Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-3_18-cv-08335/USCOURTS-azd-3_18-cv-08335-0/pdf.json

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

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WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Zachary Cox,

Plaintiff,

v. 

Commissioner of Social Security 

Administration,

Defendant.

No. CV-18-08335-PCT-DWL

ORDER 

At issue is Defendant’s denial of Plaintiff’s application for Title XVI Supplemental 

Security Income under the Social Security Act (“Act”). Plaintiff filed a Complaint (Doc. 

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

Brief (Doc. 13, “Pl. Br.”), Defendant’s Response (Doc. 16, “Def. Br.”), Plaintiff’s Reply 

(Doc. 17), and the Administrative Record (Doc. 12, “R.”). Because the Court finds legal 

error in the decision, it reverses and remands for further administrative proceedings.

I. BACKGROUND

Plaintiff filed his application on August 7, 2014, alleging disability due to epilepsy 

and other impairments as of February 1, 2013. (R. at 17, 66.) His application was denied 

initially on March 13, 2015 and upon reconsideration on September 11, 2015. (R. at 17.)

Plaintiff then appeared before an administrative law judge (“ALJ”) on August 18, 2017.

(Id.) On January 25, 2018, the ALJ issued his decision (R. at 17–28) finding Plaintiff not 

disabled, which was upheld by the Appeals Council on October 24, 2018 (R. at 1–3).

An individual is disabled on the basis of epilepsy if he experiences a generalized 

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tonic-clonic seizure once a month for three consecutive months or a dyscognitive seizure 

once a week for three consecutive months, despite adherence to prescribed treatment. 20 

C.F.R. § 404, Subpt. P, App. 1, Listing 11.02(A)–(B). Seizures that occur when an 

individual is not adhering to prescribed treatment, without good reason, do not count. Id. 

at 11.00(H)(4)(d). Here, Plaintiff testified that he experienced 5-7 seizures a month, 

consisting of 4-5 dyscognitive (or petit mal) seizures and 1-2 tonic-clonic (or grand mal) 

seizures. (R. at 50, 229-30; Pl. Br. at 5.) Despite this testimony, the ALJ found that the 

above criteria for Listing 11.02 were not met. (R. at 22.) Plaintiff disputes this finding and 

brings this appeal alleging that the ALJ erred by (1) improperly rejecting his testimony and 

(2) improperly rejecting the opinion of his treating physician, Dr. Donald Golen. (Pl. Br. 

at 3.)

II. LEGAL STANDARD

This Court has jurisdiction pursuant to 42 U.S.C. § 405(g), which provides that a 

reviewing court may affirm, modify, or reverse the decision of the Commissioner, with or 

without remanding the cause for a rehearing. The district court reviews only those issues 

raised by the party challenging the decision. Lewis v. Apfel, 236 F.3d 503, 517 n.13 (9th 

Cir. 2001). The Court may set aside the decision only if it is not supported by substantial 

evidence or is based on legal error. Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007). 

“Substantial evidence” is more than a scintilla, but less than a preponderance; it is relevant 

evidence that a reasonable person might accept as adequate to support a conclusion 

considering the record as a whole. Id. See also Jamerson v. Chater, 112 F.3d 1064, 1067 

(9th Cir. 1997) (“[T]he key question is not whether there is substantial evidence that could 

support a finding of disability, but whether there is substantial evidence to support the 

Commissioner’s actual finding that claimant is not disabled.”). The Court “must consider 

the record as a whole and may not affirm simply by isolating a specific quantum of 

supporting evidence.” Orn, 495 F.3d at 630. “Where 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). The 

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Court reviews only the “reasoning and factual findings offered by the ALJ–not post hoc

rationalizations that attempt to intuit what the adjudicator may have been thinking.” Bray 

v. Comm’r of Soc. Sec., 554 F.3d 1219, 1226 (9th Cir. 2009) (citing SEC v. Chenery Corp., 

332 U.S. 194, 196 (1947)); see also Garrison v. Colvin, 759 F.3d 995, 1010 (9th Cir. 2014)

(“We review only the reasons provided by the ALJ in the disability determination and may 

not affirm the ALJ on a ground upon which he did not rely.”).

To determine whether a claimant is “disabled” under the Act, the ALJ employs a 

five-step process. See 20 C.F.R. § 416.920(a)(4). The burden of proof is on the claimant 

for the first four steps but shifts to the ALJ at the last step. Tackett v. Apfel, 180 F.3d 1094, 

1098 (9th Cir. 1999). First, the claimant must show he is not presently engaged in 

substantial gainful activity. 20 C.F.R. § 416.920(a)(4)(i). Second, he must show she 

suffers from a “severe medically determinable” impairment(s). Id. § 416.920(4)(ii). Third, 

he must show that the impairment meets or equals an impairment in Appendix 1 of Subpart 

P of 20 C.F.R § 404. Id. § 416.920(a)(4)(iii). However, if the claimant fails to satisfy step 

three, he can still make out a prima facie case of disability at step four by showing he is 

unable to perform any past relevant work and by meeting steps one and two. Id.

§ 416.920(a)(4)(iv). The ALJ determines if the claimant met step four by assessing the 

claimant’s residual functional capacity (“RFC”). Id. At the fifth and final step, the burden 

shifts to the ALJ to show that the claimant is able to perform other work that exists in the 

national economy based on the claimant’s RFC, age, education, and work experience. Id. 

§§ 416.920(a)(4)(v).

III. ANALYSIS

A. The ALJ’s reasons for assigning “partial weight” to Dr. Golen’s opinion are 

not supported by “substantial evidence”

In assessing a claimant’s RFC, the ALJ considers and evaluates the medical 

opinions in the record, assigns a weight to each, and resolves any conflicts or ambiguities 

between them. 20 C.F.R. § 416.927(c); Garrison, 759 F.3d at 1010. Generally, opinions 

of treating physicians are entitled to the greatest weight; opinions of examining, nonCase 3:18-cv-08335-DWL Document 18 Filed 02/13/20 Page 3 of 10
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treating physicians are entitled to lesser weight; and opinions of nonexamining physicians 

are entitled to the least weight. Garrison, 759 F.3d at 1012. If an ALJ is to depart from 

this general hierarchy and credit the opinion of a non-treating physician over that of a 

treating physician where the opinions are inconsistent, the ALJ must articulate “specific 

and legitimate reasons supported by substantial evidence” for doing so. Id. An ALJ

satisfies the “substantial evidence” requirement by providing a “detailed and thorough 

summary of the facts and conflicting clinical evidence, stating his interpretation thereof, 

and making findings.” Id. In assigning weight to a medical opinion, the ALJ may consider

whether the physician examined the claimant; the length, nature, and extent of the treatment 

relationship (if any); the degree of support the opinion has, particularly from medical signs 

and laboratory findings; the consistency of the opinion with the record as a whole; the 

physician’s specialization; and “other factors.” 20 C.F.R. §§ 416.927(c)(1)-(6). An ALJ 

may reject any medical opinion that is “brief, conclusory, and inadequately supported by 

clinical findings.” Thomas, 278 F.3d at 957. See also Molina, 674 F.3d at 1111 (stating 

that an “ALJ may permissibly reject check-off reports that do not contain any explanation 

of the bases of their conclusions”) (internal quotations, brackets, and citation omitted); 

Batson v. Comm’r of Soc. Sec. Admin., 359 F.3d 1190, 1195 (9th Cir. 2004) (affirming 

rejection of a treating physician’s opinion that “was in the form of a checklist, did not have 

supportive objective evidence, was contradicted by other statements and assessments of 

[claimant’s] medical condition, and was based on [claimant’s] subjective descriptions of 

pain”). Medical opinions containing internal inconsistencies may also be properly rejected. 

Morgan v. Comm’r of Soc. Sec. Admin., 169 F.3d 595, 603 (9th Cir. 1999). 

At issue here is the ALJ’s assignment of “partial weight” to the opinion of Plaintiff’s 

treating neurologist, Dr. Donald Golen. (Pl. Br. at 9, R. at 26.) Dr. Golen rendered his 

opinions in a questionnaire dated May 24, 2016. (R. at 587-591, duplicate at R. 524–528.) 

Therein he opined that Plaintiff was capable of “moderate”1 work stress; that Plaintiff’s 

1 The options were “incapable of low stress,” “low stress,” “moderate stress,” and 

“high stress.” (R. at 589.)

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symptoms were “seldom”2severe enough to interfere with attention and concentration; and 

that Plaintiff would likely be absent 2-3 times a month due to his impairments or treatment. 

(R. at 589–590.) He further opined that Plaintiff could not work around heights, with 

machinery, or operate a motor vehicle. (R. at 589.) The ALJ justified the “partial weight”

by finding the “limits not supported by the greater record and acknowledged activity level 

of the claimant.” (R. at 26, citing R. at 232–234 (daily activities questionnaire).) The ALJ 

also found the opinion that Plaintiff’s symptoms are seldom severe enough to interfere with 

attention and concentration to be “internally inconsistent” with Dr. Golen’s other findings. 

(R. at 26.)

These reasons were specific and legitimate—an ALJ is free to consider an opinion’s 

consistency with the record as a whole, the degree of support it has, and any internal 

consistencies. However, these reasons were not supported by substantial evidence. More 

specifically, the ALJ did not provide a sufficiently “detailed and thorough summary of the 

facts and conflicting clinical evidence.” It is unclear which “limits” are not supported by 

which portions of “the greater record.” It is also unclear which of Plaintiff’s activities

contradict Dr. Golen’s opinion. The greater record, for example, may actually support a 

restriction on not operating a motor vehicle because Plaintiff testified to not driving. (R. 

at 44.) Thus, the ALJ needs to specify in greater detail exactly what evidence in the 

“greater record” undermines which parts of Dr. Golen’s opinion; which activities 

undermine the opinion; and what exactly the internal inconsistencies are. Without this 

detail, the Court does not find that substantial evidence justifies the ALJ’s reasons for 

discounting Dr. Golen’s opinion. The Court cannot supply a rationale the ALJ failed to 

supply. Bray, 554 F.3d at 1219; Garrison, 759 F.3d at 1010 (“We review only the reasons 

provided by the ALJ in the disability determination and may not affirm the ALJ on a ground 

upon which he did not rely.”).

...

...

2 The options were “never,” “seldom,” “periodically,” “frequently,” and “constantly.” 

(Id.)

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B. The ALJ improperly discounted Plaintiff’s testimony.

“Because symptoms sometimes suggest a greater severity of impairment than can 

be shown by objective medical evidence alone,” the ALJ also considers a claimant’s 

subjective testimony in determining the extent to which his impairments diminish his

capacity for work. 20 C.F.R. § 416.929(c)(3). “At the same time, the ALJ is not ‘required 

to believe every allegation of disabling pain [or symptoms], or else disability benefits 

would be available for the asking.’” Molina v. Astrue, 674 F.3d 1104, 1112 (9th Cir. 2012) 

(quoting Fair v. Bowen, 885 F.2d 597, 603 (9th Cir. 1989)). 

Because pain and symptoms “are subjective and difficult to quantify,” the ALJ must 

determine the extent to which they can “reasonably be accepted as consistent with the 

objective medical evidence and other evidence.” 20 C.F.R. § 416.929(c)(3). Unless there 

is evidence of malingering by the claimant, an ALJ may only discount pain or symptom 

testimony for reasons that are “specific, clear, and convincing.” Garrison, 759 F.3d at 

1014–15. General findings pertaining to a claimant’s credibility are not sufficient. 

Holohan v. Massanari, 246 F.3d 1195, 1208 (9th Cir. 2001). Rather, “the ALJ must 

specifically identify the testimony she or he finds not to be credible and must explain what 

evidence undermines the testimony.” Id. “Although the ALJ’s analysis need not be 

extensive, the ALJ must provide some reasoning in order for [a reviewing court] to 

meaningfully determine whether the ALJ’s conclusions were supported by substantial 

evidence.” Brown-Hunter, 806 F.3d 487, 495 (9th Cir. 2015). In evaluating the testimony, 

the ALJ may consider “(1) ordinary techniques of credibility evaluation, such as the client’s 

reputation for lying, prior inconsistent statements concerning the symptoms, and other 

testimony by the claimant that appears less than candid; (2) unexplained or inadequately 

explained failure to seek treatment or to follow a prescribed course of treatment; and (3) 

the claimant’s daily activities.” Tommasetti v. Astrue, 533 F.3d 1035, 1039 (9th Cir. 2008) 

(quoting Smolen v. Chater, 80 F.3d 1273, 1294 (9th Cir. 1996)); see also 20 C.F.R. §§ 

416.929(c)(3)(i)–(vii). Additionally, an ALJ may consider a lack of supporting medical 

evidence but may not discount the testimony solely on that basis. Burch v. Barnhart, 400 

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F.3d 676, 681 (9th Cir. 2005). The ALJ may also consider the effectiveness of medications, 

because “[i]mpairments that can be controlled effectively with medication are not disabling 

for the purpose of determining eligibility for SSI benefits.” Warre v. Comm’r of Soc. Sec., 

439 F.3d 1001, 1006 (9th Cir. 2006); see 20 C.F.R. § 416.929(c)(3)(iv).

Here, the ALJ found that, with proper medication management, Plaintiff’s seizures 

only occurred once every 3 months, despite his allegation that they occurred 5-7 times a 

month. (R. at 24.) In support, the ALJ cited a treatment record from February 24, 2015 in 

which Plaintiff’s physician noted that since Plaintiff began taking Depakote, an antiseizure 

medication, the frequency of Plaintiff’s seizures decreased to just once every 3 months. 

(Id., citing R. at 496.) In response, Plaintiff notes that the same treatment record 

simultaneously notes that his seizures occurred “MONTHLY.” (Pl. Br. at 6.) Indeed, the 

treatment record contains both notations, which are inconsistent with one another. In such 

a circumstance “[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, 278 F.3d at 954. Here, either interpretation of the record is rational. 

Thus, the ALJ did not improperly conclude that, as of February 24, 2015, Plaintiff’s 

seizures occurred only once every 3 months with adherence to prescribed medication. 

The issue then becomes whether Depakote remained an effective medication 

throughout the relevant time period or whether this was an isolated instance of 

improvement. At the next appointment on May 14, 2015, it was noted that Plaintiff was 

unable to tolerate Depakote and that lab results showed elevated amylase and lipase levels. 

(R. at 489, 492.) As a result, Plaintiff stopped taking Depakote. (R. at 492.) Thus, upon 

consideration of the record as a whole, it cannot be said that Depakote “effectively” 

controlled Plaintiff’s seizures. Therefore, the ALJ’s reference to Exhibit 19F/10 (R. at 496) 

does nothing to undermine Plaintiff’s testimony and is not a “clear and convincing” reason 

to discount it.

The ALJ also found that Plaintiff’s alleged symptoms were “not consistent with his 

reported activity level.” (R. at 26.) The ALJ cited activities discussed by Plaintiff at the 

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hearing, which included: taking online classes (R. at 40), playing guitar everyday (R. at 

46), being on a computer everyday (R. at 47), painting a couple times a week (R. at 46),

and occasionally walking around the park (R. at 48). (R. at 26.) The ALJ also cited 

activities discussed by Plaintiff in an exertional daily activities questionnaire, which 

included: watching television, doing laundry, preparing meals, and taking care of personal 

care. (R. at 23, citing R. at 232–234.) But these particular activities do not undermine 

Plaintiff’s complaints of seizures. See, e.g., Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 

1998) (noting that “disability claimants should not be penalized for attempting to lead 

normal lives in the face of their limitations”); Cooper v. Bowen, 815 F.2d 561, 557 (9th 

Cir. 1987) (“Disability does not mean that a claimant must vegetate in a dark room 

excluded from all forms of human and social activity.”) (internal quotations and citation 

omitted). The ALJ also noted that Plaintiff has not driven a car since 2013 (R. at 23), which 

would tend to corroborate the alleged severity of his seizures rather than detract from it. 

Thus, the ALJ’s discussion of Plaintiff’s activities of daily living is not a “clear and 

convincing” reason to discount his testimony.

Last, the ALJ found that “objective medical findings reveal some limitations, but 

not to the extent alleged by the claimant.” (R. at 26.) In particular, the ALJ noted that 

findings from a June 2013 EEG study were “normal.” (R. at 24, citing R. at 337–345.) 

The ALJ further noted that repeat EEG studies in October 2014 and May 2015 likewise 

“revealed no evidence of interictal discharges, clinical events, or electrographic seizures.” 

(R. at 24, citing R. at 440, 486.) In response, Plaintiff directs the Court to his physician’s 

notation on the May 2015 EEG, which states: “[T]he absence of epileptiform activity or 

electrographic seizures on EEG does not exclude the presence of epilepsy.” (Pl. Br. at 7, 

citing R. at 486.) Similarly, the regulations cited by Defendant do not require an EEG to 

establish epilepsy under Listing 11.00. 20 C.F.R. § 404, Subpt. P, App. 1, Listing 

11.00(H)(5) (“We do not require EEG test results; therefore, we will not purchase them. 

However, if EEG test results are available in your medical records, we will evaluate them 

in the context of the other evidence in your case record.”). 

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Given that EEG testing was not indicative of epilepsy on three separate occasions, 

the ALJ’s conclusion that objective medical evidence did not support Plaintiff’s allegations 

was rational. Thus, the Court finds this reason is sufficiently “clear and convincing.” 

However, because this reason is the only one the Court finds legally sufficient, the ALJ’s 

decision cannot be affirmed—the Ninth Circuit has held that a lack of objective medical 

evidence itself is insufficient to justify an adverse credibility determination.

IV. REMEDY

The credit-as-true rule provides that a remand for calculation and award of benefits 

is appropriate when: (1) the record has been fully developed and further administrative 

proceedings would serve no useful purpose; (2) the ALJ has failed to provide legally 

sufficient reasons for rejecting claimant testimony; and (3) if the improperly discounted 

testimony were credited as true, the ALJ would be required to find the claimant disabled 

on remand. Garrison, 759 F.3d at 1020. However, a court need not apply this rule rigidly 

and may instead remand for further administrative proceedings “when even though all 

conditions of the credit-as-true rule are satisfied, an evaluation of the record as a whole 

creates serious doubt that a claimant is, in fact, disabled.” Id. at 1021.

Here, even though each element of the credit-as-true rule is met, evaluation of the 

record as a whole creates serious doubt that Plaintiff is, in fact, disabled. First, the lack of 

any objective medical evidence to support Plaintiff’s allegations raises questions as to the 

alleged severity of the seizures and their effects. Second, the Court finds inconsistencies 

between Plaintiff’s hearing testimony and the record. For instance, as noted by the ALJ, 

Plaintiff testified that he would occasionally go to the park. (R. at 26, citing R. at 48.) More 

specifically, he stated that he and his girlfriend would go to the park and “walk around.” 

(R. at 48.) However, in the exertional daily activities questionnaire, Plaintiff stated, “I 

don’t go on walks because I could have a seizure.” (R. at 232.) Moreover, the seizure logs 

maintained by Plaintiff (R. at 235, 258, 284) were not always consistent with his testimony 

of experiencing 1-2 grand mal seizures per month and 4-5 petit mal seizures per month. 

For instance, his logs do not denote any kind of seizure in August 2015 or March 2017. 

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(R. at 258, 284.)

Plaintiff also seeks an award of attorney fees under the Equal Access to Justice Act, 

28 U.S.C. § 2412(d)(1)(A). The Court instructs Plaintiff to file a motion in conformance 

with 28 U.S.C. § 2412(d)(1)(B) it he intends to pursue such an award.

IT IS THEREFORE ORDERED, reversing the decision of the Commissioner and 

remanding for further administrative proceedings consistent with this Order.

IT IS FURTHER ORDERED, directing the Clerk of Court to enter judgment 

accordingly and terminate this case.

Dated this 13th day of February, 2020.

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