Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_15-cv-00024/USCOURTS-azd-2_15-cv-00024-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:405 Review of HHS Decision (SSID)

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WO NOT FOR PUBLICATION 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Michael David Saunders, 

Plaintiff, 

v. 

Carolyn W. Colvin, 

Defendant.

No. CV-15-00024-PHX-JJT

ORDER 

 At issue is the denial of Plaintiff Michael David Saunders’ Application for 

Disability Insurance Benefits by the Social Security Administration (“SSA”) under the 

Social Security Act (“the Act”). Plaintiff filed a Complaint (Doc. 1) with this Court 

seeking judicial review of that denial, and the Court now considers Plaintiff’s Opening 

Brief (Doc. 16, “Pl.’s Br.”), Defendant Social Security Administration Commissioner’s 

Opposition (Doc. 17, “Def.’s Br.”) accompanied by two Notices of Supplemental 

Authority (Docs. 19, 20), and Plaintiff’s Reply (Doc. 18, “Pl.’s Reply”). 

I. BACKGROUND

 After the denial of several previous Applications, Plaintiff filed another 

Application for a Period of Disability and Disability Insurance Benefits under Title II of 

the Act and Supplemental Security Income under Title XVI of the Act on August 30, 

2011, for a Period of Disability beginning April 30, 2006, later amended to January 1, 

2009. (Doc. 15, R. at 72-73, 169-82.) Plaintiff’s renewed claim was immediately denied, 

and it was denied on reconsideration on October 2, 2012. (R. at 111-13.) Plaintiff testified 

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at a hearing held before an Administrative Law Judge (“ALJ”) on June 6, 2013. (R. at 37-

67.) On July 19, 2013, the ALJ issued a decision denying Plaintiff’s claim. (R. at 19-30.) 

The Appeals Council upheld the ALJ’s decision on October 31, 2014. (R. at 1-3.) The 

present appeal followed. 

 The Court has reviewed the medical evidence in its entirety and provides a short 

summary here. Plaintiff saw Dr. Dale R. Schultz, a neurologist, on January 8, 2009, and 

Dr. Schultz wrote a “to whom it may concern” letter to say that Plaintiff has familial 

myotonic dystrophy—a type of muscular dystrophy characterized by muscle wasting and 

weakness—that “significantly impairs dexterity and motor function” and has “social and 

emotional consequences.” (R. at 355.) 

 On September 13, 2011, Plaintiff saw Dr. Larry Ryan, a family medicine 

physician, and Dr. Ryan completed a Residual Functional Capacity (“RFC”) 

questionnaire. (R. at 386-92.) Dr. Ryan noted that Plaintiff had myotonic muscular 

dystrophy and could sit for six hours and stand or walk for four hours in an eight-hour 

period, and he needed to take 15-minute to one-hour breaks every one to two hours. (R. at 

386.) Dr. Ryan determined that Plaintiff could use his hands, fingers or arms for 20% of 

the workday. (R. at 387.) He opined that Plaintiff needed to take more than four days off 

a month due to his impairments. (R. at 387.) Finally, Dr. Ryan said that Plaintiff had a 

generalized anxiety disorder but it was controlled with medication. (R. at 387.) 

 In treatment notes dated over two years after his initial visit, on September 23, 

2011, Dr. Schultz stated that Plaintiff visited him again “to establish his relationship with 

a neurologist and confirm his diagnosis.” (R. at 395.) Dr. Schultz noted that Plaintiff 

“vaguely recalls having seen [Dr. Schultz] in the past,” a meeting Dr. Schultz also did not 

recall because “it’s been too many years.” (R. at 395.) Plaintiff reported he had worked as 

a cashier at Wendy’s but was fired in 2008 and “has trouble holding jobs not so much 

because of his disability from myotonic dystrophy but just from ‘lack of hustle’ and/or 

personality conflicts with co-workers.” (R. at 395.) Dr. Schultz continued by stating 

Plaintiff “has apparently applied for social security disability but he is really not disabled 

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for a lot of occupational opportunities. He is largely applying for disability just on the 

basis of the diagnosis and because he can’t seem to hold a job.” (R. at 395.) 

 Dr. Schultz noted that Plaintiff suffers from chronic headaches, for which 

Dr. Schultz suggested the medication Depakote. (R. at 396.) Plaintiff said that Dr. Schultz 

had prescribed Depakote to Plaintiff in the past visit and that it had worked well to relieve 

his headaches. (R. at 396.) However, Plaintiff reported that Dr. Ryan had taken him off 

Depakote because Dr. Ryan believed it was an anti-seizure medication, perhaps not 

realizing Plaintiff was taking it as a prophylaxis for migraine headaches. (R. at 396.) 

Dr. Schultz prescribed Depakote to Plaintiff again. (R. at 396.) 

 In the neurological examination, Dr. Schultz found that Plaintiff had normal 

strength in all four extremities and, while he had trouble opening his hand back up after 

gripping something, he had no weakness in his hands and feet. (R. at 397.) All other 

results were normal, and Dr. Schultz observed that Plaintiff had “appropriate affect.” 

(R. at 398.) 

 About 18 months later, on March 8, 2013, Plaintiff saw Dr. Schultz again, and 

Dr. Schultz stated that Plaintiff’s “sole purpose today was to bring us the lengthy form 

title of residual functional capacity questionnaire.” (R. at 564.) He noted, “Apparently 

[Plaintiff] has applied for social security disability twice and has been declined both 

times,” “probably [stemming] from the fact that although he has this disorder he is still 

capable of working at some jobs.” (R. at 564.) Dr. Schultz tabulated Plaintiff’s physical 

abilities on the RFC form and stated he would complete the mental RFC portion after 

Plaintiff received the required psychometric testing. (R. at 564, 566.) Neither the physical 

nor mental RFC evaluations are attached to Dr. Schultz’s treatment notes.1

 On March 20, 

 

1

 The ALJ noted that Plaintiff first testified that Dr. Schultz gave to Plaintiff the physical RFC portion of the questionnaire, and later that Dr. Schultz never conducted the 

physical RFC evaluation (R. at 26), which contradicts Dr. Schultz’s explicit statement that he filled out the physical RFC portion of the questionnaire (R. at 564, 566). As for 

the mental RFC, there is no record Plaintiff ever obtained the required psychometric testing. (R. at 26.) When asked if she had obtained the physical RFC portion of the questionnaire, Plaintiff’s counsel responded that her firm had not obtained the record 

because Plaintiff was no longer treated by Dr. Schultz. (R. at 26.) 

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2013, Dr. Schultz’s office received a call from Plaintiff’s mother and noted Plaintiff 

“does not want to see Dr. Schultz” and “wants someone else asap.” (R. at 621.) 

 On April 12, 2013, Dr. Ryan completed another RFC questionnaire for Plaintiff. 

(R. at 572-73.) The results did not differ significantly from the previous RFC 

questionnaire Dr. Ryan completed. (R. at 386-92, 572-73.) 

 Plaintiff underwent a psychological evaluation by state examiner Dr. Celia Drake 

on April 18, 2012. (R. at 509-12.) Dr. Drake reported that Plaintiff sometimes feels 

depressed but has not sought psychiatric or mental health care. (R. at 510.) She noted 

Plaintiff “was a poor historian,” his “report of symptoms was somewhat vague,” his 

depression is controlled with medication, and he “indicated no need for mental health 

treatment.” (R. at 511.) On September 10, 2012, Dr. Jonathan Zuess, a state nonexamining physican, agreed with Dr. Drake’s assessment based on his review of the 

medical records and also noted that Plaintiff was medication non-compliant. (R. at 95-

98.) 

 Plaintiff underwent a mental RFC evaluation by state examiner Dr. Diane Kogut 

on May 3, 2012. (R. at 546-48.) Dr. Kogut found that Plaintiff had no significant 

limitations in understanding and memory; no significant limitations in four areas of 

sustained concentration and persistence and moderate limitations in the remaining four 

areas; moderate limitations in one of the five areas of social interaction and no other 

significant limitations; and moderate limitations in two of the four areas of adaptation and 

no other significant limitations. (R. at 546-47.) 

 Dr. Kogut noted that Plaintiff’s depression/anxiety was controlled with medication 

and that Plaintiff was alert and oriented with a normal affect and average intelligence. 

(R. at 548.) Like Dr. Drake, Dr. Kogut observed that Plaintiff’s symptoms “were 

somewhat vague” but that his depression was associated with coping with chronic illness. 

(R. at 548.) She reported that Plaintiff reads, cares for dogs, has no problems with 

personal care and shops in stores. (R. at 548.) She concluded that Plaintiff has some 

limitations due to muscular dystrophy but is not markedly impaired due to a mental 

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disorder. (R. at 548.) Dr. Kogut also noted that Plaintiff is not undergoing mental health 

treatment and his anxiety is controlled. (R. at 548.) As a result, Dr. Kogut concluded that 

Plaintiff retains the mental capacity for unskilled work. (R. at 548.) 

II. ANALYSIS 

 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, but less than a 

preponderance; it is 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).

To determine whether a claimant is disabled for purposes of the 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 presently 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. 20 C.F.R. § 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. Part 404. 20 C.F.R. § 404.1520(a)(4)(iii). 

If so, the claimant is automatically found to be disabled. Id. If not, the ALJ proceeds to 

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step four. Id. At step four, the ALJ assesses the claimant’s RFC and determines whether 

the claimant is still capable of performing past relevant work. 20 C.F.R. 

§ 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 in the national economy based on the claimant’s RFC, age, 

education, and work experience. 20 C.F.R. § 404.1520(a)(4)(v). If so, the claimant is not 

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

A. The ALJ Assigned Proper Weight to the Assessments of Plaintiff’s 

Treating Physicians and Properly Considered the Record as a Whole

 Plaintiff disputes the ALJ’s finding at step five of the five-step process, 

specifically, that when considering the combination of Plaintiff’s impairments, Plaintiff’s 

RFC allowed him to perform work in the national economy. Plaintiff’s first argument is 

that the ALJ committed reversible error by assigning inadequate weight to the 

assessments of Plaintiff’s family doctor, Dr. Ryan, and failing to account for RFC 

limitations in concentration, persistence or pace. (Pl.’s Br. at 12-17.) Defendant argues 

that the ALJ properly weighed the treating professionals’ assessments, offering specific 

and legitimate reasons supported by substantial evidence in the record for giving little 

weight to Dr. Ryan’s assessments. (Def.’s Br. at 5-13.) 

 An ALJ “may only reject a treating or examining physician’s uncontradicted 

medical opinion based on ‘clear and convincing reasons.’” Carmickle v. Comm’r of Soc. 

Sec., 533 F.3d 1155, 1164 (9th Cir. 2008) (citing Lester v. Chater, 81 F. 3d 821, 830-31 

(9th Cir. 1996)). “Where such an opinion is contradicted, however, it may be rejected for 

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

Id. 

In this instance, the ALJ found that the assessments of Plaintiff’s family doctor, 

Dr. Ryan, were contradicted by the assessments of Plaintiff’s neurologist, Dr. Schultz. 

(R. at 25-28.) The Court must therefore examine whether the ALJ provided specific and 

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legitimate reasons for discounting the assessments of Dr. Ryan, supported by substantial 

evidence when examining the record as a whole. See Carmickle, 533 F.3d at 1164. 

 In giving significant weight to Dr. Schultz’s assessments and little weight to 

Dr. Ryan’s assessment, the ALJ noted that, as a neurologist, Dr. Schultz is a specialist, 

and his opinion is therefore entitled to more weight than that of Dr. Ryan. (R. at 27.) The 

ALJ also noted Dr. Schultz’s observations that Plaintiff visited him solely to obtain a 

diagnosis to seek disability benefits and did not seek regular care, as well as the fact that 

an apparently negative physical RFC evaluation completed by Dr. Schultz disappeared 

and that no mental RFC evaluation or psychometric testing was completed. (R. at 26.) In 

addition, the ALJ noted that Dr. Ryan’s opinions were not consistent with the treatment 

records, which showed among other things that Plaintiff’s mental impairments were 

effectively treated with medication—to the extent Plaintiff followed his medication 

regimen. (R. at 24-26.) 

 The Court finds that the ALJ provided specific and legitimate reasons, as required, 

for rejecting Dr. Ryan’s assessments of Plaintiff’s RFC, and the RFC applied by the ALJ 

was supported by substantial evidence in the record as a whole, including Dr. Schultz’s 

assessments. The ALJ properly included in the RFC the limitations in Plaintiff’s dexterity 

and motor function observed by Dr. Schultz and the other examining physicians. (R. at 

25.) 

 B. The ALJ Properly Interpreted the Examining and Non-Examining 

 Physicians’ Mental Health Assessments 

Plaintiff also argues that the ALJ erred in her interpretation of the opinions of 

examining physician Dr. Kogut and non-examining physician Dr. Zuess, who Plaintiff 

contends concluded that he has moderate limitations in concentration, persistence and 

pace that make him unable to perform even simple work. (Pl.’s Br. at 16-17; Pl.’s Reply 

at 3-6.) In response, Defendant contends that the ALJ properly interpreted the evaluations 

of Drs. Kogut and Zuess as a whole, including their narrative descriptions of Plaintiff’s 

RFC limitations. (Def.’s Br. at 13-16.) 

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 The ALJ gave “great weight” to the mental RFC assessment of Dr. Kogut.2 (R. at 

27.) Upon examination of Plaintiff, Dr. Kogut concluded in checkbox form that Plaintiff 

had moderate limitations in four of the eight categories of sustained concentration and 

persistence. (R. at 546-47.) However, as the ALJ noted, Dr. Kogut concluded that 

Plaintiff retains the RFC for unskilled work. (R. at 27, 548.) In so concluding, Dr. Kogut 

observed in narrative form that Plaintiff’s depression/anxiety was controlled with 

medication; Plaintiff was alert and oriented with a normal affect and average intelligence; 

Plaintiff’s report of his symptoms was somewhat vague; Plaintiff reads, cares for dogs, 

has no problems with personal care and shops in stores; and, while Plaintiff reports 

mental health issues, Plaintiff has not sought any mental health treatment. (R. at 548.) In 

the checklist, Dr. Kogut noted that Plaintiff had no significant limitations in half of the 

categories of sustained concentration and persistence. (R. at 546-47.) Moreover, as the 

ALJ observed in her interpretation of Dr. Kogut’s report, Dr. Kogut also found that 

Plaintiff “could perform work where interpersonal contact was incidental to the work 

performed; complexity of tasks was learned and performed by rote with few variables 

and little judgment; and the supervision required was simple, direct, and concrete (i.e. 

unskilled).” (R. at 27.) Finally, the ALJ noted that a finding that Plaintiff retains the 

mental RFC—including concentration—to perform unskilled work is consistent with the 

treatment records and other evaluations of Plaintiff, including that of Dr. Drake. (R. at 

27.) 

 Nevertheless, Plaintiff argues that the ALJ erred when she considered Dr. Kogut’s 

conclusion that Plaintiff retains the mental RFC to perform unskilled work because such 

a determination is the province of the ALJ, not an examining physician. (Pl.’s Reply at 4-

5.) However, as pointed out above, the ALJ does far more than rely on Dr. Kogut’s 

conclusion in interpreting Dr. Kogut’s evaluation and making the mental RFC 

 

2

 To the extent Plaintiff argues that the ALJ should also have given great weight to Dr. Ryan’s mental RFC assessments, the argument fails for the reasons set forth above 

and particularly because, as pointed out by the ALJ, Dr. Ryan is not a mental health specialist. (See R. at 27-28.)

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determination. The ALJ properly considered the record as a whole, and, so far as 

Dr. Kogut’s evaluation is concerned, the ALJ properly considered the entire evaluation, 

including the narrative portions. See Rounds v. Comm’r of Soc. Sec. Admin., 807 F.3d 

996, 1005 (9th Cir. 2015) (as amended). 

 Similarly, Plaintiff’s argument as to the assessment of Dr. Zuess, a non-examining 

physician, fails. Dr. Zuess read and relied on Dr. Kogut’s conclusions in reaching his 

own, and, indeed, explicitly agrees with the assessment of Dr. Drake. The ALJ’s decision 

to exclude additional limitations in Plaintiff’s ability to concentrate in the final mental 

RFC determination was supported by substantial evidence in the record.3

 C. The ALJ Properly Weighed Plaintiff’s Testimony

 Finally, Plaintiff argues that the ALJ erred in her consideration of Plaintiff’s 

symptom testimony. (Pl.’s Br. at 18-21.) In response, Defendant contends that the ALJ 

gave Plaintiff’s testimony the proper weight because some of his testimony was not 

supported by objective medical evidence, Plaintiff was successful in controlling his 

symptoms with medication and failed to follow certain medication regimens, and Plaintiff 

engaged in physical activity despite his claimed limitations. (Def.’s Br. at 17-22.) 

 While credibility is the province of the ALJ, an adverse credibility determination 

requires the ALJ to provide “specific, clear and convincing reasons for rejecting the 

claimant’s testimony regarding the severity of the claimant’s symptoms.” Treichler v. 

Comm’r of Soc. Sec., 775 F.3d 1090, 1102 (9th Cir. 2014) (citing Smolen v. Chater, 80 

F.3d 1273, 1281 (9th Cir. 1996)). The ALJ disagreed with certain statements of Plaintiff 

regarding the intensity, persistence and limiting effects of his conditions and his 

conclusion that he is unable to perform even unskilled work. (R. at 27, 41.) 

 In the instances in which the ALJ assigned little value to Plaintiff’s statements, the 

Court finds the ALJ gave specific, clear and convincing reasons for doing so. The ALJ 

 

3

 Because the Court finds that the ALJ did not err in her RFC determination and 

the RFC was reflected in the hypotheticals she posed to the Vocational Expert, the Court need not address Plaintiff’s final argument that the hypotheticals posed to the Vocational Expert did not include all of Plaintiff’s limitations. (See Pl.’s Br. at 21-22.) 

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pointed out that Plaintiff’s reports of his functional limitations were not consistent with 

the objective findings of examining physicians, and particularly Drs. Schultz, Drake and 

Kogut (as detailed above); Plaintiff’s impairments were controlled with medication and 

he failed to take the prescribed medication to control certain conditions; and Plaintiff 

engaged in physical activities inconsistent with his reports of impairment, such as 

household chores and looking for work. (R. at 24-25.) The ALJ’s credibility 

determination was supported by substantial evidence in the record and free from error. 

See 20 C.F.R. § 404.1529(c)(3); Stubbs-Danielson v. Astrue, 539 F.3d 1169, 1175 (9th 

Cir. 2008); Warre ex rel. E.T. IV v. Comm’r of Soc. Sec. Admin., 439 F.3d 1001, 1006 

(9th Cir. 2006). 

III. CONCLUSION

 Plaintiff raises no error on the part of the ALJ, and the SSA’s decision denying 

Plaintiff’s Application for a Period of Disability and Disability Insurance Benefits under 

the Act was supported by substantial evidence in the record. 

 IT IS THEREFORE ORDERED affirming the July 19, 2013 decision of the 

Administrative Law Judge (R. at 19-30) as upheld by the Appeals Council on October 31, 

2014 (R. at 1-3). 

 IT IS FURTHER ORDERED directing the Clerk to enter final judgment 

consistent with this Order and close this case. 

 Dated this 31st day of March, 2016. 

Honorable John J. Tuchi

United States District Judge

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