Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_13-cv-00422/USCOURTS-azd-4_13-cv-00422-0/pdf.json

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

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WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Jose Arturo Alvarez, 

Plaintiff, 

v. 

Carolyn W. Colvin, Acting Commissioner 

of Social Security, 

Defendant.

No. CV-13-00422-TUC-BPV

ORDER

Plaintiff, Jose Alturo Alvarez, filed this action for review of the final decision of 

the Commissioner of Social Security pursuant to 42 U.S.C. § 405(g). Plaintiff presents 

two issues on appeal: (1) whether the ALJ’s determination that Plaintiff’s spinal 

condition does not meet or equal any of the listed impairments in 20 C.F.R. 404, Subpart 

P, Appendix 1 (“the Listings” or “Listing of Impairments”) is supported by substantial 

evidence; and (2) whether substantial evidence supports the ALJ’s residual functional 

capacity (RFC) assessment. (Doc. 21.) Before the court is an opening brief filed by 

Plaintiff (Doc. 21), and the Commissioner’s opposition (Doc. 22), no reply brief was 

filed. 

The United States Magistrate Judge presides over this case pursuant to 28 U.S.C. § 

636 (c) and Fed.R.Civ.P. 73, having received the written consent of both parties. (Doc. 

12.) 

The Commissioner’s decision denying benefits is reversed and remanded for 

further proceedings consistent with this order. 

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I. Background 

Plaintiff filed an application for Disability Insurance Benefits (DIB) on August 3, 

2010, with a protective filing date of July 20, 2010, alleging disability as of November 1, 

2008, due to congenital fusion of C2-C3 cervical spine, a right ear hearing problem, and a 

right eye vision problem. Transcript/Administrative Record (Tr.) 158, 162. The 

application was denied initially and on reconsideration. Tr. 67-96, 98-100. Plaintiff 

appeared with counsel and testified before an ALJ at an administrative hearing. Tr. 34-66. 

On January 13, 2012 the ALJ issued a decision finding Plaintiff not disabled within the 

meaning of the Social Security Act. Tr. 7-18. 

A. Plaintiff’s Background and Statements in the Record 

Plaintiff was 43 years of age on the November 1, 2008 alleged disability onset 

date, and 46 years of age as of the date of the Commissioner’s final decision. Tr. 141. 

Plaintiff has a 12th grade education, and past work experience as a mining car loader, a 

construction worker, and a cable service technician. Tr. 163, 168, 199. 

Plaintiff testified at a hearing before the ALJ on December 5, 2011 that he had not 

worked at all since November 2008. Tr. 39. Plaintiff testified that he could not return to 

any of his previous jobs because he “wouldn’t be able to handle them” because he 

doesn’t have the strength, and couldn’t stand up that long. Tr. 50-51. He testified that he 

couldn’t do a sedentary job because he can’t be sitting down for a long time. Tr. 54, 58-

59. 

Plaintiff testified that he could probably walk for about 15 to 20 minutes before he 

needed sit down for five to 10 minutes, and then could walk again, and that he normally 

walks with a slow gait. Tr. 39-40, 46. Plaintiff can only sit or stand for five minutes at a 

time. Tr. 40-41. Plaintiff can lift 15 to 20 pounds with each arm. 

Plaintiff testified that his pain has gotten worse, and his primary doctor told him 

that the cause of the pain is the fusion in his spine, and two pinched nerves in his neck. 

Tr. 42. Plaintiff didn’t recall ever telling the consultative examining physician that he 

didn’t have any problems walking. Tr. 45-46. 

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Plaintiff testified he lost his hearing in his right ear, and his sight in his right eye. 

Tr. 47. On further questioning, Plaintiff explained he can see with his right eye, but has 

problems seeing. Tr. 47. Plaintiff needs glasses but cannot afford them. Tr. 48. Plaintiff 

testified that his hearing loss in his right ear had gotten worse since his assessment of 

mild hearing loss in April 2011. Tr. 49-50. 

B. Vocational Expert Testimony 

A vocational expert (VE) testified that Plaintiff’s jobs had all been more than 

sedentary, and the ALJ found that he would not be able to perform his past relevant work. 

Tr. 61. The ALJ posed the following hypothetical limitations to the VE: “limited to 

sedentary level work. ... [C]annot use ladders, ropes, or scaffolds. ... [C]annot perform 

tasks in a fast paced production environment... [and] is to avoid concentrated exposure to 

excessive noise or hazards. ... [M]ust be afforded a sit stand option during the work day 

one to two minutes every hour or so. ... [and] is limited to occupations that allow such an 

individual to use either glasses or a hearing aid on the job as needed. ... and has the same 

vocational and education background as ... Claimant.” Tr. 61-62. The VE testified that 

the hypothetical individual could perform sedentary, unskilled and semi-skilled jobs, such 

as a sorter and a document specialist. Tr. 63. 

The VE testified that if the hypothetical individual could not attend and 

concentrate for up to two hours at a time with appropriate breaks, the individual would 

not be able to maintain employment because of the disruption of the pace of the job. Tr. 

64. Furthermore, if an individual can only sit for five minutes, then has to stand up and 

walk around for two or three minutes, and then can sit back down, the VE testified that 

such an individual could not perform any of the jobs the VE proffered. 

C. The ALJ’s Findings and Conclusions 

 The ALJ found that Plaintiff last met the insured status requirements of the Social 

Security Act through December 31, 2013. Tr. 12, ¶ 1. The ALJ found that Plaintiff had 

not engaged in substantial gainful activity since the alleged onset date of November 1, 

2008. Tr. 12 ¶ 2. The ALJ found that Plaintiff has the following severe impairments: 

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degenerative disc disease and congenital fusion of the cervical spine, unilateral hearing 

loss, and visual field contraction. Tr. 12, ¶ 3. The ALJ found that Plaintiff’s impairments 

did not meet or equal any of the impairments found in the Listings, sections 1.04, 2.03, 

and 2.10. Tr. 13, ¶ 4. The ALJ found that Plaintiff has the RFC to perform sedentary 

work subject to the following: “He requires the option to alternate at will between seated 

and standing positions every hour or so for 1-2 minutes; he cannot climb ladders, ropes or 

scaffolds; he cannot perform tasks in a fast-paced production environment; he should 

avoid concentrated exposure to excessive noise, and to hazards such as unprotected 

heights or dangerous machinery; and he is further limited to occupations that allow an 

individual to use eyeglasses or a hearing aid on the job, as needed. Tr. 14, ¶ 5. The ALJ 

found that Plaintiff is unable to perform any past relevant work. Tr. 16, ¶ 6. The ALJ 

further found that considering the claimant’s age, education, work experience, and RFC, 

there are jobs that exist in significant numbers in the national economy that Plaintiff can 

perform and concluded that Plaintiff was not under a disability from October 1, 2006 

through the date of the ALJ’s decision. Tr. 17-18, ¶¶ 7-11. 

This decision became the Commissioner’s final decision when the Appeals 

Council denied review. Tr. 1-3. Plaintiff then commenced this action for judicial review 

pursuant to 42 U.S.C. § 405(g). (Doc. 1.) 

II. Legal Standard 

 The Court has the “power to enter, upon the pleadings and transcript of the record, 

a judgment affirming, modifying, or reversing the decision of the Commissioner of Social 

Security, with or without remanding the cause for a rehearing.” 42 U.S.C. § 405(g). The 

Commissioner’s decision to deny benefits “should be upheld unless it is based on legal 

error or is not supported by substantial evidence.” Ryan v. Comm’r of Soc. Sec., 528 F.3d 

1194, 1198 (9th Cir. 2008). “ ‘Substantial evidence’ means more than a mere scintilla, but 

less than a preponderance; it is such relevant evidence as a reasonable person might 

accept as adequate to support a conclusion.” Lingenfelter v. Astrue, 504 F.3d 1028, 1035 

(9th Cir. 2007) (citing Robbins v. Comm’r, Soc. Sec. Admin., 466 F.3d 880, 882 (9th Cir. 

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2006)). In determining whether the decision is supported by substantial evidence, the 

Court “must consider the entire record as a whole and may not affirm simply by isolating 

a ‘specific quantum of supporting evidence.’” Id. (quoting Robbins, 466 F.3d at 882). The 

Court reviews 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. Garrison v. Colvin, --- 

F.3d ---, 2014 WL 3397218 at *11 (9th Cir. July 14, 2014) (citing Connett v. Barnhart, 

340 F.3d 871, 874 (9th Cir. 2003)). 

 Whether a claimant is disabled is determined using a five-step evaluation process. 

To establish disability, the claimant must show (1) he has not worked since the alleged 

disability onset date, (2) he has a severe impairment, and (3) his impairment meets or 

equals the severity of a disabling impairment in the Listings or (4) his RFC precludes him 

from performing his past work. At step five, the Commissioner must show that the 

claimant is able to perform other work. See 20 C.F.R. § 404.1520(a). 

III. Analysis 

A. The ALJ’s RFC Findings 

The Plaintiff argues that the ALJ’s RFC determination was not supported by 

substantial evidence, specifically, that, in making the RFC determination, the ALJ failed 

to obtain a psychiatric consultative examination, failed to consider Plaintiff’s physical 

therapy treatment, and erred in finding Plaintiff not credible. (Doc. 21, at 15-20.) 

1. The ALJ Did Not Err by Failing to Obtain a Psychiatric 

Consultation. 

 Plaintiff contends that the ALJ erred by failing to seek a psychiatric consultation 

given the evidence of Plaintiff’s diagnosis and treatment for depression. (Doc. 21, at 17.) 

 At the reconsideration stage of Plaintiff’s disability determination, State Agency 

non-examining consultative physician, Martha Goodrich, M.D., requested that hearing 

and vision consultative examinations be obtained. Tr. 85. Subsequently, in April 2011, an 

eye examination was performed by State Agency Examiner Jonathon Gross, M.D., who 

opined that the etiologic factor responsible for Plaintiff’s primary eye condition was 

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“suspect emotional disturbance” and recommended reading glasses and a psychiatric 

consult. Tr. 315-16. Based on Dr. Gross’s note, and the evidence of depression and 

treatment in the record, Plaintiff asserts the ALJ erred by failing to seek a psychiatric 

consultation. (Doc. 21, at 17.) 

 There is no indication in the record that Dr. Gross reviewed any of Plaintiff’s 

medical records from Plaintiff’s treating physician, Edgardo Laguillo, M.D. Tr. 315-21. 

Treatment notes from Dr. Laguillo reveal that Plaintiff was diagnosed and successfully 

treated for depression. Dr. Laguillo noted psychological symptoms of anxiety, 

depression, and sleep disturbances at Plaintiff’s new patient examination in December 

2009, and diagnosed depression and prescribed fluoxetine. Tr. 225. By February 2010, 

Plaintiff reported that he was “feeling much better from the standpoint of his mood” and 

Dr. Laguillo assessed Plaintiff with “Depression, clinically improved.” Tr. 221, 223. In 

April 2010, and again in June 2010, Dr. Laguillo again noted that Plaintiff’s depression 

was “Better” and assessed the condition as “clinically improved.” Tr. 210, 212, 215, 217. 

By July 2010, Dr. Laguillo noted that were no new psychological symptoms, and 

assessed Plaintiff with “Depression, stable.” Tr. 207, 209. 

 The ALJ’s duty to develop the record exists even when, as in this case, the 

claimant is represented by counsel. See DeLorme v. Sullivan, 924 F.2d 841, 849 (9th Cir. 

1991). The ALJ can develop the record by making a reasonable attempt to obtain medical 

evidence from the claimant's treating sources, ordering a consultative examination when 

the medical evidence is incomplete or unclear and undermines ability to resolve the 

disability issue, subpoenaing or submitting questions to the claimant's physicians, 

continuing the hearing; or keeping the record open for supplementation. Tonapetyan v. 

Halter, 242 F.3d. 1144, 1150; 20 C.F.R. 404.1517; 42 U.S.C. § 423(d)(5)(A), (B). 

Generally, the ALJ need only obtain further information when the record does not contain 

sufficient medical evidence of the impairment. 20 C.F.R. § 404.1517. Within this 

regulatory framework, the Commissioner “has broad latitude in ordering a consultative 

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examination.” Reed v. Massanari, 270 F.3d 838, 842 (9th Cir. 2001) (citing Diaz v. 

Secretary of Health and Human Services, 898 F.2d 774, 778 (10th Cir. 1990)). 

 The ALJ did not err by failing to order a psychiatric consultative examination. 

Treatment notes from Arlo Brakel, M.D., a board certified neurosurgeon, from May 

2010, demonstrated normal speech, normal memory, normal attention and concentration, 

intact cognition, the absence of evidence of disordered thought processes, the absence of 

naming or repetition difficulty, and, importantly, in light of possible non-physiologic 

vision loss, the absence of evidence of abnormal thought content, such as delusions or 

hallucinations, and no clinical features of depression. Tr. 245, 249. Plaintiff denied 

having anxiety, depression, or thought disorders. Tr. 248. Dr. Laguillo’s treatment notes, 

described above, demonstrate that Plaintiff reported psychological symptoms once, in 

December 2009, of depression, anxiety and sleep disturbance, (Tr. 225) but that these 

symptoms were successfully treated by medication, with no reports by Plaintiff to his 

treating physician of continuing symptoms arising from his depression. Tr. 204-221. 

Notably, on several occasions in the disability application process Plaintiff denied he was 

disabled due to any mental condition, and was no longer being treated for or taking 

medications for a mental condition. See Tr. 162, 164-65, 182-183, 185, 192, 195. 

Moreover, while Dr. Gross may have suspected an emotional disturbance as the cause of 

Plaintiff’s vision loss, the only evidence in the record that suggests any symptomatic or 

limiting features of the emotional disturbance, the vision loss, was already taken into 

account in Dr. Gross’s report. There is nothing else in the record, outside of Plaintiff’s 

successful treatment for depression, to suggest that Plaintiff suffered from an emotional 

disturbance, or any other symptoms or limitations that could be attributed to an emotional 

disturbance. Accordingly, there was sufficient evidence in the record from which to 

conclude that Plaintiff’s psychological symptoms were non-severe, or to the extent they 

affected his vision, were taken into account by Dr. Gross, and the ALJ did not err by 

failing to order a psychiatric consultative examination or include limitations due to any 

psychiatric condition in Plaintiff’s RFC. See Tr. 12, ¶3. See McLeod v. Astrue, 640 F.3d 

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881, 884 (9th Cir.2011) (ALJ had no duty to further develop the record when there was 

“nothing unclear or ambiguous” about what the treating physicians said). 

2. The ALJ Erred by Failing to Acknowledge “Other Source” 

Evidence. 

 Plaintiff argues that failure to acknowledge or provide an explanation for rejecting 

the report form Plaintiff’s physical therapist constituted error by the ALJ. (Doc. 21, at 

18.) 

 On May 6, 2010, at Dr. Laguillo’s request, (Tr. 234) Plaintiff was evaluated by Dr. 

Brakel for “[a]bnormal cervical MRI.” Tr. 235. The Plaintiff presented with “[n]eck pain 

with headache and arm pain.” Tr. 235. After review of Plaintiff’s MRI and a physical 

examination of Plaintiff, Dr. Brakel noted his impression as including cervical syndrome 

with MRI features of disc bulge and stenosis of cervical 3-4, and cervical pain syndrome 

with clinical features of right C7 radiculitis and question of ligamentous instability. Tr. 

237. 

 At Plaintiff’s follow up appointment to review cervical spine films, Dr. Brakel 

found Plaintiff’s physical exam and diagnostic impression to be essentially identical to 

that of his first exam, with one exception, that there was no supportive evidence for 

ligamentous instability on plain spine films, and opined: 

At his initial evaluation, we reviewed diagnostic studies and the most 

congruent with his complaints was that of a cervical MRI done on 

4/8/2010. This notes a congenital fusion at C2-3 and the first mobile 

segment below this (i.e., (sic) segment C3-4) has bulge. Degenerative 

changes with disc bulging are noted at C5-6 and C8-7. 

Tr. 231. Dr. Brakel reported that he did not identify a neurosurgical disorder, and 

recommended conservative treatment, specifically physical therapy with cervical traction. 

Tr. 230, 234. 

 On August 18, 2010, Dr. Brakel signed the Physician’s Medical Assessment & 

Treatment Plan Certification and Outpatient Physical Therapy Order, certifying that he 

had “examined the patient and therapy is necessary on an outpatient basis, that services 

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will be furnished while the patient is under my care, and that the plan is established and 

will be reviewed every 30 days or more often if patient’s condition requires.” Tr. 256. On 

October 1, 2010, after fourteen physical therapy visits, Plaintiff’s therapist completed an 

assessment that stated that Plaintiff had made progress towards his goal of sitting for 15 

minutes without limitation, but that he did not meet his goals of standing and walking for 

15 minutes without limitation. Tr. 255 Dr. Brakel signed a second assessment and order 

on October 3, 2010, with the same certification as his previous order. Tr. 260. 

 The Court agrees with the Commissioner’s contention that Plaintiff’s physical 

therapist is not an acceptable medical source, as provided in 20 C.F.R. § 404.1513. (Doc. 

22, at 17.) Additionally, there is no indication that the physical therapist worked under a 

physician’s close supervision, thus the therapist’s opinion is not entitled to the same 

deference as a treating source. Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012) 

(“other sources” not entitled to the same deference as acceptable medical sources). Thus, 

to the extent Plaintiff is arguing that the physical therapist is a treating source and that 

this opinion should be adopted as such, the Court rejects this argument. 

 Medical diagnoses are beyond the competence of lay witnesses and do not 

constitute competent evidence, see Nguyen v. Chater, 100 F.3d 1462, 1467 (9th Cir. 

1996), the ALJ, however, is required to “consider observations by non-medical sources as 

to how an impairment affects a claimant's ability to work.” Sprague v. Bowen, 812 F.2d 

1226, 1232 (9th Cir. 1987). The ALJ may discount such testimony from “other sources” 

only if the ALJ “‘gives reasons germane to each witness for doing so.’” See Turner v. 

Comm’r of Soc. Sec., 613 F.3d 1217, 1224 (9th Cir. 2010) (quoting Lewis v. Apfel, 236 

F.3d 503, 511 (9th Cir. 2001)). Here, the ALJ erred by failing to address the physical 

therapists opinion in its entirety. 

 While the Commissioner argues that there is no rigid requirement that the ALJ 

specifically refer to every piece of evidence in his decision, (Doc 22, at 17) citing Dyer v. 

Barnhart, 395 F.3d 1206, 1211 (11th Cir. 2005), when determining a claimant’s RFC, the 

“ALJ must consider all relevant evidence in the record including, inter alia, medical 

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records, lay evidence, and ‘the effects of symptoms, including pain, that are reasonably 

attributed to a medically determinable impairment.’” Robbins, 466 F.3d at 883 (quoting 

SSR 96-8p). An ALJ should consider evidence from nurses and other medical 

professionals because such evidence may provide information regarding the severity of a 

claimant's impairment. 20 C.F.R. § § 404.1513(d); SSR 06–03p. Social Security Ruling 

06–03p confirms that “the factors in 20 CFR 404.1527(d)” for the evaluation of medical 

opinions from “acceptable medical sources” can be applied to opinion evidence from 

‘other sources,’.” See SSR 06–03p. Such factors include how long the source has known 

and how frequently the source has seen the individual, how consistent the opinion is with 

other evidence, the degree to which the source presents relevant evidence to support the 

opinion, how well the source explains the opinion, whether the source has a specialty or 

areas of expertise related to the individual’s impairment(s), and any other factors that 

tend to support or refute the opinion. Id. The ALJ may discount testimony from “other 

sources” if the ALJ “’gives reasons germane to each witness for doing so.” Molina, 674 

F.3d at 1111 (citations omitted). Here, the ALJ erred by failing to address the records 

from the physical therapist or to provide reasons why he disregarded the physical therapy 

assessment.1

3. The ALJ’s Credibility Analysis as to Plaintiff’s Pain Testimony is 

Not Supported by Substantial Evidence 

 The ALJ determined that Plaintiff’s testimony regarding limitations in his ability 

to walk and sit, his hearing loss in the right ear, his allegations of right eye blindness, and 

his complaints of severe back and neck pain with radicular symptoms, were not supported 

by the objective evidence: “Having fully considered the medical evidence in the case, the 

record supports the allegation that the claimant would have some ongoing functional 

limitations, however, they are less than totally disabling in severity, and substantially less 

 

1

 Though Plaintiff did not argue that the ALJ erred by not addressing the objective findings of Plaintiff’s neurologist, Dr. Brakel, (aside from the MRI that Dr. Brakel 

considered), the Court notes that the ALJ failed to address Dr. Brakel’s objective findings, and, on remand, the ALJ should consider the objective findings in Dr. Brakel’s 

treatment notes. 

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severe than the claimant’s testimony would suggest.” Tr. 15. Plaintiff contends that the 

ALJ erred by relying solely on objective evidence to dismiss Plaintiff’s credibility. (Doc. 

21, at 20) citing Bunnell v. Sullivan, 947 F.3d 341, 345 (9th Cir. 1991). (Once the 

claimant has produced medical evidence of an underlying impairment which is 

reasonably likely to be the cause of the alleged pain, medical findings are not required to 

support the alleged severity of pain). The Commissioner asserts that, while an ALJ may 

not reject a claimant’s subjective complaints based solely on the lack of objective 

medical evidence to fully corroborate the alleged severity of pain, the lack of objective 

medical evidence supporting the claimant’s claims may support the ALJ’s finding that the 

claimant is not credible. (Doc. 22, at 20) citing Rollins v. Massanari, 261 F.3d 853, 856-

57 (9th Cir. 2001); Fair v. Bowen, 855 F.2d 597, 602 (9th Cir. 1989); and Batson v. 

Comm’r of the Soc.Sec. Admin., 359 F.3d 1190, 1197 (9th Cir. 2003). 

 When assessing a claimant’s credibility, the “ALJ is not required to believe every 

allegation of disabling pain or other non-exertional impairment.” Orn v. Astrue, 495 F.3d 

625, 635 (9th Cir. 2007) (internal quotation marks and citation omitted). Where, as here, 

the claimant has produced objective medical evidence of an underlying impairment that 

could reasonably give rise to the symptoms and there is no affirmative finding of 

malingering by the ALJ, the ALJ’s reasons for rejecting the claimant’s symptom 

testimony must be specific, clear and convincing. Garrison, --- F.3d at ---, 2014 WL 

3397218 at *16; Tommasetti v. Astrue, 533 F.3d 1035, 1039 (9th Cir. 2008); Orn, 495 

F.3d at 635; Robbins, 466 F.3d at 883. “The ALJ must state specifically which symptom 

testimony is not credible and what facts in the record lead to that conclusion.” Smolen v. 

Chater, 80 F.3d 1273, 1284 (9th Cir. 1996); see also Orn, 495 F.3d at 635 (the ALJ must 

provide specific and cogent reasons for the disbelief and cite the reasons why the 

testimony is unpersuasive). In assessing the claimant’s credibility, the ALJ may consider 

ordinary techniques of credibility evaluation, such as the claimant’s reputation for lying, 

prior inconsistent statements about the symptoms, and other testimony from the claimant 

that appears less than candid; unexplained or inadequately explained failure to seek or 

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follow a prescribed course of treatment; the claimant’s daily activities; the claimant’s 

work record; observations of treating and examining physicians and other third parties; 

precipitating and aggravating factors; and functional restrictions caused by the 

symptoms. Lingenfelter, 504 F.3d at 1040; Smolen, 80 F.3d at 1284. See also Robbins,

466 F.3d at 884 (“To find the claimant not credible, the ALJ must rely either on reasons 

unrelated to the subjective testimony (e.g., reputation for dishonesty), on conflicts 

between his testimony and his own conduct, or on internal contradictions in that 

testimony.”) 

 The ALJ stated with the required specificity what symptom testimony he found 

not credible and what facts in the record led to that conclusion. See Tr. 15. Regarding his 

ability to walk and sit, the ALJ noted that the objective evidence did not support 

Plaintiff’s allegations, and, in addition, noted that Plaintiff’s testimony was inconsistent2

with Plaintiff’s report to Dr. Callahan on July 12, 2011, that he denies any difficulty 

walking. Thus, as to Plaintiff’s testimony regarding his ability to walk and sit, the ALJ 

did not err by relying solely on the objective evidence to dismiss Plaintiff’s credibility. 

 While The Commissioner notes that there are other inconsistencies in the record 

that support the ALJ’s findings regarding his vision and hearing loss, as well as 

suggestions of malingering (See Tr. 176-77, 301, 304, 327) the ALJ failed to note these 

inconsistencies in his opinion. This Court's review is limited to the “reasons 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 Soc. Sec. Admin., 554 F.3d 1219, 

1225–26 (9th Cir.2009). Accordingly, the Court limits its analysis to the rationale and 

facts upon which the ALJ relied in determining that Plaintiff was not disabled. See

Garrison, --- F.3d ---, 2014 WL 3397218 at *11 (citing Connett, 340 F.3d at 874. 

 The ALJ may not discredit Plaintiff’s allegations of pain solely on the ground that 

the allegations are unsupported by objective medical evidence. See Bunnell, 947 F.2d at 

 

2

 Although the ALJ includes this reference in his discussion of the objective medical evidence refuting Plaintiff’s claim, it is actually a report of Plaintiff’s subjective complaints which this Court considers as inconsistent with Plaintiff’s testimony. 

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347-48. In this case, the ALJ identified contradictions between Plaintiff’s testimony of 

total hearing loss in his right ear and right eye blindness with objective medical evidence 

from testing done in the months before the hearing that he had normal bilateral visual 

acuity with correction and that his hearing threshold in the affected ear remained fair to 

good. Tr. 15. Accordingly, the Court finds that the ALJ rejected Plaintiff’s testimony not 

solely on a lack of corroborating medical evidence, but based on a finding that the 

clinical evidence contradicted Plaintiff’s testimony. See Carmickle v. Comm’r Social Sec. 

Admin., 533 F.3d 1155, 1161 (9th Cir. 2008) (citing Johnson v. Shalala, 60 F.3d 1428, 

1434 (9th Cir. 1995)). 

 Moreover, testimony of the extent to which Plaintiff can see or hear is 

fundamentally different from pain or other symptom testimony which cannot be 

corroborated by medical evidence, and the rationale for declining to require objective 

medical evidence to corroborate the severity of pain should not apply to a limitation that 

can be scientifically corroborated. Cf. Bunnell, 947 F.2d at 347-48 (declining to conclude 

that Congress intended to require objective medical evidence to fully corroborate the 

severity of pain while aware of the inability of medical science to provide such evidence). 

The rationale for this restriction is that pain testimony may establish greater limitations 

than can medical evidence alone. Burch v Barnhart, 400 F.3d 676, 680 (9th Cir 

2005)(citing SSR 96-7p (1996)). In this case, unlike attempting to ascertain the subjective 

sense of pain, Plaintiff’s ability to hear and see can be established to a certain degree of 

scientific accuracy.3

 

 The Court notes, however, that the ALJ mischaracterized, in part, Plaintiff’s 

testimony that he had total hearing loss. Although Plaintiff initially stated he “lost [his] 

right ear,” when asked if it was a complete loss he clarified that he could actually see the 

ALJ, but needed to position himself in a different location in order to do so. Tr. 47. When 

 

3

 This is not to say that Plaintiff’s limitations as they affect his ability to perform activities of daily living or to work can be objectively assessed. However, in this case, 

there is no evidence that Plaintiff alleged difficulty in performing specific tasks due to vision or hearing loss. 

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asked if he “totally” lost his hearing in his right ear, Plaintiff stated “Yeah. I mean what I 

hear is, when you’re talking to me I have this one turning like this because I just hear, 

like a thumping in my right ear.” Tr. 49. Because the ALJ focused on Plaintiff’s initial 

claims of complete right side hearing and vision loss, the ALJ did not inquire into how 

Plaintiff’s hearing loss and diminishment in his vision affected his ability to work. In fact, 

Plaintiff stated, twice during his testimony, that it was his inability to sit for long periods 

that rendered him unable to work. Tr. 54, 59. 

 Finally, the ALJ rejected Plaintiff’s complaints of severe back and neck pain with 

radicular symptoms because the evidence did not corroborate the Plaintiff’s subjective 

symptoms. The Commissioner does not address this finding in his response, and the 

Court finds that the ALJ erred by relying solely on a lack of objective medical evidence 

to support his credibility finding as to Plaintiff’s complaints of pain. See Burch, 400 F.3d 

at 681 (“lack of medical evidence” can be “a factor” in rejecting credibility, but cannot 

“form the sole basis”). 

B. The ALJ Did Not Err in Determining that Plaintiff’s Impairment Does 

Not Meet or Equal a Listed Impairment 

 In the third step of the five-step analysis, the ALJ must determine whether a 

claimant’s impairment meets or equals an impairment in the Listing of Impairments, 

found at 20 C.F.R. Part 404, Subpt. P, App. 1. See 20 C.F.R. § 1520(a)(4)(iii) and (d). 

Plaintiff contends that the ALJ’s determination that the Plaintiff’s spinal condition does 

not meet or medically equal the requirements of the Listings, § 1.04(A), regarding 

disorders of the spine is not supported by substantial evidence. (Doc. 21 at 12-15.) 

 The Listings describe specific impairments of each of the major body systems 

which are considered “severe enough to prevent a person from doing any gainful activity, 

regardless of his or her age, education, or work experience” and designate “the objective 

medical and other findings needed to satisfy the criteria of that listing.” See 20 C.F.R. §§ 

404.1525(a) and (c)(3). A claimant with an impairment which (1) meets or equals an 

impairment listed in Appendix I and (2) meets the duration requirement is awarded 

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benefits at step three without further inquiry. See 20 C.F.R. § 404.1520(d). A mere 

diagnosis is insufficient to meet or equal a listed impairment; a claimant must establish 

that he or she “satisfies all of the criteria of that listing, including any relevant criteria in 

the introduction.” See 20 C.F.R. §§ 404.1525(c)(3) and (d). To equal a listed impairment, 

a claimant must establish symptoms, signs, and laboratory findings “at least equal in 

severity and duration” to the characteristics of a relevant listed impairment. See generally 

20 C.F.R. § 404.1526 (explaining medical equivalence). A generalized assertion of 

functional problems is not enough to establish disability at step three. Tackett v. Apfel, 

180 F.3d 1094, 1100 (9th Cir. 1999) (citing 20 C.F.R. § 404.1526.) 

 Section 1.04(A) requires a claimant to show disorders of the spine, such as 

herniated nucleus pulposus, spinal arachnoiditis, spinal stenosis, osteoarthritis, 

degenerative disc disease, facet arthritis, or vertebral fracture, resulting in compromise of 

a nerve root or the spinal cord with evidence of nerve root compression characterized by 

neuro-anatomic distribution of pain, limitation of motion of the spine, motor loss (atrophy 

with associated muscle weakness or muscle weakness) accompanied by sensory or reflex 

loss and, if there is involvement of the lower back, positive straight-leg raising test 

(sitting and supine). See 20 C.F.R. pt. 404, subpt. P, app. 1, § 1.04 (A) (2013). 

 The ALJ determined that the objective evidence did not establish compromise of a 

nerve root or the spinal cord with additional findings of nerve root compression or spinal 

arachnoiditis or lumbar spinal stenosis. Tr. at 13. Plaintiff submits that Plaintiff has a 

qualifying disorder of the spine, a congenital vertebral fusion at C2 and C3 with 

cervicalgia (painful sensation in the neck area) and cephalgias (headache) and 

degenerative changes at the adjacent segments including disc disease (bulge) resulting in 

a compromise of the nerve root (i.e. stenosis at C3-C4, per and /or radiculitis at C7). 

 Even if Plaintiff’s contentions are accurate, Plaintiff has not established that he 

“satisfies all of the criteria of that listing, including any relevant criteria in the 

introduction.” See 20 C.F.R. § 404.1525(c)(3). Functional loss caused by a 

musculoskeletal system disorder is defined as the inability to ambulate effectively on a 

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sustained basis for any reason, including pain associated with the underlying 

musculoskeletal impairment, or the inability to perform fine and gross movements 

effectively on a sustained basis for any reason, including pain associated with the 

underlying musculoskeletal impairment.” See the Listing of Impairments § 1.00(B)(2)(a). 

 The inability to ambulate effectively means “an extreme limitation of the ability to 

walk; i.e., an impairment(s) that interferes very seriously with the individual's ability to 

independently initiate, sustain, or complete activities.” See id. § 1.00(B)(2)(b)(1). 

Ineffective ambulation is defined generally as having insufficient lower extremity 

functioning to permit independent ambulation without the use of a hand-held device that 

limits the function of both upper extremities. See id. “To ambulate effectively, 

individuals must be capable of sustaining a reasonable walking pace over a sufficient 

distance to be able to carry out activities of daily living. They must have the ability to 

travel without companion assistance to and from a place of employment or school. 

Therefore, examples of ineffective ambulation include, but are not limited to, the inability 

to walk without the use of a walker, two crutches or two canes, the inability to walk a 

block at a reasonable pace on rough or uneven surfaces, the inability to use standard 

public transportation, the inability to carry out routine ambulatory activities, such as 

shopping and banking, and the inability to climb a few steps at a reasonable pace with the 

use of a single hand rail. The ability to walk independently about one's home without the 

use of assistive devices does not, in and of itself, constitute effective ambulation.” See id.

§ 1.00(B)(2)(b)(2). 

 The inability to perform fine and gross movements effectively means “an extreme 

loss of function of both upper extremities; i.e., an impairment(s) that interferes very 

seriously with the individual's ability to independently initiate, sustain, or complete 

activities.” See id. § 1.00(B)(2)(c). “To use their upper extremities effectively, individuals 

must be capable of sustaining such functions as reaching, pushing, pulling, grasping, and 

fingering to be able to carry out activities of daily living. Therefore, examples of inability 

to perform fine and gross movements effectively include, but are not limited to, the 

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inability to prepare a simple meal and feed oneself, the inability to take care of personal 

hygiene, the inability to sort and handle papers or files, and the inability to place files in a 

file cabinet at or above waist level.” See id. 

 As the Commissioner correctly points out, objective medical evidence does not 

demonstrate the required degree of limitation in the ability to walk or use the upper 

extremities to constitute a functional loss equal to or equivalent in severity to meet the 

requirements of the Listing of Impairments. Examinations consistently revealed normal 

lower extremity muscle strength, a normal gait, and normal balance (Doc. 22, at 11, 

citing Tr. 208, 211, 216, 222, 227, 233, 327). Similarly, objective medical evidence did 

not demonstrate the required degree of limitation of function of both upper extremities to 

constitute ineffective performance of fine and gross movements. In fact, examinations 

consistently revealed normal upper extremity muscle strength and the absence of upper 

extremity muscle weakness (Id. citing Tr. 233, 237, 327). Plaintiff has not sustained his 

burden of showing how his symptoms, signs, and laboratory findings were equivalent in 

severity to the required extreme functional limitations noted above. 

IV. Remedy 

 The Ninth Circuit has held that a court should remand to an ALJ with instructions 

to calculate and award benefits where three conditions are met: “(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.” Garrison, --- F.3d. ---, 2014 WL 3397218 at *20 (citations and footnote 

omitted). Even when all conditions of the credit-as-true rule are satisfied, a court should 

nonetheless remand for further proceedings when “an evaluation of the record as a whole 

creates serious doubt that a claimant is, in fact, disabled.” Id. A district court abuses its 

discretion, however, by remanding for further proceedings where the credit-as-true rule is 

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satisfied and the record affords no reason to believe that the claimant is not, in fact, 

disabled. Id. 

 After applying the credit-as-true rule to improperly discredited evidence, 

outstanding issues remain to be resolved before determining that Plaintiff is entitled to 

benefits. As discussed above, the ALJ failed to provide legally sufficient reasons for 

rejecting the physical therapist’s assessment and for finding portions of Plaintiff’s 

testimony as to pain not credible. There is, however, no testimony by the vocational 

expert that crediting these statements as true would preclude past work or any work.

 In cases where the testimony of a vocational expert has failed to address functional 

limitations as established by improperly discredited evidence, this Circuit “consistently 

[has] remanded for further proceedings rather than payment of benefits.” Harman v. 

Apfel, 211 F.3d 1172, 1180 (9th Cir. 2000) (citation omitted). Thus, a remand for further 

proceedings is appropriate in this case. 

 IT IS ORDERED: 

1. The Commissioner’s decision denying benefits is REVERSED. 

2. The case is REMANDED for further proceedings consistent with this order. 

3. The Clerk is directed to enter judgment accordingly. 

Dated this 19th day of September, 2014. 

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