Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_06-cv-01257/USCOURTS-caed-1_06-cv-01257-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:1383 Review of HHS Decision

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UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

DELFINA RAMIREZ, )

)

Plaintiff, )

v. )

)

MICHAEL J. ASTRUE, )

Commissioner of Social )

Security, )

)

Defendant. )

)

 )

1:06-cv-001257-AWI-SMS

FINDINGS AND RECOMMENDATIONS RE:

PLAINTIFF’S SOCIAL SECURITY

COMPLAINT (DOC. 1)

Plaintiff is represented by counsel and is proceeding with

an action seeking judicial review of a final decision of the

Commissioner of Social Security (Commissioner) denying

Plaintiff’s application for disability insurance benefits (DIS)

and supplemental security income (SSI) benefits under Titles II

and XVI of the Social Security Act (Act). The matter has been

referred to the Magistrate Judge pursuant to 28 U.S.C.§ 636(b)

and Local Rule 72-302(c)(15). The matter is currently before the

Court on the parties’ briefs, which have been submitted without

oral argument to the Honorable Sandra M. Snyder, United States

Magistrate Judge.

///

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I. Procedural History

On February 16, 2001, Plaintiff filed a claim for disability

insurance benefits (DIB) under Title II of the Act, alleging

disability due to problems with her back, legs, and shoulder

beginning on September 11, 2000; and on March 13, 2002, Plaintiff

filed an application for SSI benefits under Title XVI of the Act

alleging disability beginning on September 11, 2000. (A.R. at 63-

68, 93, 273-75.) Plaintiff’s claim was denied initially and on

reconsideration. (Id. at 43-62.) Plaintiff’s request for hearing

was denied by an administrative law judge (ALJ) because of

Plaintiff’s failure to appear at the hearing. (A.R. 283-84.) The

Appeals Council vacated the dismissal and directed the ALJ to

provide Plaintiff another opportunity for a hearing. (A.R. 285-

88.) A hearing was held before a different ALJ of the Social

Security Administration (SSA), the Honorable James E. Ross, on 

May 3, 2005. Plaintiff appeared with an attorney and testified

before the ALJ. (A.R. 506-16.) On June 20, 2005, the ALJ denied

Plaintiff’s application for benefits. (Id. at 19-23.) Plaintiff

appealed the ALJ's decision to the Appeals Council, and on July

13, 2006, the Appeals Council denied Plaintiff’s the request for

review. (Id. at 7-11.) 

On September 13, 2006, Plaintiff filed the complaint in the

instant action. On June 10, 2007, Plaintiff filed an opening

brief. On August 10, 2007, briefing was completed with the

Defendant’s filing of a brief in opposition.

II. Standard and Scope of Review

Congress has provided a limited scope of judicial review of

the Commissioner's decision to deny benefits under the Act. In

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reviewing findings of fact with respect to such determinations,

the Court must determine whether the decision of the Commissioner

is supported by substantial evidence. 42 U.S.C. § 405(g).

Substantial evidence means "more than a mere scintilla,"

Richardson v. Perales, 402 U.S. 389, 402 (1971), but less than a

preponderance, Sorenson v. Weinberger, 514 F.2d 1112, 1119, n. 10

(9th Cir. 1975). It is "such relevant evidence as a reasonable

mind might accept as adequate to support a conclusion."

Richardson, 402 U.S. at 401. The Court must consider the record

as a whole, weighing both the evidence that supports and the

evidence that detracts from the Commissioner's conclusion; it may

not simply isolate a portion of evidence that supports the

decision. Robbins v. Soc. Sec. Admin., 466 F.3d 880, 882 (9 Cir. th

2006); Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). It

is immaterial that the evidence would support a finding contrary

to that reached by the Commissioner; the determination of the

Commissioner as to a factual matter will stand if supported by

substantial evidence because it is the Commissioner’s job, and

not the Court’s, to resolve conflicts in the evidence. Sorenson

v. Weinberger, 514 F.2d 1112, 1119 (9 Cir. 1975). th

In weighing the evidence and making findings, the

Commissioner must apply the proper legal standards. Burkhart v.

Bowen, 856 F.2d 1335, 1338 (9th Cir. 1988). This Court must

review the whole record and uphold the Commissioner's

determination that the claimant is not disabled if the

Commissioner applied the proper legal standards, and if the

Commissioner's findings are supported by substantial evidence.

See, Sanchez v. Secretary of Health and Human Services, 812 F.2d

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509, 510 (9th Cir. 1987); Jones v. Heckler, 760 F.2d at 995. If

the Court concludes that the ALJ did not use the proper legal

standard, the matter will be remanded to permit application of

the appropriate standard. Cooper v. Bowen, 885 F.2d 557, 561 (9th

Cir. 1987). 

III. Disability

In order to qualify for benefits, a claimant must establish

that she is unable to engage in substantial gainful activity due

to a medically determinable physical or mental impairment which

has lasted or can be expected to last for a continuous period of

not less than twelve months. 42 U.S.C. §§ 416(i), 1382c(a)(3)(A).

A claimant must demonstrate a physical or mental impairment of

such severity that the claimant is not only unable to do the

claimant’s previous work, but cannot, considering age, education,

and work experience, engage in any other kind of substantial

gainful work which exists in the national economy. 42 U.S.C.

1382c(a)(3)(B); Quang Van Han v. Bowen, 882 F.2d 1453, 1456 (9th

Cir. 1989). The burden of establishing a disability is initially

on the claimant, who must prove that the claimant is unable to

return to his or her former type of work; the burden then shifts

to the Commissioner to identify other jobs that the claimant is

capable of performing considering the claimant's residual

functional capacity, as well as her age, education and last

fifteen years of work experience. Terry v. Sullivan, 903 F.2d

1273, 1275 (9 Cir. 1990). th

The regulations provide that the ALJ must make specific

sequential determinations in the process of evaluating a

disability: 1) whether the applicant engaged in substantial

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28 All references are to the 2005 version of the Code of Federal Regulations unless otherwise noted. 1

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gainful activity since the alleged date of the onset of the

impairment, 20 C.F.R. § 404.1520 (1997); 2) whether solely on the 1

basis of the medical evidence the claimed impairment is severe,

that is, of a magnitude sufficient to limit significantly the

individual’s physical or mental ability to do basic work

activities, 20 C.F.R. § 404.1520(c); 3) whether solely on the

basis of medical evidence the impairment equals or exceeds in

severity certain impairments described in Appendix I of the

regulations, 20 C.F.R. § 404.1520(d); 4) whether the applicant

has sufficient residual functional capacity, defined as what an

individual can still do despite limitations, to perform the

applicant’s past work, 20 C.F.R. §§ 404.1520(e), 404.1545(a); and

5) whether on the basis of the applicant’s age, education, work

experience, and residual functional capacity, the applicant can

perform any other gainful and substantial work within the

economy, 20 C.F.R. § 404.1520(f). 

With respect to SSI, the five-step evaluation process is

essentially the same. See 20 C.F.R. § 416.920.

Here, the ALJ concluded that Plaintiff, who was sixty years

old at the time of the hearing, had a sixth-grade education in

Mexico, and had performed past relevant work as an agricultural

packer and sorter, had a severe impairment consisting of lumbar

strain superimposed on pre-existent degenerative disc disease but

had no combination of impairments that met or medically equaled a

listing; Plaintiff had the residual functional capacity (RFC) to

perform light work, or lift and carry twenty pounds occasionally

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and ten pounds frequently, and stand, walk, and sit six hours in

an eight-hour work day with occasional stooping and crouching.

Because Plaintiff could perform her past relevant work as an

agricultural sorter, Plaintiff was not disabled.

IV. Rejection of Plaintiff’s Subjective Complaints

There is no merit to Plaintiff’s contention that the ALJ’s

reasons for rejecting Plaintiff’s credibility with respect to her

subjective symptoms were legally inadequate and unsupported by

adequate evidence in the record.

 The court in Orn v. Astrue, 495 F.3d 625, 635 (9 Cir. th

2007), summarized the pertinent standards for evaluating the

sufficiency of an ALJ’s reasoning in rejecting a claimant’s

subjective complaints:

An ALJ is not “required to believe every

allegation of disabling pain” or other non-exertional

impairment. See Fair v. Bowen, 885 F.2d 597, 603 (9th

Cir.1989). However, to discredit a claimant's testimony

when a medical impairment has been established, the ALJ

must provide “ ‘specific, cogent reasons for the

disbelief.’ “ Morgan, 169 F.3d at 599 (quoting Lester,

81 F.3d at 834). The ALJ must “cit[e] the reasons why

the [claimant's] testimony is unpersuasive.” Id. Where,

as here, the ALJ did not find “affirmative evidence”

that the claimant was a malingerer, those “reasons for

rejecting the claimant's testimony must be clear and

convincing.” Id.

Social Security Administration rulings specify the

proper bases for rejection of a claimant's testimony.

See S.S.R. 02-1p (Cum. Ed.2002), available at Policy

Interpretation Ruling Titles II and XVI: Evaluation of

Obesity, 67 Fed.Reg. 57,859-02 (Sept. 12, 2002); S.S.R.

96-7p (Cum. Ed.1996), available at 61 Fed.Reg.

34,483-01 (July 2, 1996). An ALJ's decision to reject a

claimant's testimony cannot be supported by reasons

that do not comport with the agency's rules. See 67

Fed.Reg. at 57860 (“Although Social Security Rulings do

not have the same force and effect as the statute or

regulations, they are binding on all components of the

Social Security Administration, ... and are to be

relied upon as precedents in adjudicating cases.”); see

Daniels v. Apfel, 154 F.3d 1129, 1131 (10th Cir.1998)

(concluding that ALJ's decision at step three of the

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disability determination was contrary to agency

regulations and rulings and therefore warranted

remand). Factors that an ALJ may consider in weighing a

claimant's credibility include reputation for

truthfulness, inconsistencies in testimony or between

testimony and conduct, daily activities, and

“unexplained, or inadequately explained, failure to

seek treatment or follow a prescribed course of

treatment.” Fair, 885 F.2d at 603; see also Thomas, 278

F.3d at 958-59.

Further, it is established that an ALJ may rely on the

conservative nature of treatment or a lack of treatment in

rejecting a claimant’s subjective complaint of pain. Johnson v.

Shalala 60 F.3d 1428, 1433-34 (9 Cir. 1995). It is permissible th

to rely upon opinions of physicians concerning the nature,

severity, and effect of the symptoms of which the claimant

complains. Thomas v. Barnhart, 278 F.3d 947, 958-59 (9 Cir. th

2002). A doctor’s opinion that a claimant can work is

appropriately considered. Moncada v. Chater, 60 F.3d 521, 524 (9th

Cir. 1995). The ALJ may consider whether the Plaintiff’s

testimony is believable or not. Verduzco v. Apfel, 188 F.3d 1087,

1090 (9 Cir. 1999). Although the inconsistency of objective th

findings with subjective claims may not be the sole reason for

rejecting subjective complaints of pain, Light v. Chater, 119

F.3d 789, 792 (9 Cir. 1997), it is one factor which may be th

considered with others, Moisa v. Barnhart, 367 F.3d 882, 885 (9th

Cir. 2004); Morgan v. Commissioner 169 F.3d 595, 600 (9 Cir. th

1999).

Here, the ALJ expressly considered Plaintiff’s subjective

complaints. (A.R. 20.) He recited Plaintiff’s testimony that she

quit working in September 2000 after an injury to her back; had

constant back pain involving the mid-back radiating to both arms

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and an inability to perform bending, stooping, or twisting

without pain; could stand only two hours, walk less than one

hour, and lift six to eight pounds; and was limited to daily

activities of shopping, doing no cooking or cleaning, attending

church two to four Sundays a month, and driving only in an

emergency. (A.R. 21.) 

The ALJ found that although her impairments could reasonably

be expected to produce some symptoms, the degree of limitation

alleged was not supported by the objective medical evidence and

was not entirely credible. (A.R. 20.)

The ALJ detailed the objective medical evidence, considered

but put very little weight on the only contrary opinion of Dr.

Wageneck from February 2005, and relied on the opinions of

specific examining physicians and the state agency medical

consultants concerning Plaintiff’s abilities to perform work

activities. (A.R. 20-21.) In reviewing the evidence, the ALJ

noted and relied on the opinions of multiple physicians that

Plaintiff had essentially normal examinations with no clinical

signs consistent with the claimed degree of limitation; further,

he noted that Plaintiff had conservative treatment (A.R. 20), the

physicians had opined that Plaintiff was capable of working

(id.), Plaintiff exhibited reluctance to perform usual maneuvers

required for physical examinations that were normal for women in

her age group, Plaintiff had not participated well in physical

therapy (A.R. 20), Plaintiff repeatedly exhibited symptom

magnification during functional capacity evaluation by her

rehabilitation therapist and manifested profound symptom

embellishment to her consulting examiner with giveaway weakness

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of both upper and lower extremities, and she was evaluated by her

treating physician as having no credibility whatsoever in her

description of complaints (A.R. 21).

Substantial evidence supported the ALJ’s reasons.

First, a review of the objective medical evidence shows that

it was inconsistent with Plaintiff’s subjective complaints, and

there was substantial evidence supporting the ALJ’s findings that

treating and evaluating practitioners had found that Plaintiff

retained an RFC to perform work activities.

Plaintiff sustained an injury to the low back and right knee

and ankle from slipping on a piece of waxed paper at work in

September 2000; the ankle and knee pain resolved, but her

complaints of pain in the back did not. Dr. Richard H. Thorp, a

neurological surgeon, examined Plaintiff in December 2000 after

Plaintiff had attempted physical therapy but claimed to continue

to have constant low-grade low back pain extending into the

posterior thigh and down to the foot, with numbness and tingling

in both feet. (A.R. 174.) He concluded that from an objective

point of view, Plaintiff had recovered satisfactorily from her

fall based on findings that she had a normal neurological and

general physical exam; her straight leg raising maneuvers were

ninety degrees on either side with a negative Lasegue’s maneuver;

there was normal sensory exam, normal motor exam with normal tone

and no evidence of atrophy; deep tendon reflexes were

symmetrically equal; and extremities were within normal limits.

Further, the MRI of October 9, 2000, revealed only a minor bulge

within normal limits for a woman in Plaintiff’s age group; it did

not appear to contact or involve the S1 nerve roots on either

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side, and there was normal cushioning around the nerve roots.

(A.R. 174-78.)

Plaintiff’s primary treating physician reported after a

physical examination in February 2001 that despite treatment with

modified work duty, anti-inflammatory medication, analgesics, and

physical therapy, Plaintiff continued to complain of lower back

pain; examination revealed full range of motion in the back

without spasm or tenderness; there were no objective physical

findings to support the patient’s subjective complaints; previous

tests revealed only mild degenerative joint disease at L4-5 and

L5-S1, mild osteoporosis, a three millimeter central disc

protrusion at L5-S1 without disc bulge, protrusion, or extrusion,

and with widely patent neural foramina; the diagnosis was lumbar

sprain/strain, with subjective complaints unsupported by

objective findings. (A.R. 192-94.)

Treating orthopaedic surgeon Dr. John L. Branscum opined

after examining Plaintiff on March 5, 2001, that despite

Plaintiff’s claim of worsening symptoms, Plaintiff was permanent

and stationary; Plaintiff complained of subjective pain and

tenderness in the back and numbness and tingling in both legs,

but the physical examination revealed no objective findings; the

MRI showing the disc protrusion at L5-S1 was the only abnormality

shown by the MRI and had no clinical significance because there

was no root compression, and the neural foramina were widely

patent; Plaintiff’s mild degenerative disc disease at L5-S1 would

preclude only very heavy lifting (anything over sixty pounds on a

one-time basis, or over thirty pounds repetitively) on a

prophylactic basis; no further medical care was needed, and

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Plaintiff could return to her usual and customary occupation.

(A.R. 218-24.) 

Consulting orthopaedic surgeon Dr. Charles J. Heller, M.D.

concluded after examining Plaintiff in August 2001 that despite

her complaints of constant low back pain of nine on a scale of

one to ten with radiation to the extremity from the hip and with

occasional numbness of both legs, the examination revealed

tenderness over the lumbosacral spine with no paravertebral

muscle spasm; twenty per cent of flexion and ten per cent of

extension, but at times there was a full range of motion of the

back; and although Plaintiff refused to perform straight leg

raising more than twenty degrees bilaterally, at times there was

almost a full straight leg raising without pain. Dr. Heller found

Plaintiff to have been permanent and stationary in March 2001,

and he diagnosed lumbar strain resulting only in precluding

Plaintiff from lifting over twenty-five pounds prophylactically.

It was recommended that she should be given oral antiinflammatory medications and continue on an exercise program.

(A.R. 252-60.)

In September 2002, agreed medical examiner Dr. Rolf G.

Scherman examined Plaintiff, who continued to complain of

constant pain in the back and both legs but without weakness or

numbness in the legs. Dr. Scherman found diffused tenderness over

the lower back without any muscle spasm, reduced lateral flexion

and extension, no pain on straight leg raising at ninety degrees,

no weakness or atrophy of the legs, normal sensory testing, and

knee and ankle jerks that were 1+ and equal. He noted that MRI

studies revealed no disc herniation or findings of radiculopathy. 

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The only findings were restriction of back movements; he opined

that she could not engage in heavy lifting and was unable to

return to her usual and customary job. (A.R. 261-66.)

In September 2003, Dr. Michael Duffy examined Plaintiff, who

sought his help in obtaining Social Security disability. Dr.

Duffy stated that he in turn told Plaintiff that unless her

condition had changed significantly, he doubted that the outcome

would be any different, and he recommended treatment with

nonsteroidal anti-inflammatory medication and offered a referral

to a specialist if needed. (A.R. 394.) In April 2004, Plaintiff

again requested assistance with disability, and Dr. Duffy

reported that he saw no evidence the Plaintiff’s condition had

changed significantly and thus was not willing to grant permanent

disability. (A.R. 393.)

In March 2004 Dr. Richard J. Hammond examined Plaintiff, who

complained of constant back pain radiating in the legs to her

toes, and primarily on the right. Plaintiff was in no acute

distress; motor strength was 5/5 in the upper and lower

extremities with normal, rapid, alternating movements and tone;

reflexes were 1+ throughout, sensory exam was normal to light

touch, and gait and station were normal; there was minimal spasm

of the lumbar paraspinals, and they were moderately tender to

palpation, but there was no other significant spasm of her neck

or back. The only abnormality shown by an MRI report was a three

millimeter disc protrusion at L5-S1. Dr. Hammond concluded that

Plaintiff would have no difficulty doing a job that required

sitting, standing, walking, lifting, carrying, handling objects,

hearing, speaking, or traveling. (A.R. 387-88.)

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In March 2004, state agency physician Dr. Thomas T. Coolidge

opined that Plaintiff could perform light work (lift twenty

pounds occasionally, ten pounds frequently, six, stand, and walk

about six hours in an eight-hour workday) with only occasional

kneeling and crouching, and avoidance of concentrated exposure to

vibrations. (A.R. 411-19.)

In May 2004, state agency physician Leslie Arnold, M.D.,

agreed with Dr. Coolidge’s assessment. (A.R. 418.)

There was the contrary opinion of treating physician, Dr.

Wageneck, that Plaintiff in February 2005 could only lift a

maximum of ten pounds occasionally, three to four pounds

frequently, walk four hours in an eight-hour day but only thirty

minutes without interruption, and never climb, stoop, kneel,

balance, crouch, or crawl, with instability at heights and

inability to move machinery. (A.R. 420-22.) However, the

objective medical evidence was overwhelmingly consistent with the

ALJ’s characterization of it, and thus, substantial evidence

supported the ALJ’s reasoning.

The Court further concludes that substantial evidence

supports the ALJ’s finding that Plaintiff had exaggerated her

symptoms or had failed to give adequate effort during

examinations. 

In December 2000, consulting neurosurgeon Dr. Thorp noted

that Plaintiff spontaneously moved remarkably easily, rose

rapidly, walked without a limp, and was able to climb on to the

table and perform all the usual activity required without

apparent discomfort; however, Plaintiff refused to perform a

range of back movement, and he concluded:

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I do not feel that she has sustained any

injury to the back or to the neural elements

which would support her symptomatology. I think

she should be able to perform those activities any

woman in her age group would normally perform.

(A.R. 176.) 

In January 2001, in the course of performing a functional

capacity evaluation for work activity, physical therapist James

Bolich concluded that after performing a section of the

evaluation that was to determine if Plaintiff was displaying

symptom magnification behavior, the test results revealed that

Plaintiff was magnifying symptoms on fifty per cent of the tests

concerning superficial stroking to upper back and posterior

thighs, passive great toe flexion/extension on right and left,

passive knee toggle on the right and left sides, and axial

loading. (A.R. 181.) He concluded that Plaintiff’s desire to work

was a separate question from her capacity. He stated:

Mrs. Ramirez seemed annoyed to be in the clinic setting

and gave the impression that it was a waste of time to

be here. Mrs. Ramirez’ limitations with activities were

only limited by her desire to work. She did not want to

work at any activity that she thought might increase

her subjective pain. Therefore, it became extremely

difficult to assess her true safe maximal abilities.

(A.R. 181.) His final conclusion was that Plaintiff displayed a

tendency to over-project her symptom complex. (A.R. 182.)

Plaintiff’s primary treating physician, Dr. Joaquin Oliver,

concluded after an essentially normal examination in February

2001 that Plaintiff could do the same activities that she could

before the illness, and the only future medical treatment

indicated was over-the-counter medication. (A.R. 192-94.) He

concluded:

In view of the reports from the Physical Therapist and 

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Dr. Thorp, and the results of the Functional Capacity

Evaluation, it is my professional opinion, based on 42

years of experience in family practice and 20 years

of experience in treating industrial injuries, that the

patient has no credibility whatsoever in her description

of her complaints. I believe that she has at most 

constant, minimal pain in the lumbar area with no loss

of working capacity.

(A.R. 194.)

Consulting orthopedist Dr. Charles Heller examined Plaintiff

in August 2001. He found subjective complaints with no objective

findings. (A.R. 255.) On the credibility testing portion of the

exam, Dr. Heller reported inappropriate findings for axial

loading, passive rotation, distraction test, diffuse tenderness,

non-anatomic nerve distribution, histrionic movements, and

reverse sciatic tension test. (A.R. 255.)

In March 2004, Dr. Hammond observed after examining

Plaintiff that Plaintiff had very poor effort and profound

giveaway throughout, poor effort during range of motion, and

would not allow leg bending beyond thirty degrees or straight leg

raising while supine. (A.R. 388.) Dr. Hammond’s exam produced

essentially normal findings. He concluded in pertinent part:

Mrs. Ramirez complains of significant low back pain

but she has a completely normal exam. She has profound

embellishment of her symptoms with giveaway weakness of

both upper and lower extremities. She will not allow me

to do straight leg raising greater than 30 degrees supine

while it was 90 degrees sitting without any pain. She

has very poor effort during the exam. There was no

significant muscle spasm in her lumbar paraspinals....

(A.R. 388.)

Thus, the record supports the ALJ’s findings concerning

Plaintiff’s exaggeration of her symptoms.

Plaintiff argues that the ALJ’s failure to mention

Plaintiff’s hyperthyroidism or hyperparathyroidism and to include

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them in his assessment of credibility was legal error because the

conditions are likely to produce pain. 

The Court notes that the ALJ recited all Plaintiff’s

testimony concerning her pain; further, he expressly stated that

Plaintiff’s impairments could reasonably be expected to produce

some of the symptoms she alleged. (A.R. 21-22, 20.) The ALJ had

obviously reviewed the records concerning Plaintiff’s thyroid

condition and treatment because he referred to them in his review

and evaluation of Dr. Wageneck’s medical assessment and his

treating records. (A.R. 21 [referring to Ex. 25F, pp. 1-15,

constituting A.R. 491-505].) 

The records reflect that in September 2004 through April

2005, Plaintiff complained to Dr. Wageneck of unspecified,

diffuse bone pain and myalgias after having been diagnosed by

another doctor with hyperparathyroidism; Dr. Wageneck diagnosed

primary hyperparathyroidism with myalgia and cephalgia likely

secondary to primary hyperparathyroidism, and he referred her to

an ear, nose, and throat surgeon for resection of her parathyroid

glands. Plaintiff’s treatment by Dr. Wageneck consisted of

laboratory tests and medications. However, Plaintiff also was

suffering cervical spine strain at the time, and she was

apparently prescribed Flexeril, Bextra, and Tylenol for those

symptoms (A.R. 496, 493.) She was also encouraged to start a

walking program and to follow the South Beach Diet for weight

loss and musculoskeletal pain. (A.R. 493.)

It therefore does not appear that the ALJ failed to consider

Plaintiff’s thyroid condition or failed to consider any specific

subjective claims arising therefrom. It does not appear that the

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ALJ erred in a manner that would implicate the validity of the

ALJ’s assessment of Plaintiff’s credibility. 

However, should the ALJ have erred in not specifically

referring to Plaintiff’s thyroid condition in the credibility

analysis, the Court concludes that Plaintiff has not demonstrated

that any harm resulted therefrom. The particular analytical step

affected, namely, that of whether or not Plaintiff had pain and

whether or not her impairments reasonably could have been

expected to produce some of the symptoms she alleged, were

resolved in Plaintiff’s favor. See, Stout v. Commissioner, 454

F.3d 1050 (9 Cir. 2006). Further, as will be discussed infra, th

the ALJ specifically evaluated Dr. Wageneck’s assessment of

Plaintiff’s functional capacity and rejected it in part because

of Dr. Wageneck’s chart notes concerning Plaintiff’s conditions,

including her thyroid condition, did not support his functional

assessment, and further because Dr. Wageneck based his functional

capacity assessment entirely on Plaintiff’s subjective

complaints, to which the ALJ assigned very little weight. (A.R.

21.) 

The Court concludes that the ALJ cited clear and convincing

reasons for rejecting Plaintiff’s subjective complaints of pain

to the extent alleged, and that the ALJ’s reasons were properly

supported by the record and sufficiently specific to allow this

Court to conclude that the ALJ rejected the claimant's testimony

on permissible grounds and did not arbitrarily discredit

Plaintiff’s testimony.

V. Failure to Include an Impairment 

Plaintiff argues that the ALJ’s failure to mention

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Plaintiff’s hyperthyroidism or hyperparathyroidism “in his

assessment” was erroneous and contrary to the SSA’s duty to

consider the combined effects of all a claimant’s impairments

without regard to whether any single impairment would be of such

severity. It therefore appears that Plaintiff is referring to a

failure at the second step of the five-step analysis.

At step two, the Secretary considers if claimant has "an

impairment or combination of impairments which significantly

limits his physical or mental ability to do basic work

activities." 20 C.F.R. §§ 404.1520(c), 416.920(c). This is

referred to as the "severity" requirement and does not involve

consideration of the claimant's age, education, or work

experience. Id. The step-two inquiry is a de minimis screening

device to dispose of groundless claims. Bowen v. Yuckert, 482

U.S. 153-54 (1987). The Secretary is required to "consider the

combined effect of all of the individual's impairments without

regard to whether any such impairment, if considered separately,

would be of [sufficient medical] severity." 42 U.S.C. §

1382c(a)(3)(F).

Basic work activities include the abilities and aptitudes

necessary to do most jobs, such as physical functions of walking,

standing, sitting, lifting, pushing, pulling, reaching, carrying,

or handling; capacities for seeing, hearing, and speaking;

understanding, carrying out, and remembering simple instructions;

use of judgment; responding appropriately to supervision, coworkers and usual work situations; and dealing with changes in a

routine work setting. 20 C.F.R. §§ 404.1521(b), 416.921(b).

An impairment or combination thereof is not severe when

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medical evidence establishes only a slight abnormality or a

combination of slight abnormalities which would have no more than

a minimal effect on an individual's ability to work. An

impairment is not severe if it does not significantly limit a

claimant’s physical or mental ability to do basic work

activities. 20 C.F.R. §§ 404.1521(a), 416.921(a); Soc. Sec.

Ruling 85-28; Smolen v. Chater, 80 F.3d 1273, 1289-90 (9 Cir. th

1996).

As previously noted, it is Plaintiff’s burden to establish

disability; thus, with respect to severity, it is Plaintiff’s

burden to prove that the impairment had a functionally limiting

effect. Here, Plaintiff points to no evidence that Plaintiff’s

thyroid condition had any effect on Plaintiff’s ability to

perform work activities other than Dr. Wageneck’s opinion.

Accordingly, substantial evidence supports the ALJ’s

implicit decision that Plaintiff’s thyroid condition was not a

severe impairment, but rather had no more than a minimal effect

on Plaintiff’s ability to work. See, Webb v. Barnhart, 433 F.3d

683, 686-87 (9 Cir. 2005). th

VI. Treatment of the Expert Opinions

Plaintiff argues that the ALJ erred in his treatment of two

of the expert medical opinions.

The pertinent legal standards were recently summarized:

The opinions of treating doctors should be given

more weight than the opinions of doctors who do not

treat the claimant. Lester [v. Chater, 81 F.3d 821, 830

(9th Cir.1995) (as amended).] Where the treating

doctor's opinion is not contradicted by another doctor,

it may be rejected only for “clear and convincing”

reasons supported by substantial evidence in the

record. Id. (internal quotation marks omitted). Even if

the treating doctor's opinion is contradicted by

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another doctor, the ALJ may not reject this opinion

without providing “specific and legitimate reasons”

supported by substantial evidence in the record. Id. at

830, quoting Murray v. Heckler, 722 F.2d 499, 502 (9th

Cir.1983). This can be done by setting out a detailed

and thorough summary of the facts and conflicting clinical

evidence, stating his interpretation thereof, and making

findings. Magallanes [v. Bowen, 881 F.2d 747, 751 (9th

Cir.1989).] The ALJ must do more than offer his

conclusions. He must set forth his own interpretations

and explain why they, rather than the doctors', are

correct. Embrey v. Bowen, 849 F.2d 418, 421-22 (9th

Cir.1988).

 Reddick v. Chater, 157 F.3d 715, 725 (9th Cir.1998);

accord Thomas, 278 F.3d at 957; Lester, 81 F.3d at

830-31.

Orn v. Astrue, 495 F.3d 625, 632 (9 Cir. 2007). th

Further, the medical opinion of a nontreating doctor may be

relied upon instead of that of a treating physician only if the

ALJ provides specific and legitimate reasons supported by

substantial evidence in the record. Holohan v. Massanari, 246

F.3d 1195, 1202 (9 Cir. 2001) (citing Lester v. Chater, 81 F.3d th

821, 830 (9 Cir. 1995)). The contradictory opinion of a th

nontreating but examining physician constitutes substantial

evidence, and may be relied upon instead of that of a treating

physician, where it is based on independent clinical findings

that differ from those of the treating physician. Andrews v.

Shalala, 53 F.3d 1035, 1041 (9 Cir. 1995). The opinion of a th

nontreating, nonexamining physician can amount to substantial

evidence as long as it is supported by other evidence in the

record, such as the opinions of other examining and consulting

physicians, which are in turn based on independent clinical

findings. Andrews v. Shalala, 53 F.3d at 1041.

A. Dr. Scherman

Plaintiff argues that the ALJ erred in not addressing the

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portion of the opinion of Dr. Scherman in which the doctor stated

that Plaintiff was unable to return to her usual and customary

job. (A.R. 265.)

In September 2002, agreed medical examiner Dr. Rolf G.

Scherman examined Plaintiff, who continued to complain of

constant pain in the back and both legs but without weakness or

numbness in the legs. Dr. Scherman found diffused tenderness over

the lower back without any muscle spasm, reduced lateral flexion

and extension, no pain on straight leg raising at ninety degrees,

no weakness or atrophy of the legs, normal sensory testing, and

knee and ankle jerks that were 1+ and equal. He noted that MRI

studies revealed no disc herniation or findings of radiculopathy. 

The only findings were restriction of back movements; he opined

that she could not engage in heavy lifting and was unable to

return to her usual and customary job. (A.R. 261-66.)

The ALJ noted Dr. Scherman’s diagnosis of lumbar strain

superimposed on pre-existent degenerative disc disease. (A.R. 20

[citing to Ex. 8F p. 5, or A.R. 265].) He then stated that

Plaintiff underwent extensive evaluations and treatment from many

specialists resulting in a wide range of opinions concerning

Plaintiff’s condition and work-related abilities. (A.R. 20.) The

ALJ recited the various opinions, stating in part the following:

In March 2001, orthopedic surgeon Dr. Branscum

opined that the claimant was permanent and stationary

and could perform work involving not lifting over

60 pounds on a one-time basis or over 30 pounds 

repetitively (Exhibit 5F, p. 7). In August 2001,

Qualified Medical Examiner Dr. Heller concluded that

at the present time the claimant would be able to

lift 25 pounds (Exhibit 7F, p. 7). In September 2002,

Agreed Medical Examiner, Dr. Scherman agreed with

Drs. Heller and Branscum that the claimant was 

permanent and stationary and should be precluded 

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from heavy lifting (Exhibit 8F, p. 5).

(A.R. 21.)

A fundamental principle of review operative in this case is

that this Court is limited to reviewing the findings of the ALJ

and to reviewing the specific facts and reasons that the ALJ

asserts. Connett v. Barnhart, 340 F.3d 871, 874 (9 Cir. 2003) th

(holding in part that the mere presence of evidence in the record

that would support an ALJ’s conclusions, in the absence of the

ALJ’s discussion thereof, was insufficient). An ALJ need not

discuss evidence that is neither significant nor probative.

Howard v. Barnhart, 341 F.3d 1006, 1012 (9 Cir. 2003). However, th

with respect to significant, probative evidence, such as an

expert opinion, an ALJ must explicitly reject the opinion and set

forth specific reasons of the requisite force for doing so.

Nguyen v. Chater, 100 F.3d 1462, 1464 (9 Cir. 1996) (holding th

that the ALJ erred in failing to explicitly reject an opinion and

set forth specific, legitimate reasons for crediting another

opinion). The district court cannot make findings for the ALJ.

Id. A district court cannot affirm the judgment of an agency on a

ground the agency did not invoke in making its decision. Pinto v.

Massanari, 249 F.3d 840, 847-48 (9 Cir. 2001). Even application th

of the harmless error rule is circumscribed by this basic

requirement. It has recently been held that where an error

consists of an ALJ’s failure to discuss probative evidence

properly, a reviewing court cannot consider the error harmless

unless it can confidently conclude that no reasonable ALJ, when

fully crediting the evidence, could have reached a different

disability determination. Stout v. Commissioner of Social

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Security, 454 F.3d 1050, 1056 (9 Cir. 2006) (concluding that an th

ALJ’s failure to evaluate and state reasons for evaluating lay

testimony was not harmless). The authorities thus reflect the

fundamental principle that the ALJ’s opinion must contain

sufficient findings to permit intelligent judicial review,

particularly with respect to significant probative evidence.

Vincent v. Heckler, 739 F.2d 1393, 1395 (9 Cir. 1984). th

Here, it is clear from an examination of the decision that

the ALJ did not fail to consider or evaluate Dr. Scherman’s

opinion. Instead, the ALJ considered it and interpreted it as

being essentially consistent with the other decisions that the

ALJ addressed, including those of Drs. Branscum and Heller, which

primarily addressed Plaintiff’s lifting capacity. Indeed, Dr.

Scherman expressly interpreted those two doctors’ opinions as

precluding heavy lifting. (A.R. 263-64.) Dr. Scherman further

expressly stated, “I also agree with Dr. Branscum on the level of

disability, namely a disability precluding heavy lifting.” (A.R.

265.)

It is true that the ALJ failed to mention in his decision

the part of Dr. Scherman’s opinion that Plaintiff could not

return to her usual and customary job. However, the decision also

contains the ALJ’s assessment of Plaintiff’s past relevant work.

The ALJ noted Plaintiff’s former work as an agricultural sorter

at a packing house, concerning which Plaintiff testified that she

had to lift twenty to twenty-five pounds. (A.R. 21.) Further, the

ALJ noted that pursuant to the Dictionary of Occupational Titles,

Plaintiff’s past relevant work as an agricultural sorter as

generally performed in the national economy was classified as

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light work and required lifting no more than twenty pounds

occasionally. (A.R. 21, 22.) Likewise, the ALJ clearly credited

the consistent opinions of most of the doctors to the effect that

Plaintiff’s limitation was a preclusion against heavy lifting,

which had been expressly described or limited by those experts as

affecting lifting of over twenty-five pounds. It therefore

appears that the ALJ credited the portion of Dr. Scherman’s

opinion that was consistent with all the other opinions and that

was necessary to his conclusion, namely, that Plaintiff could

engage in work that involved lifting no more than twenty pounds. 

To the extent that Dr. Scherman opined that Plaintiff could

not return to her previous work, it was apparently not an opinion

that precluded working while lifting less than twenty-five pounds

or that was otherwise was inconsistent with the affirmative RFC

found by the ALJ. It therefore appears that to the extent

required for the RFC assigned by the ALJ, the ALJ considered the

pertinent significantly probative evidence, assigned weight to it

to the extent that it was consistent with the other substantial

medical opinions of record and was based on significant objective

findings, and adequately stated reasons for the record. 

Plaintiff’s contention that the report of Dr. Scherman must

be interpreted or weighed in a particular fashion because it was

generated within a state worker’s compensation system is not

meritorious. The opinion of Dr. Scherman and the similar opinions

of other experts were specific with respect to precise lifting

capacities; within the specific context of the present case, the

Court does not find any significant likelihood of confusion or

misinterpretation.

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The Court concludes that the ALJ cited specific and

legitimate reasons, supported by substantial evidence, in support

of his weighing of Dr. Scherman’s opinion.

B. Dr. Wageneck

Dr. Robert Wageneck examined Plaintiff in May 2003, found

her to be asymptomatic and suffering from malaise, and noted that

it was somewhat unclear as to why Plaintiff was there (A.R. 504);

he treated her and oversaw her treatment for mild

hyperparathyroidism in 2004 and 2005 and encouraged her to start

an exercise walking program (A.R. 493, 498, 503). In February

2005, Dr. Wageneck completed a medical assessment of Plaintiff’s

ability to do work-related activities, and concluded that based

on Plaintiff’s reported ability to carry, she could lift a

maximum of ten pounds occasionally, three to four pounds

frequently, walk four hours in an eight-hour day but only thirty

minutes without interruption; and Plaintiff could never climb,

stoop, kneel, balance, crouch, or crawl. Further, Plaintiff was

unstable at heights and unable to move machinery due to lack of

strength because of Plaintiff’s weakness and pain. (A.R. 420-22.)

Again, the restrictions were expressly based on the patient’s

report. (A.R. 420-21.) 

The ALJ referred to Dr. Wageneck’s opinion that Plaintiff

had the capacity for sedentary work, but he concluded that the

opinion was not consistent with the doctor’s own treating records

and further was based entirely on the Plaintiff’s subjective

complaints. Accordingly, the ALJ gave very little weight to Dr.

Wageneck’s opinion. (A.R. 21.)

Substantial evidence supports the ALJ’s finding that Dr.

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Wageneck’s functional limitations were based on Plaintiff’s

subjective complaints. The doctor relied on Plaintiff’s

statements of pain, weakness, or more generally on the patient’s

report in all instances except with respect to Plaintiff’s

inability to move machinery, which was based on Plaintiff’s lack

of strength. (A.R. 420-22.) As has been previously analyzed, the

ALJ’s rejection of Plaintiff’s subjective complaints was

supported by substantial evidence and was based on proper legal

standards. Where the record supports an ALJ’s rejection of the

claimant’s credibility as to subjective complaints, the ALJ is

free to disregard a doctor’s opinion that was premised upon the

claimant’s subjective complaints. Tonapetyan v. Halter, 242 F.3d

1144, 1149 (9 Cir. 2001). th

Likewise, Dr. Wageneck’s treatment notes referred to by the

ALJ (A.R. 21, A.R. 491-505 [Ex. 25F pp. 1-15]) are inconsistent

with the doctor’s conclusion that Plaintiff could lift only three

to four pounds frequently and ten occasionally, walk a total of

four hours and no more than half an hour at a time, and never

climb, stoop, kneel, balance, crouch, or crawl. Plaintiff was

asymptomatic in May and June 2003 (A.R. 503-04.) She complained

of bone pain in September 2004, but no abnormalities were noted

in the examination in September; diffuse bone pain and multiple

somatic complaints mostly related to myalgias were reported in

October 2004; and she reported pain in the back of the head in

November 2004, at which time she also complained of pain in the

cervical spine accompanied by findings on examination of moderate

to severe spasm that affected the range of motion of the cervical

spine, which was treated with Flexeril and Tylenol. (A.R. 496-98,

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502.) In December 2004, Plaintiff reported body ache and

headaches for a few days, but there were no findings upon

examination, and Plaintiff was treated with medication and

referral to a specialist. (A.R. 494.) In January 2005, Plaintiff

reported that a consulting endocrinologist opined that

Plaintiff’s hyperparathyroidism was mild and possibly related to

her thyroid disorder; there was no malignancy but a multinodular

goiter, and Plaintiff was started on propylthiouracil; her chief

complaint was cervicothoracic pain that was worse with exertion,

but Plaintiff did walk. Dr. Wageneck found moderate tenderness to

palpation in the cervical spine and painful range of motion of

the cervical and thoracic spine, but no obvious deformity. His

assessment was hyperparathyroidism, multinodular goiter, obesity,

and cervicothoracic strain, to be treated with Bextra for

musculoskeletal pain, as well as walking, exercise, medication,

and monitoring of free T4 and TSH. (A.R. 493.)

The treatment notes do not reflect findings on examination,

assessments, or courses of treatment that were consistent with an

impairment so severe that Plaintiff was rendered unable to

perform all but sedentary work. Plaintiff was treated with antiinflammatory medications only and was encouraged to improve her

diet and to exercise. The Court thus concludes that substantial

evidence supported the ALJ’s reasoning that Dr. Wageneck’s

treatment notes did not support his functional assessment.

Therefore, the Court concludes that the ALJ stated specific

and legitimate reasons, based on substantial evidence, for his

weighing of the expert opinions.

/////

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VII. Recommendation

Pursuant to the foregoing analysis, it is concluded that

Plaintiff’s arguments should be rejected. The ALJ’s decision was

reached by the use of proper legal standards and is supported by

substantial evidence.

Accordingly, it IS RECOMMENDED that

1. Plaintiff’s social security complaint BE DENIED; and

2. Judgment for Defendant Michael J. Astrue, Commissioner of

Social Security, and against Plaintiff Delfina Ramirez, BE

ENTERED.

This report and recommendation is submitted to the United

States District Court Judge assigned to the case, pursuant to the

provisions of 28 U.S.C. § 636 (b)(1)(B) and Rule 72-304 of the

Local Rules of Practice for the United States District Court,

Eastern District of California. Within thirty (30) days after

being served with a copy, any party may file written objections

with the court and serve a copy on all parties. Such a document

should be captioned “Objections to Magistrate Judge’s Findings

and Recommendations.” Replies to the objections shall be served

and filed within ten (10) court days (plus three days if served

by mail) after service of the objections. The Court will then

review the Magistrate Judge’s ruling pursuant to 28 U.S.C. § 636

(b)(1)(C). The parties are advised that failure to file

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objections within the specified time may waive the right to

appeal the District Court’s order. Martinez v. Ylst, 951 F.2d

1153 (9th Cir. 1991).

IT IS SO ORDERED.

Dated: January 30, 2008 /s/ Sandra M. Snyder 

icido3 UNITED STATES MAGISTRATE JUDGE

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