Unreported / Non-Citable
Background
Plaintiff D.I., whose name is partially redacted, applied for Supplemental Security Income on September 2, 2022, alleging disability beginning March 31, 2014. After denials at the initial and reconsideration levels, an administrative law judge (ALJ) held a hearing on October 22, 2024 and issued an unfavorable decision on December 20, 2024. The Appeals Council denied review on October 1, 2025, and Plaintiff sought judicial review under 42 U.S.C. § 405(g) before a magistrate judge sitting by consent.
The ALJ found severe impairments of fibromyalgia, PTSD, and depressive and anxiety disorders, no listed impairment, and no past relevant work. The residual functional capacity (RFC) permitted light work with simple, routine, repetitive tasks, only incidental public contact, and brief, superficial contact with coworkers and supervisors, but contained no attendance limitation. Relying on jobs such as housekeeping cleaner, the ALJ found Plaintiff not disabled.
A consultative psychologist, Dr. Salvadore-Moses, examined Plaintiff in December 2023 and assessed marked impairment in attending usual work situations (including attendance), handling changes, persistence, and interacting with supervisors and coworkers. The ALJ found the opinion only partially persuasive. Plaintiff challenged that finding, the treatment of two therapists' letters, the rejection of her symptom testimony, and the RFC, seeking an award of benefits or alternatively remand. The Commissioner cross-moved to affirm.
The Court’s Holding
The Court granted Plaintiff's motion, denied the Commissioner's cross-motion, and reversed. It held the ALJ's evaluation of Dr. Salvadore-Moses was not supported by substantial evidence. On supportability, the ALJ cited eye contact, cooperative behavior, and calculation ability but ignored the examiner's abnormal findings, such as depressed mood, intermittent auditory hallucinations, and distraction by flashbacks. Citing Ortiz v. Bisignano, the Court noted that a person may do well on an isolated examination yet be unable to work full time. On consistency, some cited "normal" records actually showed depressed or anxious mood or passive suicidal ideation. The ALJ also never addressed the marked attendance limitation, which the RFC omitted, or explained why the RFC's social limits departed from the marked limitation.
A social worker's letter describing over twenty therapy sessions was discounted because treatment notes were missing. The Court held the letter triggered the ALJ's duty to develop the record, whether or not it was a formal medical opinion. It did not decide whether the intern therapist's letter was a medical opinion, only that the ALJ must consider it when evaluating symptom complaints. Because the ALJ found no malingering, clear and convincing reasons were required, and the Court found none. Normal gait, strength, and range of motion do not address pain. Routine mental status snapshots do not contradict episodic symptoms. Medication inconsistency was not linked to evidence that duloxetine relieved them. Travel and household activities were not analyzed for what they demand. The Court agreed the ALJ did not rely on lack of treatment. The errors were not harmless because they affected the step-five finding.
The Court refused to order benefits. Even crediting the testimony and opinion as true, doubt remained. The vocational expert said one absence a month or ten percent off-task time would preclude work, but the record did not establish that Plaintiff would have that much. The ALJ also never asked about limited ability to interact appropriately with supervisors and coworkers. The Court remanded for further administrative proceedings, with a separate judgment to follow.
Key Takeaways
- An ALJ rejecting a medical opinion as unsupported or inconsistent must give a reasoned explanation supported by substantial evidence and cannot rely only on the normal portions of an examination.
- Normal gait, strength, and range of motion do not necessarily contradict testimony about pain, and the cited evidence must address the symptom at issue.
- When a claimant submits a provider's letter pointing to treatment records not in the file, the ALJ may have a duty to develop the record rather than discount the letter for lacking notes.
- Where the RFC departs from a medical opinion's marked limitations, such as attendance or supervisor interaction, the ALJ must explain why the opinion was not adopted.
- Reversal did not mean benefits: the Court remanded because the vocational record on attendance and social interaction was undeveloped.
Why It Matters
This is a magistrate judge's order in a single case. It was not designated as reported, so it is persuasive only. Its value lies in applying recent Ninth Circuit authority, Ortiz v. Bisignano and Ferguson v. O'Malley, to episodic physical and mental symptoms.
The Court decided only that the ALJ erred and that disability remained uncertain. On remand the Commissioner must reevaluate the opinion evidence, symptom testimony, and RFC, consider the therapists' evidence, and obtain vocational testimony on a proper hypothetical. Whether Plaintiff is disabled remains open.