Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_15-cv-01490/USCOURTS-azd-2_15-cv-01490-0/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 

Kelly Teresa Fisher, 

Plaintiff, 

v. 

Carolyn W. Colvin, Acting Commissioner 

of Social Security, 

Defendant. 

No. CV-15-01490-PHX-NVW 

ORDER 

Plaintiff Kelly Teresa Fisher 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 not supported by substantial evidence and is based 

on legal error, the Commissioner’s decision will be vacated and the matter remanded for 

calculation and award of benefits. 

I. BACKGROUND 

Plaintiff was born in May 1967 and was 42 years old at the onset of her disability. 

She completed a high school education and obtained a cosmetology license. Her only 

past relevant work was as a staffing coordinator. She underwent a spinal laminectomy in 

2001 and a spinal fusion in 2004. She had a spinal cord stimulator implanted in 2006. In 

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addition to these procedures, she has had spinal injections. She suffers from chronic back 

pain, migraine headaches, fatigue, insomnia, and depression. 

In August 2011, Plaintiff applied for disability insurance benefits and 

supplemental security income, alleging disability beginning March 20, 2010. On 

September 9, 2013, she appeared with her attorney and testified at a hearing before the 

ALJ. A vocational expert also testified. On December 19, 2013, the ALJ issued a 

decision 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. On August 3, 2015, 

Plaintiff sought review by this Court. 

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); 

accord Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012) (“Even when the evidence 

is susceptible to more than one rational interpretation, we must uphold the ALJ’s findings 

if they are supported by inferences reasonably drawn from the record.”). 

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III. 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 the burden shifts to the Commissioner at 

step five. 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 

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 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 residual functional capacity, 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, 2015, and that she has not engaged in 

substantial gainful activity since March 20, 2010. At step two, the ALJ found that 

Plaintiff has the following severe impairments: lumbar degenerative disc disease, facet 

osteoarthritis, left S1 radiculopathy (compressed nerve), left sacroiliac arthralgia (joint 

pain), migraine, headaches, and chronic pain syndrome. At step three, the ALJ 

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

meets or medically equals an impairment listed in 20 C.F.R. Part 404, Subpart P, 

Appendix 1. 

At step four, the ALJ found that Plaintiff: 

has the residual functional capacity to perform the full range of light work 

as defined in 20 CFR 404.1567(b) and 416.967(b) with the following 

limitations: The claimant is capable of no more than occasional postural 

maneuvers such as balancing, stooping, kneeling, crouching, crawling and 

climbing on ramps and stairs; but must avoid climbing on ladders, ropes 

and scaffolds. The claimant cannot be exposed to dangerous machinery 

and unprotected heights. She will require a sit/stand option at will provided 

it include not being off task for more than 10% of the day. 

The ALJ further found that Plaintiff is capable of performing past relevant work as a 

staffing coordinator. 

IV. ANALYSIS 

A. The ALJ Did Not Provide Clear and Convincing Reasons for 

Discrediting Plaintiff’s Symptom Testimony. 

In evaluating the credibility of a claimant’s testimony regarding subjective pain or 

other symptoms, the ALJ is required to engage in a two-step analysis: (1) determine 

whether the claimant presented objective medical evidence of an impairment that could 

reasonably be expected to produce some degree of the pain or other symptoms alleged; 

and, if so with no evidence of malingering, (2) reject the claimant’s testimony about the 

severity of the symptoms only by giving specific, clear, and convincing reasons for the 

rejection. Vasquez v. Astrue, 572 F.3d 586, 591 (9th Cir. 2009). “This is not an easy 

requirement to meet: ‘The clear and convincing standard is the most demanding required 

in Social Security cases.’” Garrison v. Colvin, 759 F.3d 995, 1015 (9th Cir. 2014) 

(quoting Moore v. Comm’r of Soc. Sec. Admin., 278 F.3d 920, 924 (9th Cir. 2002)). 

If a claimant’s statements about pain or other symptoms are not substantiated by 

objective medical evidence, the ALJ must consider all of the evidence in the case record, 

including any statement by the claimant and other persons, concerning the claimant’s 

symptoms. SSR96-7p. Then the ALJ must make a finding on the credibility of the 

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claimant’s statements about symptoms and their functional effects. Id. The claimant is 

not required to produce objective medical evidence of the symptom or its severity. 

Garrison, 759 F.3d at 1014. 

In making a credibility determination, an ALJ “may not reject a claimant’s 

subjective complaints based solely on a lack of objective medical evidence to fully 

corroborate the claimant’s allegations.” Bray v. Comm’r of Soc. Sec. Admin., 554 F.3d 

1219, 1227 (9th Cir. 2009) (internal quotation marks and citation omitted). But “an ALJ 

may weigh inconsistencies between the claimant’s testimony and his or her conduct, 

daily activities, and work record, among other factors.” Id. The ALJ must consider all of 

the evidence presented, including the claimant’s daily activities; the location, duration, 

frequency, and intensity of the pain or other symptoms; factors that precipitate and 

aggravate the symptoms; effectiveness and side effects of any medication taken to 

alleviate pain or other symptoms; treatment other than medication; any measures other 

than treatment the claimant uses to relieve pain or other symptoms; and any other factors 

concerning the claimant’s functional limitations and restrictions due to pain or other 

symptoms. SSR 96-7p. 

To ensure meaningful review, the ALJ must specifically identify the testimony 

from a claimant the ALJ finds not to be credible and explain what evidence undermines 

the testimony. Treichler v. Comm’r of Soc. Sec. Admin., 775 F.3d 1090, 1102 (9th Cir. 

2014). “General findings are insufficient.” Id. The ALJ must make findings 

“sufficiently specific to permit the court to conclude that the ALJ did not arbitrarily 

discredit claimant’s testimony.” Thomas v. Barnhart, 278 F.3d 947, 958 (9th Cir. 2002); 

accord Tommasetti v. Astrue, 533 F.3d 1035, 1039 (9th Cir. 2008). 

Here, the ALJ found that Plaintiff’s “medically determinable impairments could 

reasonably be expected to cause the alleged symptoms.” The medically determinable 

impairments found by the ALJ are lumbar degenerative disc disease, osteoarthritis, left 

sacroiliac joint pain and radiculopathy, migraines, headaches, and chronic pain syndrome. 

Then the ALJ found Plaintiff’s “statements regarding the intensity, persistence, and 

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limiting effects of the symptoms not entirely credible to the extent they are inconsistent 

with the residual functional capacity assessment.” 

Plaintiff testified that she is unable to sit, walk, or stand for any length of time 

because of the pain it causes. She said she is unable to bend or crouch and has difficulty 

lifting her legs to get in and out of the shower and to get dressed. She further testified 

that she has a lot of pain in her legs with swelling and cramping. Plaintiff also testified 

that she is taking a lot of medication for these symptoms, which makes her drowsy and 

unable to function. She said she lies in bed most of the day, watching television. She 

testified that she makes only easy, fast meals, such as soup or microwave meals. She said 

she rarely drives and only goes grocery shopping with assistance. Plaintiff testified that 

she follows her physician’s instructions regarding medications, stretching, and applying 

ice and heat. 

The ALJ found Plaintiff’s “alleged impairments and her characterization of pain 

are not consistent with the medical evidence of record.” The ALJ commented that 

Plaintiff was able to work in the past with her back impairment and stopped working due 

to kidney stones. The ALJ stated that Plaintiff did not take any medication from April 

2011 until 2013, has had only limited conservative treatment for pain, and has had 

minimal treatment for her back impairments. The ALJ acknowledged that “the 

occasional gaps in treatment are due to the lack of insurance and funds to receive care,” 

but concluded “the medical evidence that is present in the record does not support the 

claimant’s allegations of disabling symptoms and limitations.” The ALJ found that the 

treatment records, diagnostic studies, and physical examinations do not support Plaintiff’s 

allegations of disabling symptoms and limitations. The ALJ further concluded, “The 

claimant’s subjective complaints are less than fully credible and the objective medical 

evidence does not support the alleged severity of symptoms.” 

The ALJ did not identify the specific testimony from Plaintiff the ALJ found not 

to be credible and did not explain what evidence undermines the testimony. See 

Treichler, 775 F.3d at 1102. The ALJ did not expressly consider all of the record 

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evidence, such as Plaintiff’s daily activities, location of pain, factors that precipitate and 

aggravate the symptoms, effectiveness and side effects of any medication taken to 

alleviate pain or other symptoms, treatment other than medication; and measures Plaintiff 

uses to relieve pain. See SSR 96-7p. The ALJ impermissibly rejected Plaintiff’s 

“subjective complaints based solely on a lack of objective medical evidence to fully 

corroborate the claimant’s allegations.” See Bray, 554 F.3d at 1227. Finally, the ALJ 

failed to make findings “sufficiently specific to permit the court to conclude that the ALJ 

did not arbitrarily discredit claimant’s testimony.” See Thomas, 278 F.3d at 958. 

B. The ALJ Erred in Weighing Medical Source Opinion Evidence. 

1. Legal Standard 

In weighing medical source opinions in Social Security cases, the Ninth Circuit 

distinguishes among three types of physicians: (1) treating physicians, who actually treat 

the claimant; (2) examining physicians, who examine but do not treat the claimant; and 

(3) non-examining physicians, who neither treat nor examine the claimant. Lester v. 

Chater, 81 F.3d 821, 830 (9th Cir. 1995). The Commissioner must give weight to the 

treating physician’s subjective judgments in addition to his clinical findings and 

interpretation of test results. Id. at 832-33. Where a treating physician’s opinion is not 

contradicted by another physician, it may be rejected only for “clear and convincing” 

reasons, and where it is contradicted, it may not be rejected without “specific and 

legitimate reasons” supported by substantial evidence in the record. Id. at 830; Orn v. 

Astrue, 495 F.3d 625, 632 (9th Cir. 2007) (where there is a conflict between the opinion 

of a treating physician and an examining physician, the ALJ may not reject the opinion of 

the treating physician without setting forth specific, legitimate reasons supported by 

substantial evidence in the record). 

“Even if a treating physician’s opinion is contradicted, the ALJ may not simply 

disregard it. The ALJ is required to consider the factors set out in 20 C.F.R. 

§ 404.1527(c)(2)-(6) in determining how much weight to afford the treating physician’s 

medical opinion.” Ghanim v. Colvin, 763 F.3d 1154, 1161 (9th Cir. 2014). If a treating 

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source’s medical opinion does not meet the test for controlling weight, it still may be 

entitled to the greatest weight and should be adopted. Id. “Similarly, an ALJ may not 

simply reject a treating physician’s opinions on the ultimate issue of disability.” Id. The 

ALJ may, however, discount a treating provider’s opinion if it is based primarily on the 

claimant’s self-reports and the ALJ finds the claimant not credible. Id. at 1162. 

Further, an examining physician’s opinion generally must be given greater weight 

than that of a non-examining physician. Lester, 81 F.3d at 830. As with a treating 

physician, there must be clear and convincing reasons for rejecting the uncontradicted 

opinion of an examining physician, and specific and legitimate reasons, supported by 

substantial evidence in the record, for rejecting an examining physician’s contradicted 

opinion. Id. at 830-31. The opinion of a non-examining physician is not itself substantial 

evidence that justifies the rejection of the opinion of either a treating physician or an 

examining physician. Id. at 831. 

Factors that an ALJ may consider when evaluating any medical opinion include 

“the amount of relevant evidence that supports the opinion and the quality of the 

explanation provided; the consistency of the medical opinion with the record as a whole; 

[and] the specialty of the physician providing the opinion.” Orn, 495 F.3d at 631. In 

deciding weight to give any medical opinion, the ALJ considers not only whether the 

source has a treating or examining relationship with the claimant, but also whether the 

treatment or examination is related to the alleged disability, the length of the relationship, 

frequency of examination, supporting evidence provided by the source, and medical 

specialization of the source. 20 C.F.R. § 404.1527(c). Generally, more weight is given 

to the opinion of a specialist about medical issues related to his area of specialty than to 

the opinion of a source who is not a specialist. 20 C.F.R. § 404.1527(c)(5). 

The ALJ may discount a physician’s opinion that is based only the claimant’s 

subjective complaints without objective evidence. Batson v. Comm’r of Soc. Sec. Admin., 

359 F.3d 1190, 1195 (9th Cir. 2004). 

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2. Treating Family Practitioner Philo Rogers, D.O. 

Dr. Rogers began treating Plaintiff in August 2009; she returned monthly through 

April 2011. Dr. Rogers documented physical examination findings that included 

abdominal tenderness and muscle spasms and tenderness in all areas of the spine. He 

prescribed multiple medications, including pain relievers, a muscle relaxant, and 

migraine medication. He referred Plaintiff to a neurologist and a pain clinic. On multiple 

occasions, Dr. Rogers administered trigger point injections to Plaintiff’s spine. In July 

2012, Dr. Rogers administered trigger point injections to Plaintiff’s lumbosacral spine 

and renewed pain medication prescriptions. Plaintiff saw Dr. Rogers again on October 5, 

2012. 

On October 15, 2012, Dr. Rogers submitted a statement that Plaintiff suffers from 

back pain with lumbar neuropathy, degenerative disc disease, and failed back surgeries. 

In addition, he wrote, she has hypertension and fatigue. He opined that she is “totally and 

permanently disabled from any type of gainful employment due [to] the chronic pain 

syndrome and neuropathy symptoms.” 

On December 6, 2012, Dr. Rogers submitted a Multiple Impairment 

Questionnaire. He identified Plaintiff’s conditions as back pain, lumber neuropathy, 

headaches, fatigue, chronic pain syndrome, and degenerative disc disease. He reported 

that his diagnoses were supported by evidence of failed back surgeries, MRIs, and CT 

scans. He reported her primary symptoms as constant severe pain and lower extremity 

neuropathy, which has not been relieved with medication without unacceptable side 

effects. He said the pain is located in her back and pelvis and radiates down her legs. Dr. 

Rogers opined that in an 8-hour day, Plaintiff can only sit 0-1 hours and stand/walk 0-1 

hours. He further opined that she should not sit or stand/walk continuously. He opined 

that Plaintiff’s experience of pain, fatigue, or other symptoms would constantly interfere 

with attention and concentration. Dr. Rogers also opined that Plaintiff is depressed and 

frustrated by her constant severe pain. He further opined that Plaintiff would need to take 

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frequent long unscheduled breaks to rest and is likely to be absent from work more than 3 

times per month. On June 14, 2013, Dr. Rogers submitted an updated medical source 

statement that was consistent with the information he provided December 6, 2012. 

The ALJ said he gave “no weight” to Dr. Rogers’ opinion because he is a primary 

care physician and not an orthopedic specialist, “his opinions rely heavily on the 

claimant’s subjective complaints and the totality of the evidence does not support these 

subjective complaints.” In other words, because Plaintiff’s pain testimony was not 

corroborated by objective evidence, the ALJ found it not credible and concluded Dr. 

Rogers could not rely on it either. 

3. Examining Consultants 

The ALJ gave great weight to the opinion of Bradley H. Werrell, D.O., who 

conducted a one-time physical evaluation of Plaintiff and submitted a Medical Source 

Statement dated December 10, 2011, on behalf of the State agency. Dr. Werrell’s 

physical examination showed almost entirely normal results. He diagnosed history of 

lumbar laminectomy and history of migraine headaches, but opined these conditions 

would not impose any limitations for 12 continuous months. Despite giving “great 

weight” to Dr. Werrell’s opinion of no limitations, the ALJ included many limitations in 

her residual functional capacity assessment. 

The ALJ gave great weight to the opinion of Jeffrey Levison, M.D., who 

conducted a one-time physical examination of Plaintiff and submitted a Medical Source 

Statement dated May 17, 2013, on behalf of the State agency. The pages of Dr. 

Levison’s statement are numbered, and page four of six is missing. Page four apparently 

includes questions 1 and 2 because page five begins with question 3 regarding Plaintiff’s 

capacity to sit. On the pages that are included in the record, Dr. Levison opined that 

Plaintiff has no limitations in sitting, but may need to stretch intermittently. He also 

opined that Plaintiff is limited to frequent stooping, but not limited regarding climbing, 

kneeling, crouching, crawling, reaching, handling, fingering, and feeling. He opined that 

Plaintiff has no environmental limitations. Dr. Levison’s opinion regarding Plaintiff’s 

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functional capacity for lifting, carrying, standing, or walking is not included in the record. 

Dr. Levison’s physical examination findings are essentially normal. He commented that 

Plaintiff reported low back pain, but did not show evidence of significant pain in her 

movements or heart rate. Despite giving “great weight” to Dr. Levison’s opinion that 

Plaintiff can perform unlimited sitting with intermittent stretching, the ALJ found 

Plaintiff requires “a sit/stand option at will provided it include not being off task for more 

than 10% of the day.” The ALJ’s residual capacity determination also disagrees with Dr. 

Levison regarding climbing, kneeling, crouching, crawling, and working around 

dangerous machinery and unprotected heights. 

The ALJ gave little weight to the August 26, 2013 Medical Source Statement of 

John P. Kelley, M.D., because (1) Dr. Kelley saw Plaintiff only once, and (2) 

“considering the relative[ly] positive evaluation, it appears Dr. Kelley relied heavily on 

the claimant’s subjective complaints in making his opinion.” Upon physical 

examination, Dr. Kelley found limited range of motion in Plaintiff’s neck and lower back, 

palpable upper body muscle tenderness, tenderness in lower abdominal quadrants, and 

absent left Achilles reflex. Dr. Kelley opined that in an 8-hour day Plaintiff can sit 3-4 

hours and stand/walk 0-1 hours, and she was likely to be absent from work more than 3 

times a month as a result of her impairments or treatment. He opined that anxiety 

contributes to the severity of Plaintiff’s symptoms and functional limitations. However, 

he also opined that pain and fatigue would seldom interfere with Plaintiff’s attention and 

concentration, and she is capable of tolerating moderate stress. 

Because the opinions of examining physicians contradict that of treating physician 

Dr. Rogers, the ALJ was required to set forth specific and legitimate reasons for rejecting 

Dr. Rogers’ opinion. Further, the ALJ was required to consider the factors set out in 

20 C.F.R. § 404.1527(c)(2)-(6) in determining how much weight to give Dr. Roger’s 

opinion. Therefore, the ALJ should have considered how long Dr. Rogers had treated 

Plaintiff, the number of times Dr. Rogers had seen Plaintiff, and the kinds and extent of 

examinations and testing Dr. Rogers performed or ordered from specialists. It was not 

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sufficient for the ALJ to reject Dr. Rogers’ opinion merely because he is not an 

orthopedic surgeon and Plaintiff’s testimony regarding the severity of her pain was not 

corroborated by objective evidence. 

C. Remand 

If the ALJ’s decision is not supported by substantial evidence or suffers from legal 

error, the district court has discretion to reverse and remand either for an award of 

benefits or for further administrative proceedings. Smolen v. Chater, 80 F.3d 1273, 1292 

(9th Cir. 1996); Sprague v. Bowen, 812 F.2d 1226, 1232 (9th Cir. 1987). “Remand for 

further proceedings is appropriate if enhancement of the record would be useful.” 

Benecke v. Barnhart, 379 F.3d 587, 593 (9th Cir. 2004). “Conversely, where the record 

has been developed fully and further administrative proceedings would serve no useful 

purpose, the district court should remand for an immediate award of benefits.” Id. (citing 

Smolen, 80 F.3d at 1292). 

Moreover, rejected symptom testimony and/or medical opinion evidence should be 

credited as true, and the case remanded with instructions to calculate and award benefits 

if three conditions are satisfied: “(1) the record has been fully developed and further 

administrative proceedings would serve no useful purpose; (2) the ALJ has failed to 

provide legally sufficient reasons for rejecting evidence, whether claimant testimony or 

medical opinion; and (3) if the improperly discredited evidence were credited as true, the 

ALJ would be required to find the claimant disabled on remand.” Garrison v. Colvin, 

759 F.3d 995, 1020 (9th Cir. 2014). 

All three conditions are satisfied here. There are no outstanding medical records 

or medical source opinions to be obtained. Further administrative proceedings would 

serve no useful purpose. The ALJ failed to provide legally sufficient reasons for 

discrediting Plaintiff’s testimony and the opinion of her treating physician. When the 

vocational expert was presented with a hypothetical including the limitations opined by 

Dr. Rogers, the expert said there would be no jobs existing in the national economy that 

could be performed by the hypothetical individual. Therefore, if Plaintiff’s testimony 

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were credited as true and Dr. Rogers’ opinion given controlling weight, the ALJ would be 

required to find Plaintiff disabled on remand. 

IT IS THEREFORE ORDERED that the final decision of the Commissioner of 

Social Security is VACATED and this case is REMANDED for immediate calculation 

and award of benefits. The Clerk shall enter judgment accordingly and shall terminate 

this case. 

Dated this 14th day of March, 2016. 

Neil V. Wake

United States District Judge

 

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