Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_00-cv-01687/USCOURTS-cand-3_00-cv-01687-0/pdf.json

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

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United States District Court

For the Northern District of California

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United States District Court

For the Northern District of California

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

JOANNE DALLEY,

Plaintiff,

 v

COMMISSIONER OF SOCIAL SECURITY,

Defendant.

 /

No C 00-01687 VRW

ORDER

Plaintiff appeals from the final decision of the Social

Security Administration (SSA) denying her application for

supplemental security income (SSI) benefits for the closed period of

August 20, 1996 through June 30, 1998. Plaintiff’s chief complaint

in support of her claim for benefits was migraine headaches. The

parties have filed cross-motions for summary judgment. For the

reasons stated herein, the court finds errors committed by the

Administrative Law Judge (ALJ) require remand to the agency for

further evaluation. 

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1 The administrative record provided by defendant omits pages 3 and 4 of the

ALJ’s decision. The missing pages are in the court’s record as attachments to

plaintiff’s brief: Pl’s Motion Att A (Doc # 11) at 1-4.

2

 I 

A

Plaintiff was born on January 8, 1953, obtained a high

school education and worked as a bank teller until 1980. 

Administrative Record (Doc # 10) (AR) at 37-40. In July 1998, she

resumed her work as a bank teller part-time. Pl’s Motion (Doc #11)

Att A, 11

. The period of alleged disability at issue on this appeal

occurred before her return to the workforce. 

In March of 1980, after the birth of her son, plaintiff

began seeing Dr Carl Watanabe, a general practitioner (AR 77), for

headaches; he referred her to neurologist Dr Thomas Harter. AR 43,

95. According to plaintiff’s testimony, between 1980 and 1990

plaintiff raised her son and helped take care of her father, who had

Parkinson’s disease. AR 42. Plaintiff’s headaches became more

severe in 1990 and required her to stop assisting with her father’s

care. AR 43. During these years plaintiff’s son began helping to

take care of her. AR 46. By age “16 [when] he got his license[,]

he was running the household, doing all the errands and groceries

and taking care of [me].” Id. After the headaches further

intensified in 1996, Dr Watanabe again referred plaintiff to Dr

Harter, whom she saw “two and three times a week.” AR 42-44. 

Plaintiff stated in her Disability Report, submitted with

her application for benefits, “when I have the migraine headaches, I

basically am unable to function. It could last as long as 5 days.” 

AR 76. Plaintiff stated that her medications caused upset stomach,

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sleepiness, dizziness, inability to focus and increased difficulty

to remember. AR 76, 98, 108. When referring to Dr Harter’s

treatment, plaintiff stated: “my pain from migraine was so bad []

he had to give me two kinds of shots. I was unsuccessful with the

medicine he gave me.” AR 95. 

In August 1996, Dr Harter wrote a letter seeking to have

plaintiff excused from jury duty because she “has severe migraine

which is not under control at the moment.” AR 151. Two months

later, in October 1996, plaintiff sought urgent care for lower

abdominal pain; possible fibroid tumors were noted. AR 174. While

seeing Dr Harter, plaintiff also attended eighteen medical

appointments with Dr Watanabe in the ten-month period from December

26, 1996 through October 31, 1997. AR 239-45. 

On February 22, 1997, in connection with her SSI claim,

plaintiff was referred for a psychiatric consultation with Dr

Richard Mark Patel of the Eastview Medical Group (EMG). AR 137. Dr

Patel noted plaintiff’s “numerous medications” including: 

Verapamil, Triamterence HCT, Lanoxin, Triavil, “PRN medication for

migraines and headaches,” Tylenol with codeine, Fiorinal and

Compazine suppositories for cramps. AR 140. Dr Patel noted that

plaintiff “does her own shopping, cooking, housekeeping, provides

her own transportation by private or public means, does pay her own

bills, and does take adequate care of her personal hygiene.” AR

139. Dr Patel found plaintiff somewhat depressed and anxious, but

found her ability to function largely intact, including in “work or

work-like situations.” Id. Finding her able to relate and interact

with coworkers and supervisors and to remember, understand and carry

out instructions, Dr Patel noted that plaintiff’s ability to deal

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with the public “may be slightly hindered due to her nervous affect”

and wrote “the patient’s ability to withstand the stresses and

pressures associated with day-to-day work activity is where the

patient displays her largest deficits, being easily brought to tears

and becoming very nervous when asked to perform certain tasks.” AR

139-40. Dr Patel’s diagnoses included: (1) possible major

depressive disorder with anxious features, chronic dysthymia,

medication-induced depressive disorder, NOS, and some degree of

somatization; (2) possible dependent personality disorder; (3)

patient self-report of migraines; (4) “psychosocial stressors are

mild to moderate: physical complaints of headaches; financial”; and

(5) global assessment of functioning (GAF) of 60. AR 140.

In March of 1997, plaintiff saw Dr Satish Sharma for an

internal medicine consultative exam at EMG. AR 141-44. Dr Sharma

noted plaintiff’s headaches to be “frontotemporal, throbbing, sharp,

and associated with nausea * * * on the average [plaintiff] gets

headaches once a week * * * [and] sometimes she has to go to the

emergency room to get injections such as Demerol for relief of her

headaches.” AR 141. This report does not make note of any other

complaints besides migraine headaches. Dr Sharma’s functional

capacity assessment noted no limitations in sitting, standing,

walking, bending, stooping, holding, fingering, feeling objects,

lifting, carrying, pushing, pulling, speech, hearing, or vision ——

in short, no physical limitations of any kind. AR 144.

In March of 1997, agency doctors reviewed plaintiff’s

record and completed assessments finding plaintiff minimally

limited. On a Psychiatric Review Technique Form (PRTF), AR 116-25,

a reviewing agency physician checked boxes for “impairment[s] not

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severe” and “affective disorders,” AR 117, “disturbance of mood,

accompanied by a full or partial manic or depressive syndrome 

* * *.” AR 119-20. Limitations in the form of “restriction of

activities of daily living,” “difficulties in maintaining social

functioning” and deficiencies of concentration, persistence or pace

were marked “slight,” while “episodes of deterioration or

decompensation in work or work-like settings” was marked “once or

twice.” AR 124.

On a Physical Residual Functional Capacity Assessment

(PRFCA) form, AR 126-33, reviewing agency physicians marked boxes

indicating no established exertional, postural, manipulative,

visual, communicative or environmental limitations. AR 127-31. The

form also indicated that its conclusions were not significantly

different from “treating/examining source conclusions about the

claimant’s limitations or restrictions” in the file. AR 132. The

March 1997 assessments were affirmed by other agency doctors. AR

117, 126. 

On July 11, 1997, Dr Harter wrote:

 [P]laintiff gets daily headaches now. They are

bitemporal usually and mild. When she gets a

severe migraine, she has visual scotomata in the

peripheral vision bilaterally associated with a

unilateral throbbing headache, usually in the

temples, photophobia, retching, and nausea and

vomiting. These are related to her menstrual cycle

in that they usually start with ovulation and

continue on through the last half of the menstrual

cycle until menstruation. 

AR 149.

From July 1997 to May 1998, plaintiff continued her

treatment with Dr Harter, attending twenty-five medical

appointments. AR 152-53. Plaintiff reported the occurrence of

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headaches at twenty of the twenty-five appointments. Id. Of the

twenty appointments which mentioned headaches, six resulted in a

notation improved/somewhat controlled headaches. Id. Each record

of improved/somewhat controlled headaches occurred before

plaintiff’s surgery on December 17, 1997. Id. During the period

from July 1997 to October 1997, Dr Harter also noted that various

medications caused leg swelling, sweating and sleepiness. Id. 

In the fall of 1997, after unsuccessful treatment to

control the migraine headaches, Dr Watanabe referred plaintiff to Dr

Lisa Keller, a gynecologist, to discuss a possible hysterectomy. AR

47 and 160. Dr Keller listed plaintiff’s current medications as

Lanoxin, Dyazide, lisinopril, Triavil, Cardene, and “intermittent

Motrin, Tylenol with codeine, or Vicodin.” AR 209. In addition to

the migraine headaches, Dr Keller found plaintiff to have a rapidly

growing uterine fibroma and determined that surgery was appropriate. 

AR 188. She wrote that there were “two indications for surgery

including quite symptomatic uterine leiomyomata and menstrual cycle

related migraine headaches.” AR 210. On December 17, 1997,

plaintiff underwent a total abdominal hysterectomy and bilateral

salpingo-oophorectomy. AR 167. 

On January 7, 1998, plaintiff reported: “has had headaches

but not as bad —— feels significant improvement.” AR 159. But on

May 19, 1998, Dr Harter wrote plaintiff’s migraine headaches were

“refractory to medical amelioration * * * [and] her headaches are

her only hindrance to gainful employment.” AR 147. 

Meanwhile, plaintiff had applied to work at Wells Fargo

Bank but although “they were ready to take [her], [she] had to wait”

because of she had broken her foot. AR 48. Towards the end of July

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2

 Plaintiff later moved to dismiss her claim for disability insurance

benefits. The ALJ refused, instead denying the claim based on a finding

that plaintiff had no “severe” impairment prior to the expiration of her

insured status in 1985. AR 12. Plaintiff did not appeal this ruling. 

7

1998, however, the bank hired her. AR 48-49. In September of 1998

clinic notes reported that plaintiff “still has headaches but now

has a job and feels good at work.” AR 156. As of the time the

complaint was filed, November 9, 2001, plaintiff was working at

Wells Fargo Bank twenty hours a week. AR 38. 

B

On December 22, 1996, plaintiff applied for SSI benefits. 

AR 218-21. On December 24, 1996, plaintiff also applied for

disability insurance benefits under Title II.2

 AR 70. On April 2,

1997, plaintiff received notice that her claim for SSI was denied

based on the EMG psychiatric and internal medicine reports dated

February 27, 1997 and March 19, 1997, respectively. AR 223-26. The

notice of determination stated: 

[T]he medical evidence shows that though you may have

migraine headaches, they are not of such frequency or

severity as to significantly interfere with most normal

activities * * * [t]hough you may at times be

depressed, you are able to act in your own interests. 

Id. Plaintiff requested reconsideration, following which the SSA

reaffirmed its denial. AR 61-63 and 228. Plaintiff’s “migraines

can be controlled with treatment. While [plaintiff] may experience

some discomfort, this should not prevent all work-related activity.” 

AR 63. 

Plaintiff requested a hearing, which took place on

February 23, 1999. AR 11. Plaintiff was accompanied by an

attorney. There were no other witnesses. During the hearing,

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plaintiff testified that her migraines were “excruciating,” “so bad

that [I] would just lay there and it would hurt for a tear to roll

down my face * * * I had vomiting * * * after I was done vomiting I

would have dry heaves, just convulsing, dry heaves sometimes every

20 minutes for 24 hours.” AR 45. She further testified that the

hysterectomy had alleviated her headaches: “I don’t have these

headaches that last a week anymore, two or three days. I can think. 

I’m not medicated. I can work now. It was impossible before. I

couldn’t even fathom trying to work back then.” AR 47.

On April 16, 1999, the ALJ issued a decision denying

plaintiff’s SSI claim based on a finding, at step three of the fivestep sequential analysis (infra), that the medical evidence

established that plaintiff did not have a “severe” impairment during

the claimed period of disability and was therefore not under a

disability at any time through the date of the decision. Pl’s

Motion Att A, 4.

The ALJ explained his decision thusly:

There is no medical evidence which would suggest

the need to restrict the claimant’s activities in a

routine work environment. Therefore, during

periods of no-work when the claimant alleges

disability, she cannot be found to have had a

severe impairment. She is not shown to have any

impairment or combination of impairments which was

anything more than slight or having more than a

minimal effect on her ability to perform basic work

activities.

Id at 2. The ALJ accorded substantial weight to the opinions of the

non-examining agency physicians as set forth in the PRTF and PRFCA

reports. Id at 4. 

The ALJ apparently afforded little or no weight to

plaintiff’s treating sources. Regarding the records from

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plaintiff’s neurologist, Dr Harter, the ALJ stated that he “cannot

reasonably infer limitations from the records.” Id at 3. The ALJ

made only passing reference to the records provided by plaintiff’s

treating physicians, Dr Watanabe or Dr Keller, describing the care

they provided, presumably including the hysterectomy, as “minor.” 

Id. He concluded: “None of these sources indicates anything of

significance that would lead to a finding that a ‘severe’ impairment

existed during the period in question.” Id. 

Regarding the consulting examiners’ reports, the ALJ noted

that consulting internal medicine specialist Dr Sherma “found

[plaintiff] to be without restrictions, despite her history of

migraine headaches.” Id at 3. He found Dr Patel’s report, which he

discussed at some length, not to support a finding of psychiatric

impairment. Id at 3-4. 

In support of his general finding that the “claimant’s

testimony was not credible to the extent of establishing workrelated restrictions,” id at 4, the ALJ commented, inter alia, that: 

“[h]eadaches are not shown in the medical evidence to be of a

severity to account for her allegedly dysfunctional state during the

period at issue”; plaintiff’s MRI showed no abnormalities; plaintiff

“had only routine office visits without the need for stronger

medications administered in an emergency room setting”; and

plaintiff “was tried on various medications, with some degree of

success, according to Dr Harter * * * [but] functionally limiting

medication side effects are not shown.” Id at 4-5. 

The ALJ’s OHA Psychiatric Review Technique Form (OHA-PRTF)

marked boxes showing affective disorder and somatoform disorder as

present. AR 14. When describing the affective disorders in section

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C of the OHA-PRTF, the ALJ marked “depressive syndrome” and

“unrealistic interpretation of physical signs or sensations

associated with the preoccupation or belief that one has a serious

disease or injury” as absent, but marked “symptom magnification” as

present. AR 14-15. The ALJ also noted slight “restrictions of

activities of daily living” and slight “difficulties in maintaining

social functioning.” AR 15. 

Plaintiff appealed the ALJ’s decision to the SSA’s Appeals

Council, which denied review. AR 3. Plaintiff then filed her

complaint seeking judicial review of the SSA’s decision. Doc #1. 

II

A

Under 42 USC § 405(g), a decision to deny benefits may be

overturned if it is not supported by substantial evidence

or is based on legal error. Thomas v Barnhart, 278 F3d 947, 954

(9th Cir 2002). “Substantial evidence means more than a scintilla

but less than a preponderance.” Id. “Substantial evidence is

relevant evidence which, considering the record as a whole, a

reasonable person might accept as adequate to support a conclusion.” 

Id. Where the evidence is susceptible to more than one

interpretation, one of which supports the ALJ’s decision, the ALJ’s

conclusion must be upheld. Id.

“Disability” is defined as “the inability to do any

substantial gainful activity by reason of any medically determinable

physical or mental impairment which can be expected to result in

death or which has lasted or can be expected to last for a

continuous period of not less than 12 months.” 20 CFR § 416.905.

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To determine whether a claimant is disabled and entitled

to benefits, the SSA conducts a five-step sequential inquiry. 20

CFR § 416.920. Under the first step, the ALJ considers whether the

claimant is currently employed in substantial gainful activity. If

not, the second step examines whether the claimant has a “severe

impairment” that significantly affects his or her ability to conduct

basic work activities. In step three, the ALJ determines whether

the claimant has a condition which “meets” or “equals” the

conditions outlined in the Listing of Impairments in 20 CFR Part

404, Subpart P, Appendix 1. If the claimant does not have such a

condition, the ALJ proceeds to step four, which assesses the

claimant’s residual functional capacity and asks whether the

claimant can perform her past relevant work. If not, the ALJ moves

to step five, which considers whether the claimant has the ability

to perform other work which exists in substantial numbers in the

national economy. 20 CFR §§ 416.920(b)-(f). 

 The regulations do not directly define “severe,” but do

define a “non-severe impairment” as an impairment or combination of

impairments that “does not significantly limit your physical or

mental ability to do basic work activities.” 20 CFR § 416.921(a). 

Social Security Ruling (SSR) 85-28 states that a finding of “not

disabled” at step two is appropriate “when medical evidence

establishes only a slight abnormality or a combination of slight

abnormalities which would have no more than a minimal effect on an

individual’s ability to work * * *.” 

Even if, at step three, the plaintiff cannot establish

disability based on the listing of impairments, a claimant can make

out a prima facie case of disability if she proves, in addition to

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the first two requirements, that she is not able to perform any work

that she has done in the past. Thomas, 278 F3d at 955. If the

claimant makes out a prima facie case, the burden shifts to the

Commissioner to establish that the claimant can perform a

significant number of other jobs in the national economy. Id. The

Commissioner can meet this burden through the testimony of a

vocational expert or by reference to the Medical Vocational

Guidelines at 20 CFR Part 404, Subpart P, Appendix 2. Id. If the

Commissioner meets her burden, the claimant has failed to establish

disability.

The social security regulations distinguish among the

opinions of three types of physicians: (1) treating physicians; (2)

non-treating examining physicians and (3) those who neither examine

nor treat the claimant. 20 CFR § 416.927(d); Lester v Chater, 81

F3d 821, 830 (9th Cir 1996). As a general rule, more weight is

given to the opinion of a treating source than a non-treating one. 

Id. Where the treating doctor’s opinion is not contradicted by

another doctor, it may be rejected only for “clear and convincing

reasons.” Baxter v Sullivan, 923 F2d 1391, 1396 (9th Cir 1991). 

Even if the treating doctor’s opinion is contradicted by another

doctor, the ALJ may not reject this opinion without providing

“specific and legitimate reasons.” Murray v Heckler, 722 F2d 499,

502 (9th Cir 1983). 

In deciding whether to accept a claimant’s subjective

symptom testimony, an ALJ must perform two stages of analysis: (1)

the analysis required by Cotton v Bowen, 799 F2d 1403 (9th Cir

1986); and (2) an analysis of the credibility of the claimant’s

testimony regarding the severity of her symptoms. Smolen v Chater,

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80 F3d 1273, 1281 (9th Cir 1996). “The Cotton test imposes only two

requirements on the claimant: (1) she must produce objective medical

evidence of an impairment or impairments; and (2) she must show that

the impairments could reasonably be expected to (not that it did in

fact) produce some degree of symptom.” Id at 1282.

B

In her appeal, plaintiff argues that the “finding of no

‘severe impairment’ was not supported by substantial evidence” and,

specifically, that “the ALJ failed to give any reason for rejecting

the opinion of a treating doctor.” Pl Mot at 4, 5. 

As an initial matter, there appears to be little support

in the record for the idea that plaintiff’s alleged depression ever

met the listing criteria for establishing disability at 20 CFR Part

404, Subpart P, Appendix 1 § 112.00. Even if considered in

combination with the headaches, the medical evidence does not point

to depression as a significant factor affecting plaintiff’s ability

to work. At most, the depression appears secondary. The ALJ’s

decision with respect to plaintiff’s alleged depression is supported

by substantial evidence and is therefore upheld. 

The court next considers plaintiff’s challenge to the

ALJ’s handling of the evidence of migraine headaches. Plaintiff

contends that the ALJ did not give adequate reasons for rejecting

and/or ignoring the evidence from treating physicians Watanabe,

Keller and Harter and her own testimony in determining that

plaintiff’s migraines were “not severe.” The court agrees. 

A substantial hurdle plaintiff faced in attempting to

establish disability for SSI eligibility purposes was that migraine

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headaches cannot be evidenced by imaging studies, laboratory tests

or other ordinary “objective” evidence. Indeed, SSR 96-7p, which

offers guidance for “assessing the credibility of an individual’s

statements,” states “[n]o symptom or combination of symptoms can be

the basis for a finding of disability, no matter how genuine the

individual’s complaints may appear to be, unless there are medical

signed and laboratory findings demonstrating the existence of a

medically determinable * * * impairment that could reasonably be

expected to produce the symptoms.” The Act, however, does not

require diagnostic tests, but allows the determination of a

medically determinable impairment by means of “medically acceptable

clinical and laboratory diagnostic techniques.” 42 USC § 423(d)(3).

This use of the disjunctive leaves little doubt that “clinic

diagnostic techniques” are a legally acceptable substitute for

laboratory diagnostic techniques. 

A further hurdle plaintiff faced was that the occurrence

of cyclical, severe headaches does not match up with the checklists

or forms used for determining residual functional capacity (RFC) in

the social security context. For example, Dr Sharma’s evaluation

found plaintiff fully able to push, pull, stand and so on, but

simply did not address the impact of severe headaches on her ability

to work. AR 144. The ALJ nonetheless relied on Dr Sharma’s finding

of no restrictions without acknowledging the fact that the

evaluation was not designed to —— and did not —— take into account

plaintiff’s severe, recurring pain from migraine headaches. 

Yet migraine headaches are a common malady that are

readily diagnosed through the evaluation of symptoms. They are

difficult to control with or without medication. According to the

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current on-line version of the Merck Manual, twenty-four million

Americans suffer from migraines and diagnosis “is based on the

symptom patterns when there is no evidence of intracranial

pathologic changes. * * * No diagnostic tests are useful, except to

exclude other causes.” Other relevant information includes the

following:

The cause is unknown, and the pathophysiology is

not fully understood. Changes in brain and scalp

arterial blood flow occur * * *. The inflammation

leads to irritation of perivascular trigeminal

sensory fibers. A cascade of events follows,

causing changes in blood flow and the severe

headache.

The mechanism for migraines is not well defined,

but several triggers are recognized. Cycling

estrogen, a significant trigger, may explain why

there are three times as many women with migraines

as men. Evidence of estrogen's role as a trigger

includes the following: During puberty, migraine

becomes much more prevalent in females than in

males; migraines are particularly difficult to

control in the premenopausal period; and oral

contraceptives and estrogen replacement therapy

often make migraine worse. Other triggers include

insomnia, barometric pressure change, and hunger.

http://www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/s

ection14/chapter168/168b.jsp%3Fregion%3Dmerckcom&word=migraine&domain

=www.merck.com#hl_anchor (August 30, 2006). 

At least one other court, moreover, has overturned an ALJ’s

determination that migraine headaches may not constitute a “severe

impairment” where the claimant displayed classic migraine symptoms

but had a normal MRI, CT scan and opthalmological examination. In

Federman v Chater, 1996 WL 107291 (SDNY 1996), the court held

“[b]ecause there is no test for migraine headaches, ‘when presented

with documented allegations of symptoms which are “entirely

consistent with the symptomatology” for evaluating [migraine], the

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Secretary cannot rely on the ALJ’s rejection of the claimant’s

testimony based on the mere absence of objective evidence.’” See

generally, B Samuels, Social Security Disability Claims: Practice &

Procedure, § 22:63 at 22-201 and n 17 (Clark Boardman Callaghan, 2nd

ed rev 2000) regarding proof of chronic fatigue syndrome, migraine,

somatoform and like disorders which cannot be established through

laboratory or imaging tests. 

The three doctors who treated plaintiff during the period

in question relied on her reports of severe headaches and treated

her accordingly. The treatments were not occasional or incidental

to other medical problems. The evidence shows that plaintiff sought

treatment for migraine headaches as a chief medical complaint over

the entire period and that her quest for relief from these headaches

was at least part of the reason for her decision to undergo a

hysterectomy. The fact that post-hysterectomy, plaintiff’s

migraines gradually became less severe, moreover, is consistent with

the medical literature cited above. Furthermore, while, as noted

above, there was not and could not be laboratory or imaging test

results in the record establishing unequivocally the occurrence,

frequency or intensity of plaintiff’s headaches, there is no medical

or other evidence in the administrative record casting doubt on

whether plaintiff experienced them or suggesting that she was

malingering. 

The opinion of a treating physician may be rejected only

for “clear and convincing” reasons. Lester, 81 F3d at 830. The

sole reason provided by the ALJ for ignoring the evidence provided

by plaintiff’s treating physicians was that he could not “reasonably

infer limitations” from the medical evidence. Instead, “[i]n

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finding no ‘severe’ impairment, I give weight to the assessments of

State Agency Medical consultant [sic] which find no significant

physical or mental limits.” Moreover, while hysterectomy may be a

common procedure, the ALJ’s characterization of it as “minor” was

unreasonable.

“Where the [ALJ] fails to provide adequate reasons for

rejecting the opinion of a treating or examining physician, we

credit that opinion ‘as a matter of law.’” Lester 81 F3d at 834;

quoting Hammock v Bowen, 879 F2d 498, 502 (9th Cir 1989). 

The ALJ not only ignored or discredited treating physician 

evidence, he discredited plaintiff’s own testimony in a manner that

was erroneous as a matter of law. This appeal turns largely on the

apparent disparity between plaintiff’s testimony about her

subjective pain symptoms and the ALJ’s conclusion of “no severe

impairment” at step two of the five-step sequential analysis. 

“It is improper as a matter of law to discredit excess

pain testimony solely on the ground that it is not fully

corroborated by objective medical findings.” Cotton, 799 F2d at

1407. The law governing the ALJ’s responsibilities in cases

involving excess pain is well-developed in this circuit. “Excess

pain” is “pain at a level above that supported by medical findings.” 

Chavez v Department of Health and Human Services, 103 F3d 849, 853

(9th Cir 1996). If a claimant is able to produce objective medical

evidence of an underlying impairment, an ALJ may not reject his

subjective complaints based solely on lack of objective medical

evidence to corroborate the alleged severity of pain. Moisa v

Barnhart, 367 F3d 882, 885 (9th Cir 2004). If the ALJ finds the

claimant’s pain testimony not to be credible, the ALJ “must

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specifically make findings that support this conclusion.” Id. 

Absent “affirmative evidence that the claimant is malingering,” the

ALJ must provide clear and convincing reasons for rejecting the

claimant’s testimony regard the severity of symptoms. Id. 

The ALJ did not give “clear and convincing” reasons for

discrediting plaintiff’s subjective pain testimony. The

administrative record contains no evidence of malingering and

plaintiff’s extensive medical records relating to migraine headaches

are in direct contradiction to the ALJ’s statements downplaying

their severity. Contrary to the ALJ’s findings, if plaintiff and

her treating physicians are to be believed, her severe, cyclical

migraine headaches “significantly limit[ed her] physical or mental

ability to do basic work activities,” 20 CFR § 416.921(a), having

more than a “minimal” effect on her ability to work. 

In summary, the ALJ erred at step two by rejecting or

failing to give proper weight to the treating physicians’ and

examining physicians’ reports and by improperly rejecting

plaintiff’s own testimony. Where the ALJ improperly rejects the

opinion of a treating or examining physician, that opinion is

credited “as a matter of law.” Lester, 81 F3d at 834. Thus

crediting the disregarded evidence, and taking into account the

evidence in the record as a whole, the court finds that substantial

evidence in the record compels a finding that plaintiff had a

“severe impairment” from August 20, 1996 until sometime after her

recovery from her hysterectomy in 1998. Unfortunately, because the

ALJ incorrectly found that plaintiff never had a severe impairment,

he did not attempt to identify the date upon which plaintiff’s

migraine-related severe impairment ended. 

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The next step would be to determine whether plaintiff’s

condition met or equaled a listed impairment in 20 CFR Part 404,

Appendix 1. Plaintiff’s migraine headaches, however, are not among

the listed impairments. “Not all possible medical conditions,

diseases, or ailments are contained in the Listings. The Listings

are selective, not exhaustive. Many serious and potentially

disabling impairments are not found in the Listings[,] * * * only

the most frequently diagnosed impairments.” B Samuels, Social

Security Disability Claims: Practice & Procedure, § 22:74 at 22-215. 

The inquiry would then move to step four, at which plaintiff must

show that she could not perform her past relevant work —— i e, her

job as bank teller. 

III

This matter is remanded to the Social Security

Administration for reconsideration beginning at step four of the

five-step sequential analysis, 20 CFR § 416.920. The clerk shall

enter judgment in favor of plaintiff and against defendant and shall

close the file. 

IT IS SO ORDERED.

 

VAUGHN R WALKER

United States District Chief Judge

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