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Ramona R. v. Commissioner of Social Security

United States District Court, N.D. California

January 7, 2020

RAMONA R., [1] Plaintiff,




         Plaintiff Ramona R. brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final decision of Defendant Commissioner of Social Security that denied Plaintiff's claim for disability benefits. Pending before the Court are the parties' cross-motions for summary judgment. ECF Nos. 19 (Pl.'s Mot.), 25 (Def.'s Mot.). Pursuant to Civil Local Rule 16-5, the motions have been submitted on the papers without oral argument. Having reviewed the parties' positions, the Administrative Record (“AR”), and relevant legal authority, the Court hereby DENIES Plaintiff's motion and GRANTS Defendant's cross-motion for the following reasons.


         A. Age, Education and Work Experience

         Plaintiff is 55 years old. AR 73. She attended the 12th grade but did not graduate from high school. AR 43. She stopped working in 2013. AR 406. Her date of last insured was March 31, 2016. AR 73.

         B. Medical Evidence

         1. Consultative Psychiatric Evaluation by Dr. Larson

         On February 21, 2015, J. Larson, Psy. D., completed a comprehensive psychiatric evaluation of Plaintiff. AR 405-10. Plaintiff reported medical issues including a recent concussion, broken nose, memory issues, sinus problems, and chronic pain. AR 406. She reported symptoms of depression and grief, including sadness, tearfulness, feeling overwhelmed, having lethargy, and social anxiety. Id. She reported that she stayed in her home throughout most of the day as she was embarrassed that someone might see her if she went out. AR 407. Dr. Larson observed that Plaintiff's overall stated mood was depressed. Id. Plaintiff denied ever being hospitalized for psychiatric reasons or ever obtaining outpatient psychiatric services. AR 406.

         Dr. Larson noted that Plaintiff could identify the president and vice president but could not name or even guess any states bordering California. AR 408. Dr. Larson noted that Plaintiff's concentration was moderately to severely impaired. Id. When asked to count by threes, Plaintiff laughed uncomfortably, tried but failed to do so, tried to correct, and then became distressed before Dr. Larson discontinued the exercise. Id. Dr. Larson noted that Plaintiff “[d]id not necessarily give up easily, but did become frustrated and overwhelmed” and had “no real recognition or response to failure once she was quite overwhelmed.” Id.

         Dr. Larson concluded that that Plaintiff's remote memory was moderately impaired, and that her fund of knowledge was moderately impaired. Id. Dr. Larson opined that Plaintiff's delayed recall was severely impaired as she could not recall any of three objects after a short delay. Id. Dr. Larson opined that Plaintiff's immediate recall was moderately impaired. Id. Dr. Larson diagnosed Plaintiff with major depressive disorder with recurrent, severe depression. AR 409. Dr. Larson provided a “Functional Assessment/Medical Source Statement” on Plaintiff. Dr. Larson assessed that Plaintiff followed instructions, but that her ability to follow through with certain instructions for more complex tasks required some redirection or assistance. Id.. Dr. Larson concluded that Plaintiff's ability to perform simple and repetitive tasks was moderately impaired, and that her ability to perform detailed and complex tasks was moderately to markedly impaired; that Plaintiff's ability to accept instructions from supervisors was unimpaired, but that her ability to interact with coworkers and the public was markedly impaired; that, based on difficulties in the evaluation, she appeared to struggle even with short interactions; that her ability to perform work activities on a consistent basis without special or additional instruction was markedly impaired; that her ability to maintain regular attendance in the workplace was markedly impaired; that her ability to complete a normal workday or workweek without interruptions from a psychiatric condition was moderately impaired; and that her “ability to deal with the usual stressors encountered in the workplace [was] markedly impaired as evidenced by her relatively rapid deterioration and decompensation during the course of this evaluation.” AR 409-10. Dr. Larson opined, however, that it was “unclear somewhat about [Plaintiff's] ability to function overall. Again, additional information would assist with this.” AR 409-10.

         2. Critical Care Consultation by Dr. Rothenberg

         On April 15, 2015, Peter Rothenberg, M.D., completed a Critical Care Consultation on Plaintiff at Petaluma Valley Hospital, after Plaintiff awakened that morning vomiting blood and was admitted for an upper gastrointestinal bleed. AR 469-71. Plaintiff reported to Dr. Rothenberg that she drank four to five beers daily, but that her last drink was two weeks prior to the consultation. AR 469. Dr. Rothenberg noted Plaintiff had a past medical history of hepatitis C from IV drug use, but did not see any previous admissions for alcohol excess. Id. Plaintiff denied use of any regular medications. Id. A laboratory report from that date noted that Plaintiff suffered from advanced liver fibrosis. AR 440. Plaintiff was administered Protonix, a proton pump inhibitor (antacid)[2], and a single dose of octreotide. AR 471.

         On June 21, 2015, Plaintiff was again evaluated at Petaluma Valley Hospital after feeling very weak and arriving to the emergency room. AR 530. The evaluation noted that Plaintiff was hospitalized on April 15, 2015 due to upper gastrointestinal bleeding secondary to acute alcoholic gastritis. AR 530. It noted that after the April 15, 2015 admission, Plaintiff was advised to pursue alcohol cessation, but that Plaintiff admitted she had resumed drinking four to five beers daily. Id. Dr. Rothenberg assessed that Plaintiff had an upper gastrointestinal bleed, anemia due to blood loss, and thrombocytopenia (low platelet count[3]). AR 591-96.

         3. Verification of Physical/Mental Incapacity by Dr. Licht

         On August 28, 2015, N. Licht, M.D., completed a Verification of Physical/Mental Incapacity concerning Plaintiff. AR 601. Licht stated that Plaintiff was unemployable as of May 16, 2015. Id. For an impairment, Licht stated that, “alcoholism has led to cirrhosis (liver failure) with resulting disability.” Id. On August 11, 2017, Dr. Licht prepared a letter stating his opinion that, “[d]ue to liver failure with cirrhosis, ascites, and encephalopathy, I do not believe [Plaintiff] is employable.” AR 900.


         On October 8, 2014, Plaintiff protectively filed a claim for Disability Insurance Benefits (“DIB”), and on December 1, 2017 protectively filed a Title XVI application for supplemental security income (“SSI”). AR 12, 195, 200. In both applications, Plaintiff alleged disability beginning on July 4, 2014. AR 12, 243. On June 10, 2015, the agency denied Plaintiff's claims, finding Plaintiff did not qualify for disability benefits. AR 12, 195. Plaintiff subsequently filed a request for reconsideration, which was denied on November 2, 2015. AR 12, 109, 110-15. On November 22, 2015, Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”). AR 116-17. ALJ Serena S. Hong conducted a hearing on September 14, 2017. AR 12. Plaintiff testified in person at the hearing and was represented by D. McCaskell, a non-attorney representative. The ALJ also heard testimony from Vocational Expert V. Rei.

         A. Plaintiff's Testimony

         Plaintiff testified at her administrative hearing that she had problems walking and with her legs. AR 55. She testified that the most she could walk at once was “maybe to my mailbox and back, ” “like 60 steps.” AR 55-56. She testified that she could be up standing and walking for “about maybe 20 minutes” before having to lie down. AR 57. She testified that she would experience leg swelling, cramps, and spasms. AR 59. And she described her pain level as 10 when experiencing leg spasms. Id.

         B. ALJ's Decision and Plaintiff's Appeal

         On February 22, 2018, the ALJ issued a partially favorable decision finding: Plaintiff was not disabled for DIB through June 30, 2016, the date Plaintiff was last insured, AR 22; but Plaintiff was disabled as of February 13, 2017-but not before that date-for purposes of SSI, AR 22-23. This decision became final when the Appeals Council declined to review it. AR 1-4.[4]Having exhausted all administrative remedies, Plaintiff commenced this action for judicial review pursuant to 42 U.S.C. § 405(g). On August 30, 2019, Plaintiff filed the present Motion for Summary Judgment. On October 22, 2019, the Commissioner filed a Cross-Motion for Summary Judgment.


         This Court has jurisdiction to review final decisions of the Commissioner pursuant to 42 U.S.C. § 405(g). An ALJ's decision to deny benefits must be set aside only when it is “based on legal error or not supported by substantial evidence in the record.” Trevizo v. Berryhill, 871 F.3d 664, 674 (9th Cir. 2017) (citation and quotation marks omitted). Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019) (citation and quotation marks ...

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