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Cosse v. Berryhill

United States District Court, N.D. California, Eureka Division

February 27, 2018

ERNEST E. COSSE IV, Plaintiff,
v.
NANCY A. BERRYHILL, Defendant.

          ORDER RE PLAINTIFF'S AND DEFENDANT'S MOTIONS FOR SUMMARY JUDGMENT RE: DKT. NOS. 17, 22

          ROBERT M. ILLMAN, UNITED STATES MAGISTRATE JUDGE

         Plaintiff 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.

         LEGAL STANDARDS

         The 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. 2005).

         SUMMARY OF MEDICAL EVIDENCE[1]

         1. Clearlake Family Health Center

         On 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).

         2. El Dorado Community Health Centers

         Plaintiff 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).

         At a 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).

         Neurologist 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 398).

         On 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. (AR 403).

         Dr. 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 406).

         3. Melody Samuelson, Psy.D. - SSA Consultative Psychologist

         Dr. 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).

         Dr. 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 ...


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