Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_06-cv-02109/USCOURTS-azd-2_06-cv-02109-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:205 Denial Social Security Benefits

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WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Daniel C. Powers, 

Plaintiff, 

vs.

Michael J. Astrue, Commissioner, Social

Security Administration, 

Defendant. 

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No. CV 06-2109-PHX-MHM

ORDER

Plaintiff Daniel C. Powers seeks judicial review of the Administrative Law Judge’s

decision denying his claim for disability insurance benefits. 42 U.S.C. §405(g).

I. PROCEDURAL HISTORY

Plaintiff applied for Disability Insurance Benefits under Title II of the Social

Security Act , 42 U.S.C. §423, in May 2003 based on his inability to work beginning on

April 15, 2002. (Transcript (“Tr.”) 19). Plaintiff’s application was denied initially and

also upon reconsideration. (Id.). Plaintiff timely filed a request for a hearing and a

hearing was held before Administrative Law Judge (“ALJ”) Michael J. Cianci, Jr., on

June 1, 2005. (Id.). On July 14, 2005, the ALJ issued a partially favorable decision

granting disability benefits from April 15, 2002, through April 30, 2003. (Dkt. #1, p.2). 

However, the ALJ found improvement in Plaintiff’s condition beginning May 1, 2003 and

concluded that Plaintiff could have returned to his past work at that time. (Id.). Plaintiff

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filed an administrative appeal with the Appeals Council which was summarily denied by

notice dated July 7, 2006, making the decision of the ALJ final. (Dkt. #1, p.2). Plaintiff

claims that the ALJ’s decision errs in fact and in law and is unsupported by evidence. 

(Dkt. 31, p.3). Furthermore, Plaintiff claims still to be disabled and entitled to Social

Security benefits. (Id.). 

Plaintiff commenced an action for review of the administrative determination in

this Court on September 1, 2006, pursuant to 42 U.S.C. §§405(g) and 1383(c). Defendant

filed an answer and a certified copy of the transcript of record on November 13, 2006. 

(Dkt. #9). On February 26, 2007, Plaintiff filed a motion for summary judgement (Dkt.

#16) supported by a statement of facts (Dkt. #19) and memorandum of points and

authorities (Dkt. #21). On March 28, 2007, Defendant filed a cross-motion for summary

judgment (Dkt. #23) supported by a statement of facts (Dkt. #24) and a memorandum of

points and authorities. (Dkt. #25). Plaintiff filed a response to Defendant’s cross-motion

for summary judgment and a reply to the Commissioner’s response to Plaintiff’s motion

for summary judgment on April 16, 2007. (Dkt. #27,28).

II. STANDARD OF REVIEW

This Court must affirm the ALJ’s findings if they are supported by substantial

evidence and free from reversible legal error. Marcia v. Sullivan, 900 F.2d 172, 174 (9th

Cir. 1990). Substantial evidence means “more than a mere scintilla” and “such relevant

evidence as a reasonable mind might accept as adequate to support a conclusion.” 

Richardson v. Perales, 402 U.S. 389, 401 (1971); Clem v. Sullivan, 894 F.2d 328, 330

(9th Cir. 1990).

In determining whether substantial evidence supports a decision, the Court

considers the record as a whole. Richardson, 402 U.S. at 401; Tylitzki v. Shalala, 999

F.2d 1411, 1413 (9th Cir. 1993). If there is sufficient evidence to support the ALJ’s

determination, the Court cannot substitute its own determination. Young v. Sullivan, 911

F.2d 180, 184 (9th Cir. 1990). Where evidence is inconclusive, “questions of credibility

and resolution of conflicts in the testimony are functions solely of the [Commissioner].” 

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Sample v. Schweiker, 694 F.2d 639, 642 (9th Cir. 1982). Therefore, if on the whole

record before the Court, substantial evidence supports the Commissioner’s decisions, this

Court must affirm. Hammock v. Bowen, 879 F.2d 498, 501 (9th Cir. 1989); 42 U.S.C. §

405(g). 

An ALJ determines an applicant’s eligibility for disability benefits through the

following five steps:

(1) determine whether the applicant is engaged in “substantial

gainful activity”;

(2) determine whether the applicant has a “medically severe

impairment or combination of impairments”;

(3) determine whether the applicant’s impairment equals one of a

number of listed impairments that the Commissioner

acknowledges as so severe as to preclude the applicant from

engaging in substantial gainful activity;

(4) if the applicant’s impairment does not equal one of the “listed

impairments,” determine whether the applicant is capable of

performing his or her past relevant work;

(5) if the applicant is not capable of performing his or her past

relevant work, determine whether the applicant “is able to

perform other work in the national economy in view of his [or

her] age, education, and work experience.”

Bowen v. Yuckert, 482 U.S. 137, 140-41 (1987) (citing 20 C.F.R. §§ 404.1520(b)-(f)). 

See 20 C.F.R. § 416.920. At the fifth step, the burden of proof shifts to the

Commissioner. Penny v. Sullivan, 2 F.3d 953, 956 (9th Cir. 1993). 

III. BACKGROUND FACTS

Plaintiff was injured at work in December 2001 while lifting some heavy objects. 

(Tr. 21). He was diagnosed with cervical disease and cervical myelopathy with some

prominence on the right side, and underwent a trilevel cervical decompression and fusion

surgery on April 15, 2002. (Id.). Plaintiff also suffers from depression and anxiety. 

(Dkt. #16 ¶5). 

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A. MEDICAL RECORDS FROM APRIL 15, 2002 THROUGH APRIL 30,

2003

Following the April 15, 2002 surgery, the surgeon, Paul W. LaPrade, Jr., M.D.,

saw Plaintiff on three occasions. (Tr. 198, 195, 191). Although Dr. LaPrade noted that

Plaintiff was doing better, Plaintiff still had pain and numbness in his right arm and hand. 

(Tr. 185). An MRI in June of 2002 revealed that Plaintiff had neural foraminal stenosis

(narrowing of the space inside the bony spine) primarily on the right side due to

degenerative changes (Tr. 213) with no cord compression. (Tr. 212). A neuromuscular

electrodiagnostic examination indicated that Plaintiff was experiencing right cervical

radiculopathy involving the right C6-7 nerve roots and mild carpal tunnel syndrome. (Tr.

169). Dr. LaPrade authorized Plaintiff to return to work on July 8, 2002. (Tr. 181). The

ALJ rejected the opinion of Dr. LaPrade, that Plaintiff could return to work, as

“incongruent with the evidence as a whole.” (Tr. 22). However, the ALJ also found this

same opinion “to be probative,” and used it to support their decision that Plaintiff was no

longer disabled as of May 1, 2003. (Tr. 27). 

Plaintiff was referred by Dr. LaPrade to a physical medicine specialist, John M.

Kozak, M.D., in September 2002, because of Plaintiff’s ongoing pain. (Tr. 177). 

Plaintiff complained of “right neck pain with significant limitations in range of motion. 

He [had] intermittent sharp pain down the right arm with spasming in the right hand.” 

(Id.). He also gets “numbness and tingling in the right hand with associated weakness in

the right arm.” (Id.). Dr. Kozak diagnosed Plaintiff with chronic right cervical

radiculopathy, cervical spinal stenosis with myelopathy status post C4 to C7

decompression with fusion, secondary cervical strain, and significant neck and shoulder

girdle atrophy. (Tr. 179). He prescribed physical therapy for strengthening and pain

reduction. (Id.). Electrical stimulation was prescribed for the atrophy and pain control. 

(Id.). Neurontin was prescribed to treat neuropathic pain; and epidural injections, also for

pain. (Id.). On a follow up visit in October 2002, Dr. Kozak noted improvements and

continued with the same treatment. Dr. Kozak authorized golfing and fishing. (Tr. 366). 

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At that time, Plaintiff only complained of pain with sudden neck movement and

occasional paresthesias in the upper extremities. (Tr. 366). 

Plaintiff moved to South Carolina where he was seen by William M. Rambo, Jr.,

M.D., a neurosurgeon, in January 2003. (Tr. 222). Plaintiff was still experiencing pain

and weakness and also complained of facial pain. (Tr. 222). Dr. Rambo commented that

Plaintiff’s “symptoms are not out of the ordinary for this size of procedure.” (Tr. 223). 

Dr. Rambo’s radiographic review showed some mild cord compression. (Tr. 222). After

reviewing the plain films and being satisfied with the progress of the cervical spine, Dr.

Rambo recommended continuing the exercise rehabilitation program and discontinuing

the neurosurgical evaluation and treatment. (Tr. 221). Dr. Kozak later indicates that Dr.

Rambo was disinclined from doing anything more because the surgery had been

performed by someone else. (Tr. 364). 

B. MEDICAL RECORDS AFTER APRIL 30, 2003

In June 2003, Plaintiff was seen by W. Randal Westerkam, M.D., a physical

medicine specialist. (Tr. 278). Plaintiff complained of intermittent numbness in his left

hand and forearm as well as his right forearm. (Tr. 278). He also complained of

intermittent severe pain at the back of his neck, intermittent spasms, and fatigue. (Tr.

279). Dr. Westekam noted decreased range of motion in all planes. (Tr. 279). He noted

that Plaintiff “has done fairly well following rather extensive surgery with the majority of

his neurologic symptoms improved.” (Tr. 279). However, he also noted that “because of

his fusion, there is some mechanical disadvantage of the scapular and other cervical

musculature which is creating ongoing pain.” (Tr. 280). He recommended continued

exercise and opined that ongoing use of Neurontin may be contributing to Plaintiff’s

fatigue and decided to take Plaintifff off of it. (Tr. 280). He recommended Plaintiff

continue taking Motrin, as needed, for pain. (Tr. 280). 

In August 2003, Plaintiff was assessed by Joyce Lewis, M.D., a non-examining

physician employed by a state agency. Dr. Lewis performed a “Physical Residual

Functional Capacity Assessment” (Tr. 241-248) and determined Plaintiff was capable of

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doing light (Dkt. #24 p.4) or medium (Dkt. #16 p.11) work. In making its determination,

the ALJ found that Dr. Lewis’ opinion was “no longer supportable in light of the entire

record.” (Tr. 22). However, the ALJ also concluded that Dr. Lewis’ opinion supported

the finding that Plaintiff was no longer disabled after May 1, 2003, and took it into

consideration as a “nonexamining expert source.” (Tr. 27). 

In November 2003, Plaintiff was examined psychologically at the request of the

state agency by J.P. Ginsburg, Ph.D. (Tr. 250). The prior diagnosis of panic disorder was

confirmed, and Dr. Ginsburg also diagnosed Plaintiff with adjustment disorder with

depression and anxiety. (Tr. 252). Plaintiff was given a global assessment of functioning

(“GAF”) score of 59 (Tr. 259) which is a moderate level of functioning. (Dkt. #19 p.12). 

Dr. Ginsburg stated that Plaintiff’s “[i]mpairments due to his disorder (not counting

physical limitations) appear to be mild for activities of daily living and social

interactions.” (Tr. 253). With regard to the workplace environment, Dr. Gingsburg stated

that, given the chronic and sometimes severe pain, Plaintiff's overall ability in the

workplace would be fair and the likelihood of decompensation would be great. (Tr. 253). 

In November 2003, Plaintiff saw Dr. Westerkam for a follow-up visit. (Tr. 276). 

Plaintiff complained of low abdominal pain, low back pain, and other musculoskeletal

pains. (Tr. 276). Dr. Westerkam found these symptoms to be consistent with sacroiliitis

and prescribed more physical therapy and an anti-inflammatory. (Id.). An MRI of the

lumbar spine, conducted the following month at Dr. Westerkam's request, revealed an

L3-4 annular bulge impressing upon the thecal sac. (Tr. 281). The MRI also showed

signs of degenerative joint disease (DJD), and a disc protrusion resulting in “mild to

moderate canal stenosis in association with bilateral facet joint hypertrophic DJD

changes.” (Tr. 281). During a follow-up visit in January, Plaintiff reported that he was

doing better with the physical therapy and medication, though he was still experiencing

intermittent neck pain as well as low back pain radiating down the right leg. (Tr. 274). 

Dr. Westerkam noted that there is no significant disc protrusion or spinal stenosis upon

review of the December MRI. (Id.). 

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In March 2004, Plaintiff was assessed by Richard Weymouth, M.D., a

nonexamining physician employed by a state agency. (Tr. 311-318). A “Physical

Residual Functional Capacity Assessment” administered by Dr. Weymouth showed

limitations consistent with “medium” exertional level work. (Dkt. #19 p. 14). This

assessment was similar to the nonexamining physician assessment conducted in August

2003, and was also considered by the ALJ as a “nonexamining medical source.” (Tr. 22).

In April 2004, upon returning to Phoenix, Plaintiff saw Dr. Kozak again. (Tr.

364). Plaintiff continued to experience neck problems and problems with his right side,

including right-sided sciatica. (Id.). He continued to suffer from fatigue. (Id.). Dr.

Kozak noted “marked limitations in all planes secondary to increased pain and stiffness.” 

(Tr. 365). Dr. Kozak diagnosed chronic right cervical radiculopathy, cervical stenosis

with myelopathy status post C4-7 decompression with fusion, and cervicothoracic strain. 

(Id.). He prescribed a low dose of Neurontin again. Since plaintiff had experienced

gastro-intestinal bleeding, anti-inflammatory medication could no longer be prescribed. 

(Id.). The cervical MRI screening prescribed by Dr. Kozak revealed “mild, multi-level

neural foraminal narrowing and spinal canal stenosis.” (Tr. 361-362). The lumbar spine

MRI revealed disc protrusion, mild central canal stenosis, bilateral pars interarticularis

defects, and moderate facet arthrosis. (Tr. 358). 

In May 2004 , Plaintiff was referred to Harry S. Morehead Jr., M.D., a neurologist. 

Dr. Morehead examined Plaintiff in order to address his intermittent neurologic

symptoms which he found to be related to the cervical region. (Tr. 391). He made no

changes to the medication and prescribed tests that later ruled out some of his suspicions

about the source of the symptoms. (Id.).

In May 2004, Plaintiff again saw Dr. Kozak. (Tr. 353-354). Dr. Kozak found

Plaintiff's status essentially was unchanged. (Id.). Dr. Kozak discontinued physical

therapy but continued the home exercise program. (Id. at 354). By Plaintiff’s July 2004

visit, Plaintiff’s pain had increased. (Tr. 349). Dr. Kozak increased the Plaintiff’s

Neurontin dosage and prescribed cervical facet joint injections for pain (Tr. 350), which

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had good results (Tr. 348). In August 2004, Dr. Kozak reported that Plaintiff was

suffering from right lumbrosacral radicular symptoms for which he prescribed an epidural

injection. (Tr. 348). Although the injections did improve symptoms, plaintiff suffered

from spasms and cramping as a result of his moving into a new apartment. (Tr. 344). 

In September 2004, Dr. Kozak reported that Plaintiff was suffering from diffuse

myalgias (muscle pain) and increased pain in the neck, back, hips, and left big toe. (Tr.

343). Plaintiff reported that he had suffered two accidental injuries since his last visit. 

(Id.). He was having gastro-intestinal problems as a result of medication. (Id.). He

thought his school attendance was increasing his pain symptoms. (Id.). He had developed

skin lesions on his back. (Id.). Dr. Kozak prescribed Medrol Dosepak (a corticosteroid),

increased Neurontin, and discontinued Vioxx. (Tr. 344).

In October 2004, Plaintiff reports to Dr. Kozak that the Medrol Dosepak injection

resolved his pain complaints for ten days. (Tr. 341). However, his symptoms worsened

and he suffered from increased fatigue as it left his system, feeling “like a train hit him.” 

(Id.). Plaintiff's positive reaction to the Medrol Dosepak injection suggested to Dr. Kozak

that he may have an underlying disorder for which he referred Plaintiff to a

rheumatologist. (Tr. 342). Plaintiff was taken off of the Neurontin because it was no

longer effective. (Id.). Dr. Kozak prescribed Mobic, a nonsteroidal anti-inflammatory,

and Keflex for the lesions on his back. (Id.). 

In October 2004, the rheumatologist, Joseph S. Habros, M.D., diagnosed

“polyarticular joint pain with variable pain on movement, soft tissue [illegible] hands and

feet which varies.” (Tr. 410). “Dermititis - hx [history] of psoriasis with the possibility

of a component of psoriatic arthritis completing the picture.” (Id.). Dr. Habros

prescribed methylprednisolone, a glucocorticoid. (Dkt. #19 p.18). Blood tests ruled out

some possible causes of Plaintiff's symptoms. (Tr. 413-415). During the follow-up visit

in November 2004, Dr. Habros prescribed Prednisone and Relafen, but Plaintiff still had

pain and decreased range of motion. (Tr. 407). Dr. Habros suspected an “inflammatory

process” or psoriatic arthritis. (Id.). Dr. Habros reported that Plaintiff was still suffering

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from pain and medications were continued during follow-up visits in January and

February. (Tr. 404-406).

In March 2005, Dr. Kozak again saw Plaintiff, who was experienceing “pain all

over.” (Tr. 339). Dr. Kozak reported that Plaintiff “seem[ed] to have a generalized

problem based on his reaction to the steroids . . . not . . . isolated musculoskeletal

problems, but more of a diffuse problem.” (Id.). Although Plaintiff had gastro-intestinal

problems with prednisone and Relafen, Dr. Kozak prescribed Relafen alone to see if he

could tolerate it. (Tr. 340). Additional tests were conducted to see if there would be any

difference since Plaintiff had been taken off steroids. (Id.). Also in March 2005, Ralph

Bennett, M.D., a rheumatologist saw Plaintiff. (Tr. 368-371). Plaintiff continued to

suffer from pain, reduced sensation, and limited range of motion. (Tr. 369). Dr. Bennett

ordered tests, which had negative results. (Tr. 372-373). 

In April 2005, Dr. Kozak saw Plaintiff and conducted an electromyographic

examination which revealed “mild bilateral carpal tunnel syndrome, most likely due to

playing musical instruments.” (Tr. 334). He characterized this disorder as “mildly

symptomatic.” (Id.). Dr. Kozak also discontinued Relafen in April. (Tr. 338).

In May 2005, Dr. Bennett diagnosed fibromyalgia (Tr. 368), “a rheumatic disease

that causes inflammation of the fibrous connective tissue compartments of muscles,

tendons, ligaments, and other tissue.” Benecke v. Barnhart, 379 F.3d 587, 589 (9th Cir.

2004). He also completed a “Pain Functional Capacity Questionnaire,” which was based

on his independent clinical judgment, in which he concluded that Plaintiff “suffered from

moderately severe pain," which is defined as "seriously affect[ing] ability to function.” 

(Tr. 381). This level of pain is often “sufficiently severe to interfere with attention and

concentration” (id) and often results in “failure to complete tasks in a timely manner (in

work settings or elsewhere).” (Tr 382). According to Dr. Bennett, the moderately severe

level of pain can “reasonably be expected to result from objective clinical or diagnostic

findings . . . documented . . . in the medical records.” (Tr. 381). 

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Dr. Habros conducted a “Medical Assessment of Ability To Do Work Related

Activities” in May 2005. (Tr. 421). Based on his clinical evaluation, Plaintiff is highly

limited in his ability to perform exertional activities, such as standing, walking, sitting,

lifting, and using hands and feet, and would probably be precluded from employment. 

(Id.). Furthermore, Dr. Habros' “Pain Functional Capacity Questionnaire” reported that

Plaintiff suffered from severe pain that constantly interferes with attention and

concentration. (Tr. 423). 

C. THE HEARING TESTIMONY

In June 2005, a hearing was held during which Plaintiff's counsel argued that

Plaintiff met the criteria for presumptive disability (Tr. 436) or, alternatively, that an

additional hearing should be held with agency medical expert testimony. (Tr. 440). 

Plaintiff testified that he suffered from ongoing pain symptoms of the neck and back since

his surgery in April 2002 (Tr. 451), and had problems involving his right arm (Tr. 449). 

Due to the persistence of Plaintiff's condition, Plaintiff's counsel argued for ongoing

disability benefits. (Tr. 469). When questioned by his attorney, Plaintiff testified

about his persistent, sometimes extreme pain. (Tr. 451). He said that it varies day-to-day

depending on his level of activity and his medication. (Id.). He testified about the

constant dysfunction of his right hand and occasional dysfunction of his left, depending

on level of activity. (Id.). Plaintiff describes the pain in the low back and the legs as

sharp, stabbing, and electric. (Id.). He states that the doctors are now focused on the

persisting body pain which was caused by spinal cord damage from the surgery. (Tr.

454). 

 When questioned by the ALJ, Plaintiff testified about his move to and from South

Carolina. (Tr. 455). The ALJ's questions highlighted Plaintiff’s various physical

activities, such as his participating in the drive to and from South Carolina, attending

school, driving to and from school, and his ability to play musical instruments. (Id.). 

Despite his condition, Plaintiff testified that he was enrolled in three music classes, to

keep his mind and body active, at the recommendation of a psychologist. (Tr. 444). 

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Plaintiff said he has difficulty driving (Tr. 443), writing (Tr. 445), reading (Tr. 446),

using a computer (Tr. 452), and playing musical instruments (Tr. 456) because of the pain

restrictions on moving his neck and hand cramping. (Tr. 445-446). He testified that he

must create modified “set-ups” for reading, note-taking, and exam-taking, in order to

compensate for his condition. (Tr. 461). Plaintiff's counsel requested that the ALJ

reject the July 2002 opinion of Dr. LaPrade, that Plaintiff could return to work just two

months after surgery, as inconsistent and inappropriate considering the other medical

evidence. (Tr. 437). Plaintiff testified that he discontinued wearing his collar for his

appointment with Dr. LaPrade in July, admitting that he was attempting to get a work

release as soon as possible in order to qualify to receive Workers' Compensation. (Tr.

450). Plaintiff was fired from his job and was unable to work after that due to his

condition. (Id.).

Maude Prall, a vocational expert (“VE”), testified that Plaintiff's previous jobs

were mostly sedentary or light work, with one medium-level work; all jobs had been

either skilled or semi-skilled. (Tr. 462). The ALJ presented the VE with a hypothetical

based on the nonexamining state agency form which asserted that Plaintiff was capable of

medium-level work. (Tr. 464). The VE responded that with the medium exertional level

capability recorded in the agency form, Plaintiff would be capable of performing all of his

previous jobs. (Tr. 464-465). Next, the ALJ's hypothetical was based on Plaintiff's

ability to perform light exertional work. (Tr. 465). The VE responded that Plaintiff

would be able to perform all of his past jobs except charter boat captain which was at the

medium level. (Id.). Plaintiff's counsel presented the VE with hypotheticals based on the

more recent medical assessments reported by treating physicians Dr. Bennett and Dr.

Habros. (Tr. 467-468). The VE responded that Plaintiff would not be able to sustain any

employment based on the severe level of pain reported by Dr. Habros, nor could he

sustain employment at the moderately severe level of pain reported by Dr. Bennett. (Id.). 

D. THE ALJ’S CONCLUSIONS

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In July 2005, the ALJ issued a partially favorable decision, granting Plaintiff

benefits from April 15, 2002 through April 30, 2003 (Tr. 20),but denying any further

coverage (Tr. 23). Turning to the five-step sequential evaluation process used by the ALJ

in determining an applicant's eligibility for disability, the ALJ first evaluated the time

period from April 15, 2002 through April 30, 2003; then the ALJ evaluated the time

period from April 30, 2003 until the present. 

In evaluating Plaintiff's case under step one, the ALJ found that Plaintiff had not

engaged in any “substantial gainful activity” since his surgery in April 2002. (Tr. 19). 

Under the second step, the ALJ found that Plaintiff's impairments were “severe.” (Tr.

20). These included “disorders of the back and neck, affective disorder, and anxiety

disorder.” (Id.). “Severe” impairments, as defined by the Social Security Administration,

are those that impose “more than a minimal effect on the claimant's physical or mental

ability to perform work related activities.” (Id.). 

Under step three, the ALJ evaluated whether Plaintiff's severe impairments met the

criteria for presumptive disability in the Listing of Impairments, and found that they did

not meet this criteria. (Tr. 20). The ALJ stated that, “there is no evidence of the

abnormal clinical findings necessary to reach listing level severity.” (Id.). The ALJ

states that it “considered the opinions of the State agency medical consultants” in support

of its decision. (Id.). The ALJ concludes that since no finding of disability can be

supported by the medical evidence alone, it was necessary to proceed to steps four and

five to determine if Plaintiff is disabled based on his residual functional capacity. (Id.). 

Under step four, the ALJ found that Plaintiff was unable to sustain work between

April 15, 2002 and April 30, 2003 because of his diminished residual functional capacity

following his surgery. (Tr. 20). However, the ALJ found that after May 1, 2003, Plaintiff

was able to perform his past relevant work. (Tr. 23). Also, the ALJ concluded that

Plaintiff's mental impairments were not significant enough to limit his residual functional

capacity. (Tr. 22). 

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Under the fifth step, the burden of proof shifts to the Social Security

Administration to show that there are other jobs in significant numbers that Plaintiff could

perform considering his age, education, work experience, and residual functional

capacity. (Tr. 23). The ALJ found that Plaintiff had no “transferable skills for jobs with

his reduced residual functional capacity” during the period from April 15, 2002 through

April 30, 2003, but that after May 1, 2003 Plaintiff could perform his past relevant work

at the light exertional level. (Id.). 

The ALJ rejected the medical opinions of treating physicians, Dr. Bennett and Dr.

Habros. (Tr. 27). The ALJ rejected Dr. Bennett's opinion because he had only seen

Plaintiff twice, and because he likely based his opinion on Plaintiff's allegations. (Id.). 

The ALJ concluded that Dr. Habros' opinion about Plaintiff's constant pain and physical

limitations was not supported by the treatment notes or the medical record as a whole, and

was also likely based on Plaintiff's allegations. (Id.). 

The ALJ also rejected Plaintiff's subjective complaints since May 1, 2003. (Tr.

26). According to the ALJ, the “objective medical evidence and minimal abnormal

clinical findings do not support the claimant's allegations.” (Id.). The ALJ refers to

progress notes citing improvement in Plaintiff's condition and Plaintiff's positive response

to injections and physical therapy in support of the conclusion that Plaintiff's condition

improved after May 1, 2003. (Tr. 24). The ALJ also notes Plaintiff's various physical

activities as inconsistent with his allegations of pain. (Tr. 26). Thus, the ALJ concluded

that Plaintiff was entitled to disability benefits from April 15, 2002 through April 30,

2003, but denied any further benefits from the Social Security Administration. (Tr. 29). 

IV. DISCUSSION

Plaintiff claims that the ALJ did not provide sufficient evidence to support its 

determination that Plaintiff was no longer disabled after May 1, 2003. Plaintiff has raised

the following grounds for error in this appeal. First, Plaintiff claims the ALJ erred in

rejecting the treating physician assessments by not referencing “specific and legitimate”

reasons supported by substantial evidence in the record. (Dkt. #21, p.6). Second,

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Plaintiff claims the ALJ erred by adopting the July 2002 opinion of Dr. LaPrade and the

assessments of nonexamining state agency physicians to find that Plaintiff was able to

work after May 1, 2003. (Id. at 14). Third, Plaintiff claims the ALJ erred by discounting

Plaintiff’s symptom complaints in the absence of clear and convincing reasons for doing

so. (Id. at 9). Fourth, Plaintiff claims the ALJ erred by determining Plaintiff’s residual

functional capacity to be at the light exertional level after May 1, 2003. (Id. at 18). 

Finally, Plaintiff claims the ALJ erred by concluding that Plaintiff’s impairments did not

meet the criteria for presumptive disability and for failing to call a medical expert to

testify on behalf of this conclusion. (Id.).

Defendant argues that the ALJ set forth substantial evidence in support of the

determination that Plaintiff was no longer disabled after May 1, 2003. (Dkt. #25, p. 2). 

According to Defendant, the ALJ interpreted the record in the light most favorable to

Plaintiff by granting disability from April 15, 2002 through April 30, 2003, despite

“increasing medical evidence of improvement,” and the medical opinions of Dr. LaPrade

and of non-examining physician’s that Plaintiff was capable of work. (Id.). 

A. THE ALJ’S DECISION TO REJECT THE OPINIONS OF DR. BENNETT

AND DR. HABROS

Plaintiff asserts that the ALJ improperly rejected treating physician’s assessments

as to Plaintiff’s pain and disability, and wrongfully accepted Dr. LaPrade’s and

non-examining physician’s opinions that Plaintiff was capable of work. As a general

rule, a treating physician’s opinion is afforded more weight than the opinion of an

examining physician; and an examining physician’s opinion is afforded more weight than

the opinion of a non-examining physician. Lester v. Chater, 81 F.3d 821, 830-31 (9th

1995); Lawson v. Massanari, 231 F. Supp. 2d 986, 996 (D.Or. 2001). Where a treating

physician’s opinion is uncontradicted by another physician, it may be rejected by the ALJ

only for “clear and convincing reasons” supported by substantial evidence in the record as

a whole, and, even if contradicted, the treating physician’s opinion may not be rejected

without “specific, legitimate reasons for doing so that are based on evidence in the

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record.” Murray v. Heckler, 722 F.2d 499, 502 (9th Cir. 1983). The ALJ can meet this

burden by setting out a detailed and thorough summary of the facts and conflicting

clinical evidence, stating his interpretation thereof, and making findings. Thomas v.

Barhhart, 278 F.3d 947, 957 (9th 2002) (quoting Magallanes v. Bowen, 881 F.2d 747,

751 (9th Cir. 1989)). Thus, the question before the Court is whether the ALJ properly

considered and disregarded two treating physicians’ opinions that Plaintiff suffered from

significant levels of pain. 

In this case, the ALJ did not provide specific and legitimate reasons supported by

evidence for rejecting the May 2005 opinions of treating specialists, Dr. Bennett or Dr.

Habros, that led to the vocational expert’s determination that Plaintiff was still disabled. 

The reasons set forth by the ALJ for rejecting Dr. Bennett’s opinion are that Dr. Bennett

only saw Plaintiff on two occasions and that there were “minimal abnormal clinical

findings and no objective evidence.” (Tr. 27). The ALJ also stated that “Dr. Bennett’s

opinion is likely based on the claimant’s allegations.” (Id.). The ALJ rejected Dr.

Habros’ opinion that Plaintiff could not perform sedentary work because it was “not

supported in Dr. Habros’ treatment notes, which show numerous complaints by the

claimant but minimal abnormal findings” (Id.). The ALJ’s reason for rejecting Dr.

Habros’ opinion that Plaintiff suffered from “severe constant pain" "is not supported in

the treatment notes or medical record as a whole.” (Id.). The ALJ has failed to recognize

the deferential value of treating physician’s opinions by not providing specific and

legitimate reasons for the rejection supported by evidence in the record. Thus, the ALJ

has committed a reversible legal error. The adoption of the recent treating physician’s

opinions on remand will naturally coincide with a rejection of the non-examining state

agency physicians’ opinions and the July 2002 opinion of Dr. LaPrade. 

B. THE ALJ’S REJECTION OF PLAINTIFF’S CREDIBILITY

Plaintiff contends that the ALJ erred by not crediting his symptom testimony. 

(Dkt#21, p.9). According to the 9th Circuit, “once the claimant produces objective

medical evidence of an underlying impairment, and adjudicator may not reject a

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claimant’s subjective complaints based solely on a lack of objective medical evidence to

fully corroborate the alleged severity of pain.” Bunnell v. Sullivan, 947 F.2d, 341, 345

(9th Cir. 1991) (citing Cotton v. Bowen, 799 F.2d 1403, 1407 (9th Cir. 1986)). “Unless

there is affirmative evidence showing that the claimant is malingering, the

Commissioner’s reasons for rejecting the claimant’s evidence must be "clear and

convincing.” Lester, 81 F.3d at 834. Participating in daily activity does not discredit a

claim for disability unless the level of activity is inconsistent with the claimed limitations. 

Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998); Lester, 81 F.3d at 833.

The ALJ broadly concluded that “[t]he objective medical evidence and abnormal

clinical findings do not fully support the extent of the claimant’s pain and limitations”

(Tr. 23) and that “[t]his evidence is likely to cause some pain, but not to the extent

alleged.” (Tr. 24). The ALJ cites occasional positive responses to treatment and

medication to support this conclusion. The ALJ also stated that “claimant’s allegations . .

. are inconsistent with his abilities,” citing various household chores, school attendance,

etc. (Tr. 26). 

In this case, there is substantial evidence of Plaintiff’s underlying impairment. 

Upon examining the record, it is clear that the ALJ has erred in characterizing the medical

record in a way that would indicate Plaintiff’s allegations were exaggerated. Although

Plaintiff experienced periodic relief from symptoms, Plaintiff consistently sought and

received medical treatment for neurologic and rheumatologic pain symptoms long after

May 1, 2003. The Ninth Circuit has recognized that an ability to engage in daily

activities does not support the conclusion that a plaintiff is able to work on a sustained

basis. Reddick, 157 F.3d at 722. Since there is substantial evidence of an underlying

condition likely to cause pain, and there is no evidence of malingering, the ALJ erred in

failing to provide clear and convincing reasons for discounting Plaintiff’s symptom

testimony. 

Plaintiff’s fourth claim is that the ALJ erred in determining his residual functional

capacity to have changed beginning May 1, 2003. (Dkt #21, p.17). After that date, the

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ALJ found that Plaintiff was capable of performing light exertional level work (Tr. 26),

based on the medical opinions of Dr. LaPrade, the non-examining physicians opinions,

and Plaintiff’s activities. (Dkt.#25, p.6). The adoption of the treating physician’s

testimony and Plaintiff’s testimony of his pain and limitations will automatically cure this

defect in the ALJ’s conclusion about Plaintiff’s ability to perform light work. When

given hypothetical questions based on Dr. Bennett’s and Dr. Habros’ assessments of

Plaintiff, the vocational expert testified that Plaintiff would not be able to sustain any kind

of employment. (Tr. 467-438). This testimony support a finding that Plaintiff continues

to be disabled for Social Security purposes. 

C. LISTED IMPAIRMENT 1.04A 

Plaintiff’s final claim is that the ALJ erred in not accepting Plaintiff’s impairment

as one of the specifically listed impairments for presumptive disability described in the

Social Security Regulations, 20 C.F.R., Part 404, Subpart P, Appendix 1. (Dkt. #21, p.

18). At the third step of the disability evaluation process described above, if the

impairment “meets or equals” one of the impairments listed under Appendix 1, then the

claimant is disabled for the purposes of receiving disability benefits. Tackett v. Apfel,

180 F.3d 1095, 1098 (9th Cir. 1999). Only if the claimant does not meet this criteria must

the inquiry proceed to the fourth and fifth steps of the inquiry which were already

addressed above. 

Plaintiff claims to meet or equal the listing criteria for “Disorder of the Spine”

because: 

He suffers a disorder of the spine, e.g., spinal stenosis, degenerative disc

disease, facet arthritis resulting in compromise of a nerve root or the spinal

cord with evidence of nerve root compression characterized by

neuro-anatomic distribution of pain, limitation of motion of the spine, motor

loss, i.e., atrophy with associated muscle weakness or muscle weakness

accompanied by sensory or reflex loss.

(Dkt. #21, p.19) (internal citations ommitted). Plaintiff argues that there is evidence in

the record establishing all of these elements and that the ALJ erred by concluding that

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Plaintiff did not meet this criteria. The ALJ states that “there is no evidence of the

abnormal clinical findings necessary to reach listing level severity” and relies on the

opinions of the non-examining state agency physicians to support this determination. (Tr.

20). In support of the ALJ’s conclusion, the Commissioner reiterates the ALJ’s

determination in a footnote. (Dkt. # 25, p.3). 

The ALJ erred in failing to provide substantial evidence in support of its

determination that Plaintiff did not meet the requirements of “Disorder of the Spine”

under 1.04A. Although the ALJ may have “properly considered and rejected" the

evidence, the ALJ did not thoroughly discuss the evidence as required by the Ninth

Circuit.” Tackett, 180 F.3d at 1100. Upon review of the requirements for “Disorder of

the Spine,” as articulated in the Social Security regulations, it clear that substantial

evidence in the record supports a finding that Plaintiff suffers from a spinal disorder, and

is per se disabled under the third step of the disability evaluation. Since rejecting

Plaintiff’s claim of per se disability is not the only error committed by the ALJ, the Court

will proceed with remanding this case for benefits rather than further proceedings on this

issue, as authorized by the Ninth Circuit. Lester, 81 F.3d at 830; Holohan v. Massanari,

246 F.3d 1195, 1211 (9th Cir. 2001).

V. CONCLUSION

Upon review of the entire record, and in accordance with the above analysis and

findings, the Court concludes that the ALJ’s decision that Plaintiff was no longer disabled

after May 1, 2003 was not supported by substantial evidence based on the record as a

whole, nor was it free from legal error. The ALJ erred by selectively focusing on the

evidence that suggested non-disability, while ignoring the substantial evidence in the

record that supported a finding that Plaintiff continues to suffer from an ongoing severe

disability. In particular, the Court concludes that the ALJ erred by not affording more

weight to Plaintiff’s symptom testimony and the opinions of Plaintiff’s treating

physicians. 

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A remand for an award for benefits is appropriate “where 1) the ALJ has failed to

articulate legally sufficient reasons for rejecting evidence; 2) there are no outstanding

issues that must be resolved before a determination of disability can be made; and 3) it is 

clear from the record that the ALJ would be required to find the claimant disabled if such

evidence is credited.” Smolen v. Chater, 80 F.3d 1273, 1292 (9th Cir. 1996). Here, the

ALJ has failed to articulate legally sufficient reasons for finding that Plaintiff was not

disabled after May 1, 2003. Once credit is given to the treating physician’s and Plaintiff’s

testimony, there are no longer any outstanding issues and the ALJ would be required to

find that Plaintiff is disabled for Social Security purposes. The Court concludes that on

remand, the only determination necessary is that of disability benefits owed to Plaintiff

from May 1, 2003 forward. 

Accordingly, 

IT IS HEREBY ORDERED that Plaintiff’s Motion for Summary Judgment is

GRANTED.

IT IS FURTHER ORDERED that the Commissioner’s Cross-Motion for

Summary Judgment is DENIED.

IT IS FURTHER ORDERED remanding the case for an award of disability

benefits owed Plaintiff from May 1, 2003 to the present. 

DATED this 24th day of September, 2007.

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