administration as of december nd two thousand and thirteen and this was not the aug th date that she had requested she continues to receive her benefits unfortunately have to go into a hearing the administrative law judge found that ms when it was never disabled he changed the decision of the administration and ms when it is now faced with potentially a very large overpayment that would include repayment of services obtained through her doctors based on billings of medicare scuse me in your brief did you outline the law about the repayment i just cus that she would be obligated to repay if the decision finding her not to sable torches was to stand i don't know that i provided citations but i don't think that's an issue we all need to worry about ok so i think we just need to be aware that absent i'm sorry for interrupting you this court to decide whether or not the decision of the administrative law judge is free of legal lever and one of the substantial issues that we've raised in the briefing is that not only have five treating sources found that ms when it could not sustain work but also one source a secure social security consulting physician found ms when it unable to perform a past work and the social security administration submitted an analysis it's part of the record indicating that ms when it would be unable to sustain work and that this particular administrative law judge rejected all of that evidence in favor of the doctor other physicians in the record based on three different points one was that i was objective finding this which he credited and gave great weight the conservative treatment that when it had rejected narcotics and botox despite recommendations and the a d l says that but you clue did a long list of walking back in vacations helping parents packing up houses five days whatever so those are the three grounds that the l g a relied on so my question is is that so substantial evidence supporting the a l j is conclusion as is that there was  specific clearing convincing or hello are we for l a that reasons for rejecting the testimony and the other doctors so if you could focus on what the argument as to why those three bases for the a  decision were not did not constitute substantial evidence that would help me ok so your honor in terms of the objective evidence the type of impairment that ms when it suffers evidence supporting your client's position the question is was there substantial evidence supporting the l j is conclusion right and so it's difficult for me because your time is ticking what's unusual about this case for me is that the expert bow i don't know if i'm individual who examined her on one occasion when she was just at the cost of perhaps going part time perhaps actually giving up her retirement so my question on that provision is that component is who decides what  necessary background information you know if that happened it is the host do you suppose if the necessary the administration it's one of their consulting physician though so and we do know if he didn't look at it or we don't do you know if he had it so the physician writes in his report that he looked at one record my experience would tell me that that's all they gave a lot of objective findings of the particular types of disability and they're noted repeatedly over and over again by her treating physicians and so that's how we get down to this that is not bound by that for sure but dr pao had to by the jail they just have to get treating history there and we don't know what he did with that there's the conservative treatment she didn't want to have botox there is no indication that there is any surgery available but dr paul makes this mention that she didn't have surgery is there is there any surgery available to treat this own subjective is was there any evidence in the records that botox raised the risks that she was concerned about all i saw was a report of her view i don't want an actual substances in my body i'm  worried that will paralyze a nerve but that's a doctor continued to reckon and so was there any medical information raising those risks well i don't know that the doctor mentioned those rests in the records but you would assume that the doctor discussed the rest ok so he has nothing on the record no but there's medical literature that we've cited that proves the point and i mean the medical literature proves a fact that we're supposed to  accept medical literature proves that there's west to botox injections i don't think that that's in dispute so just because a doctor doesn't lie there is it's like a doctor recommending surgery there's risk of death in every surgery so i have to rely on records but can i rely on somebody else who's written a book well doesn't seem to be a way to determine factual determined so you can rely on social security policy will problem with the question because this botox will not heal or i don't know that do i answer something on the record that it says it will not help with some of the symptoms there's great wes can trying it all the doctor that's what my meter or actor recommended at your time is actually expire it will give you and it free at all since we took you over time thank you on behalf of the government good morning your honour's this is when it certainly has a rare neurological condition no one disputes that it provides limits it limits or in some ways but there is substantial evidence in the record supporting the decision that it did not limit her as much as she claimed and it did not limit her to the point where she could not continue to do her work as an elementary school teacher one of the most glaring pieces of evidence in the record is the extensive travel  that that is documented throughout the record one trip was to new york to for her son's wedding one trip the problem i have it's she's not supposed to be required to sit home and do nothing there's an impressive i think history of her continuing to try to work and try to avoid narcotics medication her physicians talk to her at length about twelve years i think wearing this neck brace including to the extent of dislocating her ribs and whatnot and what seem to me to be notable about the seemed to me to be a very consistent timeline that when she tried to do these kinds of trips or activities it was quite difficult for her and the record reflect that so i'm just concerned that she's being punished for trying to do anything well i would take issue a little bit with that characterization the record your honor st of all there are a number of trips where there was she doesn't report it taking a toll on her most notably she took a vacation to italy  which was you know not not just a short trip at all and there were no complaints afterwards about problems in fact she described as a good trip you mention new york in the son's wedding in fact she seems to travel to new york every year to visit her son so what is  part with her traveling well it's not it's not so much a problem your honor and if it was just a single trip here or there i mean the question is whether she can work out whether she can travel it just this struck me as a real a listen to what you have to say on this are i mean this is a record that demonstrates i count at least ten different vacations in about a thirty three year period or three different ten different trips so we're not talking about someone who took one vacation had had a lot of trouble we're talking about someone who has taken multiple trips to mexico and when you talk about it it's not like she's you know surfing in mexico or hiking in mexico or climbing mountains in mexico it's one thing to sit on an airplane you're talking to three people who sit on airplanes a lot writing quite so so i was more concerned for example about and i think it's a fair point to talk about her helping her parents pack up their house that's visible activity but sitting on an airplane i mean that's a hard sell for me well we've also got river  rafting and again we're we're we're talking about some who claim to be extremely physically limited and when you look at some of these medical opinions that were rejected they the doctors are checking the most extreme limitations on the form and so when you look at it i think if you if you isolate any single trip you can say ok that doesn't prove anything but when you look at the evidence whole when you have ten trips in and when you look at the nature of the complaints for example when she took a four day trip to mexico with her girlfriend she came back and said it really aggravated my my dystonia my neck condition because we spent the trip traveling on a rutted dirt roads in the bounce you know how it really hurt me so when we are comparing it to this claim that i can't be an elementary school teacher or for instance when she goes to new york she she complains not actually of problems with her just tonia the disabling condition she comes back and says i've got sore calves because my my son lives in a five story building with no elevator and so i've been climbing stairs for days  we actually have a lot of the activity that when you look at is look at it as a whole indicates a greater physical capacity than she's alleging and then we throw in something like the movie where she spent five days by her own account moving her parents she said she had to do all the work by herself her parents live one hundred miles away from her so when you compare the types of claims that she's making that she's extremely physically limited that she can't she basically cannot sit comfortably for any amount of time it becomes  well it becomes a little bit difficult when you look at all of these activities that ask you another question what did the government give this expert her medical history because he makes no mention of accounting i am very concerning i  don't know i don't know it's not in the record i have no way to find that information out there we know whether anybody advised her after having i think there are discussions of resorting to narcotic pain medications to try to didn't want to do doctor her treating physician clearly told her had she done that she would be pain narcotic dependent as far as a book that's in the record as far as the botox is concerned there are there are there are several i think there's the at least three times where someone discussed botox with her and but it but i don't know if anybody said you know you know we advise that you do this having weighed the risks and benefits can you just can you show me where that was done no questions  right there was a discussion to go you know sort of consider this and i'm trying to figure out whether because of course there are some risks associated with botox and whether or not there was a discussion of risks and balances that she should go forward we know that we don't but the point is a little bit different there as jack who just pointed out that the problem is really that she was told you should go talk to the center all just about this you should go have this discussion because this is and there is no indication that there is a surgery available for this type of treatment that i can see a please tell me if i'm wrong about i am not aware of any you know i would i would concede error on that point but i believe it is harmless error in light of all the other reasons given and again to top it when it comes to the botox it's certainly willingness to have that discussion with the specialist that is the salient fact here that's what's important the unwillingness to actually pursue this to to go talk to that specialist who would be able t discount be extent to which this was a disabling condition or painful condition yes it was reasonable for the able jade to draw any inference that her unwillingness to even go have that discussion took away from the credibility of her pain complaints and i would also add that when it comes to narcotics dr toben noted that while she said that she just doesn't want to have actual things in her body she actually did rarely use hydrocodone and it's really her so she did actually use but the point there was that she only used it rarely so she it's not as if she was unwilling to use this medication or that she she just wouldn't wouldn't do it and that's the kind of record that we really frequently see and rely upon especially in cases where there is not an objective indication of a soft tissue injury or something but this was during this neck brace for twelve years he's got a medical record that is replete with indications of jack to play that he's asymmetric that her all observing it because i don't i mean i'm not sure i mean does anybody doubt unlike in a soft tissue injury where there's a concern about whether she actually suffers from this she's got this there's really objective manifestation of this condition right yes though i think you also have to look at dr bao examination results and while you do fault the dr bao for not clarifying what medical records he looked at what the l g was really relying on when it comes to dr bao is dr bao did the most extensive physical examination it's on the record his examination results are far that are far more detailed than any examination results from a treating physician and while he does recognize that there are certain limitations he knows things like she actually has a moderately good range of motion in her neck she has full grip strength all through her arms no no no reflex issues he actually does what what we would call capacity testing which is similar to the testing that current physical therapist who did on two occasions which produced results very similar to dr bowers which was that she wasn't nearly as physically limited as she claimed to be this was a year after she'd been out of work is that right excuse me this is a year after she had been had retired and had undertaken her physical therapy regime i think you know that so the most recent one was in december two thousand and fourteen where she had five physical therapy sessions i forget maybe you've answered my question  whatever and i notice here that the o j did not accept the acar punks who do we have any cases on them and we've had some cases on others but is there any pieces that the  y can be faulted for not accepting that as as a except of course medical source cases in but the regulations do actually make it clear that there is a divide and the change in terms of who we accept opinions from is based on the filing date of the application and she's under the old regulatory scheme without question and the case law that you're referring to is under that old scheme and under that  accepted as equivalent to m d s and i think i do need to quickly even though i'm over time correct myself when it comes to chiropractors even under the new regulations i am quite certain that chiropractors are actually not acceptable medical sources it's nurses that are the being a medium job meaning stand and walk all day pretty much all day and lift up to fifty pounds ok now the vocational consultant testimony is if with that particular r f c the judge issued she couldn't do the past work if she performed it so then we look at whether or not this judge found she could do her past work as a general teacher with a light r f c i want to point out that if she can't do her past work because she's limited to less than light she went so when the commissioner says oh look at all she's doing it doesn't show she's not disabled because to do her past work she'd have to be able to stand and walk the six out of eight hours and lift up to twenty pounds eight hours a day five days a week on a regular and continuous basis otherwise this decision is not supported by substantial evidence i want to quickly go over some of the vocational lecture here in motor over time so please please ok we'll we quickly the expert testified that if when it suffered from moderate pain that