Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_13-cv-01468/USCOURTS-azd-2_13-cv-01468-0/pdf.json

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

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WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Rilicia I. Leverenz, 

Plaintiff, 

v. 

Carolyn W. Colvin, Acting Commissioner 

of Social Security, 

Defendant. 

No. CV-13-01468-PHX-NVW 

ORDER 

Plaintiff Rilicia I. Leverenz seeks review under 42 U.S.C. § 405(g) of the final 

decision of the Commissioner of Social Security (“the Commissioner”), which denied her 

disability insurance benefits and supplemental security income under sections 216(i) and 

223(d) of the Social Security Act. Because the decision of the Administrative Law Judge 

(“ALJ”) is supported by substantial evidence and is not based on legal error, the 

Commissioner’s decision will be affirmed. 

I. BACKGROUND 

A. Factual Background 

Plaintiff was born in December 1976 and was 30 years old in May 2007 when her 

alleged disability began. She has an eighth grade education and has worked as a 

housekeeper, respite provider, and technician/assistant. She has chronic back pain, gets 

numbness in her legs, and has been diagnosed with migraine headaches and depression. 

In November 2007, Plaintiff had spinal fusion surgery for disc disruption at L5-S1. She 

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reports that prescribed medication helps relieve her back pain, Valium helps with her 

headaches, and she takes Paxil for depression. 

B. Procedural History 

On October 28, 2009, Plaintiff applied for disability insurance benefits and 

supplemental security income, alleging disability beginning May 5, 2007. On January 

17, 2012, she appeared with her attorney and testified at a hearing before the ALJ. A 

vocational expert also testified. 

On February 23, 2012, the ALJ issued a decision that Plaintiff was not disabled 

within the meaning of the Social Security Act. The Appeals Council denied Plaintiff’s 

request for review of the hearing decision, making the ALJ’s decision the 

Commissioner’s final decision. On July 19, 2013, Plaintiff sought review by this Court. 

II. STANDARD OF REVIEW 

The district court reviews only those issues raised by the party challenging the 

ALJ’s decision. See Lewis v. Apfel, 236 F.3d 503, 517 n.13 (9th Cir. 2001). The court 

may set aside the Commissioner’s disability determination only if the determination is 

not supported by substantial evidence or is based on legal error. Orn v. Astrue, 495 F.3d 

625, 630 (9th Cir. 2007). Substantial evidence is more than a scintilla, less than a 

preponderance, and relevant evidence that a reasonable person might accept as adequate 

to support a conclusion considering the record as a whole. Id. In determining whether 

substantial evidence supports a decision, the court must consider the record as a whole 

and may not affirm simply by isolating a “specific quantum of supporting evidence.” Id. 

As a general rule, “[w]here the evidence is susceptible to more than one rational 

interpretation, one of which supports the ALJ’s decision, the ALJ’s conclusion must be 

upheld.” Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002) (citations omitted); 

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

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

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

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Harmless error principles apply in the Social Security Act context. Molina v. 

Astrue, 674 F.3d 1104, 1115 (9th Cir. 2012). An error is harmless if there remains 

substantial evidence supporting the ALJ’s decision and the error does not affect the 

ultimate nondisability determination. Id. The claimant usually bears the burden of 

showing that an error is harmful. Id. at 1111. 

III. FIVE-STEP SEQUENTIAL EVALUATION PROCESS 

To determine whether a claimant is disabled for purposes of the Social Security 

Act, the ALJ follows a five-step process. 20 C.F.R. § 404.1520(a). The claimant bears 

the burden of proof on the first four steps, but the burden shifts to the Commissioner at 

step five. Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). 

At the first step, the ALJ determines whether the claimant is engaging in 

substantial gainful activity. 20 C.F.R. § 404.1520(a)(4)(i). If so, the claimant is not 

disabled and the inquiry ends. Id. At step two, the ALJ determines whether the claimant 

has a “severe” medically determinable physical or mental impairment. 

§ 404.1520(a)(4)(ii). If not, the claimant is not disabled and the inquiry ends. Id. At step 

three, the ALJ considers whether the claimant’s impairment or combination of 

impairments meets or medically equals an impairment listed in Appendix 1 to Subpart P 

of 20 C.F.R. Pt. 404. § 404.1520(a)(4)(iii). If so, the claimant is automatically found to 

be disabled. Id. If not, the ALJ proceeds to step four. At step four, the ALJ assesses the 

claimant’s residual functional capacity and determines whether the claimant is still 

capable of performing past relevant work. § 404.1520(a)(4)(iv). If so, the claimant is not 

disabled and the inquiry ends. Id. If not, the ALJ proceeds to the fifth and final step, 

where he determines whether the claimant can perform any other work based on the 

claimant’s residual functional capacity, age, education, and work experience. 

§ 404.1520(a)(4)(v). If so, the claimant is not disabled. Id. If not, the claimant is 

disabled. Id. 

At step one, the ALJ found that Plaintiff meets the insured status requirements of 

the Social Security Act through September 30, 2012, and that she has not engaged in 

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substantial gainful activity since May 5, 2007. At step two, the ALJ found that Plaintiff 

has the following severe impairments: sacroiliac joint dysfunction, lumbar radiculopathy, 

lumbar neuropathic pain, peripheral neuropathy, obesity, recurrent major depression, and 

migraine headaches. At step three, the ALJ determined that Plaintiff does not have an 

impairment or combination of impairments that meets or medically equals the severity of 

one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. 

At step four, the ALJ found that Plaintiff: 

has the residual functional capacity to perform light work as defined in 20 

CFR 404.1567(b) with the following function-by-function limitations: 

occasionally climb ladders, ropes, and scaffolds; avoid exposure to hot 

temperature extremes; avoid exposure to humidity; and would be limited to 

occupations requiring no more than simple, routine, repetitive tasks. 

The ALJ further found that Plaintiff is able to perform past relevant work as a 

housekeeper. 

IV. ANALYSIS 

A. The ALJ Did Not Err in Weighing Medical Source Opinion Evidence. 

1. Legal Standard 

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

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

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

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

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

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

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

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

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

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

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

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

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

substantial evidence in the record). 

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

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

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

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

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

opinion. Id. at 830-31. 

The opinion of a non-examining physician is not itself substantial evidence that 

justifies the rejection of the opinion of either a treating physician or an examining 

physician. Id. at 831. “The opinions of non-treating or non-examining physicians may 

also serve as substantial evidence when the opinions are consistent with independent 

clinical findings or other evidence in the record.” Thomas v. Barnhart, 278 F.3d 947, 957 

(9th Cir. 2002). 

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

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

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

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

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

complaints without objective evidence. Batson v. Comm’r of Soc. Sec. Admin., 359 F.3d 

1190, 1195 (9th Cir. 2004). The opinion of any physician, including that of a treating 

physician, need not be accepted “if that opinion is brief, conclusory, and inadequately 

supported by clinical findings.” Bray v. Comm’r of Soc. Sec. Admin., 554 F.3d 1219, 

1228 (9th Cir. 2009). An ALJ may reject standardized, check-the-box forms that do not 

contain any explanation of the bases for conclusions. Molina v. Astrue, 674 F.3d 1104, 

1111 (9th Cir. 2012). The Commissioner is responsible for determining whether a 

claimant meets the statutory definition of disability and does not give significance to a 

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statement by a medical source that the claimant is “disabled” or “unable to work.” 20 

C.F.R. § 416.927(d). 

Generally, more weight should be given to the opinion of a treating physician than 

to the opinions of physicians who do not treat the claimant, and the weight afforded a 

non-examining physician’s opinion depends on the extent to which he provides 

supporting explanations for his opinions. Garrison v. Colvin, 759 F.3d 995, 1012 (9th 

Cir. 2014). 

2. Treating Physician Brian Womack, D.O. 

The ALJ gave a primary reason and a secondary reason for considering, but not 

relying on, the medical source statement by Plaintiff’s primary care physician, Brian 

Womack, D.O. Regarding the secondary reason, the ALJ said Plaintiff “testified it has 

been well over a year since she last treated with Dr. Womack,” and “the break in the 

relationship detracts from Dr. Womack’s familiarity of the claimant’s impairments and 

how they affect physical function.” In January 2012, Plaintiff testified that she was 

regularly seeing a pain management specialist and a neurologist, but she had not seen Dr. 

Womack, her primary care physician, in almost a year. Plaintiff contends the ALJ erred 

because Dr. Womack saw Plaintiff one month and two months before he completed the 

questionnaire in May 2010. If the ALJ meant Dr. Womack had not seen Plaintiff for 

approximately a year before he completed the medical source statement and therefore 

was less familiar with Plaintiff’s current level of functioning, the ALJ was incorrect. 

If the ALJ meant that, at the time of the hearing in 2012, Dr. Womack had not 

recently treated Plaintiff for any condition related to his opinions, the ALJ was correct, 

but the consultative examinations were not any more current. It is true, however, that in 

the months before May 2010, Dr. Womack’s treatment notes show no assessment or 

examination related to back pain, numbness, or migraines. Rather, he treated Plaintiff for 

flu, bronchitis, laryngitis, and smoking cessation, and he changed her depression 

medication because it was causing weight gain. But even if this secondary reason for not 

relying on Dr. Womack’s statement was incorrect, the error is harmless because the 

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ALJ’s primary reason for not relying on Dr. Womack’s statement is factually correct, 

specific, and legitimate. 

The ALJ’s primary reason for not relying on Dr. Womack’s statement was that it 

was “in the form of a ‘check-off report’ without clinical findings or narrative to support 

the limitations assessed.” The ALJ’s description of Dr. Womack’s statement as a “checkoff report’ without any clinical findings or narrative to support the limitations assessed is 

accurate. Dr. Womack completed a standardized form by checking boxes and writing a 

few words in blanks. He checked “no” in response to whether Plaintiff could perform 

work eight hours a day, five days a week on a regular and consistent basis. He opined 

that Plaintiff’s use of oxycodone caused moderate limitations. He also opined that 

Plaintiff’s back pain and numbness in her legs moderately severely limited her ability to 

sustain work activity for eight hours a day, five days a week. He was asked: “Can the 

above noted limitation reasonably be expected to result from objective clinical or 

diagnostic findings which have been documented either by you, or elsewhere in 

Claimant’s medical records?” Dr. Womack responded by checking “yes” and circling the 

word “elsewhere.” In other words, he had not personally documented any findings to 

support his opinion, but he believed that such findings could be found elsewhere. On a 

separate assessment regarding mental functioning, Dr. Womack wrote, “Much of 

information regarding patient’s chronic pain are [sic] at Dr. Tadlock (pain management), 

Dr. Shelton (neurology), Dr. Kabins (neurosurgery).” Dr. Womack did not indicate that 

he personally had ever made any diagnostic findings or assessed Plaintiff’s functional 

limitations. 

The ALJ did not err by rejecting Dr. Womack’s statement on a standardized, 

check-the-box form that did not contain any explanation of the bases for his conclusions. 

See Molina, 674 F.3d at 1111. 

3. Consulting Physicians and State Agency Physician 

The ALJ stated that in assessing Plaintiff’s residual functional capacity she 

considered and relied on the medical source statements by consultative examiners Dr. 

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Sarah Shepard and Dr. Mark Brecheisen and agency medical consultant Dr. Jean Goerss. 

These opinions contradicted that of treating physician Dr. Womack. 

The ALJ said she relied on the opinions of Dr. Shepard and Dr. Brecheisen 

because they were based on objective clinical findings from personal physical 

examination of Plaintiff and because both examiners conducted a comprehensive 

examination to assess all aspects of physical function. Both doctors observed full range 

of motion in the shoulders, full motor strength, and symmetrical reflexes in all 

extremities. Dr. Shepard observed full range of motion in the cervical and lumbar spine. 

Dr. Brecheisen observed full range of motion in the cervical spine and some limitation in 

the lumbar region. Both doctors found straight leg raising in the seated position to be 

negative for reproducing low back pain; Dr. Shepard also tested in the supine position 

and found negative results. Finding no objective clinical evidence for Plaintiff’s 

subjective complaints, both doctors opined that Plaintiff’s conditions would not impose 

any limitations for twelve continuous months. 

Plaintiff contends that the ALJ could not have fully relied on the opinions of the 

examining and non-examining physicians because they opined Plaintiff had no severe 

impairment whatsoever and yet the ALJ found several. In fact, Dr. Goerrs did 

recommend some limitations. Dr. Goerss found no evidence of migraines in the file and 

no objective basis for limitations for low back pain, but she recommended precautionary 

limitations because Plaintiff had had surgery to her lumbar spine and was therefore at a 

slightly increased risk of further damage to the spine. Dr. Goerss also recommended that 

Plaintiff avoid heat and humidity because obesity predisposes one to heat stroke and 

vibration because it aggravates back pain. The ALJ relied on Dr. Goerss’ assessment 

because it cited specific evidence in support of her functional assessment even though Dr. 

Goerss did not personally examine Plaintiff. 

Thus, the ALJ provided clear, convincing, specific, and legitimate reasons for 

giving greater weight to the opinions of Dr. Shepard, Dr. Brecheisen, and Dr. Goerss than 

to that of Dr. Womack. 

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B. The ALJ Did Not Err in Evaluating Plaintiff’s Credibility. 

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

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

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

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

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

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

rejection. Vasquez v. Astrue, 572 F.3d 586, 591 (9th Cir. 2009). 

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

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

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

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

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

daily activities, and work record, among other factors.” Id. 

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

reasonably be expected to cause the alleged symptoms. Second, the ALJ found 

Plaintiff’s statements regarding the intensity, persistence, and limiting effects of the 

symptoms not credible to the extent they are inconsistent with the ALJ’s residual 

functional capacity assessment. 

During the ALJ hearing, Plaintiff testified that she can do dusting, light cleaning, 

and vacuuming, but after about 15 minutes she needs to sit down because of back pain. 

She said she can bathe and dress without assistance and lift 15–20 pounds. She testified 

that she goes to the store once or twice a week. Plaintiff testified she can walk about half 

an acre, but in her Function Report she said most of the time it hurt to walk due to hip 

pain. Plaintiff testified that she can sit no more than an hour, but in her Function Report 

she reported watching television and reading a lot, using a computer three times per 

week, and playing video games five days per week for about two hours per day. 

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Plaintiff testified that she drives a truck with a stick shift, so when her legs go 

numb she must put her foot on the clutch, “pop it into neutral and move out of the way of 

the traffic” until the numbness goes away. In her Function Report, Plaintiff said when 

she goes out she drives or rides in a car, but “at times” she cannot drive. She testified 

that she gets numbness or pain in her legs, must sit down or she will fall, falls frequently, 

but does not go to the emergency room when she falls because she does not remember 

anything about it. 

Plaintiff also testified that she had had headaches for 17 years or more, she gets 

headaches two or three days a week, and the headaches last about two days. But in her 

Function Report she made only a passing reference to migraines and did not state that she 

suffered from headaches with that frequency or duration. In fact, it would be impossible 

to play video games five days per week for about two hours per day if she had migraine 

headaches most of every week. 

Plaintiff further testified she has problems with memory and concentration, but in 

her Function Report she said she had problems with attention and concentration only 

when she was in bad pain. She did not mention that she had any difficulty watching 

television, using a computer, playing video games, paying bills or managing finances. 

The ALJ stated that she found Plaintiff not fully credible because the severity of 

her alleged shoulder, lower back, and lower extremity pain is not substantiated by 

objective medical evidence; Plaintiff’s statements were internally inconsistent; the 

severity of her alleged migraine headaches was not fully credible; and Dr. Shepard 

reported specific behavior that undermined Plaintiff’s credibility. Among the ALJ’s 

specific comments, the ALJ noted that Plaintiff alleged shoulder pain, but testified she 

can vacuum. The ALJ also noted specific evidence from two different observers that 

Plaintiff moved without appearing to be in pain when she was distracted or believed she 

was not being observed. 

Substantial evidence supports finding that the ALJ provided clear and convincing 

reasons for discrediting Plaintiff’s subjective symptom testimony. The ALJ did not reject 

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Plaintiff’s subjective complaints based solely on a lack of corroborating objective 

medical evidence, but instead weighed inconsistencies between Plaintiff’s testimony and 

her conduct and daily activities. 

C. The ALJ Did Not Err in Determining Plaintiff’s Residual Functional 

Capacity Without Including Limitations Related to Plaintiff’s 

Migraine Headaches. 

A residual functional capacity finding involves a detailed assessment of how a 

claimant’s medical impairments affect his ability to work. In determining a claimant’s 

residual functional capacity, the ALJ “must consider all relevant evidence in the record, 

including, inter alia, medical records, lay evidence, and ‘the effects of all symptoms, 

including pain, that are reasonably attributed to a medically determinable impairment.’” 

Robbins v. SSA, 466 F.3d 880, 883 (9th Cir. 2006). The ALJ must consider the combined 

effect of multiple conditions, including those that are not severe. See 20 C.F.R. 

§ 404.1545(a)(2). A plaintiff’s illnesses “must be considered in combination and must 

not be fragmentized in evaluating their effects.” Lester v. Chater, 81 F.3d 821, 829 (9th 

Cir. 1995). 

The ALJ properly found that the severity of Plaintiff’s alleged migraine headaches 

was not fully credible. Despite testimony regarding debilitating migraine headaches two 

or three days a week, each lasting about two days, with associated blurred vision and 

photophobia, Plaintiff did not seek consistent treatment or frequently report these 

headaches and symptoms to her medical providers. In her Function Report she 

mentioned “injuries and migraines,” but said nothing about limitations due to migraines. 

In fact, she reported watching television and reading a lot, using a computer three times 

per week, playing video games five days per week for about two hours per day, and 

talking on the telephone “all the time.” These reported activities directly contradict 

Plaintiff’s testimony about the frequency and severity of her migraine headaches. 

Moreover, no objective evidence in the record supports finding that Plaintiff’s residual 

functional capacity is limited by her migraine headaches. 

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Therefore, considering all relevant evidence in the record, the ALJ did not err by 

failing to include any limitation related to migraine headaches in the residual functional 

capacity assessment. 

D. The ALJ Did Not Err by Failing to Address Lay Witness Evidence. 

Plaintiff contends that the ALJ committed legal error by failing to address the lay 

witness statement offered by Plaintiff’s husband. The ALJ’s hearing decision does not 

state that she rejected the lay witness statement; it does not mention it. If the ALJ 

rejected or discounted the statement, she was required to give reasons germane to the 

specific witness. Valentine v. Comm’r of Soc. Sec., 574 F.3d 685, 693-94 (9th Cir. 2009). 

If the ALJ erred by discounting the lay witness statement without stating reasons 

or by failing to consider the statement, Plaintiff bears the burden of proving the error was 

harmful. See Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012). An error is 

harmless if there remains substantial evidence supporting the ALJ’s decision and the 

error does not affect the ultimate nondisability determination. Id. at 1115. 

On November 21, 2009, Plaintiff’s husband completed a third-party Function 

Report. Most of his responses closely parallel those of Plaintiff’s on her Function Report, 

including that Plaintiff does some household chores, cooking, driving, and shopping. 

Plaintiff’s husband agreed that she watches television, reads a lot, and talks on the phone 

a lot. Both said she either sleeps a lot or cannot sleep due to pain, and she can lift 10–15 

pounds, perform all personal care activities, pay bills, and manage bank accounts. 

Plaintiff’s husband does not offer any specific information that makes it more credible 

than Plaintiff’s testimony. 

To the extent that the third-party Function Report differs from Plaintiff’s, it does 

not support as severe limitations as Plaintiff claims. Plaintiff reported that she had 

problems with attention and concentration only when she was in bad pain. Plaintiff’s 

husband indicated she had no problem with concentration. In response to a question 

regarding how long Plaintiff can pay attention, her husband responded, “Endless.” 

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Any error the ALJ may have committed by failing to explicitly consider the thirdparty Function Report is harmless because there remains substantial evidence supporting 

the ALJ’s decision and the error does not affect the ultimate nondisability determination. 

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

Social Security is affirmed. The Clerk shall enter judgment accordingly and shall 

terminate this case. 

Dated this 8th day of October, 2014. 

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