Opinion
6:22-cv-01715-HZ
10-06-2023
Carolyn M.,[1] Plaintiff, v. COMMISSIONER, SOCIAL SECURITY ADMINISTRATION, Defendant.
John E. Haapala, Jr. Attorney for Plaintiff Kevin C. Danielson Assistant United States Attorney Erin Jurrens Social Security Administration Office of the General Counsel Attorneys for Defendant
John E. Haapala, Jr.
Attorney for Plaintiff
Kevin C. Danielson
Assistant United States Attorney
Erin Jurrens
Social Security Administration
Office of the General Counsel
Attorneys for Defendant
OPINION & ORDER
MARCO A. HERNÁNDEZ, UNITED STATES DISTRICT JUDGE
Plaintiff Carolyn M. brings this action seeking judicial review of the Commissioner's final decision to deny disability insurance benefits (“DIB”) and supplemental security income (“SSI”). This Court has jurisdiction pursuant to 42 U.S.C. § 405(g) (incorporated by 42 U.S.C. § 1383(c)(3)). The Court affirms the Commissioner's decision.
PROCEDURAL BACKGROUND
Plaintiff applied for DIB and SSI on February 13, 2019, alleging an onset date of December 13, 2018. Tr. 507-16. She amended her alleged onset date to January 23, 2017. Tr. 539. Plaintiff meets the insured status requirements of the Social Security Act through March 31, 2024. Tr. 101. Her application was denied initially and on reconsideration. Tr. 125-26, 151-52.
Citations to “Tr.” refer to the page(s) indicated in the official transcript of the administrative record, filed herein as Docket No. 9.
On December 14, 2021, Plaintiff appeared with a non-attorney representative for a hearing before an Administrative Law Judge (“ALJ”). Tr. 45. On January 12, 2022, the ALJ found Plaintiff not disabled. Tr. 181. The Appeals Council granted review and remanded with an order to complete the administrative record and offer Plaintiff a new hearing. Tr. 204. On June 30, 2022, Plaintiff appeared with a non-attorney representative for a second hearing before the ALJ. Tr. 16. On July 27, 2022, the ALJ found Plaintiff not disabled. Tr. 115. The Appeals Council denied review. Tr. 1.
FACTUAL BACKGROUND
Plaintiff initially alleged disability based on a stroke, arthritis, hepatitis C, abdominal hernia, anemia, acid reflux, depression, and high blood pressure. Tr. 576. At the time of her amended alleged onset date, she was 58 years old. Tr. 507. She has a tenth-grade education and past relevant work experience as a grocery clerk/sales clerk food. Tr. 114, 577.
SEQUENTIAL DISABILITY EVALUATION
A claimant is disabled if they are unable to “engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which . . . has lasted or can be expected to last for a continuous period of not less than 12 months[.]” 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). Disability claims are evaluated according to a five-step procedure. See Valentine v. Comm'r, 574 F.3d 685, 689 (9th Cir. 2009) (in social security cases, agency uses five-step procedure to determine disability). The claimant bears the ultimate burden of proving disability. Id.
In the first step, the Commissioner determines whether a claimant is engaged in “substantial gainful activity.” If so, the claimant is not disabled. Bowen v. Yuckert, 482 U.S. 137, 140 (1987); 20 C.F.R. §§ 404.1520(b), 416.920(b). In step two, the Commissioner determines whether the claimant has a “medically severe impairment or combination of impairments.” Yuckert, 482 U.S. at 140-41; 20 C.F.R. §§ 404.1520(c), 416.920(c). If not, the claimant is not disabled. Id.
In step three, the Commissioner determines whether the claimant's impairments, singly or in combination, meet or equal “one of a number of listed impairments that the [Commissioner] acknowledges are so severe as to preclude substantial gainful activity.” Yuckert, 482 U.S. at 141; 20 C.F.R. §§ 404.1520(d), 416.920(d). If so, the claimant is conclusively presumed disabled; if not, the Commissioner proceeds to step four. Yuckert, 482 U.S. at 141.
In step four, the Commissioner determines whether the claimant, despite any impairment(s), has the residual functional capacity (RFC) to perform their “past relevant work.” 20 C.F.R. §§ 404.1520(e), 416.920(e). If the claimant can perform past relevant work, the claimant is not disabled. If the claimant cannot perform past relevant work, the burden shifts to the Commissioner. In step five, the Commissioner must establish that the claimant can perform other work. Yuckert, 482 U.S. at 141-42; 20 C.F.R. §§ 404.1520(e)-(f), 416.920(e)-(f). If the Commissioner meets their burden and proves that the claimant can perform other work that exists in the national economy, then the claimant is not disabled. 20 C.F.R. §§ 404.1566, 416.966.
THE ALJ'S DECISION
At step one, the ALJ determined that Plaintiff had engaged in substantial gainful activity (“SGA”) after her amended alleged onset date. Tr. 101. The ALJ found that Plaintiff's periods of work in September 2017 and November 2017 through February 2018 exceeded the minimum required to constitute SGA. Tr. 102. Because there were also continuous 12-month periods during which Plaintiff did not engage in SGA, the ALJ proceeded to analyze Plaintiff's claim. Tr. 102. The ALJ evaluated Plaintiff's claim both with and without the periods of SGA earnings and concluded that the result was the same either way. Tr. 102.
Next, at steps two and three, the ALJ determined that Plaintiff has the following severe impairments: “cerebrovascular accident (‘CVA'), left shoulder arthritis and partial rotator cuff tear, and degenerative disc disease.” Tr. 102. However, the ALJ determined that Plaintiff's impairments did not meet or medically equal the severity of a listed impairment. Tr. 109. At step four, the ALJ concluded that Plaintiff has the residual functional capacity to perform light work as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b) with the following limitations:
She can occasionally climb ramps/stairs; should never climb ladders, ropes, or scaffolds. She can frequently balance, occasionally stoop, occasionally kneel, occasionally crouch, and occasionally crawl. She can occasionally reach overhead and front and laterally with the left upper extremity. On the left side, fingering is limited to frequent. She can haven [sic] no exposure to vibrations and hazards.
Tr. 109. The ALJ then concluded that even with these limitations, Plaintiff could perform her past relevant work. Tr. 114. Thus, the ALJ concluded that Plaintiff is not disabled. Tr. 114.
STANDARD OF REVIEW
A court may set aside the Commissioner's denial of benefits only when the Commissioner's findings “are based on legal error or are not supported by substantial evidence in the record as a whole.” Vasquez v. Astrue, 572 F.3d 586, 591 (9th Cir. 2009) (internal quotation marks omitted). “Substantial evidence means 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.” Id. (internal quotation marks omitted). The court considers the record as a whole, including both the evidence that supports and detracts from the Commissioner's decision. Id.; Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007). “Where the evidence is susceptible to more than one rational interpretation, the ALJ's decision must be affirmed.” Vasquez, 572 F.3d at 591 (internal quotation marks and brackets omitted); see also Massachi v. Astrue, 486 F.3d 1149, 1152 (9th Cir. 2007) (“Where the evidence as a whole can support either a grant or a denial, [the court] may not substitute [its] judgment for the ALJ's.”) (internal quotation marks omitted).
DISCUSSION
Plaintiff argues that the ALJ erred by (1) failing to develop the record and (2) rejecting the medical opinion of Dr. William Trueblood, Ph.D. Pl. Op. Br., ECF 14. The Court concludes that the record was fully developed, and substantial evidence supports the ALJ's assessment of Dr. Trueblood's opinion. The Court therefore affirms the Commissioner's decision.
I. Development of the Record
Plaintiff asserts that the ALJ failed to fully develop the record on the limitations from her CVA. Pl. Op. Br. 10-12. The claimant bears the burden to prove that they are disabled. 20 C.F.R. §§ 404.1512(a), 416.912(a). The record evidence “must be complete and detailed enough” to allow the ALJ to determine whether the claimant is disabled. Id. §§ 404.1512(a)(2), 416.912(a)(2). The ALJ must be able to determine “[t]he nature and severity” of the claimant's impairments, whether they meet the duration requirement, and what the claimant's residual functional capacity is. Id. “An ALJ's duty to develop the record further is triggered only when there is ambiguous evidence or when the record is inadequate to allow for proper evaluation of the evidence.” Mayes v. Massanari, 276 F.3d 453, 459-60 (9th Cir. 2001). See also Armstrong v. Comm'r of Soc. Sec. Admin., 160 F.3d 587, 590 (9th Cir. 1998) (holding that ALJ erred in failing to call a medical expert to determine the onset date of the claimant's disability where the record showed that the claimant suffered from various impairments for years but did not establish when they became disabling).
The Appeals Council remanded this case to the ALJ on February 23, 2022. Tr. 202-05. The Appeals Council ordered the ALJ to
Obtain additional evidence concerning the claimant's cerebrovascular accident (“CVA”) in order to complete the administrative record in accordance with the regulatory standards regarding consultative examinations and existing medical evidence (20 CFR 404.1512 and 416.912). The additional evidence may include, if
warranted and available, a consultative examination with psychological testing and medical source opinions about what the claimant can still do despite the impairment.Tr. 204. The Appeals Council also instructed the ALJ to “offer the claimant an opportunity for a hearing, take any further action needed to complete the administrative record and issue a new decision.” Tr. 204.
The Court first notes that the Appeals Council ordered the ALJ to supplement the record because Plaintiff amended her alleged onset date to January 2017. Tr. 204. The ALJ previously adjudicated the application from September 30, 2018, through the date of decision. Tr. 204. This left an unadjudicated period from January 2017 through September 2018. As discussed above, the ALJ found that Plaintiff engaged in SGA in September 2017 and from November 2017 through February 2018. Tr. 101-02. Plaintiff does not challenge this finding, and it undermines her claim of disability for much of the unadjudicated period.
Defendant argues that Plaintiff has forfeited the argument that the record was incomplete because her representative affirmed to the ALJ that it was complete. Def. Br. 6., ECF 18. The Ninth Circuit has held that, at least when the claimant is represented by counsel, the claimant must raise all issues at their administrative hearing to preserve them on appeal. Meanel v. Apfel, 172 F.3d 1111, 1115 (9th Cir. 1999), as amended (June 22, 1999). Other district courts have held that a claimant forfeits the argument that the record was incomplete where they affirm before the ALJ that the record was complete. E.g., Smith v. Saul, No. 1:19-CV-01085-SKO, 2020 WL 6305830, at *7 (E.D. Cal. Oct. 28, 2020). Plaintiff was represented by a non-attorney representative. On June 23, 2022, the representative wrote to the ALJ: “The record is complete to the best of my knowledge.” Tr. 687. A week later, at the hearing, the representative did not identify any deficiency in the record. Defendant's argument that Plaintiff has forfeited this issue has merit.
Plaintiff's argument also fails on the merits. On remand, Plaintiff's representative submitted new evidence: “A claimant declaration, an AC brief, Dr. Trueblood's Curriculum Vitae, Mosaic Medical, Rimrock Trails Counseling, The Center medical records, as well as an interview with Nick Brennan, QMHP (21E; 22E; 23E; 22F; 23F; 24F; Brennan Interview, submitted, not yet exhibited).” Tr. 688. In his decision, the ALJ stated that “the representative has submitted additional evidence with the remand that the undersigned has considered.” Tr. 98. Plaintiff does not identify what evidence the ALJ should have requested but failed to consider.
Instead, Plaintiff asserts that the record was ambiguous because the ALJ relied on the testimony of the non-examining medical expert, Lillie McCain, Ph.D., rather than the opinion of the examining psychologist, William Trueblood, Ph.D. Pl. Op. Br. 11-12. Dr. Trueblood opined that Plaintiff had limitations from a major neurocognitive disorder and major depressive disorder, while Dr. McCain opined that she did not. Tr. 56-61, 1364. According to Plaintiff, “Dr. McCain merely disagreed with Dr. Trueblood's conclusions and did not offer any new diagnosis or objective medical tests Dr. Trueblood did not consider.” Pl. Op. Br. 12. To the extent this argument challenges the ALJ's decision to credit Dr. McCain rather than Dr. Trueblood, the Court resolves that issue in addressing Plaintiff's challenge to the ALJ's rejection of Dr. Trueblood's opinion. The Court here considers only whether the record had sufficient evidence to allow the ALJ to evaluate both medical opinions.
When an ALJ needs to know the basis of a medical opinion to evaluate it, the ALJ has a duty to develop the record by subpoenaing the medical professional who issued the opinion, submitting further questions to them, or requesting further documentary submissions supporting the opinion. Smolen v. Chater, 80 F.3d 1273, 1288 (9th Cir. 1996); Tidwell v. Apfel, 161 F.3d 599, 602 (9th Cir. 1998), as amended (Jan. 26, 1999) (ALJ satisfied duty to develop record where he left it open to be supplemented by further responses from the medical professional). Here, the ALJ had enough information to evaluate the opinions of Dr. Trueblood and Dr. McCain. Dr. Trueblood completed a mental residual functional capacity assessment of Plaintiff and concluded that she had a major neurocognitive disorder and major depressive disorder. Tr. 1364-68. He described his impressions and recommendations based on a neuropsychological evaluation of Plaintiff, including both executive testing and interviews with Plaintiff and her daughter. Tr. 1369-77. He explained why he relied on input from Plaintiff's daughter in determining Plaintiff's limitations. Tr. 1386-87. The record showed the basis of Dr. Trueblood's opinion.
The record also showed the basis of Dr. McCain's opinion. The ALJ questioned Dr. McCain at the first administrative hearing. Tr. 53-65. Plaintiff's representative also examined Dr. McCain. Tr. 65-70. Dr. McCain explained the basis of her opinion that Plaintiff did not have a major neurocognitive disorder, including a lack of evidence in the record of the limitations associated with a major neurocognitive disorder. Tr. 56-59. She explained why she found no limitations from a major depressive disorder. Tr. 60-61. Dr. McCain explained why she did not fully credit Plaintiff's daughter's account of Plaintiff's symptoms. Tr. 58-59, 64.
The record was adequately developed, and it was not ambiguous. The ALJ received and considered the additional evidence Plaintiff submitted and gave Plaintiff an opportunity for a hearing. The ALJ knew the basis of Dr. McCain's opinion and Dr. Trueblood's opinion. In evaluating Dr. Trueblood's opinion, the ALJ identified specific reasons to discredit it. Tr. 10406. The Court next evaluates whether the ALJ erred in rejecting Dr. Trueblood's opinion.
II. Medical Opinion Evidence
Plaintiff argues that the ALJ improperly rejected Dr. Trueblood's opinion. Pl. Op. Br. 1217. For claims filed on or after March 27, 2017, ALJs are no longer required to give deference to any medical opinion, including treating source opinions. Rules Regarding the Evaluation of Medical Evidence, 2017 WL 168819, 82 Fed.Reg. 5844-01 (Jan. 18, 2017); 20 C.F.R. §§ 404.1520c, 416.920c. Instead, the agency considers several factors. 20 C.F.R. §§ 404.1520c(a), 416.920c(a). These are: supportability, consistency, relationship to the claimant, specialization, and “other factors.” 20 C.F.R. §§ 404.1520c(c)(1)-(5), 416.920c(c)(1)-(5). The “most important” factors in the evaluation process are supportability and consistency. 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2).
Under this framework, the ALJ must “articulate . . . how persuasive [they] find all of the medical opinions” from each doctor or other source. 20 C.F.R. §§ 404.1520c(b), 416.920c(b)(2). In doing so, the ALJ is required to explain how supportability and consistency were considered and may explain how the other factors were considered. 20 C.F.R §§ 404.1520c(b)(2), 416.920c(b)(2). When two or more medical opinions or prior administrative findings “about the same issue are both equally well-supported . . . and consistent with the record . . . but are not exactly the same,” the ALJ is required to explain how the other factors were considered. 20 C.F.R. §§ 404.1520c(b)(3), 416.920c(b)(3). “Even under the new regulations, an ALJ cannot reject an examining or treating doctor's opinion as unsupported or inconsistent without providing an explanation supported by substantial evidence.” Woods v. Kijakazi, 32 F.4th 785, 792 (9th Cir. 2022).
On May 3, 2021, Dr. Trueblood performed a mental residual functional capacity assessment of Plaintiff. Tr. 1364-68. The assessment was based on objective testing of Plaintiff's executive function as well as interviews with Plaintiff and her daughter about Plaintiff's functioning and cognition. Tr. 1369-77. Dr. Trueblood diagnosed Plaintiff with major neurocognitive disorder and major depressive disorder - single episode - mild. Tr. 1364. He noted that Plaintiff had a history of multiple strokes. Tr. 1364. He found no evidence of current drug or alcohol abuse and wrote that Plaintiff was compliant with treatment. Tr. 1365.
Dr. Trueblood assessed mild to marked limitations. For understanding and memory, he assessed a moderate limitation in Plaintiff's ability to remember locations and work-like procedures, a mild limitation in the ability to understand and remember short and simple instructions, and a marked limitation in the ability to understand and remember detailed instructions. Tr. 1365. For sustained concentration and persistence, Dr. Trueblood assessed a mild limitation in the ability to carry out short and simple instructions. Tr. 1365. He assessed moderate limitations in the ability to perform activities within a schedule, the ability to work with others without distraction, and the ability to make simple work decisions. Tr. 1365-66. And he assessed marked limitations in the ability to carry out detailed instructions and concentrate for an extended period of time, to sustain an ordinary routine without special supervision, and the ability to complete a normal workday without interruptions from psychologically based symptoms and to perform at a consistent pace without unreasonable rest periods. Tr. 1365-66.
For social interaction, Dr. Trueblood assessed moderate limitations in the ability to interact appropriately with the general public, to ask simple questions or request assistance, and to maintain socially appropriate behavior and neatness. Tr. 1366. He assessed marked limitations in the ability to accept instructions and respond appropriately to criticism from supervisors and the ability to get along with coworkers. Tr. 1366. Finally, for adaptation, Dr. Trueblood assessed a moderate limitation in the ability to travel to unfamiliar places or use public transportation, and marked limitations in the ability to respond to changes in the work setting, set realistic goals or make independent plans, and tolerate normal levels of stress. Tr. 1366-67.
Based on these limitations, Dr. Trueblood opined that Plaintiff's impairments would substantially interfere with her ability to work on a regular and sustained basis at least 20% of the time. Tr. 1367. He stated that she would need to miss one day of work per month. Tr. 1367. He stated that she could not work on a regular and sustained basis. Tr. 1367. And he wrote that Plaintiff could not manage her own funds, although it was a close call. Tr. 1367.
The ALJ found Dr. Trueblood's opinion not persuasive. Tr. 105. The ALJ found Dr. Trueblood's opinion inconsistent with his own objective testing, the longitudinal record, and Plaintiff's daily activities. Tr. 104-06. The ALJ also stated that Dr. Trueblood's opinion had “questionable supportability” because it relied on inaccurate information about Plaintiff's drug and alcohol use. Tr. 105. Instead, the ALJ found persuasive the opinion of Dr. McCain, the medical expert who testified at Plaintiff's first hearing that Plaintiff did not have limitations from a major neurocognitive disorder or major depressive disorder. Tr. 104-05. The ALJ also noted that other psychological consultants' opinions differed from that of Dr. Trueblood. Tr. 105 (citing Tr. 127-38, 139-50, 153-66, 167-80).
Plaintiff first asserts that the ALJ's assessment of Dr. Trueblood's opinion was colored by his erroneous belief that Dr. Trueblood evaluated Plaintiff mere months after Plaintiff's CVA. Pl. Op. Br. 14. The ALJ stated that Dr. Trueblood examined Plaintiff “only two months after her CVA” and concluded that his opinion “is therefore not strong evidence of her residual functional capacity following a period of recovery.” Tr. 104. Plaintiff correctly points out that her CVAs occurred between January and March of 2017, while Dr. Trueblood examined her in March 2021. Pl. Op. Br. 14 (citing Tr. 701, 867, 1377). The ALJ erred in stating that the examination occurred shortly after the stroke. The error was harmless because the ALJ gave other valid reasons to discount Dr. Trueblood's opinion. Molina v. Astrue, 674 F.3d 1104, 1115 (9th Cir. 2012) (factual error is harmless if substantial evidence still supports the decision and the ALJ would have reached the same decision absent the error), superseded on other grounds by 20 C.F.R. § 404.1502(a).
Next, Plaintiff argues that the ALJ erred in relying on Dr. McCain's opinion in rejecting Dr. Trueblood's opinion. Pl. Op. Br. 15. Plaintiff argues that Dr. McCain's opinion could not be relied on because it did not provide a new diagnosis or findings and instead “merely disagreed with Dr. Trueblood's conclusions.” Id. To the extent that Plaintiff argues that Dr. McCain was required to offer an alternate diagnosis, Pl. Op. Br. 11-12, she is incorrect. Plaintiff relies on Orn v. Astrue, 495 F.3d 625, 632 (9th Cir. 2007), a case based on the prior version of the regulations, which gave more weight to opinions of examining physicians than to opinions of non-examining physicians. As Defendant points out, under the current regulations, there is no hierarchy of medical opinions, and an ALJ's decision to discredit a medical opinion “must simply be supported by substantial evidence.” Def. Br. 11; Woods, 32 F.4th at 787. Dr. Trueblood concluded that Plaintiff had limitations due to a major neurocognitive disorder and major depressive disorder, and Dr. McCain concluded that she did not. Compare Tr. 1364 with Tr. 5661. The ALJ found Dr. McCain's opinion persuasive and Dr. Trueblood's opinion not persuasive. Tr. 104-06. Substantial evidence supports this finding.
The ALJ correctly noted that Dr. Trueblood's opinion was inconsistent with his own objective testing of Plaintiff. Tr. 104. The Ninth Circuit recently reaffirmed that an ALJ may discount a doctor's opinion when it is inconsistent with or unsupported by the doctor's own clinical findings. Kitchen v. Kijakazi, No. 22-35581, 2023 WL 5965704, at *6 (9th Cir. Sept. 14, 2023) (ALJ did not err in discounting assessment of severe limitations that was inconsistent with doctor's own unremarkable mental status examinations). The ALJ stated that Dr. Trueblood “cited mild to moderate deficits on testing, notably in memory and executive functioning, but opined that the claimant had moderate or moderate to severe executive functioning limitations based in-part on significant daily deficits reported by the claimant's daughter in a contemporaneous interview.” Tr. 104. The ALJ properly noted an inconsistency here.
Plaintiff argues that the ALJ also erred in relying on Dr. McCain's opinion because Dr. McCain improperly disregarded Plaintiff's daughter's testimony about Plaintiff's limitations. Pl. Op. Br. 15. Dr. Trueblood stated that “it is not at all unusual for there to be more indication of executive deficits in a person's functioning in day-to-day life than is demonstrated in their neurocognitive test performances.” Tr. 1374. Dr. Trueblood recorded Plaintiff's self-assessment of her cognitive deficits as “some memory loss and maybe a little concentration difficulty.” Tr. 1375. Plaintiff acknowledges that her own account of her symptoms to Dr. Trueblood did not support the assessed limitations. Pl. Op. Br. 15. Dr. Trueblood stated that Plaintiff's daughter presented a very different view of Plaintiff's ability to function. Tr. 1376. Plaintiff's daughter reported that Plaintiff struggled with time perception and impulsivity, that her judgment and decisionmaking were poor, and that her problem-solving abilities and concentration were impaired. Tr. 1376. She stated that Plaintiff could not control her emotions. Tr. 1376. She stated that Plaintiff was unaware of her own limitations. Tr. 1376. Dr. Trueblood relied on Plaintiff's daughter's assessment and explained that it was standard practice in the field of neuropsychology to rely on a third party assessment. Tr. 1386.
The Ninth Circuit has held that clinical interviews and mental status evaluations performed by psychiatrists are objective measures that “cannot be discounted as a ‘self-report.'” Buck v. Berryhill, 869 F.3d 1040, 1049 (9th Cir. 2017). A psychiatrist's partial reliance on selfreported symptoms in performing such evaluations is not a basis to reject the opinion. Id. The Ninth Circuit has also held that in rejecting lay witness testimony, the ALJ must identify reasons germane to the witness. Valentine, 574 F.3d at 694. Here, the ALJ identified adequate reasons to reject Dr. Trueblood's opinion to the extent that it relied on Plaintiff's daughter's testimony. The ALJ stated, “While [Dr. McCain] agreed with [Dr. Trueblood's] conclusion that reports from someone who knows a claimant can at times give a better indication of the claimant's day-to-day functioning than objective testing, she advised that her review of the record was inconsistent with the limitations suggested by Dr. Trueblood.” Tr. 104. The ALJ also noted that Dr. Trueblood did not review the entire medical record. Tr. 105. The ALJ found that Plaintiff's daughter's account of Plaintiff's symptoms was “generally inconsistent with the record as a whole.” Tr. 106. These reasons were valid.
The ALJ did not err in finding Dr. Trueblood's opinion inconsistent with the longitudinal record. The ALJ pointed to medical evidence that Plaintiff's mental functioning was impaired by her stroke in January 2017, but by late 2017, it had improved. Tr. 105. He found Dr. McCain's review of the record persuasive. Tr. 104-05. Dr. McCain testified that in her review of the record, she did not find evidence supporting the diagnosis of a major neurocognitive disorder. Tr. 56. She testified that such a diagnosis required evidence that Plaintiff struggled “with multiple stimuli, TV, radio, conversations, [had] difficulty holding new information, [or was] unable to perform mental calculations,” and there was no such evidence in the record. Tr. 56. Dr. McCain stated that “there's no evidence in the records that [Plaintiff] requires frequent reminders” or cannot manage her life. Tr. 57. Dr. McCain noted that at the hearing, Plaintiff “was able to freely recall what she needed to do in order to take care of those COVID-related factors” she needed to address. Tr. 57. According to Dr. McCain, the behaviors Plaintiff's daughter described were “not consistent with the diagnostic criteria for neurocognitive disorders.” Tr. 58. Dr. McCain also stated that the record did not show that any cognitive difficulties Plaintiff experienced were due to her stroke rather than her history of methamphetamine and alcohol use. Tr. 60.
The functional limitations Plaintiff's daughter described to Dr. Trueblood are not supported by the record other than, in part, the period during which Plaintiff was recovering from her stroke in 2017. But as the ALJ stated, Plaintiff returned to work in July 2017, and her earnings in September 2017 and November 2017 through February 2018 exceed the minimum amount for SGA. Tr. 101. Plaintiff does not challenge this finding or dispute that her overall functioning improved in late 2017 or early 2018. See Pl. Op. Br. 5. Her impairments in the first several months post-stroke do not support Dr. Trueblood's 2021 assessment.
The record shows that Plaintiff discussed many health matters with her providers during the relevant period, and other than the first months after her strokes, her providers did not note that Plaintiff struggled to answer questions or understand providers' instructions. The ALJ correctly observed that progress notes from 2019 through 2021 consistently stated that Plaintiff was alert and oriented, with normal behavior, unremarkable thought content and process, and appropriate judgment and insight. Tr. 105 (citing Tr. 1286, 1316, 1321, 1331, 1397). The ALJ also relied on a mini mental status exam performed on June 4, 2019. Tr. 106 (citing Tr. 1276). The medical examiner scored Plaintiff at 27 out of 30 and described her as arriving on time, alert and oriented, with intact attention and concentration, and of average intellect. Tr. 1276. Plaintiff struggled the most with calculating serial sevens and recalled two of three items independently and the third with a clue. Tr. 1276. Her thought content and processing appeared to be normal, and short- and long-term memory were grossly intact. Tr. 1276-77. Dr. Trueblood's assessed limitations are inconsistent with these findings.
Plaintiff argues that the ALJ erred in relying on her normal mental status exams. Pl. Op. Br. 16. Plaintiff argues that the mental status exams are brief and insufficient, pointing to Ghanim v. Colvin, 763 F.3d 1154, 1164 (9th Cir. 2014). In Ghanim, the Ninth Circuit held that treatment notes stating that the claimant had logical thought content and focused attention did not contradict reported symptoms of depression and social anxiety. Id. But findings that Plaintiff had normal thought processes, judgment, and behavior do contradict Plaintiff's daughter's testimony that Plaintiff was severely cognitively impaired and could not control her impulses or emotions. Mental status exams focused on cognition are relevant where the claimed disability is cognitive. Ghanim recognized as much. See id. (“First, the ALJ's reliance on Dr. McDuffee and Dr. Dees's observations about cognitive functioning is misplaced; Ghanim primarily testified that nightmares, insomnia, social anxiety, and depression-not any cognitive impairments-caused him difficulty.”). The ALJ did not err in relying on Plaintiff's mental status exams in discounting Dr. Trueblood's opinion.
With respect to depression, Dr. Trueblood diagnosed Plaintiff with major depressive disorder - single episode - mild. Tr. 1364. The explanation and interview summaries accompanying Dr. Trueblood's opinion attribute Plaintiff's limitations to a neurocognitive disorder, not depression, which was assessed as mild. Plaintiff told Dr. Trueblood that she felt “maybe a little” depressed because her ex-partner had recently died. Tr. 1375. She described feeling depressed for months after her stroke. Tr. 1375. She stated that she was on medication, and it helped her depression. Tr. 1375. While Dr. Trueblood discussed Plaintiff's cognitive abilities at length as related to her executive functioning, he did not do so for any symptoms of depression, indicating that the major neurocognitive disorder was the basis of the assessed limitations. And even if Dr. Trueblood had ascribed any limitations to Plaintiff's depression, substantial evidence supports the ALJ's rejection of Dr. Trueblood's opinion. At an office visit in February 2021, Plaintiff responded “not at all” to questions asking how often she experienced various symptoms of depression. Tr. 1318-19. In March 2021, Plaintiff told one of her doctors that she did not have depression. Tr. 1297. And in December 2021, depression was listed under “past medical history” rather than “active problems.” Tr. 1406. This contemporaneous evidence supports the ALJ's rejection of Dr. Trueblood's opinion.
The ALJ also concluded that Dr. Trueblood's opinion was inconsistent with Plaintiff's daily activities, including living alone and returning to part-time work within a year after her stroke. Tr. 106. Plaintiff does not dispute the accuracy of those findings. Both undermine the limitations in executive functioning that Dr. Trueblood assessed. Notably, Plaintiff did not cite cognitive limitations as a reason for leaving her job. Tr. 26, 589. When speaking to Dr. Trueblood, Plaintiff expressed concerns about more recent memory loss but no concerns about judgment or decisionmaking. Tr. 1375. She expressed no concerns about her ability to live alone. And even if Plaintiff's self-assessment were unreliable, there is no evidence in the record demonstrating that she cannot live alone. Plaintiff's ability to work (for the period she returned to work) and live alone undermines the degree of limitation Dr. Trueblood assessed.
Finally, the ALJ concluded that “Dr. Trueblood's opinion has questionable supportability.” Tr. 105. He wrote that it was based on a single examination “and part of the evidence relied upon is shown inaccurate when reviewing the record as a whole.” Tr. 105. As noted above, Dr. Trueblood did not review the whole record. The ALJ pointed to Dr. Trueblood's statement that Plaintiff had not used methamphetamines in 20 years, while the record showed that Plaintiff had used methamphetamines as recently as January 2017. Tr. 105 (citing Tr. 1230, 1334, 1368). Plaintiff testified at her second hearing that she last used methamphetamines around January 2017. Tr. 52. In addition, while Dr. Trueblood wrote that Plaintiff engaged in only “light” alcohol use, the ALJ stated, “recent records document that the claimant has resumed alcohol abuse and that her providers are recommending that she cut back on the amount she has been drinking.” Tr. 105 (citing Tr. 1314, 1395-96). In March 2021, close in time to Dr. Trueblood's assessment, one of Plaintiff's providers wrote in his office visit notes that Plaintiff was having one alcoholic drink per day that was equivalent to about three shots. Tr. 1314. The ALJ did not err in questioning the supportability of Dr. Trueblood's opinion because it was based on inaccurate information about Plaintiff's drug and alcohol use, both of which are relevant to an assessment of her mental state and cognition.
Plaintiff asserts that Dr. McCain, and by the extension the ALJ, disregarded evidence in the record that supported Dr. Trueblood's findings. Pl. Op. Br. 15-16. Beyond relying on her daughter's testimony to Dr. Trueblood, Plaintiff relies on her testimony at her second hearing and discussions with her therapist in 2022. Pl. Op. Br. 15-16. Neither supports the limitations Dr. Trueblood assessed. Plaintiff testified that when she first returned to work after her strokes, she didn't remember parts of her job and took longer to perform tasks. Tr. 22-26. This is consistent with evidence in the record that Plaintiff's cognitive abilities and overall executive function were notably impaired in the first several months after her stroke, including when she first returned to work in July 2017. But as discussed above, the record shows that Plaintiff's mental functioning improved thereafter, and she engaged in SGA in September 2017 and November 2017 through February 2018. Tr. 101-02. And as the ALJ stated, Plaintiff's therapist did not note major problems with Plaintiff's attention span or comprehension. Tr. 107 (citing Tr. 1445). Plaintiff does not challenge the ALJ's assessment of her symptom testimony or of her therapist's opinion.
Substantial evidence supported the ALJ's rejection of Dr. Trueblood's opinion. Dr. Trueblood's assessment of Plaintiff's limitations was inconsistent with his own objective testing, with Plaintiff's account of her limitations, and with the contemporaneous medical record. The degree of limitation he assessed was only supported by Plaintiff's daughter's account of Plaintiff's functioning. Plaintiff does not challenge the ALJ's assessment of her symptom testimony or of any other medical opinions. She does not challenge the adequacy of the physical limitations in the RFC. Nor does she explain what mental limitations should have been included in the RFC. Substantial evidence supports the RFC. The ALJ did not err in concluding that Plaintiff could perform her past relevant work and thus was not disabled.
CONCLUSION
Based on the foregoing, the Commissioner's decision is AFFIRMED.
IT IS SO ORDERED.