United States District Court, N.D. California, Eureka Division
ERNEST E. COSSE IV, Plaintiff,
NANCY A. BERRYHILL, Defendant.
ORDER RE PLAINTIFF'S AND DEFENDANT'S MOTIONS
FOR SUMMARY JUDGMENT RE: DKT. NOS. 17, 22
M. ILLMAN, UNITED STATES MAGISTRATE JUDGE
Ernest E. Cosse IV, seeks judicial review of an
administrative law judge (“ALJ”) decision denying
his application for Supplemental Security Income under Title
XVI of the Social Security Act. Plaintiff's request for
review of the ALJ's unfavorable decision was denied by
the Appeals Council. The ALJ's decision is the
“final decision” of the Commissioner of Social
Security, which this court may review. See 42 U.S.C.
§§ 405(g), 1383(c)(3). Both parties have consented
to the jurisdiction of a magistrate judge. (Docs. 11, 16).
For the reasons stated below, the court will deny
Plaintiff's motion for summary judgment and grant
Defendant's motion for summary judgment.
Commissioner's findings “as to any fact, if
supported by substantial evidence, shall be
conclusive.” 42 U.S.C. § 405(g). A district court
has a limited scope of review and can only set aside a denial
of benefits if it is not supported by substantial evidence or
if it is based on legal error. Flaten v. Sec'y of
Health & Human Servs., 44 F.3d 1453, 1457 (9th Cir.
1995). Substantial evidence is “more than a mere
scintilla but less than a preponderance; it is such relevant
evidence as a reasonable mind might accept as adequate to
support a conclusion.” Sandgathe v. Chater,
108 F.3d 978, 979 (9th Cir. 1997). “In determining
whether the Commissioner's findings are supported by
substantial evidence, ” a district court must review
the administrative record as a whole, considering “both
the evidence that supports and the evidence that detracts
from the Commissioner's conclusion.” Reddick v.
Chater, 157 F.3d 715, 720 (9th Cir. 1998). The
Commissioner's conclusion is upheld where evidence is
susceptible to more than one rational interpretation.
Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir.
OF MEDICAL EVIDENCE
Clearlake Family Health Center
February 26, 2014, Plaintiff was seen for symptoms of
recurrent vomiting at least once a month (AR 320). He also
reported back pain and requested a mental health evaluation.
Id. Plaintiff was referred for a mental health
evaluation. (AR 322).
Dorado Community Health Centers
established care at El Dorado Community Health Centers on
April 15, 2014, when he was seen by Dina Medeiros, PA-C. (AR
357-358). He reported weekly bouts of violent nausea and
vomiting after suffering a traumatic brain injury in 2004.
(AR 357). PA-C Medeiros diagnosed generalized abdominal pain,
nausea with vomiting, traumatic brain injury, lumbar pain,
and muscle spasms. (AR 358). She referred Plaintiff for a
mental health evaluation. Id. John Bachman, Ph.D.,
began treating Plaintiff on May 2, 2014. (AR 352). He
presented as somewhat paranoid and described feeling he was a
“victim” of the state police. Plaintiff reported
feeling anxious, worried, and confused. Id. A mental
status examination revealed agitated behavior, rambling and
repetitive speech, a worried and angry mood, a labile affect,
confusion and disorganized thought, superficial insight, and
poor judgment. (AR 352-353). Dr. Bachman diagnosed adjustment
disorder with mixed anxiety and depression. (AR 353).
Plaintiff returned to Dr. Bachman on July 29, 2014, due to
ongoing cognitive problems. (AR 345). He described symptoms
of anxiety, worry, feeling discouraged, memory loss, and
confusion. Id. Dr. Bachman's mental status
examination documented agitated behavior, rambling and
repetitive speech, a worried and angry mood, a labile affect,
confusion and disorganized thought content, apprehension,
remembrance of past traumas, paranoid ideation, superficial
insight, and poor judgment. (AR 346). Dr. Bachman diagnosed a
mild cognitive impairment, adjustment disorder with mixed
anxiety and depression, and cannabis dependence. He
recommended psychotherapy. Id. On August 5, 2014,
PA-C Medeiros prescribed Clonazepam. (AR 343-344).
visit on October 7, 2014, Plaintiff stated his nausea was
“much worse” over the previous month. (AR 336).
He also had difficulty sleeping due to anxiety and frequent
urination. Id. PA-C Medeiros refilled all of
Plaintiff's medications. (AR 337). On November 12, 2014,
Plaintiff returned to see Dr. Bachman. (AR 389). He reported
gastric pain and nausea with vomiting on a daily basis.
Id. Plaintiff also continued to feel stressed,
anxious, worried, and discouraged, with memory problems and
confusion. (AR 390). Additional visits with PA-C Medeiros and
Dr. Bachman documented no significant changes in
Plaintiff's impairments through March 13, 2015. (AR
387-388, 385-386, 383-384, 380-382, and 377-379).
Rajiv Pathak, M.D., evaluated Plaintiff on April 20, 2015,
due to cognitive problems, dizziness, disturbed balance, and
headaches. (AR 396). A neurological evaluation revealed poor
concentration and easy frustration. (AR 397). Dr. Pathak
diagnosed concussion with loss of consciousness and headache.
Id. He recommended continued psychotherapy. (AR
April 28, 2015, Plaintiff returned to Dr. Bachman, who found
him to be stressed, anxious and worried, as well as suffering
from memory loss, confusion, and mild cognitive impairment.
(AR 395). Plaintiff had additional therapy with Dr. Bachman
on May 7, 2015 (AR 421-423). On June 4, 2015, Dr. Bachman
wrote that Plaintiff remained confused, disorganized and
anxious. (AR 415). Plaintiff returned for additional therapy
with Dr. Bachman on June 23, 2015. (AR 412-414). Dr. Bachman
summarized Plaintiff's psychiatric conditions in a Mental
Impairment Questionnaire dated July 21, 2015. (AR 403-406).
He diagnosed cognitive impairment and anxiety disorder. (AR
403). Plaintiff's GAF score was 51. Id. Clinical
signs included persistent or generalized anxiety, feelings of
guilt or worthlessness, illogical thinking, slowed thinking
and speech, difficulty thinking or concentrating, easy
distractibility, poor immediate and recent memory, intrusive
recollections of a traumatic experience,
paranoia/suspiciousness, and social withdrawal or isolation.
(AR 404). Dr. Bachman opined Plaintiff is not a malingerer.
Bachman opined Plaintiff had “marked” limitations
(defined as “symptoms constantly interfere with
ability” or “more than 2/3 of an 8-hr.
workday”) in his ability to remember locations and
work-like procedures; understand and remember one-to-two step
instructions; carry out detailed instructions; maintain
attention and concentration for extended periods; complete a
workday without interruptions from psychological symptoms;
perform at a consistent pace without rest periods of
unreasonable length or frequency; and, travel to unfamiliar
places or use public transportation. (AR 405). In addition,
the treating psychologist found Plaintiff had
“moderate-to-marked” limitations (defined as
“symptoms frequently interfere with ability” or
from “1/3 - 2/3 of an 8-hr. workday”) in his
ability to carry out simple one-to-two step instructions;
perform activities within a schedule and consistently be
punctual; sustain ordinary routine without supervision; work
in coordination with or near others without being distracted
by them; make simple work-related decisions; accept
instructions and respond appropriately to criticism from
supervisors; respond appropriately to workplace changes; and,
be aware of hazards and take appropriate precautions.
Id. Dr. Bachman also estimated Plaintiff would miss work
more than three times a month due to his impairments. (AR
Melody Samuelson, Psy.D. - SSA Consultative Psychologist
Samuelson evaluated Plaintiff at the behest of the Social
Security Administration on November 16, 2013. (AR 308-315).
Plaintiff reported problems with memory that were attributed
to a traumatic brain injury and anxiety. (AR 308). Plaintiff
had not yet begun any mental health treatment. (AR 309). A
mental status exam revealed Plaintiff was moderately
disheveled, no evidence of feigning or exaggeration, bizarre
or psychotic thought content, a moderately flat affect,
feelings of depression that include hopelessness,
helplessness, and worthlessness. (AR 310-311). Psychological
testing was consistent with low average ability to perform a
simple task of visual search and scanning a numerical
sequence (AR 312), and borderline visual working memory
consistent with a past traumatic brain injury. (AR 314).
Samuelson diagnosed cognitive disorder, not otherwise
specified (“NOS”). (AR 314). Plaintiff's GAF
score was 46. He opined Plaintiff would have a
“significant problem” organizing himself to
implement tasks in many environments. Id. Dr.
Samuelson also opined Plaintiff had moderate limitations in
his ability to perform detailed and complex job instructions;
relate adequately to co-workers and the public; maintain
attention and concentration, persistence, and pace; associate
with day-to-day work activities, including attendance and
safety; accept instructions from ...