Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_05-cv-03602/USCOURTS-azd-2_05-cv-03602-0/pdf.json

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

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WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Derrick Diaz, 

Plaintiff, 

vs.

Jo Anne Barnhart, Commissioner of the

Social Security 

Defendant. 

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No. CIV 05-3602-PHX-MHM

ORDER

Plaintiff Derrick Diaz ("Plaintiff") seeks judicial review of the Administrative Law

Judge's ("ALJ") decision denying his claim for disability insurance benefits and supplemental

security income 

I. Procedural History

On February 11, 2003, Plaintiff filed applications for disability insurance benefits and

supplemental security income payments alleging an onset date of December 12, 2001,

because of back pain, knee pain and depression. (Transcript "Tr." 22). The claims were

denied initially and upon reconsideration. On December 8, 2004, a hearing was held in front

of an ALJ with Plaintiff, Plaintiff's counsel, and vocational expert David A. Janus ("Mr.

Janus") present. On January 27, 2005, the ALJ issued her written decision denying Plaintiff's

request for benefits finding Plaintiff not disabled within the meaning of the Social Security

Act. (Tr.21-32). Plaintiff's request for review of the ALJ's decision was denied by the

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Appeals Council on September 9, 2005. (Tr.9-11). Plaintiff then initiated the instant action

for judicial review pursuant to 42 U.S.C. §§ 405(g) and 1383(c). 

II. Background Facts

A. Plaintiff's Medical History

On December 10, 2002, Steven Kassman, M.D. ("Dr. Kassman") performed surgery

on Plaintiff's right knee to repair a torn medial meniscus and lateral meniscus. (Tr.137, 200).

From August 26, 2002, through September 16, 2003, Plaintiff was seen and treated by Autul

Patel, M.D., ("Dr. Patel"). (Tr.275-91). On August 26, 2002, Dr. Patel diagnosed Plaintiff

with mechanical lower back pain, status post back injury and lumbar degenerative disc

disease. (Tr.275). On October 7, 2002, Dr. Patel diagnosed Plaintiff with thoracolumbar

sprain and strain and a rib cage contusion. (Tr.287). Dr. Patel recommended physical therapy

and stated that Plaintiff was capable of "modified sedentary work." (Tr.287). On January 14,

2003, Dr. Patel noted that Plaintiff may be a good candidate for epidural injections and noted

that Plaintiff was capable of performing sedentary to light activity. (Tr.282-83). On June

19, 2003, an MRI scan suggested a possible re-tear or residual tear of the medial meniscus,

along with moderate joint effusion. (Tr.201). On June 30, 2003, Dr. Patel noted chronic low

back pain, obesity, poor posture and multi-level degenerative changes of the back. (Tr.278).

Dr. Patel recommended the continuation of "conservative management" as well as Plaintiff's

injections. (Id). 

On August 6, 2003, Plaintiff was examined by Malcolm McPhee, M.D. ("Dr.

McPhee"), a consultative examining physician at the request of Arizona Department of

Economic Security. (Tr.143). Dr. McPhee diagnosed Plaintiff with chronic low back pain

and status after bilateral knee arthroscopic surgeries. (Tr.144). Dr. McPhee stated that based

upon his examination, there was no reason Plaintiff could not lift 50 pounds occasionally,

25 pounds frequently, stand or walk for four hours in an eight-hour day and sit for six hours

of an eight-hour day. (Tr.144).

On August 20, 2003, Robert Hubek, M.D. ("Dr. Hubek") performed a physical

residual functional capacity assessment of Plaintiff finding that the Plaintiff could

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occasionally lift up to 50 pounds, frequently lift up to 25 pounds, could stand or walk up to

four hours in an eight-hour day and could sit for a total of six hours in an eight-hour day.

(Tr.149). Dr. Hubek noted Plaintiff's allegations to be out of proportion to the objective

findings and therefore considered Plaintiff only partially credible. (Tr.153). 

On September 7, 2004, Jacquelyn Paul, M.S., an exercise physiologist recommended

that Plaintiff could perform sedentary to light and noted that if sedentary work was pursued

the Plaintiff would require breaks every hour from sitting. (Tr.315). 

On October 2, 2003, Plaintiff was examined by Armando Bencomo, Ph.D, ("Dr.

Bencomo") a clinical psychologist. (Tr.156-60). Dr. Bencomo diagnosed Plaintiff with

adjustment disorder with depressed mood, moderate; pain disorder due to medical condition;

polysubstance abuse in sustained remission; adult antisocial behavior related to alcohol use,

in sustained remission; and hypothyroid, low back pain, knee pain and overweight. (Tr.159).

 Dr. Bencomo stated that Plaintiff was moderately depressed and would benefit from an

antidepressant for his mood and to improve pain tolerance. (Tr.159). In addition, in assessing

Plaintiff's work related activities based upon his mental state, Dr. Bencomo found Plaintiff

to be "not limited" "good" or "good to fair" in most categories. (Tr. 160). However, with

respect to Plaintiff's ability to "deal with work stresses" and "behave in an emotionally stable

manner," Dr. Bencomo found Plaintiff to be in the "fair" category. "Fair" is defined as

"seriously limited but not precluded." (Tr.160). 

On October 3, 2003, a non-examining state agency physician, James Campbell, M.D.,

("Dr. Campbell") reviewed Plaintiff's record. (Tr.161-63). Dr. Campbell in performing a

functional capacity assessment found Plaintiff able to perform substantial gainful activity and

found "no significant psychiatric illness." (Tr.163). Dr. Campbell further stated that any

limitations were somatic in nature. (Id.). 

B. Hearing Testimony

At the hearing on December 8, 2004, Plaintiff and Mr. Janus, the vocational expert

testified. (Tr.335-369). Plaintiff testified that he had two knee surgeries done on each knee,

but continued to suffer problems with pain. (Tr.344). Plaintiff also testified regarding his

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struggle with depression. For instance, Plaintiff testified to feeling tired all the time with

frequent crying at home. (Tr.348). Plaintiff further testified that although he battled with

depression he did not actively seek a lot of treatment, because he was not "raised like that."

(Tr.350). 

At the hearing, Mr. Janus classified Plaintiff's past work experience as an electrician

or electrician's helper as semi-skilled work performed at the heavy exertional level. (Tr.358).

The ALJ posed several hypothetical questions to Mr. Janus. For instance, the ALJ asked Mr.

Janus that assuming a person with the same background and residual functional capacity

assessment to that set out by the state physician, Dr. Hubek, whether Plaintiff could perform

any other work. (Tr.358-59). Mr. Janus responded that Plaintiff could perform other work

such as a night watchman, unarmed guard or parking lot attendant. (Tr.359). In response to

the ALJ's hypothetical of whether Plaintiff could perform work based upon limitations of

occasionally lifting twenty pounds and occasionally lift up to ten, could stand and walk less

than two hours and sit up to six hours in an eight-hour day and possessed a limitation with

respect to reaching and handling with unknown specificity; Mr. Janus concluded that it

would depend on the severity of the reaching and handling limitation. (Tr.360). Mr. Janus

also concluded that Plaintiff could perform other sedentary work based upon the restrictions

set forth by Ms. Paul, the exercise physiologist. (Tr.361). 

In response to the hypothetical question posed by Plaintiff's attorney regarding the

limitations noted by Dr. Bencomo as to Plaintiff's "fair" ability to "deal with work stresses"

and "behave in an emotionally stable manner," the vocational expert stated sustained work

would be precluded if an individual could not handle such matters consistently. (Tr.365).

Moreover, Mr. Janus agreed with Plaintiff's counsel that these mental limitations combined

with the limitations posed by the ALJ's hypothetical would "more clearly eliminate the ability

to work on a sustained basis." (Tr. 366). 

C. ALJ's Conclusion

In the January 27, 2005, decision the ALJ discussed her findings rejecting Plaintiff's

claim for disability. The ALJ found Plaintiff's impairments of "bilateral knee degenerative

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joint disease, degenerative disc disease of the lumbar spine, mild with mild central canal

stenosis and sleep anemia, status post surgical treatment" to be severe within the meaning of

the Regulations. (Tr.22-23). The ALJ concluded that none of the severe impairments met or

equaled the criteria supporting a finding of disability pursuant to Appendix 1, Subpart P,

Regulation No. 4. The ALJ found that Plaintiff's asserted mental impairment not to be severe

within the meaning of the Regulations. (Tr.25). The ALJ found, in part, that "[t]here is no

evidence of more than mild difficulties in concentration, persistence and pace and no

evidence of episodes of decompensation of extended duration." (Id.). The ALJ also found

Plaintiff's allegations regarding the severity of his physical limitations not totally credible.

(Tr.26). The ALJ determined that Plaintiff possessed the residual functional capacity to stand

or walk for four hours, sit for about six hours in an eight-hour day; carry 50 pounds

occasionally, and lift 25 pounds frequently. (Tr.31). Lastly, the ALJ, based upon these

findings and the testimony of Mr. Janus, concluded that Plaintiff retained the ability to

perform other work such as an unarmed security guard, parking lot attendant, messenger,

assembler and cashier. (Tr.30). 

III. Standard of Review

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

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

1990). Substantial evidence means "more than a mere scintilla" and "such relevant evidence

as a reasonable mind might accept as adequate to support a conclusion." Richardson v.

Perales, 402 U.S. 389, 401 (1971); Clem v. Sullivan, 894 F.2d 328, 330 (9th Cir. 1990).

In determining whether substantial evidence supports a decision, the Court considers

the record as a whole. Richardson, 402 U.S. at 401; Tylitzki v. Shalala, 999 F.2d 1411, 1413

(9th Cir. 1993). If there is sufficient evidence to support the ALJ’s determination, the Court

cannot substitute its own determination. Young v. Sullivan, 911 F.2d 180, 184 (9th Cir.

1990). Where evidence is inconclusive, "questions of credibility and resolution of conflicts

in the testimony are functions solely of the [Commissioner]." Sample v. Schweiker, 694 F.2d

639, 642 (9th Cir. 1982). Therefore, if on the whole record before the Court, substantial

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evidence supports the Commissioner’s decisions, this Court must affirm. Hammock v.

Bowen, 879 F.2d 498, 501 (9th Cir. 1989); 42 U.S.C. § 405(g). 

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

following five stages:

(1) determine whether the applicant is engaged in "substantial gainful

activity;"

(2) determine whether the applicant has a "medically severe impairment or

combination of impairments;"

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

of listed impairments that the Commissioner acknowledges as so severe

as to preclude the applicant from engaging in substantial gainful

activity;

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

impairments," determine whether the applicant is capable of performing

his or her past relevant work;

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

work, determine whether the applicant "is able to perform other work

in the national economy in view of his [or her] age, education, and

work experience."

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

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

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

IV. Discussion

Plaintiff raises the following issues on appeal: (1) whether the ALJ erred in finding

Plaintiff's mental impairments not "severe" within the meaning of the regulations; and, in the

alternative, whether the ALJ erred by denying Plaintiff's request for an updated consultative

examination to assess Plaintiff's mental impairments; (2) whether the ALJ erred in rejecting

the opinion of the agency's examining psychologist, Dr. Bencomo; and (3) whether the ALJ

erred in discounting the Plaintiff's credibility. 

A. ALJ's Finding of Plaintiff's Mental Impairment to be Not Severe

Plaintiff contends that the ALJ erred in finding Plaintiff's mental impairments to be

not severe within the meaning of the Regulations. In support of this argument, Plaintiff relies

upon the results of the psychological examination performed by Dr. Bencomo. (Tr.156-60).

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Social Security rulings constitute the Social Security Administrator's interpretations

of the statute it administers and its own regulations. The rulings are interpretative and do not

provide the force of law, but courts will defer to them unless they are plainly erroneous or

inconsistent with the Social Security Act or regulations. Chavez v. Department of Health and

Human Resources, 103 F.3d 849, 851 (9th Cir. 1996) (citations omitted). 

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Most notably, as referenced above, Dr. Bencomo found Plaintiff to possess only a "fair"

ability to "deal with work stresses" and "behave in an emotionally stable manner." (Tr.160).

"Fair" is defined as "seriously limited but not precluded." (Id.). Moreover, Plaintiff points

out that when these limitations were posed to the vocational expert regarding Plaintiff's

ability to work, the vocational expert agreed with Plaintiff's counsel that if the Plaintiff could

not handle such issues, the Plaintiff would not be able to work on a sustained basis. (Tr.365).

In response to the Plaintiff's argument, the Defendant asserts that the ALJ's decision on this

issue is supported by the requisite substantial evidence. The Defendant notes that "fair" does

not necessarily mean that work is precluded. (Tr.160). In addition, Defendant argues that Dr.

Bencomo's examination results reveal no significant mental impairment. Defendant also

notes the findings of Dr. Campbell, the consultative non-examining physician, that Plaintiff

possessed "no significant psychiatric illness" and that Plaintiff's disability, if any, was

somatic in nature. (Tr.163). 

In reviewing the record on this issue, the Court finds that the ALJ's decision

classifying Plaintiff's mental impairment as not severe within the meaning of the Regulations

to be unsupported by substantial evidence. As a general matter, 20 CFR § 404.1520(c)

defines a severe impairment as "any impairment or combination of impairments which

significantly limits [the claimant's] physical or mental ability to do basic work activities." 

In addition, SSR 85-28 provides guidance stating in pertinent part:

Great care should be exercised in applying the not severe impairment concept.

If an adjudicator is unable to determine clearly the effect of an impairment or

combination of impairments on the individual's ability to do basis work

activities, the sequential evaluation should not end with the not severe

evaluation step. Rather, it should be continued.1

 

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Notably, although the ALJ cited Dr. Bencomo's "fair" limitation in the decision, the

ALJ did not mention the restrictive definition accompanying such a finding; that is "seriously

limited but not precluded." (Tr.25; 160). 

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In this case, the Court finds that based upon the medical record, it is unclear, at the very

least, the extent of the impact of the Plaintiff's mental impairment, thus supporting a severe

determination within the meaning of the Regulations. The ALJ's findings as to Plaintiff's

mental impairment do not fully consider Dr. Bencomo's stated limitations regarding

Plaintiff's ability to "deal with work stresses" and to "behave in an emotionally stable

manner." (Tr.160). Rather, in finding the Plaintiff's mental impairment to be not severe the

ALJ relied primarily on selective results from Dr. Bencomo's examination, such as ratings

of "good" regarding Plaintiff's ability to relate to co-workers, deal with the public, interact

with supervisors and to relate predictably in social situations. (Tr.25; 160). The ALJ did not

evaluate Plaintiff's "fair" rating suggesting that Plaintiff was seriously limited in "deal[ing]

with work stresses" and "behav[ing] in an emotionally stable manner" (Id.).2

 The

significance of this omission is clearly bolstered by the testimony of the vocational expert,

which reveals that the Plaintiff would be precluded from work if Plaintiff was not able to

handle such issues consistently. (Tr.365). Thus, the Court finds that the ALJ's decision

classifying Plaintiff's mental impairment as not severe to be unsupported by substantial

evidence. 

The Court's above finding as to severity of Plaintiff's mental impairment also impacts

Plaintiff's second argument in support of error; specifically, that the ALJ allegedly failed to

properly reject the significant limitations cited by Dr. Bencomo of Plaintiff's ability to "deal

with work stresses" or "behave in an emotionally stable manner." (Tr.160). Plaintiff notes

that the ALJ failed to address these findings in determining Plaintiff's mental impairment to

be not severe, and argues that this omission is inconsistent with the ALJ's obligation to at

least provide specific and legitimate reasons supported by substantial evidence in the record

rejecting these findings. Smolen v. Chater, 80 F.3d 1273, 1285 (9th Cir. 1996); see also

Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995) (stating that "opinion of nonexamining

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physician cannot by itself constitute substantial evidence that justifies rejection of the opinion

of ... an examining physician."). In opposition, the Defendant contends that the ALJ did not

improperly reject the findings of Dr. Bencomo, but rather that Dr. Bencomo's findings

actually support the ALJ's determination regarding Plaintiff's non-disabled status. For

instance, Defendant notes that Dr. Bencomo's examination produced a diagnosis that Plaintiff

suffered from adjustment disorder with depressed mood as moderate. (Tr.159). In addition,

Dr. Bencomo stated that Plaintiff was "moderately depressed and would benefit from an

antidepressant for his mood." (Id.). As further support, Defendant cites the findings of Dr.

Campbell stating that Plaintiff did not suffer from any significant psychiatric illness.

(Tr.163). 

As stated above, the Court finds that the ALJ's decision finding Plaintiff's mental

impairment to be not severe is unsupported by the medical record. In addition, while the

Defendant contends that Dr. Bencomo's findings support the ALJ's determination, it is clear

that the ALJ failed to evaluate Dr. Bencomo's significant limitations implicating Plaintiff's

ability to engage in work. In light of this determination, the Court cannot find that the ALJ

properly rejected Dr. Bencomo's findings regarding Plaintiff's ability to "deal with work

stresses" or "behave in an emotionally stable manner" or that Dr. Bencomo's findings overall

support the ALJ's determination in light of her failure to discuss these limitations. As such,

the Court finds that the ALJ did not properly reject Dr. Bencomo's cited limitations.

B. Rejection of Plaintiff's Symptom Testimony

Lastly, Plaintiff contends that the ALJ erred in discounting Plaintiff's credibility as to

the severity of his symptoms. Plaintiff asserts that the ALJ failed to explain important

aspects of the credibility determination such as what testimony of Plaintiff was not

considered credible. In addition, Plaintiff contends that the ALJ improperly discounted

Plaintiff's credibility based upon the objective medical evidence and failed to even discuss

Plaintiff's mental impairments. In opposition, Defendant contends that the ALJ properly

addressed and discounted Plaintiff's credibility based upon well recognized reasons, such as

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a review of the overall medical evidence and inconsistencies between Plaintiff's testimony

and the medical evidence. 

In reviewing this issue, it is important to note that because the ALJ did not find

Plaintiff's mental impairments to be severe within the meaning of the Regulations, the ALJ

only addressed Plaintiff's physical limitations. The Court has found error with the ALJ's

determination regarding Plaintiff's mental impairments; however, it would be improper, at

this time, for the Court to find the ALJ's credibility analysis flawed because of the omission

of Plaintiff's mental impairments since the ALJ felt that the issue need not be addressed.

Thus, the Court will only address the Plaintiff's argument with respect to the ALJ's evaluation

as to Plaintiff's physical impairments and whether the ALJ complied with her obligation in

discounting Plaintiff's testimony regarding the severity of such. 

"[O]nce the claimant produces objective medical evidence of an underlying

impairment, an adjudicator may not reject a claimant's subjective complaints based solely on

a lack of objective medical evidence to fully corroborate the alleged severity of pain. Bunnell

v. Sullivan, 947 F.2d 341, 345 (9th Cir. 1991) (en banc) (citing Cotton v. Bowen, 799 F.2d

1403, 1407 (9th Cir.1986)). "Unless, there is affirmative evidence showing that the claimant

is malingering, the Commissioner's reasons for rejecting the claimant's testimony must be

'clear and convincing'" Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998) (citing Lester

81 F.3d at 834. "[T]he ALJ must identify what testimony is not credible and what evidence

undermines the claimant's complaints." Lester, 81 F.3d at 834. 

In reviewing the record on this issue, the Court finds that the ALJ did properly

discount Plaintiff's physical impairment testimony as the ALJ provided the requisite "clear

and convincing" reasons for doing so. For instance, in discounting the severity of Plaintiff's

severe back pain, the ALJ cited specific records suggesting that the impairment was not as

significant as suggested, such as the usefulness of physical therapy, and the routine and

conservative treatment. (Tr.27; 282; 291). In addition, the ALJ noted that after Plaintiff's

knee surgery the Plaintiff reported that his pain was gone and that the record reveals no

evidence of treatment after May of 2004. (Tr.27;307). Moreover, there is evidence in the

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record suggesting that the Plaintiff's condition improved significantly after the use of

injections to address his reports of pain. (Tr. 27; 193). The ALJ also evaluated the Plaintiff's

daily activities, such as yard and housework and exercise which reveal a fairly active

lifestyle. (Tr.28). In sum, the Court finds that the ALJ did properly evaluate and discount the

Plaintiff's credibility with respect to the severity of his physical impairments as the ALJ

provided "clear and convincing" reasons based upon a thorough review of the record and

relevant factors helpful in evaluating credibility. See Bunnell v. Sullivan, 947 F.2d 341, 346-

47 (9th Cir. 1991) (noting relevant factors to include the nature, duration, location, onset,

intensity of pain; functional restrictions and claimant's daily activities.); see also SSR 96-7p.

While Plaintiff clearly disagrees with the ALJ's determination, the Court finds that the ALJ's

determination is supported by the requisite "clear and convincing" reasons and therefore free

from a determination of error by this reviewing court. 

C. Future Handling 

As discussed above, the Court finds that the ALJ committed error at step two of the

sequential analysis in finding Plaintiff's mental impairments to be not severe within the

meaning of the Regulations. However, contrary to Plaintiff's argument, the Court finds that

the appropriate remedy is to remand this case with instructions to the Secretary directing

further proceedings based upon the finding that Plaintiff's mental impairment is "severe"

within the meaning of the Regulations. In doing so, the Secretary will be required to

determine whether Plaintiff's severe mental impairment, alone, or in combination with the

Plaintiff's other severe impairments support a finding of disability. See INS v. Ventura, 537

U.S. 12, 16, 123 S.Ct. 353 (2002) ("except in rare circumstances ... remand to the agency for

additional investigation or explanation" is appropriate.); see also McAllister v. Sullivan, 888

F.2d 599, 603 (9th Cir. 1989) (stating remand is appropriate when Secretary is in better

position that court to evaluate the evidence.). 

Accordingly,

IT IS HEREBY ORDERED granting in part and denying in part Plaintiff's Motion

for Summary Judgment (Dkt.#14). 

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IT IS FURTHER ORDERED granting in part and denying part Defendant's Motion

for Summary Judgment. (Dkt.#20).

IT IS FURTHER ORDERED that this matter is remanded to the Commissioner for

further proceedings to determine whether Plaintiff is disabled in light of the Court's ruling

that Plaintiff's mental impairment is severe within the meaning of the Regulations. 

DATED this 27th day of March, 2007.

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