Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_13-cv-01569/USCOURTS-azd-2_13-cv-01569-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

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WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Christina D. Murillo, 

Plaintiff, 

v. 

Carolyn W. Colvin, 

Defendant.

No. CV-13-01569-PHX-DGC

ORDER 

Plaintiff Christina D. Murillo seeks review under 42 U.S.C. § 405(g) of the final 

decision of the Commissioner of Social Security (“the Commissioner”), which denied her 

disability insurance benefits and supplemental security income under sections 216(i), 

223(d), and 1614(a)(3)(A) of the Social Security Act. Because the decision of the 

Administrative Law Judge (“ALJ”) is based on legal error, the Commissioner’s decision 

will be vacated and the matter remanded for an award of benefits. 

I. Background. 

Plaintiff was born in December 1975. She has a bachelor’s degree in social work 

and has previously worked as a benefits administrator and a benefits specialist. 

On September 3, 2009, Plaintiff applied for disability insurance benefits. On 

July 13, 2010, she applied for supplemental security income. She alleged disability 

beginning July 29, 2009 in both applications. On October 17, 2011, she appeared with 

her attorney and testified at a hearing before the ALJ. A vocational expert also testified. 

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On November 10, 2011, the ALJ issued a decision finding that Plaintiff was not 

disabled within the meaning of the Social Security Act. The Appeals Council denied 

Plaintiff’s request for review of the hearing decision, making the ALJ’s decision the 

Commissioner’s final decision. 

II. Standard of Review. 

The district court reviews only those issues raised by the party challenging the 

ALJ’s decision. See Lewis v. Apfel, 236 F.3d 503, 517 n.13 (9th Cir. 2001). The court 

may set aside the Commissioner’s disability determination only if the determination is 

not supported by substantial evidence or is based on legal error. Orn v. Astrue, 495 F.3d 

625, 630 (9th Cir. 2007). Substantial evidence is more than a scintilla, less than a 

preponderance, and relevant evidence that a reasonable person might accept as adequate 

to support a conclusion considering the record as a whole. Id. In determining whether 

substantial evidence supports a decision, the court must consider the record as a whole 

and may not affirm simply by isolating a “specific quantum of supporting evidence.” Id. 

As a general rule, “[w]here the evidence is susceptible to more than one rational 

interpretation, one of which supports the ALJ’s decision, the ALJ’s conclusion must be 

upheld.” Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002) (citations omitted). 

III. ALJ’s Five-Step Sequential Evaluation Process. 

To determine whether a claimant is disabled for purposes of the Social Security 

Act, the ALJ follows a five-step process. 20 C.F.R. § 404.1520(a). The claimant bears 

the burden of proof on the first four steps, but at step five, the burden shifts to the 

Commissioner. Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). 

At the first step, the ALJ determines whether the claimant is engaging in 

substantial gainful activity. 20 C.F.R. § 404.1520(a)(4)(i). If so, the claimant is not 

disabled and the inquiry ends. Id. At step two, the ALJ determines whether the claimant 

has a “severe” medically determinable physical or mental impairment. 

§ 404.1520(a)(4)(ii). If not, the claimant is not disabled and the inquiry ends. Id. At step 

three, the ALJ considers whether the claimant’s impairment or combination of 

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impairments meets or medically equals an impairment listed in Appendix 1 to Subpart P 

of 20 C.F.R. Pt. 404. § 404.1520(a)(4)(iii). If so, the claimant is automatically found to 

be disabled. Id. If not, the ALJ proceeds to step four. At step four, the ALJ assesses the 

claimant’s residual functional capacity (“RFC”) and determines whether the claimant is 

still capable of performing past relevant work. § 404.1520(a)(4)(iv). If so, the claimant 

is not disabled and the inquiry ends. Id. If not, the ALJ proceeds to the fifth and final 

step, where he determines whether the claimant can perform any other work based on the 

claimant’s RFC, age, education, and work experience. § 404.1520(a)(4)(v). If so, the 

claimant is not disabled. Id. If not, the claimant is disabled. Id. 

At step one, the ALJ found that Plaintiff meets the insured status requirements of 

the Social Security Act through December 31, 2014, and that she has not engaged in 

substantial gainful activity since July 29, 2009. At step two, the ALJ found that Plaintiff 

has the following severe impairments: fibromyalgia, migraine headaches, and obesity. 

The ALJ also found that Plaintiff has mild sleep apnea. At step three, the ALJ 

determined that Plaintiff does not have an impairment or combination of impairments that 

meets or medically equals an impairment listed in Appendix 1 to Subpart P of 20 C.F.R. 

Pt. 404. At step four, the ALJ found that Plaintiff has the RFC to perform: 

[L]ight work as defined in 20 CFR 404.1567(b) and 

416.967(b), with the ability to lift and carry 10 pounds 

frequently and 20 pounds occasionally, sit, stand and walk for 

6 out of 8 hours per day with a sit-stand option required at 

will, unlimited pushing and pulling with the upper and lower 

extremities as long as within these weight limits, occasional 

balancing, climbing, crouching and crawling, frequent 

stooping and kneeling, and the need to avoid extremely cold 

temperatures, dust, fumes and gases, humidity, hazardous 

heights and moving machinery, and no more than moderate 

noise levels, and the ability to tolerate office-level noise. 

A.R. 23-24. The ALJ further found that Plaintiff is able to perform her past relevant 

work as a benefits administrator or benefits specialist because such work does not require 

the performance of work-related activities precluded by Plaintiff’s RFC. 

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IV. Analysis. 

Plaintiff argues the ALJ’s decision is defective for two reasons: (1) the ALJ 

erroneously weighed medical source evidence, and (2) the ALJ improperly evaluated 

Plaintiff’s credibility and discounted her subjective testimony. Because the Court finds 

that the ALJ erroneously weighed medical source evidence, it need not address Plaintiff’s 

assertion that the ALJ improperly evaluated her credibility. 

A. Weighing of Medical Source Evidence. 

Plaintiff argues that the ALJ improperly weighed the medical opinions of the 

following medical sources: treating physicians Drs. Dai, Bhalla, and Tran; examining 

psychologist Dr. Walter; licensed professional counselor Mr. Tucker; and examining 

physical therapist and disability specialist Mr. Randall. Doc. 10 at 5. Because the Court 

finds that the ALJ erroneously weighed Dr. Dai’s medical opinion, it will not address 

Plaintiff’s arguments regarding the other medical sources. 

1. Legal Standard. 

The Ninth Circuit distinguishes between the opinions of treating physicians, 

examining physicians, and non-examining physicians. See Lester v. Chater, 81 F.3d 821, 

830 (9th Cir. 1995). Generally, an ALJ should give greatest weight to a treating 

physician’s opinion and more weight to the opinion of an examining physician than to 

one of a non-examining physician. See Andrews v. Shalala, 53 F.3d 1035, 1040-41 (9th 

Cir. 1995); see also 20 C.F.R. § 404.1527(c)(2)-(6) (listing factors to be considered when 

evaluating opinion evidence, including length of examining or treating relationship, 

frequency of examination, consistency with the record, and support from objective 

evidence). If it is not contradicted by another doctor’s opinion, the opinion of a treating 

or examining physician can be rejected only for “clear and convincing” reasons. Lester, 

81 F.3d at 830 (citing Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir. 1988)). A 

contradicted opinion of a treating or examining physician “can only be rejected for 

specific and legitimate reasons that are supported by substantial evidence in the record.” 

Lester, 81 F.3d at 830-31 (citing Andrews, 53 F.3d at 1043). 

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An ALJ can meet the “specific and legitimate reasons” standard “by setting out a 

detailed and thorough summary of the facts and conflicting clinical evidence, stating his 

interpretation thereof, and making findings.” Cotton v. Bowen, 799 F.2d 1403, 1408 (9th 

Cir. 1986). But “[t]he ALJ must do more than offer [her] conclusions. [She] must set 

forth [her] own interpretations and explain why they, rather than the doctors’, are 

correct.” Embrey, 849 F.2d at 421-22. The Commissioner is responsible for determining 

whether a claimant meets the statutory definition of disability and does not give 

significance to a statement by a medical source that the claimant is “disabled” or “unable 

to work.” 20 C.F.R. § 416.927(d). 

2. Anita Dai, M.D. 

Plaintiff’s treating physician, Anita Dai, M.D., specializes in internal medicine. 

Doc. 10 at 5. On November 6, 2010, Dr. Dai opined that Plaintiff suffered from frequent 

migraine headaches lasting three hours or more. A.R. 541. She opined that Plaintiff’s 

headaches were accompanied with vertigo/dizziness, nausea, fatigue, and pain, and that 

the headaches occurred 15 times per month. Id. She further opined that Plaintiff had 

moderate restrictions on exposure to unprotected heights, moving machinery, marked 

changes in temperature and humidity, and dust, fumes and gases. Id. The ALJ did not 

accord Dr. Dai’s opinion about Plaintiff’s migraine headaches “greater weight” because, 

the ALJ explained, “the greater objective record fails to show [Plaintiff’s] headaches 

have occurred as frequently or with the severity of those cited by Dr. Dai, or that 

[Plaintiff] is otherwise unable to sustain at least sedentary work activity.” A.R. 27. 

Dr. Dai’s medical opinion was contradicted by the opinions of Drs. Marc 

Wasserman, M.D. and D. Fruchtman, D.O., examining physicians who opined that 

Plaintiff had greater abilities than those identified in Dr. Dai’s opinion. A.R. 25-26. The 

ALJ therefore could discount Dr. Dai’s opinion for specific and legitimate reasons 

supported by substantial evidence. Lester, 81 F.3d at 830-31. 

Unfortunately, the ALJ’s reason for discounting Dr. Dai’s opinion was limited to a 

single phrase – “the greater objective record fails to show the claimant’s headaches have 

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occurred as frequently or with the severity of those cited by Dr. Dai” – and no citations to 

the record. AR 27.1

 If the Court looks elsewhere in the ALJ’s opinion to try and 

determine the reasons for the ALJ’s conclusion, little support can be found. 

The ALJ’s discussion of the record provides only two references to migraine 

headaches that plausibly contradict Dr. Dai’s opinion. First, the ALJ cites Dr. 

Wasserman’s statement that Plaintiff’s migraines were “under decent control.” A.R. 25, 

716. But Dr. Wasserman did not explain what he meant by “decent control,” and his 

opinion states that Plaintiff suffers from migraine headaches three times per week. 

AR 716. Second, the ALJ states that “[a]s of April 28, 2011, [Plaintiff] reported 

improvement in her headaches.” Unfortunately, the ALJ provides no citation to the 

1,095-page record for this statement. A.R. 25. 

That’s it. The ALJ’s opinion cites no other portions of the “greater objective 

record” to support her conclusion that Plaintiff’s headaches occur less frequently and 

with less severity than described by Dr. Dai. Mere references to an unclear statement by 

Dr. Wasserman and an incited report by Plaintiff, neither of which is even mentioned in 

the ALJ’s discussion of Dr. Dai’s opinion, certainly do not constitute specific and 

legitimate reasons supported by substantial evidence in the record. Nor do they satisfy 

the Ninth Circuit’s requirement that the ALJ provide a “detailed and thorough summary 

of the facts and conflicting clinical evidence, stating [her] interpretation thereof, and 

making findings.” Cotton, 799 F.2d at 1408. 

The Commissioner admits “that Plaintiff had ‘severe’ migraine headaches,” but 

argues that Plaintiff’s neurological exams were consistently normal and provides 

numerous supporting citations. Doc. 14 at 9. The Court cannot, however, consider 

reasons or factual findings not provided by the ALJ. “Long-standing principles of 

administrative law require us to review the ALJ’s decision based on the reasoning and 

factual findings offered by the ALJ – not post hoc rationalizations that attempt to intuit 

 

1

 The only two citations in this paragraph of the ALJ’s opinion are to Dr. Dai’s opinions. AR 27. 

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what the adjudicator may have been thinking.” Bray v. Comm’r of Soc. Sec. Admin., 554 

F.3d 1219, 1225 (9th Cir. 2009). The same is true for the Commissioner’s assertion that 

Plaintiff denied headaches, that Plaintiff reported fewer headaches, or that Drs. 

Wasserman, Mantey, and Johnson – and Dr. Dai herself – all concluded that Plaintiff’s 

headaches were controlled or stable with treatment. Doc. 14 at 10, 13. None of these 

reasons was cited by the ALJ, and the Court cannot “intuit” from her vague reference to 

“the greater objective record” that she relied on them.2

 

Because the ALJ clearly failed to provide specific and legitimate reasons 

supported by substantial evidence for discounting Dr. Dai’s opinion, the Court concludes 

that the ALJ committed legal error. Her decision must therefore be vacated.3

 

B. Remand. 

Where an ALJ fails to provide adequate reasons for rejecting the opinion of a 

physician, the Court must credit that opinion as true. Lester, 81 F.3d at 834. An action 

should be remanded for an immediate award of benefits when the following three factors 

are satisfied: (1) the ALJ has failed to provide 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 were such evidence credited as true. Smolen v. 

Chater, 80 F.3d 1273, 1292 (9th Cir.1996). 

 

2

 Defendant’s brief included a thorough and careful review of the record, as well 

as detailed arguments. Defendant is reminded, however, of the need to comply with the Court’s local rules on lines per page and font size in text and footnotes. See LRCiv 

7.1(b)(1). 

3

 Although the Court need not address them, the ALJ discounted the opinions of Drs. Bhalla and Tran for the same cryptic reason – that their opinions were not supported by “the greater objective record.” AR 28. When the Ninth Circuit has repeatedly instructed that treating physician opinions may be discounted by ALJs only for clear and convincing or specific and legitimate reasons, the Court finds it very frustrating to see opinions such as the one in this case. Such opinions invite reversal and remand for an 

award of benefits under the established credit-as-true doctrine, when simple compliance with the Ninth Circuit’s longstanding instructions for writing decisions might well result in different outcomes. 

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At Plaintiff’s hearing, a vocational expert testified that an individual who suffered 

from less severe and less frequent headaches than those described in Dr. Dai’s opinion 

would be disabled. A.R. 57. When Dr. Dai’s opinion is credited as true, therefore, the 

expert opinion makes clear that the Court must remand for an award of benefits. 

IT IS ORDERED:

1. The final decision of the Commissioner of Social Security is vacated and 

this case is remanded for an award of benefits. 

2. The Clerk shall enter judgment accordingly and terminate this action. 

Dated this 28th day of May, 2014. 

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