United States District Court, E.D. California
ORDER AFFIRMING AGENCY'S DENIAL OF BENEFITS AND ORDERING JUDGMENT FOR COMMISSIONER
SANDRA M. SNYDER, Magistrate Judge.
Plaintiff Angelic Renee Pallesi, by her attorneys, Law Offices of Lawrence D. Rohlfing, seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying her application for disability insurance benefits pursuant to Title II and for supplemental security income ("SSI") pursuant to Title XVI of the Social Security Act (42 U.S.C. § 301 et seq. ) (the "Act"). The matter is before the Court on the parties' cross-briefs, which were submitted, without oral argument, to the Honorable Sandra M. Snyder, U.S. Magistrate Judge.
The sole issue in this case is whether the Administrative Law Judge (ALJ) erred in failing to give reasons for her rejection of the opinions of Plaintiff's treating physician. Following a review of the complete record and applicable law, the Court finds the decision of the Administrative Law Judge ("ALJ") to be supported by substantial evidence in the record as a whole and based on proper legal standards.
I. Procedural History
On November 23, 2010, Plaintiff filed applications for disability insurance benefits and for supplemental security income. Plaintiff alleged disability beginning December 18, 2007. The Commissioner initially denied the claims on February 25, 2011, and upon reconsideration, on June 16, 2011. On July 6, 2011, Plaintiff filed a timely request for a hearing.
Plaintiff appeared and testified at a hearing on May 22, 2012. Alan E. Cummings, an impartial vocational expert, also appeared and testified.
On May 25, 2012, Administrative Law Judge Tamia N. Gordon denied Plaintiff's application. The Appeals Council denied review on September 12, 2013. On November 7, 2013, Plaintiff filed a complaint seeking this Court's review.
II. Factual Summary of Administrative Record
Plaintiff's testimony. Plaintiff (born October 28, 1981) completed high school and vocational college training to be a medical assistant. Her prior work included managing a McDonald's restaurant and installing rain gutters. Unemployed since September 2009, Plaintiff supported herself and her eight-year-old son on welfare, food stamps, and Medi-Cal.
Plaintiff saw Dr. Luu at the Fresno County Department of Behavioral Health for medications every three months. She also met with a therapist twice a month. Plaintiff complained that her anxiety was worsening, even though her doctor had doubled Plaintiff's medication. Her depression was also worsening; she was "stuck grieving." AR 47. Three or four times daily, she experienced bouts of crying that lasted five to ten minutes. As a result of her anxiety and the side effects of her medications, the back of Plaintiff's head has been "completely bald" for the past two years. AR 41. Plaintiff has not used illegal drugs since 2009.
Plaintiff typically began her day by walking her son to school, then returning directly home since she was "frightened to go outside." AR 42. On days when she felt too frightened to escort her son to school, he walked with his cousin who lived in the same apartment complex. She spent her days doing housework and watching television. Because her feet swell, Plaintiff could not do housework for more than an hour at a time. She cooked only supper since her son received breakfast and lunch at school. Plaintiff last drove about a year before the hearing, subsequently relying on family members to drive her. She shopped once monthly when her grandmother took her to the supermarket.
Plaintiff estimated that she could lift thirty or forty pounds, about the weight of her television set. Plaintiff could walk about twenty minutes before she needed to rest. Because of her back pain she could sit for only thirty minutes. Unable to concentrate, she never finished tasks.
Plaintiff completed an adult function report dated January 5, 2011. On a typical day, she woke up, took medications, exercised, and attended the Pathways program. She spent evenings with her son. She fed and cared for her cat. Her grandmother provided support with life management skills and caring for her son as well as giving her financial support since she could not make ends meet on welfare.
"I just gave up when my baby died, " wrote Plaintiff. AR 211. She had difficulty sleeping. Stress made her hair fall out. She bathed twice daily but wore the same clothes day after day. The outside world scared her.
Plaintiff's grandmother, Barbara Slavin, provided a third-party adult function report dated January 5, 2011. Ms. Slavin opined that even before she applied for disability benefits, Plaintiff had "trouble coping with life." AR 203. She had difficulty getting along with others and could not take direction. She was depressed and preoccupied with her baby's death. She had problems with memory and concentration, and thought others were "out to get her." AR 207.
Plaintiff, who was insecure going out alone, generally stayed home, reported Ms. Slavin, although she attended counseling five times weekly. Plaintiff watched television and listened to music. She needed reminders to clean her home. Ms. Slavin did not know about Plaintiff's cooking or grocery shopping habits.
Medical and Treatment Reports. Although Plaintiff's baby died in June 2010, there is no record of her seeking or receiving mental health treatment until November 8, 2010, when she began Pathways to Recovery (Mental Health Track Supported Employment Services), a welfare-to-work program intended to get recipients of public assistance into education or a job. Phase I (Learning to Manage Your Thinking, Feeling Behavior and/or Substance Use Challenges) was to take ninety days, ending on February 6, 2011. Phase II (Applying Your Wellness & Recovery Plan at Work or School) was to follow for ninety more days, ending on May 7, 2011.
As part of the Pathways program, Plaintiff was admitted to treatment with Fresno County Mental Health on November 8, 2010. Jamie L. Powers, L.M.F.T., prepared the comprehensive intake assessment. Plaintiff used or abused alcohol, caffeine, nicotine, and cannabis. She had previously used amphetamines but stopped in 2005. She complained of hypersomnia during the day and insomnia at night. Ms. Powers noted symptoms of depression, anxiety, and paranoia, as well as phobias, rituals, and obsessions. Plaintiff's diagnosis was:
Axis I major depressive disorder (296.32) panic disorder without agoraphobia (300.01) obsessive-compulsive disorder (300.3)
Axis II no diagnosis (V71.09)
Axis III arthritis, hernia repair
Axis IV Economic, employment, primary support system, inadequate social support
Axis V GAF 50 (current) 65 (past year)
See AR 254-255.
Psychiatrist Richard Guzzetta, M.D., saw Plaintiff at Fresno County Mental Health Services to manage her medications. On November 17, 2010, her prescriptions included Ambien, Zoloft, MVI, Depo-Provera, and Seroquel SR. She told Dr. Guzzetta that she had stopped using cannabis. Noting that Plaintiff was experiencing weight gain and excessive sedation ("all she wants to do is sleep"), Dr. Guzzetta substituted Abilify for Seroquel, increased Zoloft, and added Naprosyn for arthritis. AR 249. As would be the case at nearly all of her appointments, her mental status was normal, and she was alert, organized, and well-groomed.
Plaintiff did not show for her December 14, 2010 appointment with Dr. Guzzetta.
Following her December 20, 2010 appointment with Ms. Powers, the social worker noted that Plaintiff exhibited poor hygiene, agitation, soft and slow speech, guarded interview behavior, and aggressive behavior. Plaintiff reported that she was still using cannabis occasionally. Although she was attending the Pathways program, her progress was slow, and her prognosis was poor.
By her December 21, 2010, appointment with Dr. Guzzetta, Plaintiff had begun taking Clonodine, which was helping, although Plaintiff still felt anxious and irritable.
On January 7, 2011, Ms. Power opined that Plaintiff had fair ability to understand, remember, and carry out simple instructions, and to perform activities within a schedule and maintain regular attendance. She had poor ability to understand, remember, and carry out complex instructions; to maintain concentration, attention, and persistence; to complete a normal workday and workweek without interruptions from psychologically based symptoms; and to respond appropriately to changes in a work setting.
When Plaintiff saw Dr. Guzzetta on January 12, 2011, she complained of trouble sleeping and of sores filled with pus all over her body. When Plaintiff saw Dr. Guzzetta on January 25, 2011, she complained that although Trazadone helped her sleep, she did not feel like getting out of bed when she awoke.
In February 2011, orthopedist Theodore Georgis, Jr., M.D., prepared a consultative report for the state agency. Plaintiff reported neck and back injuries incurred in a 2006 motor vehicle accident, for which she had undergone chiropractic treatment. Although she described constant, severe pain and numbness of her fingertips, Plaintiff did not experience radiating pain, weakness of her extremities, walking imbalance, or bladder or bowel incontinence. Her range of motion was generally within normal limits, except for minor reduction of the range of motion of her lumbar spine. Dr. Georgis observed no evidence of joint pain, swelling, tenderness, or inflammation. He opined:
The claimant can lift and carry fifty pounds occasionally and 20 pounds frequently. The claimant can stand and walk six hours out of an eight-hour day with normal breaks. The claimant can sit without restriction. Exertional ...