Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_04-cv-02684/USCOURTS-cand-3_04-cv-02684-0/pdf.json

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

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United States District Court

For the Northern District of California

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United States District Court

For the Northern District of California

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

ALFONSO D ROCHELL,

Plaintiff,

v

JO ANNE B BARNHART, Commissioner

of Social Security,

Defendant. /

No C 04-02684 VRW

ORDER

Plaintiff Alfonso Rochell appeals from the decision of

the Social Security Administration (“SSA”) denying him social

security disability benefits and supplemental security income

(“SSI”). The court now considers cross motions for summary

judgment. Pl Mot (Doc #18); Def Mot (Doc #19); Pl Rep Mot (Doc

#24). For the reasons stated herein, the court GRANTS plaintiff’s

motion and DENIES defendant’s motion.

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United States District Court

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I

A

Plaintiff was born on October 19, 1976. Administrative

Record (“AR”) (Doc #15) at 185. During his childhood, plaintiff

developed end stage renal disease that required dialysis for eight

to nine months. In 1991, at the age of fifteen, he received a

kidney transplant. AR at 289, 329. 

On July 14, 1993, the SSA designated plaintiff “disabled”

within the meaning of the Social Security Act with an established

onset date of October 1, 1986. AR at 24. The SSA’s initial

decision used medical evidence to show that plaintiff suffered from

end stage renal failure. AR at 24. Plaintiff was diagnosed with

nephritic syndrome (an inflammation of the kidneys) and chronic

renal failure secondary to glomerulosclerosis (scarring and

degeneration of structures within the filtering units of the

kidneys). Id. Also, plaintiff’s creatinine levels, which are

generally indicative of diminished kidney function, were measured

“as high as 3.3”. Id. The decision also noted that plaintiff had

a shunt implanted for dialysis treatment and was prescribed

Prednisone to relieve his kidney ailments. Id.

Plaintiff testified to orthopedic problems with his left

knee, stating that in 1991 he underwent arthroscopic surgery on his

left knee because of a deteriorating bone, AR at 53, 56, and that,

soon after recovering from surgery, he fractured his kneecap while

playing sports and required three additional surgeries. AR at 53-

54. The record contains no medical records concerning this medical

history. 

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3

Immediately following high school in 1994, plaintiff

enrolled at the City College of San Francisco. AR at 40, 64. 

Although the college tried to place plaintiff in “ESL special ed

classes,” he enrolled in regular classes such as English, math,

criminology and physical education. AR at 64. Plaintiff attended

college for less than one year because he only made “Ds, Fs, and 

* * * a B in gym.” Id. 

Since 1993, plaintiff has engaged in varied employment

including security guard, customer service officer and clerical

aide. AR at 98-99, 204-06. From 1996 to 1997, plaintiff engaged

in his longest period of employment (approximately eighteen months)

working for a private security company as a patrolman and traffic

officer. AR at 40, 46, 205. He again worked as a security guard

from 2000 to 2001 for the San Francisco Baseball Associates. AR at

38-39, 210. Plaintiff has also worked as a clerical aide and sales

representative. From 1993 to 1994, while still in school, he

answered phones and filed records for the Japanese Community Youth

Council. AR at 39, 204. As a sales representative in retail

stores, plaintiff worked as a cashier and stocked shelves. AR at

40-41, 43, 205.

Plaintiff has not been employed since approximately May

2001. AR at 47. In 2001, he earned approximately $10,627.00,

working for two companies: Virologic and McCoy Patrol Service. AR

at 46-47, 210. While at Virologic, plaintiff worked in a warehouse

lifting supplies weighing from ten to twenty pounds and,

occasionally, some supplies that he could not handle that weighed

fifty to one hundred pounds. AR at 47. Since then, plaintiff has

not worked. 

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4

 According to plaintiff, many of his jobs lasted only a

couple of months. During his first administrative law judge

(“ALJ”) hearing on June 2, 2002, plaintiff explained “[s]ome of

them, I was fired from, because of medical reasons. Some of them I

quit.” AR at 41. He clarified that employers “would get mad * * *

because I didn’t show up to work, because I wasn’t feeling right *

* *. My knees were giving me problems. My back was giving me

problems. And my hands would cramp up to where I couldn’t work for

a long period of time.” AR at 42. At a second ALJ hearing on

September 25, 2003, plaintiff asserted that he was physically

unable to engage in any previous types of employment. AR at 76. 

Since 1995, plaintiff has been under the care of Donald

Potter, MD, a pediatric kidney specialist, who practices at the

Children’s Renal Center at the University of California San

Francisco Medical Center. AR at 50-51, 329. At the first ALJ

hearing, plaintiff testified that he sees Dr Potter on a regular

basis and that Dr Potter is his “only medical care.” AR at 51. 

Although Dr Potter has treated plaintiff since 1995, the record

contains none of plaintiff’s medical records prior to 2000. 

On September 18, 2000, Dr Potter treated plaintiff for

migraines and lower thoracic back pain. AR at 262. Plaintiff also

reported sharp, acute back pains of twenty minutes’ duration. Id. 

Dr Potter determined that there was “[m]inimal anterior compression

of the T11-T12 vertebral bodies, consistent with mild compression

fractures of uncertain duration.” AR at 259. 

On July 14, 2000, plaintiff visited Dr Potter complaining

of blood in his urine (“gross hematuria”), AR at 277, for which he

was referred to Laurence Baskin, MD, the chief pediatric urologist

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5

at University of California San Francisco Medical Center. AR at

277, 267. On August 2, 2000, Dr Baskin conducted a cystoscopy on

plaintiff that proved normal. AR at 263, 266. Dr Baskin opined

that there was no “obvious” cause for plaintiff’s hematuria. Id.

On May 16, 2001, Farah Rana, MD, an internal medicine

physician, conducted a consultative internal medical evaluation of

plaintiff on behalf of the SSA. AR at 289. Plaintiff stated he

was taking immunosuppressants and claimed his renal functions were

fine but complained of migraines, low back pain and pain in both

his knees. Id. Dr Rana diagnosed plaintiff with a history of

hypertension, end stage renal disease, status post kidney

transplant, history of migraine headaches, arthritis in the knees

and chronic low back pain that was most likely secondary to

degenerative joint disease. AR at 291. Dr Rana also noted that

plaintiff had taken Prednisone since 1990. Id. Dr Rana opined

that plaintiff could: (1) stand and walk six hours with breaks in

an eight hour day; (2) carry twenty pounds consistently and forty

pounds occasionally; (3) make any motion without limitations; and

(4) handle, manipulate and feel things without any problem. Id. 

On July 6, 2001, Janine Marinos, PhD, a licensed

psychologist, completed a consultative psychological evaluation of

plaintiff on behalf of the SSA. AR at 310. Based on tests to

evaluate plaintiff’s cognitive functioning and a mental status

examination, Dr Marinos diagnosed plaintiff with a “Depressive

Disorder NOS” and “Borderline Intelligence.” AR at 313. Dr

Marinos stated that plaintiff appeared to have “significant

depression related to his chronic medical problems and associated

limitations,” id, and that his depression would “likely limit his

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ability to tolerate the day-to-day stresses of regular, full-time

employment.” Id. She opined that plaintiff had an “adequate

ability to understand, remember, and carry out simple instructions,

but may have some difficulty carrying out novel or complex tasks

with adequate pace or persistence.” Id. 

In July 2002, plaintiff experienced an acute transplant

rejection requiring two hospitalizations and treatment with high

doses of immunosuppressive drugs. AR at 329. Plaintiff’s

creatinine level soared to 4.2 and then decreased to 1.9 with

treatment. Id. During treatment, plaintiff suffered from episodes

of nausea and diarrhea, which resolved after adjustment of the

dosage. Id. On August 14, 2002, the SSA received a note written

by Dr Potter stating plaintiff had “been hospitalized twice in the

last three weeks for severe kidney transplant rejection,” AR at

328, that he could not currently work and “his ability to work full

time in the future is problematic.” AR at 328.

On June 25, 2003, Dr Potter provided the SSA with an

updated assessment of plaintiff’s health. Dr Potter diagnosed

plaintiff with chronic rejection of kidney transplant, chronic

renal insufficiency, hypertension, anemia, gout and ankle edema. 

AR at 24, 330-31. Dr Potter also noted plaintiff’s medication

routine as follows:

1. * * * Lasix 40 mg daily * * *. 

2. Prednisone 7.5 mg daily,

3. CellCept 750 mg b.i.d.,

4. Tacrolimus 5 mg in the morning, 6 mg at night,

5. Amlodipine 10 mg daily,

6. Benazepril 10 mg daily,

7. Atenolol 25 mg daily,

8. Ferrous sulfate 325 mg daily,

9. Protonix 40 mg daily,

10. Sodium bicarbonate 1.2 g twice a day,

11. Calcitriol 0.25 mg three times a week,

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12. Erythropoietin 6000 units twice a week, and

13. calcium carbonate 1.25 g daily.

AR at 330.

In addition, Dr Potter stated that plaintiff’s medical

history included: chronic renal insufficiency secondary to chronic

transplant rejection and creatinine levels “usually” ranging from

1.9 to 2.5; two episodes of gout; severe anemia requiring treatment

with erythropoietin injections; “fairly severe hypertension”; a

history of requiring anti-depressants; and various musculoskeletal

deficiencies, including unexplained tingling in his fingers, pain

in the base of his hand lasting for up to two days, swelling in his

ankles for a two month period and a chronically damaged left knee,

for which he occasionally wore a knee brace. AR at 329-30. 

Finally, Dr Potter opined that it is “questionable whether

[plaintiff] is able to hold down a job.” AR at 331.

B

On July 14, 1993, the SSA designated plaintiff “disabled”

with an established onset date of October 1, 1986. AR at 23. On

July 23, 2001, however, a Notice of Disability Cessation ended

plaintiff’s benefits based on medical evidence demonstrating

satisfactory kidney function and improved overall health. AR at

118. Plaintiff filed for reconsideration. A Disability Hearing

Officer heard the case and upheld the SSA’s decision. AR at 122,

130. Plaintiff then requested a hearing before an ALJ. AR at 158.

On June 6, 2002, the ALJ heard testimony from plaintiff,

who appeared without representation, two medical experts — Dr Alan

Coleman, an internal medicine physician, and Dr Thomas Singer, a

psychiatrist — and a vocational expert (“VE”), Mr Richard Hincks. 

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AR at 97, 161, 165, 168. On July 8, 2002, the ALJ found that

plaintiff had neither a continuing disability nor a new one. AR at

97-102. 

Plaintiff appealed to the SSA Appeals Council (“AC”). AR

at 171. On October 9, 2002, the AC vacated the ALJ’s decision and

remanded the case to obtain further evidence from plaintiff’s

treating physician, Dr Potter, regarding the kidney transplant

rejection episode, which had occurred after the first ALJ hearing. 

AR at 172. The AC also directed the ALJ to: (1) give greater

consideration to examining and non-examining source opinions; (2)

further consider plaintiff’s maximum residual functional capacity;

(3) further evaluate plaintiff’s mental impairments; and (4)

determine whether plaintiff could engage in substantial gainful

activity if there had been medical improvement under the evaluation

steps cited in 20 CFR 416.994(b)(5). AR at 172-73.

At the second ALJ hearing on September 25, 2003, the ALJ

again heard testimony from plaintiff, who again was unrepresented,

from the same two medical experts, Drs Coleman and Singer, and from

new VE, Ms Nancy Rynd. AR at 69. Plaintiff testified that the

pain was then more severe than at the first hearing, AR at 74, and

that he continued to have back pains, neck pains, finger cramping

and gout in his toe. AR at 70-71. Specifically, plaintiff

testified that both knees hurt, which made it difficult to walk and

even harder to walk up stairs or hills, and that he suffered from

shortness of breath. AR at 70, 75. He also stated that his hands

and fingers cramp for twenty- to forty-minute episodes. AR at 70. 

Plaintiff stated that his doctors “don’t really do nothing,” AR at

72, for his pain and that the Tylenol he took did not really help. 

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AR at 74. But he also testified that he took nine other

medications daily for other medical ailments. AR at 71. He also

admitted that his doctor had referred him to a pain clinic in

August 2002 but that he never made an appointment. AR at 72-73. 

After hearing plaintiff’s testimony and reviewing the

medical evidence, Dr Coleman opined that plaintiff’s kidney

functioned quite adequately, despite losing some of its function. 

AR at 79. He stated that plaintiff remains on several medications

to prevent rejection and, although his kidney is currently stable,

he may suffer progressive loss of kidney functions in the future. 

Id. Dr Coleman observed that plaintiff’s complaints were not about

kidney failure but mostly musculoskeletal issues. Id. Moreover,

he expressed uncertainty as to why plaintiff complained of such

severe musculoskeletal problems because plaintiff’s medical record

was “quite silent” and did not support such a finding. AR at 79-

80. Further, Dr Coleman stated that plaintiff’s ailments did not

meet or equal any listing and he “should be able to do sedentary

work, certainly.” AR at 80. Of note, Dr Coleman stated he changed

his evaluation from medium work in the first ALJ hearing to an

evaluation of sedentary work because he was “swayed by

[plaintiff’s] testimony” despite “no objective evidence to support”

it. AR at 81.

Dr Singer testified to plaintiff’s mental impairments

after reviewing the 2001 consultative psychological evaluation by

Dr Marinos (discussed in Part I.A, supra). He opined that, despite

reference to a learning disability and some cognitive limitations,

plaintiff’s WAIS-III test scores (AR at 312) fell within a high

borderline range and did not meet a listing for disability. AR at

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84. Dr Singer expressed disagreement with Dr Marinos’ conclusion

that plaintiff had a depressive disorder stating it was “not

supported by the clinical evidence.” AR at 85. Instead, Dr Singer

attributed plaintiff’s “depressive component” to an adjustment to a

lifelong chronic illness, which did not meet or equal a listing for

a psychiatric disorder. Id. 

The ALJ then compared evidence from the comparison point

decision (“CPD”) of July 14, 1993 that found plaintiff disabled, to

the recent medical evidence and plaintiff’s testimony at the first

and second ALJ hearings. Then to determine whether plaintiff’s SSI

should continue, the ALJ used a two-step test: (1) whether there

had been medical improvement related to plaintiff’s ability to

work; and (2) whether plaintiff currently had impairments that

prevented him from working. AR at 24. 

The ALJ found that “the record clearly indicated medical

improvement.” AR at 25. While the ALJ recognized that plaintiff

“has had a multitude of medical problems in the 10 years since the

last CPD,” he found that plaintiff’s “allegations of continuing

disability [were] not totally credible and only partially

substantiated by the medical evidence.” AR at 25. Specifically,

the ALJ discredited plaintiff’s September 2003 testimony that he

could only walk one to two blocks and was unable to work due to

knee problems. AR at 26. In so doing, the ALJ relied on four

pieces of evidence: (1) Dr Rana’s May 2001 findings that plaintiff

had normal muscle strength and no muscle atrophy in his lower

extremities; (2) the fact that plaintiff was able to perform many

activities of daily living without assistance; (3) the inference

that plaintiff could not have held his job as a security guard for

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over a year if he could only walk two blocks; and (4) the fact that

plaintiff performed substantial gainful activity in 2001, as a

security guard and warehouse worker. Id. The ALJ then concluded

that plaintiff’s medical improvement allowed him to perform

substantial gainful activity. Id.

In determining plaintiff’s residual functional capacity

(“RFC”), the ALJ rejected plaintiff’s complaints as “not generally

credible and not supported by substantial medical evidence.” AR at

27-28. The ALJ then found that plaintiff could not perform his

past relevant work but could perform “sedentary work with slight

limitations due to his depression that would preclude performing

complex and detailed tasks.” AR at 27.

The ALJ next heard from VE Nancy Rynd to determine

whether plaintiff could perform any jobs that exist in significant

numbers in the national economy. AR at 29, 87. The ALJ posed a

hypothetical question to Ms Rynd that, given an individual with

plaintiff’s background, education, and work experience and “a

residual functional capacity for sedentary work, and only slight

limitations in the nature of depression, are there jobs which such

an individual could do?” AR at 89. Ms Rynd responded

affirmatively, stating that plaintiff “would be appropriate for

customer service or telemarketing positions. As well for some

clerical positions that are sedentary.” AR at 89-90. The ALJ then

asked plaintiff if he had any questions for Ms Rynd, to which he

answered “No, I don’t.” AR 90-91. 

//

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On October 15, 2003, the ALJ issued his decision stating

that although plaintiff’s exertional and nonexertional limitations

did not allow him to perform the full range of sedentary work, he

could perform a significant number of unskilled sedentary jobs in

the national economy. AR at 30. Because the ALJ determined

plaintiff could engage in substantial gainful activity, he found

plaintiff’s disability to have ceased in July 2001. Id.

Plaintiff again appealed to the SSA Appeals Council. AR

at 13. On May 12, 2004, the AC denied plaintiff’s request for

review and the ALJ’s decision became final. AR at 8. On July 6,

2004, plaintiff filed this appeal. Doc #1. Shortly afterward,

plaintiff secured counsel to represent him in this matter. AR at

7. Plaintiff claims that he is still disabled and unable to

perform substantial gainful activity.

II

The court must uphold the SSA’s decision to deny benefits

if it is supported by substantial evidence and is not based on

legal error. Andrews v Shalala, 53 F3d 1035, 1039 (9th Cir 1995). 

Substantial evidence is “more than a mere scintilla but less than a

preponderance; it is such relevant evidence as a reasonable mind

might accept as adequate to support a conclusion.” Id. The ALJ is

responsible for determining credibility, resolving conflicts in

medical testimony and resolving ambiguities. Id.

//

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III

A

Under the Act, a “disability” is the “inability to do any

substantial gainful activity by reason of any medically

determinable physical or mental impairment which can be expected to

result in death or which has lasted or can be expected to last for

continuous period of not less than 12 months.” 42 USC §

423(d)(1)(A). An individual will be found disabled if his

impairments are such that “he is not only unable to do his previous

work but cannot, considering his age, education, and work

experience, engage in any other kind of substantial gainful work

which exists in the national economy * * *.” Id.

Once a claimant is found disabled, the burden of

establishing a continuing disability lies with the claimant, but an

earlier finding of disability gives rise to the presumption that

the condition still exists. Brown v Heckler, 713 F2d 441, 442 (9th

Cir 1983). Although the claimant retains the burden of proof, this

presumption shifts the burden of production to the commissioner to

produce evidence to meet or rebut this presumption. Id.

Disability benefits cannot be terminated unless

substantial evidence demonstrates medical improvement in the

claimant's impairment so that the claimant can engage in

substantial gainful activity. See 42 USC § 423(f); Murray v

Heckler, 722 F2d 499, 500 (9th Cir 1983). “Medical improvement” is

any decrease in the medical severity of the claimant’s impairment

following a favorable determination by the SSA to grant disability

benefits. 20 CFR § 416.994(b)(1)(i).

//

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To determine whether a recipient of SSI who is over

eighteen remains disabled, the ALJ must follow a seven-step

evaluation. 20 CFR § 416.994(b)(5). In general, § 416.994(b)

provides that in order to find whether a claimant’s disability

continues, the SSA must determine if there has been any medical

improvement in the claimant’s impairment and, if so, whether the

medical improvement is related to the claimant’s ability to work.

Specifically, the ALJ must apply a seven-step, sequential

evaluation considering: (1) whether the claimant has an impairment

or combination of impairments that meets or equals the severity of

an impairment listed in Appendix 1 of Subpart P of part 404; (2)

whether there has been medical improvement in the claimant's

condition; (3) whether the medical improvement in the claimant's

condition relates to his ability to work; (4) whether any of the

listed exceptions in § 416.994(b)(3) or (b)(4) apply, if there has

been no medical improvement in the claimant’s ability to work; (5)

whether all of the claimant's current impairments, in combination,

are severe; (6) whether the claimant can perform his past relevant

work after considering his residual functional capacity in light of

his severe impairments; (7) whether the claimant can do other work,

if he can no longer perform his past relevant work. 20 CFR §

416.994(b)(5)(i) to (vii).

Accordingly, the proper inquiry is whether, applying the

seven-step evaluation, “the Secretary's finding of improvement to

the point of no disability is supported by substantial evidence.”

Simpson v Schweiker, 691 F2d 966, 969 (11th Cir 1982).

//

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B

Plaintiff’s principal challenges to the ALJ’s final

decision are that the ALJ: (1) failed adequately to develop the

record (Pl Mot at 6-7); (2) failed to list all of plaintiff’s

impairments in the hypothetical presented to the vocational expert

(Pl Rep Mot at 8-9); and (3) failed properly to evaluate and make

specific findings regarding plaintiff’s credibility concerning his

testimony of pain (Pl Mot at 4-6; Pl Rep Mot at 4-6).

1

Plaintiff contends that the ALJ failed to develop the

record regarding plaintiff’s impairments and disabilities because

the ALJ did not consider the side effects of plaintiff’s numerous

medications on his ability to work. Pl Mot at 5. The court

agrees. The ALJ’s failure to address the effects of plaintiff’s

medications led to an incomplete record upon which the VE based her

opinion that plaintiff could perform sedentary work. And because

the VE’s opinion led the ALJ to terminate plaintiff’s benefits,

remand is appropriate.

The ALJ must fully and fairly develop the record to

assure that plaintiff’s interests are considered. See Tonapetyan v

Halter, 242 F3d 1144, 1150 (9th Cir 2001). Among the facts

relevant to a finding of disability are the “limitations or

restrictions imposed by the mechanics of treatment” including the

frequency of treatment and side effects of medications. SSR 96-8p. 

In addition, the Ninth Circuit held that “the side effects of

medications can have a significant impact on an individual's

ability to work and should figure in the disability determination

process.” Varney v Secretary of Health and Human Services, 846 F2d

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581, 585 (9th Cir 1988). And although the ALJ “is not required to

make specific findings concerning the side effects of prescription

drugs on the claimant's ability to work,” the ALJ must include

enough information for the reviewing court to determine whether

substantial evidence supports the decision. Herron v Shalala, 19

F3d 329, 335 (7th Cir 1994).

Furthermore, if an ALJ discredits the claimant’s

testimony, he must make specific findings. Varney, 846 F2d at 585. 

In Varney, the claimant testified that she took several medications

that “caused side effects ranging from fatigue to nausea, swollen

ankles, diarrhea and constipation.” Id at 582. The ALJ did not

inquire further into the claimant’s side effects but instead

discredited the claimant’s testimony as being “subjective symptoms

and limitations.” Id at 585. Consequently, the ALJ found that the

claimant was not disabled and could perform sedentary work. Id at

582. The court found that the ALJ made a reversible error because:

[h]e did not * * * make any findings with regard to the

side effects; he did not ask the medical expert who

testified at the hearing about the side effects that

could reasonably be expected from Varney's medications;

he did not consider the impact of the side effects on

Varney's ability to work, or include them as a limitation

in his hypothetical question to the vocational expert.

Id at 585.

Although Varney’s facts differ from the present case, its

principle governs here. While an ALJ should not have to inquire

into a claimant’s side effects from medication under every

circumstance, plaintiff’s use of thirteen medications should have

led the ALJ to inquire further. Instead the record is silent. 

Despite evidence in the form of plaintiff’s testimony and a letter

from plaintiff’s treating physician, the ALJ did not ask the two

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medical experts a single question about actual or potential side

effects from this combination of medications. And as in Varney,

failure of the ALJ to inquire properly into the side effects of

plaintiff’s medications was error.

Moreover, the ALJ never asked the VE whether plaintiff’s

daily use of some thirteen medicines or the logistics of managing a

complex medication regime would interfere with his ability to work. 

AR at 89. Nor did the plaintiff, who was unrepresented, develop

the record on the same issues. AR at 91. As a result, the only

limitation on plaintiff’s work capacity in the ALJ’s hypothetical

question posed to the VE was for “slight limitations in the nature

of depression.” AR at 89.

Accordingly, the hypothetical question posed to the VE

failed to reflect each of plaintiff’s limitations and thus, the

VE’s answer has limited evidentiary value. See Gallant v Heckler,

753 F2d 1450, 1456 (9th Cir 1984) (“Because neither the

hypothetical nor the answer properly set forth all of Gallant's

impairments, the vocational expert's testimony cannot constitute

substantial evidence to support the ALJ's findings.”). Hence, the

ALJ could not properly base his decision to terminate plaintiff’s

disability status on the VE’s opinion.

 Without the VE’s opinion and other necessary evidence in

the record regarding plaintiff’s medication regime, the record

lacks the substantial evidence to uphold the ALJ’s decision. On

remand, the ALJ should thoroughly develop the record by inquiring

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into plaintiff’s side effects from medication, frequency of medical

treatment, disruption to routine and any other limitations

appropriate under SSR 96-8p. The ALJ should then revisit step

seven in 20 CFR § 416.994(b)(5)(vii) to determine if any of these

limitations affect plaintiff’s ability to work.

 2

Plaintiff also contends that the ALJ did not properly

evaluate and make specific findings in discrediting plaintiff’s

testimony regarding pain. The court finds that the ALJ’s

determination that plaintiff’s “allegations of continuing

disability are not totally credible,” AR at 25, was not supported

by proper findings under the law of this circuit.

“Once 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 F2d 341, 345 (9th Cir

1991). To find a claimant lacks credibility, the ALJ must make

specific findings supported by the record and cannot “arbitrarily

discredit a claimant's testimony regarding pain.” Id at 345-46

(internal quotation marks omitted). The ALJ's reasons for

rejecting a claimant's testimony must be “clear and convincing,”

Lester v Chater, 81 F3d 821, 834 (9th Cir 1995), and must provide

“specific, cogent reasons for the disbelief.” Rashad v Sullivan,

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903 F2d 1229, 1231 (9th Cir 1990). General findings are

insufficient; the ALJ must identify what testimony is not credible

and what evidence undermines the claimant's complaints. Lester, 81

F3d at 834.

 At the second ALJ hearing, plaintiff testified that he

had not worked since 2001, because of “back pains, neck pains,

finger cramping and swelling of the toe” and that he is in “bed all

day long, because of the pain.” AR at 71. He also testified that

both knees hurt, which made it difficult to walk, especially up

hills and stairs. AR at 70. The ALJ then found that plaintiff was

“not totally credible regarding his inability to work.” AR at 29. 

In particular, the ALJ discredited plaintiff’s testimony regarding

his back, knee and hand pain.

To offer corroborating objective medical evidence for his

knee pain, plaintiff testified that, in 1991, he had arthroscopic

surgery on his left knee because his bone was deteriorating, which

then required an additional three surgeries to further repair his

knee. AR at 53-54, 56. Although plaintiff’s medical record

contains no evidence of these surgeries, Dr Potter and Dr Rana both

corroborate plaintiff’s testimony. In a letter to the SSA, Dr

Potter stated that plaintiff has “a chronically damaged left knee.” 

AR at 330. And in May 2001, during the SSA consultative medical

exam, Dr Rana acknowledged that plaintiff’s medical history

included “left arthroscopic knee surgery” and diagnosed him with

“[a]rthritis in knees.” AR at 289, 291. 

The record also corroborates plaintiff’s back pain. On

September 18, 2000, Dr Potter saw plaintiff for lower thoracic back

pain accompanied by sharper pains lasting about 20 minutes and

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determined there were "[m]inimal anterior compression of the

T11-T12 vertebral bodies, consistent with mild compression

fractures of uncertain duration." AR at 259, 262. Dr Rana also

corroborated plaintiff’s back pain with a diagnosis of chronic low

back pain, which was most likely “secondary to degenerative joint

disease.” AR at 291. 

Moreover, the ALJ recognized that “evidence confirms knee

and back pain,” AR at 26, and this court agrees with that

determination. Accordingly, a review of the record indicates that

there is objective medical evidence to substantiate plaintiff’s

subjective complaints of knee and back pain. 

The court must now determine whether the ALJ’s reasons

for discrediting plaintiff’s testimony are “specific, cogent

reasons for the disbelief.” Rashad, 903 F2d at 1231. The ALJ

discredited plaintiff’s pain testimony with the following pieces of

evidence: (1) that plaintiff performs many activities of daily

living without assistance, takes public transportation, uses a

cane, and sat for ninety minutes in the hearing without difficulty;

(2) Dr Rana’s May 2001 findings that plaintiff had “normal muscle

strength and no muscle atrophy in his lower extremities”; (3) the

inference that plaintiff could not have held his job as a security

guard for over a year if he could only walk two blocks; and (4) the

fact that plaintiff performed substantial gainful activity in 2001

as a security guard and warehouse worker. AR at 26.

This court does not find the ALJ’s reasoning “clear and

convincing.” Plaintiff demonstrated with objective medical

evidence that his back and knee ailments could reasonably produce

pain. In response, the ALJ primarily relied on evidence from

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before May 2001 to discredit plaintiff’s September 2003 pain

allegations. There is no logic to this reasoning. It was improper

for the ALJ to discredit plaintiff’s allegations of pain by using

outdated evidence; the correct analysis requires consideration of

all relevant evidence, especially that evidence established within

the previous twelve months. See 20 CFR § 416.912(d) (implying that

the SSA will focus upon evidence from the preceding twelve months)

OR (“Complete medical history” focuses on the previous twelve

months of a claimant’s medical history, unless the SSA deems it

necessary to develop the record further. Implicit in this

definition is that the SSA gives more weight to recent evidence

over older evidence). Accordingly, this court finds that the ALJ

did not give due consideration to evidence from the relevant time

period to discredit plaintiff’s September 2003 pain allegations.

Additionally, the ALJ stated that he considered the

plaintiff’s subjective allegations of pain and “finds them not

generally credible and not supported by substantial medical

evidence.” AR at 28. In Bunnell, the Ninth Circuit required a

claimant to produce “objective medical evidence of an underlying

impairment” to support his subjective allegations of pain. 

Bunnell, 947 F 2d at 345. Here, the ALJ erred as a matter of law

by requiring substantial medical evidence, as opposed to the

correct and less stringent legal standard of objective medical

evidence, to support plaintiff’s allegations of pain.

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 3

Given the court’s determination that the ALJ erred as a

matter of law in applying the seven-part test articulated under 20

CFR § 416.994(b)(5). It is unnecessary to reach the merits of

plaintiff’s other arguments. 

Although the ALJ applied the general analysis of 20 CFR §

416.994(b), the ALJ did not “follow specific steps in reviewing the

question of whether [plaintiff’s] disability continues.” 20 CFR §

416.994(b)(5). In its remand order, the Appeals Council directed

the ALJ to determine whether plaintiff could “engage in substantial

gainful activity under the evaluation steps cited in 20 CFR

416.994(b)(5)(v) through 416.994(b)(5)(vii).” AR at 173. Despite

this guidance, the ALJ did not follow these steps and cited “20 CFR

§ 416.1594(a)” (AR at 24), a regulation that does not exist, as

authority for evaluating whether plaintiff’s disability continues. 

Accordingly, on remand, the ALJ should determine whether

plaintiff’s disability continues or ends using the specific, sevenstep test articulated under 20 CFR §§ 416.994(b)(5)(i)-(vii).

C

Lastly, the court must consider whether to remand for

additional proceedings or for the payment of benefits. In general,

remand for additional administrative proceedings “is appropriate if

enhancement of the record would be useful.” Harman v Apfel, 211

F3d 1172, 1178 (9th Cir 2000). Moreover, when a court reverses an

administrative determination, “the proper course, except in rare

circumstances, is to remand to the agency for additional

investigation or explanation.” INS v Ventura, 537 US 12, 16 (2002)

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(per curiam); (quoting Florida Power & Light Co v Lorion, 470 US

729, 744 (1985)); see also Moisa v Barnhart, 367 F3d 882, 886-87

(9th Cir 2004) (stating, in a Social Security disability case, that

remand is appropriate in most circumstances). 

“Conversely, where the record has been developed fully

and further administrative proceedings would serve no useful

purpose, the district court should remand for an immediate award of

benefits.” Benecke v Barnhart, 379 F3d 587, 593 (9th Cir 2004). 

More specifically, the court should credit evidence and direct an

immediate award of benefits if:

(1) the ALJ has failed to provide legally sufficient

reasons for rejecting the evidence, (2) there are no

outstanding issues that must be resolved before a

determination of disability can be made, and (3) it

is clear from the record that the ALJ would be

required to find the claimant disabled were such

evidence credited. 

Id at 593 (quoting Harman, 211 F3d at 1178).

Here, substantial evidence in the record establishes that

plaintiff’s medication regime was complex and that he had

experienced serious side effects requiring medical care from at

least one of the medications. The record is otherwise silent,

however, as to how the thirteen daily medications, or the

combination of them, affect plaintiff’s ability to work. Hence, it

is necessary to remand for further development of the record and

resolution of this issue before the ALJ can determine whether to

terminate plaintiff’s disability status. 

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 IV

For the foregoing reasons, the court GRANTS plaintiff’s

motion for summary judgment (Doc #18) and DENIES defendant’s motion

for summary judgment (Doc #19). The court VACATES the ALJ’s

decision to deny benefits and REMANDS for further proceedings in

accordance with this order. The clerk is directed to close the

file and terminate all pending motions.

IT IS SO ORDERED.

 

VAUGHN R WALKER

United States District Chief Judge

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