Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_18-cv-07648/USCOURTS-cand-3_18-cv-07648-0/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 

NORTHERN DISTRICT OF CALIFORNIA 

ROSALINDA M., 

Plaintiff, 

v. 

ANDREW SAUL, 

Commissioner of Social Security, 

Defendant. 

Case No. 18-cv-07648-JSC 

ORDER RE: CROSS MOTIONS FOR 

SUMMARY JUDGMENT 

Re: Dkt. Nos. 23, 28 

Plaintiff Rosalinda M. seeks social security benefits for physical and mental impairments, 

including osteoarthritis and high blood pressure. (Administrative Record (“AR”) 126.) Pursuant 

to 42 U.S.C. Section 405(g), Plaintiff filed this lawsuit for judicial review of the final decision by 

the Commissioner of Social Security (“Commissioner”) denying her benefits claim. Now before 

the Court are Plaintiff’s and Defendant’s Motions for Summary Judgment.1 (Dkt. Nos. 23 & 28.) 

Because the Administrative Law Judge’s (“ALJ’s”) consideration of the medical opinion evidence 

constitutes reversible error, the Court GRANTS Plaintiff’s motion, DENIES Defendant’s crossmotion, and REMANDS for further proceedings. 

LEGAL STANDARD 

A claimant is considered “disabled” under the Social Security Act if she meets two 

requirements. See 42 U.S.C. § 423(d); Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). 

First, the claimant must demonstrate “an inability to engage in 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 a continuous period of not less 

1

 Both parties have consented to the jurisdiction of a magistrate judge pursuant to 28 U.S.C. § 

636(c). (Dkt. Nos. 13 & 14.) 

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than 12 months.” 42 U.S.C. § 423(d)(1)(A). Second, the impairment or impairments must be 

severe enough that she is unable to do her previous work and cannot, based on her age, education, 

and work experience “engage in any other kind of substantial gainful work which exists in the 

national economy.” 42 U.S.C. § 423(d)(2)(A). To determine whether a claimant is disabled, an 

ALJ is required to employ a five-step sequential analysis, examining: (1) whether the claimant is 

“doing substantial gainful activity”; (2) whether the claimant has a “severe medically determinable 

physical or mental impairment” or combination of impairments that has lasted for more than 12 

months; (3) whether the impairment “meets or equals” one of the listings in the regulations; (4) 

whether, given the claimant’s “residual functional capacity,” (“RFC”) the claimant can still do her 

“past relevant work”; and (5) whether the claimant “can make an adjustment to other work.” 

Molina v. Astrue, 674 F.3d 1104, 1110 (9th Cir. 2012); see also 20 C.F.R. §§ 404.1520(a), 

416.920(a). 

An ALJ’s “decision to deny benefits will only be disturbed if it is not supported by 

substantial evidence or it is based on legal error.” Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 

2005) (internal quotation marks and citation omitted). “Substantial evidence means such relevant 

evidence as a reasonable mind might accept as adequate to support a conclusion.” Id. (internal 

quotation marks and citation omitted). “Where evidence is susceptible to more than one rational 

interpretation, it is the ALJ’s conclusion that must be upheld.” Id. In other words, if the record 

“can reasonably support either affirming or reversing, the reviewing court may not substitute its 

judgment for that of the Commissioner.” Gutierrez v. Comm’r of Soc. Sec., 740 F.3d 519, 523 

(9th Cir. 2014) (internal quotation marks and citation omitted). However, “a decision supported 

by substantial evidence will still be set aside if the ALJ does not apply proper legal standards.” Id.

BACKGROUND 

I. Procedural Background 

On August 18, 2015, Plaintiff filed an application for social security disability benefits, 

alleging disability beginning July 30, 2015. (AR 23.) The Commissioner first denied the 

application on December 14, 2015, (AR 163), and again denied the application upon ALJ. (AR 

178.) On July 10, 2017, Plaintiff appeared and testified before ALJ Cheryl Tompkin. (AR 106.) 

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Ruth Van Vleet, a vocational expert (“VE”), also testified during the hearing. (AR 115.) 

 On January 19, 2018, the ALJ issued an unfavorable decision. (AR 20-36.) Two months 

later, Plaintiff filed a request for review of the ALJ’s decision. (AR 224-26.) In November 2018, 

the Appeals Council determined that it would not review the ALJ’s findings, making the ALJ’s 

decision final. (AR 1-9.) 

II. Administrative Record 

 Plaintiff was born on May 9, 1961 and resides in Antioch, California. (AR 126.) She 

asserts that she has been unable to work since July 30, 2015 because of “severe arthritis and 

fibromyalgia.” (Dkt. No. 23 at 7; see also AR 405.) 

A. Medical Evaluations and Physician Statements

 1. Physical Examination by Dr. Calvin Pon 

 Dr. Calvin Pon is a consultative examining orthopedic physician who met with Plaintiff on 

May 6, 2013. (AR 343.) Dr. Pon’s report notes that Plaintiff’s chief complaints were “bilateral 

hand pain, left knee pain, right knee pain, and bilateral ankle and foot pain.” (Id.) Dr. Pon’s 

report includes the following diagnoses: (1) “chronic bilateral hand pain secondary to degenerative 

arthritis;” (2) history of three operations to the left knee with “chronic residual left knee pain, 

probable degenerative arthritis;” (3) history of three to four operations to the right knee with 

“chronic residual right knee pain, probable degenerative arthritis;” and (4) “chronic bilateral ankle 

and foot pain, probable degenerative changes, possible musculoligamentous/soft tissue pain, or a 

combination of these.” (AR 345.) 

 Dr. Pon’s “functional capacity assessment” opined that Plaintiff can stand and walk 

approximately four hours and sit six hours out of an eight-hour workday. (Id.) Further, Plaintiff 

can carry “frequently 10 lbs. and occasionally up to 20 lbs.” (Id.) There is “no functional 

impairment with her ability to perform fine manipulative tasks” with her right hand even though 

there “might be some symptomatic limitations,” and Plaintiff is “very functional” in performing 

fine manipulative tasks with her left hand. (Id.) She has “no restriction in stooping” and can 

rarely to occasionally “perform limited crouching, kneeling and squatting.” (Id.) Dr. Pon opined 

that Plaintiff can “take public transportation.” (AR 346.)

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2. Physical Examinations and Statement from Rheumatologist Dr. 

 Zuzana U. Foster 

Dr. Zuzana U. Foster is Plaintiff’s treating rheumatologist. (AR 405.) Dr. Foster reported 

that she had treated Plaintiff since October 2009 and saw Plaintiff “every 2-6 months.” (Id.) Dr. 

Foster met with Plaintiff on October 29, 2015 for complaints of “ongoing pain in joints and 

muscles,” “stiffness,” and “chronic symptoms of fatigue.” (AR 385.) Per the report, Plaintiff’s 

history of present illness includes osteoarthritis, fibromyalgia, back pain, and drug monitoring. 

(Id.) Dr. Foster conducted a physical examination and found “[osteoarthritis] changes hands; no 

overt synovitis; hand joint deformities present; tender large muscle groups; tender and swollen 

right dorsal foot.” (AR 386.) 

Dr. Foster met with Plaintiff again on November 12, 2015 for complaints of continuing 

“pain in the knees, hands, muscles.” (AR 382.) The report notes that Plaintiff “is tolerating meds 

but is only taking [M]otrin and needs a cortisone injection.” (Id.) Dr. Foster conducted a 

musculoskeletal physical exam and found “[osteoarthritis] changes hands; crepitus knees; no 

synovitis; tender shoulders with limited ROM; [bilateral sacroiliac joint pain].” (AR 383.) Dr. 

Foster administered a “right sacroiliac joint injection” and noted that Plaintiff should “return in 2-

3 months, sooner if needed,” and “continue [her] current regimen” of taking ibuprofen and using 

Lidoderm adhesive patches in addition to various high blood pressure medications. (AR 384.) 

Dr. Foster examined Plaintiff on January 20, 2016 for a complaint of “pain in the hands.” 

(AR 378.) Plaintiff reported fatigue, back pain, joint pain, and myalgia. (AR 379.) In pertinent 

part, Dr. Foster diagnosed Plaintiff with “[o]ther intervertebral disc degeneration” in the “lumbar 

region” and “lumbosacral region,” “[p]ain in [an] unspecified ankle and joints of [an] unspecified 

foot,” and “[p]rimary generalized (osteo)arthritis.” (AR 379-80.) 

 In a January 2016 “Arthritis Medical Source Statement,” Dr. Foster diagnosed Plaintiff 

with “generalized osteoarthritis” and indicated that it was a “chronic lifelong condition.” (Id.) Dr. 

Foster indicated that Plaintiff’s reported symptoms include chronic joint pain, stiffness, muscle 

pain, fatigue, and sleep disturbance. (Id.) Dr. Foster further found that Plaintiff experiences pain 

in the “hands, neck, back, feet . . . worse with activity/use; severe pain at times 8-10/10.” (Id.) 

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Dr. Foster reported that Plaintiff is not required to use an assistive device while “engaging 

in occasional standing/walking.” (AR 407.) Dr. Foster indicated that Plaintiff could stand/walk 

for less than two hours total in an eight-hour work-day, and that she would need unscheduled 

breaks “every 10-30 minutes” during a work-day. (AR 406.) Further, Plaintiff can rarely lift less 

than ten pounds and never lift more than ten pounds. (AR 407.) Dr. Foster also reported that 

Plaintiff has “significant limitations with reaching, handling or fingering.” (Id.) Dr. Foster opined 

that Plaintiff’s symptoms would likely interfere with her “attention and concentration needed to 

perform even simple work tasks” for at least 25% of a typical work-day. (Id.) Dr. Foster further 

opined that Plaintiff is “incapable of [tolerating] even ‘low stress’ work,” and Plaintiff would 

likely miss more than four days of her work per month due to her “impairments or treatment.” 

(Id.) 

 3. Physical Examination by Dr. Satish K. Sharma 

Dr. Satish K. Sharma is a consultative examining physician who met with Plaintiff on 

November 5, 2015. (AR 372.) Dr. Sharma’s report notes Plaintiff’s chief complaints were “low 

back pain; joint pain; hypertension; obesity; high cholesterol.” (Id.) Dr. Sharma’s report includes 

the following diagnoses: (1) low back pain secondary to musculoskeletal strain; (2) joint pain 

secondary to osteoarthritis; (3) obesity; (4) hypertension; and (5) high cholesterol. (AR 374.) Dr. 

Sharma noted that Plaintiff walks with a limp on the left lower extremity and “could not do toe 

walking and heel walking” but she did not require an assistive device to walk. (Id.) Dr. Sharma 

reported that Plaintiff has swelling in the interphalangeal joints of the fingers in both hands and 

has no tenderness to palpitation and full range of motion in the finger joints. (AR 373.) Dr. 

Sharma indicated that Plaintiff has tenderness to palpitation in both knees and no evidence of 

patellar instability. (Id.) Further, Plaintiff has tenderness to palpitation “over the lumbar spine 

and in the paravertebral region” of her back. (AR 374.) Dr. Sharma opined that the “straight leg 

raising” test was negative and did not note any muscle spasms. (Id.) 

 Dr. Sharma’s “functional assessment / medical source statement” opined that Plaintiff can 

stand, walk, and sit six hours cumulatively out of an eight-hour workday with appropriate breaks. 

(Id.) Further, Plaintiff can carry “50 pounds occasionally and 25 pounds frequently.” (Id.) She 

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has “no limitation” for the “use of the hands for fine and gross manipulative movements,” and can 

occasionally bend and stoop. (Id.) 

 4. Non-Examining State Agency Physicians 

In December 2015, a non-examining state agency physician reviewed Plaintiff’s medical 

records and determined that while Plaintiff’s impairments cause some limitations on her ability to 

perform work activities, those limitations do not prevent her from performing her past relevant 

work as an “administrative assistant.” (AR 133.) Thus, the state agency physician concluded that 

Plaintiff can “perform light work activity.” (AR 134.) Another state agency physician made the 

same determination upon reconsideration of Plaintiff’s application in March 2016. (See AR 146.) 

B. ALJ Hearing 

 1. Plaintiff’s Testimony 

 Plaintiff reported past work as an administrative assistant for two years from 2013 to 2015. 

(AR 106-07.) Before that, Plaintiff worked “as a backup” in the trauma unit at John Muir Medical 

Center where she helped “set up tables on an emergency basis.” (Id.) Both jobs required frequent 

use of hands “and lifting and typing.” (AR 107.) 

While working at John Muir, on “about three different occasions being in a hurry and [her] 

grip not being good,” she dropped sterile packs which caused the staff to “stop the surgeries” and 

“go back and get new equipment.” (AR 106.) Further, this was “time-consuming and also [a] 

danger to the patients.” (Id.) After the third occasion, Dr. Foster suggested that Plaintiff should 

retire because her hands “weren’t going to get any better or any stronger and they couldn’t do any 

more surgeries on [her] hands.” (Id.) Plaintiff “went ahead at the advice of human resources” and 

was “kind of forced to retire” from her role. (Id.) 

Plaintiff is a fall risk because she has lost “most of the muscle mass” in her legs. (AR 

108.) Plaintiff no longer has balance “in [her] legs and [her] knee” and the “arthritis in there has 

separated [her] kneecaps.” (AR 108.) Plaintiff gets “shooting pains” in her fingers when she 

“grab[s] things” and “personal care at times [is] difficult.” (AR 108-09.) She “just has to stop 

what [she is] doing because it hurts so bad.” (Id.) Plaintiff’s treatment includes hip injections and 

“Norco to help [her] sleep.” (AR 109-10.) Plaintiff previously received an injection “up to 

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[every] six months” but now “it [the injection] only lasts about four to five” months. (AR 109.) 

The injections help her “do things a little easier” but they “don’t alleviate the pain.” (AR 109-10.) 

Plaintiff is “always, very tired” and she has to “sit down at least three or four times in between 

doing any little tasks.” (AR 110.) 

Plaintiff does not sleep well when the pain is “really intense” and she “[has] to take Norco 

to help [her] sleep” but “all it does is make [her] groggy.” (Id.) The ALJ asked Plaintiff how 

often she takes Norco to treat her pain. (AR 111.) Plaintiff takes Norco “probably about three 

times per week” depending on the “weather.” (AR 112.) During the winter, she takes Norco 

“probably every night, sometimes during the day.” (Id.) 

 When Plaintiff’s counsel asked Plaintiff if she was “suffering from any depression,” 

Plaintiff testified she “[doesn’t] feel like a complete person anymore” because she can no longer 

do “eighty percent of what [she] used to do . . . and it makes her really sad when [she] sees 

everybody get up and go to work in the morning and [she] just [has] to stay home because [she is] 

not used to that” as Plaintiff “worked all [her] life.” (AR 111-12.) On an average day Plaintiff 

wakes up and stays upstairs “probably until two or three in the afternoon” and then goes 

downstairs to “kind of wait around” to see her husband or one of her adult children arrive at home. 

(AR 112-13.) The ALJ asked Plaintiff if she spends her day watching TV. (AR 113.) Plaintiff 

does not “even hardly do that” and does not “do much of anything.” (Id.) Plaintiff “likes to look 

at [her] pictures” and she “sleep[s] a lot.” (AR 114.) She is “scared” and does not “want to go 

anywhere by [her]self” because she trips easily. (AR 113-14.) The ALJ then asked Plaintiff if she 

uses a cane or a similar device. (AR 114.) Plaintiff responded that she has a walker at home but 

does not use it because she is only “cautious about” walking up and down the stairs in her house. 

(Id.) 

 2. Vocational Expert’s Testimony 

Vocational expert Ruth Van Vleet classified Plaintiff’s recent relevant work history as 

follows: department secretary at a hospital as “sedentary;” and administrative assistant as 

“sedentary.” (AR 116-17.) Ms. Van Vleet testified that Plaintiff’s role as department secretary as 

“sedentary” because Plaintiff indicated in the work history form that she lifted less than ten 

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pounds when retrieving items for surgeries and the emergency department. (AR 117.) The ALJ 

posited the following hypothetical to Ms. Van Vleet regarding both roles: 

Assume an individual of claimant’s age, education and work 

experience who is able to perform work at the light exertion level. 

The individual can lift or carry 20 pounds occasionally and 10 pounds 

frequently. The individual can sit, stand or walk for six hours in an 

eight hour work day. The individual can occasionally climb ramps 

and stairs and never climb ladders, ropes or scaffolds. The individual 

can frequently balance and occasionally stoop, kneel, crouch or crawl. 

The individual can frequently but not constantly handle and finger 

bilaterally. The individual should avoid concentrated exposure to 

extreme cold and work place hazards such as unprotected heights and 

moving machinery. Can an individual with these limitations perform 

claimant’s past work as claimant performed it or as customarily 

performed? 

(AR 117-18.) Ms. Van Vleet responded that the individual could do so per the Dictionary of 

Occupational Titles. (AR 118.) The ALJ posited a second hypothetical to Ms. Van Vleet: 

[A]ssume the same facts as in hypothetical one except the individual 

would be able to stand or walk for four hours and could stoop or 

crouch rarely to occasionally and rarely is defined as two point five 

hours or less. The individual could push or pull bilaterally with the 

upper extremity, occasionally to frequently and could push or pull 

frequently with the lower extremity. The individual could frequently 

finger and feel bilaterally. So can an individual with these limitations 

perform claimant’s past work as claimant performed it or as 

customarily performed? 

(AR 118-19.) Ms. Van Vleet responded that the individual could not do so. (AR 119.) The ALJ 

asked Ms. Van Vleet if there were “any transferable skills under this hypothetical.” (Id.) Ms. Van 

Vleet responded that Plaintiff’s transferable skills included: “answer[ing] her phone;” “deal[ing] 

with the public;” “customer service;” and “us[ing] a computer.” (Id.) Ms. Van Vleet indicated that 

based on the second hypothetical, these skills transfer to the following roles: receptionist, 

telephone solicitor, and information clerk. (AR 119-20.) The ALJ posited a third hypothetical to 

Ms. Van Vleet: 

[A]ssum[ing] the facts as in hypothetical two except the individual 

would be able to stand or walk for 30 minutes at a time for a total of 

four hours and would need to rest, let’s say for three minutes after 

walking 30 minutes and the individual is able to sit for . . . six hours 

in an eight hour work day but would need the option to shift positions 

by standing or sitting at a work station while remaining on task and 

she would need to do that every hour and add that additional limitation 

that the individual would be off task let’s say seven perfect of the 

work day due to pain or other conditions. So, can an individual with 

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these limitations perform claimant’s past work as claimant performed 

it or as customarily performed? 

 (AR 120.) Ms. Van Vleet responded that an individual could perform Plaintiff’s past work and as 

customarily performed, but “not as Plaintiff defined [the work] in her work history form” because 

the Dictionary of Occupational Titles does not “address the option of shifting and standing or 

being off task.” (AR 120-21.) 

C. ALJ’s Decision 

 On January 19, 2018, the ALJ issued a written decision denying Plaintiff’s application and 

finding that Plaintiff was not disabled within the meaning of the Social Security Act based on the 

testimony, evidence, and the Social Security Administration’s five-step sequential evaluation 

process for determining disability. (AR 24.) 

 At step one, the ALJ concluded that Plaintiff had not engaged in substantial gainful activity 

since July 30, 2015, the alleged onset date, through her date of last insured, which is June 30, 

2019. (AR 24.) 

 At step two, the ALJ concluded that the objective medical evidence indicated that 

Plaintiff’s “osteoarthritis of the bilateral hands, feet, knees, and back; obesity; fibromyalgia” 

constitute severe impairments. (AR 25 (citing 20 C.F.R. § 404.1520(c)).) The ALJ also 

considered evidence of Plaintiff’s treatment for “high blood pressure and high cholesterol” and 

Plaintiff’s “history of high blood pressure for over ten years.” (AR 26.) The ALJ determined that 

Plaintiff’s high blood pressure and high cholesterol were non-severe because the “evidence does 

not demonstrate that these impairments cause more than a minimal impact on [Plaintiff’s] ability 

to perform basic work activities.” (Id.) 

 As to Plaintiff’s claimed depression, the ALJ found that “the record as a whole does not 

establish the presence of a medically determinable mental impairment.” (Id.) The ALJ noted that 

Plaintiff “did not allege depression in her application for disability benefits, but endorsed 

symptoms of depression at the hearing.” (Id.) The ALJ determined that “apart from a prior (2013) 

consultative psychological examination, the record contains no evidence that the [Plaintiff] has 

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sought or received mental health treatment, or that she has reported related complaints.” (Id.)

2

 

Further, the ALJ noted that “throughout the period at issue, clinicians regularly reported 

unremarkable mental status observations, including appropriate mood and affect, good insight, and 

good judgment.” (Id.) 

 At the third step, the ALJ concluded 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 CFR Part 404, Subpart P, Appendix 1.” (AR 26 (citing 20 C.F.R. §§ 

404.1520(d), 404.1525, 404.1526).) The ALJ reached this conclusion by evaluating the severity 

of Plaintiff’s impairments “under listings 1.02 (major joint dysfunction) and 1.04 (disorders of the 

spine, the listings most applicable in this case.” (Id.) The ALJ considered fibromyalgia and 

obesity “in combination with [Plaintiff’s] co-existing impairments” even though “fibromyalgia 

and obesity are not listed impairments.” (Id.) The ALJ concluded that the “medical evidence does 

not establish nerve root compromise or the requisite sensory, motor, or reflex loss identified in 

listing 1.04.” (Id.) The ALJ further concluded that the “record does not show sufficient 

demonstration of an inability to ambulate effectively or to perform fine and gross movements 

effectively as defined in section 1.00B2 and required of listing 1.02.” (Id.) 

 Before reaching step four, the ALJ considered Plaintiff’s RFC and determined that Plaintiff 

“has the residual functional capacity to perform light work” as defined under 20 C.F.R. § 

404.1567(b) with the following exceptions: 

[Plaintiff] can stand or walk for 4 hours in an 8-hour day, and sit for 

6 hours. She can occasionally climb ramps or stairs, but never 

ladders, ropes, or scaffolds. She can frequently balance, and can 

occasionally kneel and crawl. She can stoop or crouch rarely (defined 

as 2.5 hours or fewer in an 8-hour day). She can push or pull 

bilaterally with the upper extremities occasionally to frequently, and 

can push or pull frequently with the lower extremities. She can 

frequently handle, finger, and feel bilaterally. She must avoid 

concentrated exposure to extreme cold and to workplace hazards such 

as moving machinery and unprotected heights. 

2

 Dr. April Young, a consultative examining psychologist, examined Plaintiff on April 10, 2013 

(over two years prior to the disability onset date) and diagnosed Plaintiff with an “Adjustment 

Disorder with Depressed Mood” and ruled out “Mood Disorder due to Pain.” (See AR 338-39.) 

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(AR 26.) 

 In making her RFC determination, the ALJ found that Plaintiff’s “medically determinable 

impairments could reasonably be expected to produce the . . . alleged symptoms; however, 

[Plaintiff’s] statements considering the intensity, persistence and limiting effects of these 

symptoms are not entirely consistent with the medical evidence or other evidence in the record.” 

(AR 28.) The ALJ cited in support of her determination the objective medical evidence, Plaintiff’s 

treatment history and subjective symptoms reported to treatment providers, and Plaintiff’s 

“capacity for a wide range of light work.” (AR 28-30.) 

 As for the medical opinion evidence, the ALJ afforded “significant weight to the opinions 

of DDS medical consultants, who found [Plaintiff] capable of light work,” noting that “their 

assessment is largely reflected in the [RFC determination].” (AR 30.) The ALJ afforded “partial 

weight” to Dr. Sharma’s opinion, noting that “while Dr. Sharma’s assessment is generally 

consistent with his examination findings at the time,” the “weight of the evidence . . . supports the 

greater limitations identified in [the RFC determination].” (Id.) The ALJ also noted that Dr. 

Sharma “did not observe evidence of patellar instability or significant hand dysfunction” during 

the examination, but the ALJ “considered evidence of prior remote surgeries on [Plaintiff’s] hands 

and knees” and “[Plaintiff’s] testimony that she was previously issued a handicap placard, in 

assessing her overall functioning.” (Id.) 

 The ALJ afforded “some, but limited weight” to Dr. Calvin Pon’s physical examination. 

(AR 30.) The ALJ determined that “Dr. Pon’s clinical findings do not vary significantly from 

those of Dr. Sharma or from clinician observations during the relevant period, and generally 

demonstrate that [Plaintiff’s] functioning has remained stable,” but “Dr. Pon’s examination was 

performed over two years prior to the alleged disability onset date.” (Id.) The ALJ noted that “Dr. 

Pon’s assessment is also generally consistent with [Plaintiff’s RFC].” (Id.) 

The ALJ also assigned “limited weight” to Dr. Foster’s opinion that Plaintiff is “limited to 

a significantly reduced range of sedentary work, including the inability to perform even low stress 

work, and the need to miss more than four days of work per month.” (AR 29.) The ALJ noted 

that Dr. Foster “wrote a letter at [Plaintiff’s] request to take her off work for three months as of 

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July 30, 2015 (the alleged disability onset date), and opine[d] that [Plaintiff] is not able to work 

due to “severe, disabling” osteoarthritis chiefly affecting her hands;” yet, the “accompanying 

contemporaneous treatment records do not evidence clinical findings or significant changes in 

[Plaintiff’s] course of treatment to support such extreme limitations.” (AR 29.) Further, the ALJ 

noted that Dr. Foster’s opinion “regarding [Plaintiff’s] inability to work appears to rely heavily on 

the claimant’s reported symptoms and complaints with specific regard to her most recent job.” 

(Id.) In sum, the ALJ determined “after careful consideration of the entire evidentiary file and 

hearing testimony,” that Plaintiff’s RFC assessment “is supported by the weight of the evidence.” 

(AR 30.) 

 At step four, the ALJ cited the vocational expert’s hearing testimony and concluded that 

Plaintiff “cannot perform her past relevant work, either as actually performed or as generally 

performed in the national economy.” (Id. (citing 20 C.F.R. § 404.1565).) 

 At step five, the ALJ determined that Plaintiff “had acquired work skills from past relevant 

work” as an administrative assistant and department secretary “that are transferable to other 

occupations with jobs existing in significant numbers in the national economy.” (AR 31 (citing 20 

C.F.R. §§ 404.1568(d), 404.1569(a)).) The ALJ thus determined that Plaintiff “has not been under 

a disability, as defined in the Social Security Act, from July 30, 2015, through the date of this 

decision.” (Id. (citing 20 C.F.R. § 404.1520(f)).) 

DISCUSSION 

Plaintiff asserts that the ALJ committed reversible error by failing to: (1) appropriately 

weigh the medical opinion evidence in addressing Plaintiff’s fibromyalgia; (2) address Plaintiff’s 

“mental illness”; (3) consider Plaintiff’s “pain in accordance with Social Security Ruling 16-3P”; 

and (4) “meet her burden of proof at step five by using the medical vocational profiles.” (Dkt. No. 

23 at 13-22.) The Court agrees that the ALJ committed reversible error in weighing the medical 

opinion evidence to assess Plaintiff’s fibromyalgia; further, that error is related to Plaintiff’s 

additional arguments because it affected the ALJ’s analysis of Plaintiff’s subjective symptom 

testimony and the step-five finding based on the vocational expert’s testimony. Plaintiff’s 

argument regarding the ALJ’s weighing of the medical opinion evidence is thus dispositive and 

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the Court need not address the additional arguments. 

I. ALJ’s Consideration of Medical Opinion Evidence 

A. Legal Standard 

In the Ninth Circuit, courts must “distinguish among the opinions of three types of 

physicians: (1) those who treat the claimant (treating physicians); (2) those who examine but do 

not treat the claimant (examining physicians); and (3) those who neither examine nor treat the 

claimant (nonexamining physicians).” Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995) (as 

amended (Apr. 9, 1996)). “A treating physician’s opinion is entitled to more weight than that of 

an examining physician, and an examining physician’s opinion is entitled to more weight than that 

of a nonexamining physician.” Orn v. Astrue, 495 F.3d 625, 631 (9th Cir. 2007). If a treating 

physician’s opinion is not contradicted by another physician, it may be rejected only for “clear and 

convincing” reasons. Baxter v. Sullivan, 923 F.2d 1391, 1396 (9th Cir. 1991). “The opinion of an 

examining [physician], even if contradicted by another [physician], can only be rejected for 

specific and legitimate reasons that are supported by substantial evidence in the record,” and the 

ALJ “must provide “clear and convincing” reasons for rejecting an uncontradicted opinion of an 

examining physician. Lester, 81 F.3d at 830-31. 

If the ALJ determines that a treating physician’s opinion is not entitled to controlling 

weight, the opinion is still “entitled to deference.” Orn, 495 F.3d at 633 (internal citation 

omitted). To determine the amount of deference, the ALJ must consider the following factors in 

determining the weight to give to all medical opinions: (1) examining relationship; (2) treatment 

relationship; (3) supportability; (4) consistency; (5) specialization; and (6) other factors brought to 

the ALJ’s attention. 20 C.F.R. § 416.927(c)(5). “The opinion of a nonexamining physician cannot 

by itself constitute substantial evidence that justifies the rejection of the opinion of either an 

examining physician or a treating physician.” Id. at 831. 

“When an ALJ does not explicitly reject a medical opinion or set forth specific, legitimate 

reasons for crediting one medical opinion over another, [she] errs.” Garrison v. Colvin, 759 F.3d 

995, 1012-13 (9th Cir. 2014) (internal citation omitted). Namely, an ALJ errs by “reject[ing] a 

medical opinion or assign[ing] it little weight while doing nothing more than ignoring it, asserting 

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without explanation that another medical opinion is more persuasive, or criticizing it with 

boilerplate language that fails to offer a substantive basis for [her] conclusion.” Id. “The ALJ can 

meet [her] burden by setting out a detailed and thorough summary of the facts and conflicting 

medical evidence, stating his interpretation thereof, and making findings.” Cotton v. Bowen, 799 

F.2d 1403, 1407 (9th Cir. 1986). Ultimately, “the ALJ must do more than offer [her] conclusions. 

[She] must set forth his own interpretations and explain why they, rather than the doctors’, are 

correct.” Embrey v. Bowen, 849 F.2d 418, 421-22 (9th Cir. 1988). 

B. The ALJ’s Analysis 

Plaintiff insists that in assessing the severity of Plaintiff’s functional limitations the ALJ 

“committed legal error [in] giving little weight” to the opinion of her “treating rheumatologist,” 

Dr. Foster, and greater weight to the opinion of Dr. Satish K. Sharma, a “non-treating nonspecialist.” (Dkt. No. 23 at 13-14.) The ALJ gave “limited weight” to treating rheumatologist Dr. 

Foster’s assessment because the “contemporaneous treatment records” did not show “clinical 

findings or significant changes in [Plaintiff’s] course of treatment to support such extreme 

limitations” such as a “reduced range of sedentary work.” (AR 29 (citing AR 380, 390).) The 

ALJ observed that Dr. Foster’s opinion “appears to rely heavily on [Plaintiff’s] reported symptoms 

and complaints with specific regard to her most recent job.” (Id.) Plaintiff contends that the 

ALJ’s reasons for giving little weight to the opinion of Dr. Foster are neither specific nor 

legitimate and are not supported by substantial evidence in the record. 

First, there are clinical findings to support the treatment records. The ALJ does not 

reference the clinical findings of physicians Dr. Basel Kashlan, Dr. Umesh Gheewala, Dr. Daniel 

Lively, Dr. Mark Allan Smith, or Dr. Lawrence W. Chan regarding Plaintiff’s fibromyalgia and 

osteoarthritis anywhere in her decision. Dr. Kashlan completed a blood test report for Plaintiff on 

June 14, 2017 and reported a positive value of Antinuclear Antibodies (“ANA”), which is 

“suggestive of autoimmune disease and reflexes to titer and pattern.” (AR 41-42.)3

 

3

 ANA tests identify the presence of autoantibodies, which can signal the existence of autoimmune 

disease, such as rheumatoid arthritis. See Antinuclear Antibodies, WebMD, 

https://www.webmd.com/a-to-z-guides/what-is-an-antinuclear-antibody-test#1 (last visited March 

6, 2020). Plaintiff asserts that this positive test result is “indicative of the body’s system break 

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Dr. Gheewala examined Plaintiff on June 20, 2017 for a follow up appointment regarding 

her arthritis and complaints of “pain in [her] hands [and] fingers.” (AR 62.) Dr. Gheewala 

conducted a physical examination of Plaintiff and diagnosed her with osteoarthritis which was 

“likely erosive [osteoarthritis] . . . [m]ostly in both fingers and [bilateral] [k]nees.” (AR 65.) 

Dr. Lively conducted a physical examination on January 11, 2018 and found “decreased 

range of motion, swelling, effusion, laceration, abnormal patellar mobility and bony tenderness” in 

the left knee and “medial joint line, lateral joint like and patellar tendon tenderness.” (AR 72.) 

Dr. Lively endorsed the pain medication needed for Plaintiff’s chronic osteoarthritis and ordered 

the “labs and imaging studies” requested by Plaintiff. (Id.)

 4 

Dr. Smith examined Plaintiff on January 25, 2018 for complaints of “[bilateral] knee pain 

for years markedly worse in left knee one month after hearing feeling a pop” and noted Plaintiff’s 

“[history] of surgery for patellar instability [bilateral] . . . with surgical intervention over 30 years 

ago.” (AR 82-83.) Dr. Smith ordered an x-ray and diagnosed Plaintiff with “chronic knee 

instability, unspecified laterality” and “chronic pain of both knees.” (Id.) 

Dr. Chan conducted an x-ray of Plaintiff’s knee on January 29, 2018 and determined that 

Plaintiff had “severe patellofemoral compartment osteoarthritis bilaterally; mild left joint effusion; 

and calcium pyrophosphate deposition disease.” (AR 98.) The ALJ does not acknowledge the 

aforementioned findings which document Plaintiff’s ongoing pain associated with her 

fibromyalgia. “[T]here are no laboratory tests to confirm the diagnosis [of fibromyalgia]”; 

instead, fibromyalgia is “diagnosed entirely on the basis of patients’ reports of pain and other 

symptoms.” Benecke v. Barnhart, 379 F.3d 587, 590 (9th Cir. 2004). Further, the ALJ does not 

address whether the clinical findings provide support for Dr. Foster’s treatment records and thus 

fails to provide a valid reason based on substantial evidence in the record to ascribe limited weight 

to Dr. Foster’s opinion. Benecke, 379 F.3d at 594 (finding that an ALJ’s “[s]heer disbelief is no 

substitute for substantial evidence” where “[Plaintiff] consistently reported severe fibromyalgia 

down causing breaks in the joint[s] and cartilage.” (Dkt. No. 23 at 15.) 4

 Plaintiff called and requested an appointment because she “need[ed] x-ray order on her left knee 

still on [sic] pain.” A Patient Coordinator scheduled the appointment because Plaintiff “was seen 

by Dr. Lively on January 11, 2018 and [the] medication didn’t work.” (AR 79.) 

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symptoms both before and after diagnosis, and much of her medical record substantially pre-dates 

her disability application”). Although these clinical findings generally post-date Dr. Foster’s 

opinion, much of the record supports Plaintiff’s fibromyalgia diagnosis and the ALJ must weigh 

Dr. Foster’s opinion in consideration of “the record as a whole.” See Batson v. Comm’r Soc. Sec., 

359 F.3d 1190, 1195 (9th Cir. 2004) (ALJ may discredit treating-physician opinion that is 

“conclusory, brief, and unsupported by the record as a whole, . . . or by objective medical 

findings”); 20 C.F.R. §§ 404.1527(c)(4), 416.927(c)(4) (“Generally, the more consistent an 

opinion is with the record as a whole, the more weight we will give to that opinion.”). 

Second, changes in the course of treatment for fibromyalgia are not indicative of the 

degree and severity of the disease and thus do not serve as a valid basis for rejecting Dr. Foster’s 

opinion. The ALJ discounts the severity of Plaintiff’s fibromyalgia because the record “largely 

consists of periodic and routine office visits to administer cortisone injections . . . with little 

variation in the frequency or in the extent of treatment.” (AR 28.) The ALJ’s suggestion that a 

change in frequency and method of treatment by Dr. Foster would better support Plaintiff’s 

“reports of longstanding arthritic pain” is entirely speculative. (Id.) “Conservative treatment is a 

legitimate reason for an ALJ to discredit a claimant’s testimony regarding the severity of an 

impairment.” Trejo v. Berryhill, No. EDCV-17-0879-JPR, 2018 WL 3602380, at *4 (C.D. Cal. 

July 25, 2018) (citing Parra v. Astrue, 481 F.3d 742, 751 (9th Cir. 2007)). However, “[a] claimant 

‘cannot be discredited for failing to pursue non-conservative treatment options where none exist.’” 

Id. (quoting Lapeirre-Gutt v. Astrue, 382 F. App’x 662, 664 (9th Cir. 2010)). Here, the ALJ cites 

evidence that Dr. Foster made referrals for imaging studies and physical therapy, “[but] no such 

studies or therapy records are available [in the record].” (AR 28.) However, the ALJ did not 

identify any other viable, more invasive treatment options that Dr. Foster could have implemented 

to better address Plaintiff’s fibromyalgia. 

Moreover, “[a]ny evaluation of the aggressiveness of a treatment regimen must take into 

account the condition being treated.” Revels v. Berryhill, 874 F.3d 648, 667 (9th Cir. 2017). A 

course of treatment for fibromyalgia consisting of a variety of prescription medications and steroid 

injections is not conservative. Id. “Fibromyalgia is treated with medications and self-care, rather 

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than surgery or other more radical options.” Trejo, 2018 WL 3602380, at *15 (internal quotation 

marks and citation omitted). There is substantial evidence in the record that Plaintiff actively 

sought and received such treatment from Dr. Foster for her fibromyalgia symptoms. (See AR 387, 

388 (noting Plaintiff’s ongoing treatment of ibuprofen and Lidoderm adhesive patches); 384 

(noting administration of cortisone injection in right sacroiliac joint in addition to ongoing 

treatment); 380 (noting addition of Medrol, Norco, and Pennsaid to ongoing treatment).) Thus, 

the ALJ does not provide a specific nor legitimate reason to give limited weight to Dr. Foster’s 

opinion as to the intensity, persistence, and limiting effects of Plaintiff’s fibromyalgia. 

 Further, the ALJ’s opinion improperly disregards the length and nature of Dr. Foster’s 

extensive treatment relationship with Plaintiff and does not offer a legitimate reason for doing so. 

See Trevizo v. Berryhill, 871 F.3d 664, 676 (9th Cir. 2017) (finding reversible error in failing to 

“consider factors such as the length of the treatment relationship, the frequency of examination, 

[and] the nature and extent of treatment relationship”) (citing 20 C.F.R. § 404.1527(c)(2)-(6)). 

The ALJ also erred in ascribing more weight to consultative examiner Dr. Sharma than to 

treating rheumatologist Dr. Foster without providing specific and legitimate reasons supported by 

substantial evidence for doing so. The ALJ assigned greater weight to Dr. Sharma’s opinion 

because his “assessment [was] generally consistent with his examination findings at the time.” 

(AR 29.) The ALJ notes that Dr. Sharma and Dr. Foster each examined Plaintiff during the same 

month in 2015 but only Dr. Foster observed tenderness in Plaintiff’s hands and shoulders. (AR 29 

(“Dr. Foster noted bilateral shoulder tenderness with limited range of motion” whereas “in the 

same month . . . Dr. Sharma did not report shoulder tenderness or range of motion loss, and noted 

full (5/5) upper extremity strength.”) (citing AR 373, 383).) The ALJ does not explain how she 

chose to resolve the conflict between the assessments in Dr. Sharma’s favor beyond a circular 

reference to the consistency of Dr. Sharma’s assessment with his sole physical examination of 

Plaintiff. (See AR 29.) The ALJ’s treatment of the medical opinion evidence is particularly 

concerning given that she fails to acknowledge that Dr. Sharma conducted his examination 

without Plaintiff’s medical records. (See AR 372.) 

Further, Dr. Sharma’s opinion does not address Plaintiff’s fibromyalgia. (See AR 25, 374.) 

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“Rheumatology is the relevant specialty for fibromyalgia” and such “[s]pecialized knowledge may 

be particularly important with respect to a disease such as fibromyalgia.” See Benecke, 379 F.3d 

at 594 n.4. Here, as Plaintiff’s treating rheumatologist, Dr. Foster is better suited to address and 

assess Plaintiff’s pain and tenderness associated with fibromyalgia; Dr. Sharma is a consultative 

examining physician who as an internist (AR 375) lacks the specialization required to accurately 

assess the pain and severity of Plaintiff’s conditions. Because Dr. Foster’s medical opinion 

contradicted Dr. Sharma’s medical opinion as to Plaintiff’s functional limitations, the ALJ was 

required to “summarize[ ] the facts and conflicting clinical evidence in detailed and thorough 

fashion, stating [her] interpretation and making findings.” Magallanes v. Bowen, 881 F.2d 747, 

755 (9th Cir. 1989). The ALJ briefly summarizes the conflicting nature of Dr. Foster’s and Dr. 

Sharma’s opinions but does not cite substantial evidence in the record to support her summary. 

(See AR 28-29.) The ALJ was required to analyze the disparate opinions regarding the degree, 

severity, and associated pain of Plaintiff’s physical impairments rather than reject Dr. Foster’s 

opinion solely because it was inconsistent with Dr. Sharma’s opinion. In sum, in ascribing more 

weight to the opinion of Dr. Sharma with inadequate explanation, the ALJ fails to identify 

substantial evidence in the record to support her decision. 

 The ALJ’s failure to resolve the conflict among medical opinions regarding the severity 

of Plaintiff’s conditions as they relate to her functional limitations infected the ALJ’s analysis at 

other steps. Thus, the ALJ’s error was not harmless because it was not “inconsequential to the 

ultimate nondisability determination.” Molina, 674 F.3d at 1115 (internal quotation marks and 

citation omitted); see also McLeod v. Astrue, 640 F.3d 881, 888 (9th Cir. 2011) (noting that 

remand is appropriate “where the circumstances of the case show a substantial likelihood of 

prejudice” to the party claiming error); Cunningham v. Colvin, No. C-10-4313-LB, 2014 WL 

4965028, at *9 (N.D. Cal. Oct. 3, 2014) (finding reversible error in discrediting treating 

physician’s medical opinion on basis of lack of objective evidence regarding Plaintiff’s pain). 

// 

// 

II. Remand or Credit-As-True 

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Plaintiff asks the Court to reverse the ALJ’s decision and remand “for payment of 

benefits” because her “testimony is consistent with the medical record” and her “treating 

Specialist Dr. Foster’s evaluation [that] she is disabled is uncontroverted.” (Dkt. No. 23 at 22.) 

Alternatively, Plaintiff asks the Court to reverse the ALJ’s decision and remand for further 

administrative proceedings. (Dkt. No. 23 at 22-23.) 

When a court reverses an ALJ’s decision, “the proper course, except in rare circumstances, 

is to remand to the agency for additional investigation or explanation.” Benecke, 379 F.3d at 595. 

A remand for an award of benefits is proper, however, “where (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 evidence, whether claimant testimony or 

medical opinion; and (3) if the improperly discredited evidence were credited as true, the ALJ 

would be required to find the claimant disabled on remand.” Revels, 874 F.3d at 668 (internal 

quotation marks and citation omitted). 

Here, there are outstanding issues that must be resolved before a final disability 

determination can be made because the ALJ’s failure to properly consider the medical opinion 

evidence when assessing Plaintiff’s RFC affected the subsequent analysis at steps four and five. 

Thus, the Court cannot conclude on this record that the ALJ would be required to find Plaintiff 

disabled. Accordingly, on remand the ALJ must appropriately analyze the impairments and 

limitations caused by Plaintiff’s fibromyalgia and osteoarthritis—regardless of severity—at 

subsequent steps of the sequential evaluation and reassess the weighing of all medical opinion 

evidence. 

CONCLUSION 

For the reasons stated above, the Court GRANTS Plaintiff’s motion, DENIES Defendant’s 

cross-motion, and REMANDS for further proceedings. 

This Order disposes of Docket Nos. 23 and 28. 

// 

// 

// 

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IT IS SO ORDERED. 

Dated: April 1, 2020 

 

JACQUELINE SCOTT CORLEY 

United States Magistrate Judge 

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