, the Ninth Circuit has long observed that “it is a questionable practice to chastise 20 one with a mental impairment for the exercise of poor judgment in seeking rehabilitation.” 21 Nguyen v. Chater, 100 F.3d 1462, 1465 (9th Cir. 1996). 22 Moreover, the Court observes that the ALJ failed to discuss Dr. Cunningham’s diagnosis 23 of Plaintiff’s agoraphobia, her observation that Plaintiff’s “feelings of anxiety increase when she 24 1 is in public places” or that Plaintiff “avoids places and situations that might increase her fear and 2 the panic attacks.” AR 20, 731. The ALJ’s finding that Plaintiff’s lack of treatment was a basis 3 for discounting Dr. Cunningham’s opinion was error, and “[b]y glossing over [Plaintiff]’s 4 complaints, depression screening[ ], and [other] reasons for declining counseling, the ALJ 5 adopted a slanted view of the record on a threshold issue.” Salina S. v. Kijakazi, No. 1:20-CV- 6 00515-REP, 2022 WL 3700880, at *8 (D. Idaho Aug. 25, 2022). 7 Next, the ALJ also found Dr. Cunningham’s opinion was inconsistent with Plaintiff’s 8 statements because “records from July 2024 show that the claimant underwent a mental health 9 assessment and was referred for counseling, [but] there is no evidence of significant visits since 10 that time and the assessment shows that [Plaintiff] largely complained of physical symptoms.” 11 AR 20. The existence—and Plaintiff’s acknowledgement of—physical symptoms does not 12 preempt Plaintiff from also suffering from mental impairments, nor does this observation 13 constitute “substantial evidence.” 14 To the contrary, Dr. Cunningham opined that Plaintiff had “marked” limitations on her 15 ability to participate in basic work activities due to her mental impairments, and “an ALJ cannot 16 reject an examining or treating doctor’s opinion as unsupported or inconsistent without providing 17 an explanation supported by substantial evidence.” Woods, 32 F.4th at 792; see also Russell v. 18 Colvin, 9 F.Supp.3d 1168, 1186 (D. Or. 2022) (emphasis in original) (concluding that the ALJ 19 “erred in not taking due consideration of [a psychologist]’s opinion as to [the plaintiff]’s 20 limitations” where the psychologist observed that the plaintiff was “more impaired by her back 21 condition than by her psychological condition, but [the psychologist] nonetheless observed 22 numerous signs of a severe mental condition[.]”). Plaintiff’s allegations of disability primarily 23 due to physical impairments is not a sufficient reason for the ALJ to discount Dr. Cunningham’s 24 1 medical opinion regarding Plaintiff’s mental impairments. For this reason, the ALJ erred in 2 concluding that Dr. Cunningham’s opinion was not persuasive, in part, because it was 3 inconsistent with Plaintiff’s testimony “largely complain[ing] of physical symptoms.” AR 24. 4 Finally, the ALJ found that Dr. Cunningham’s opinion was inconsistent with “the largely 5 unremarkable mental status evaluations noted throughout the record.” Id. The Court observes 6 that, in making this finding, the ALJ cites to no instances of “largely unremarkable mental status 7 evaluations in the record.” Id. This was error. See Blakes v. Barnhart, 331 F.3d 565, 569 (7th 8 Cir. 2003) (“We require the ALJ to build an accurate and logical bridge from the evidence to 9 [their] conclusions so that we may afford the claimant meaningful review of the SSA’s ultimate 10 findings.”). 11 At bottom, the Court concludes that the ALJ erred in considering Plaintiff’s mental 12 impairments at Step Two because “an ALJ cannot reject an examining or treating doctor’s 13 opinion as unsupported or inconsistent without providing an explanation supported by substantial 14 evidence.” Woods, 32 F.4th at 792. Plaintiff “submitted evidence of a severe impairment” via Dr. 15 Cunningham’s psychological evaluation, and after analyzing the ALJ’s Step Two denial of 16 Plaintiff’s severe mental impairments, the Court concludes that there was not “substantial 17 evidence to [support the ALJ’s] find[ing] that the medical evidence clearly establish[ed] 18 [Plaintiff] did not have a medically severe impairment or combination of impairments.’” 19 Glanden, 86 F.4th at 844 (citation omitted). 20 However, in many cases, the ALJ’s failure to characterize impairments as “severe” may 21 not prove harmful because the ALJ must consider all limitations and restrictions when 22 formulating the RFC, even those stemming from impairments that are not “severe.” See Buck, 23 869 F.3d at 1049; 20 C.F.R. § 404.1520(e). For this reason, the RFC “should be exactly the same 24 1 regardless of whether certain impairments are considered ‘severe’ or not” at step two, and so, 2 ordinarily, a finding that an impairment is not severe at step two is harmless error. Buck, 869 3 F.3d at 1049. 4 “[H]armless error principles apply in the Social Security Act context.” Molina v. Astrue, 5 674 F.3d 1104, 1115 (9th Cir. 2012), superseded on other grounds by 20 C.F.R. § 404.1502(a). 6 Generally, an error is harmless if it is not prejudicial to the claimant and is “inconsequential to 7 the ultimate nondisability determination.” Stout v. Comm’r, Soc. Sec. Admin., 454 F.3d 1050, 8 1055 (9th Cir. 2006). 9 However, the RFC does not appear to have incorporated these rejected impairments, and 10 therefore, the error is not harmless. On remand, the Court instructs the ALJ to reconsider 11 Plaintiff’s disability claim, beginning at Step Two, to determine whether Plaintiff’s mental 12 limitations, as observed in Dr. Cunningham’s mental evaluation, constitute a severe impairment. 13 For this reason, the Court need not consider Plaintiff’s remaining arguments with respect to her 14 subjective symptom testimony. 15 Plaintiff contends that the matter should be remanded for a directed award of benefits. 16 Dkt. 10 at 18–19. The Court may remand a case “either for additional evidence and findings or to 17 award benefits.” Smolen, 80 F.3d at 1292. Generally, “the proper course, except in rare 18 circumstances, is to remand to the agency for additional investigation or explanation.” Benecke v. 19 Barnhart, 379 F.3d 587, 595 (9th Cir. 2004). Benefits should only be awarded where (1) the ALJ 20 “has failed to provide legally sufficient reasons for rejecting [the claimant’s] evidence”; (2) 21 where there are “no outstanding issues that must be resolved before a determination of disability 22 can be made”; and (3) where “it is clear from the record that the ALJ would be required to find 23 the claimant disabled were such evidence credited.” Smolen, 80 F.3d at 1292. 24 1 Here, the Court determined that the ALJ must re-evaluate Plaintiff’s mental health 2 impairments at Step Two of the sequential evaluation process and assess RFC limitations 3 consistent with the limitations caused by these impairments. Because there are outstanding issues 4 that must be resolved before a determination of disability can be made, the proper course is to 5 remand this matter to the agency for additional proceedings consistent with this order. 6 IV. CONCLUSION 7 Based on these reasons and the relevant record, the Court ORDERS that this matter be 8 REVERSED and REMANDED pursuant to sentence four of 42 U.S.C. § 405(g) for further 9 administrative proceedings consistent with this Order. 10 11 Dated this 19th day of March, 2026. 12 A 13 14 Grady J. Leupold United States Magistrate Judge 15 16 17 18 19 20 21 22 23 24