Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_15-cv-00669/USCOURTS-casd-3_15-cv-00669-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:0405id Review of HHS Decision (SSID)

---

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

"I , 

f'lLED 

~r6jul28 PH '1;03 

UNITED STATES DISTRICT COURT 

SOUTHERN DISTRICT OF CALIFORNIA 

JERRY DEW A YNE LORD, 

Plaintiff, 

v. 

CAROLYN W. COLVIN, Acting 

Commissioner of Social Security, 

Defendant. 

Case No.: 15cv669-BEN(KSC) 

REPORT AND RECOMMENDATION RE CROSS-MOTIONS FOR 

SUMMARY JUDGMENT 

[Doc. Nos. 13 and 18] 

18 Pursuant to Title 42, United States Code, Section 405(g), ofthe Social Security Act 

19 ("SSA"), plaintiff filed a Complaint to obtain judicial review of a final decision by the 

20 Commissioner of Social Security ("Commissioner") denying him disability and 

21 supplemental security income benefits. [Doc. No.1.] Pursuant to Title 28, United States 

22 Code, Section 636(b)(1)(B), and Civil Local Rules 72. 1 (c)(I)(c) and n.2(a), this matter 

23 was assigned to the undersigned Magistrate Judge for a Report and Recommendation. 

24 Presently before the Court are: (1) plaintiffs Motion for Surmnary Judgment [Doc. 

25 No. 13]; (2) defendant's Cross-Motion for Summary Judgment [Doc. No. 18]; 

26 (3) plaintiffs Reply to defendant's Opposition [Doc. No. 20]; and (5) the Administrative 

27 Record [Doc. No. 12]. 

28 / / / 

lScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 1 of 31
1 Plaintiffs Motion for Summary Judgment challenges the final decision of the 

2 Commissioner denying his application for disability and supplemental security income 

3 benefits, because the Administrative Law Judge ("ALl") allegedly failed to properly 

4 evaluate the testimony of the medical expert who testified at his hearing. As a result, 

5 plaintiff contends that the ALJ erroneously concluded he retains the capacity to perform 

6 his past relevant work as a license or administrative clerk. [Doc. No. 13-1, at p. 2.] In 

7 addition, plaintiff challenges the ALl's alternative finding that he could return to his past 

8 relevant work as a sedentary, skilled real estate clerk. According to plaintiff, the 

9 testifying vocational expert mischaracterized his work as a real estate clerk, so the ALl's 

10 alternative conclusion is incorrect. [Doc. No. 13-1, at pp. 5-11.] 

11 Defendant contends that the ALJ properly assessed plaintiff s residual functional 

12 capacity. In addition, defendant argues that the Court should affirm the ALl's decision to 

13 deny benefits, because the ALl's residual functional capacity assessment is supported by 

14 substantial evidence. [Doc. No. 18, at p. 3.] After careful consideration ofthe moving 

15 and opposing papers, as well as the Administrative Record and the applicable law, this 

16 Court RECOMMENDS that the District Court DENY plaintiff s Motion for Summary 

17 Judgment [Doc. No. 13] and GRANT defendant's Cross-Motion for Summary Judgment 

18 [Doc. No. 18]. 

19 1. Background and Procedural History. 

20 On May 3, 2011, plaintiff submitted an application for disability insurance benefits 

21 indicating he became unable to work as of March 30,2006. [Doc. No. 12-5, at p. 2; Doc. 

22 No. 12-5, at p. 5.] On September 20,2011, plaintiff was notified that his application had 

23 been reviewed but he did not qualify for disability benefits because his health problems 

24 were not severe enough to prevent him from working. [Doc. No. 12-4, at pp. 2-6.] 

25 Plaintiff requested reconsideration of this decision on October 6, 2011. [Doc. No. 12-4, 

26 at pp. 7-12.] After reconsideration, the decision to deny benefits was affirmed on 

27 February 10,2012. [Doc. No. 12-4, at pp. 8-12.] On March 16, 2012, plaintiff submitted 

28 additional evidence in support of his claim for benefits and requested a hearing before an 

2 

lScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 2 of 31
1 ALl [Doc. No. 12-4, at pp. 15-16.] A hearing was held on April 16, 2013. [Doc. No. 

2 12-4, at pp. 50-54.] 

3 On May 2, 2012, about one year after he submitted his application for disability 

4 insurance benefits, plaintiff submitted an application for supplemental security income 

5 benefits and stated his disability began on January 1,2009. [Doc. No. 12-5, at p. 9.] 

6 On May 14,2013, the ALJ concluded that plaintiff was not disabled within the 

7 meaning of the SSA and did not qualify for disability insurance benefits. The ALJ also 

8 concluded plaintiff did not qualify for supplemental security income benefits. [Doc. No. 

9 12-2, at pp. 33-48.] 

10 Plaintiff requested review of the ALJ's decision by the Appeals Council. [Doc. 

11 No. 12-2, at pp. 8-9; 15-24.] On January 30, 2015, the Appeals Council denied review of 

12 the ALJ's May 14,2013 decision. As a result, the ALJ's decision became the final 

13 decision of the Commissioner. [Doc. No. 12-2, at pp. 1-6.] The Complaint in this action 

14 was then filed on March 25, 2015. [Doc. No. 1.] 

15 II. Standards of Review. 

16 Pursuant to Federal Rule of Civil Procedure 56(a), "[t]he court shall grant summary 

17 judgment ifthe movant shows that there is no genuine dispute as to any material fact and 

18 the movant is entitled to judgment as a matter oflaw." Fed.R.Civ.P.56(a). "Summary 

19 judgment motions, as defined by Fed.R.Civ.P. 56, contemplate the use of evidentiary 

20 material in the form of affidavits, depositions, answers to interrogatories, and admissions. 

21 In Social Security appeals, however, the Court may 'look no further than the pleadings 

22 and the transcript of the record before the agency,' and may not admit additional 

23 evidence. Morton v. Califano, 481 F.Supp. 908, 914 n. 2 (E.D.Tenn.1978); 42 U.S.C. 

24 § 405(g). "[A]lthough summary judgment motions are customarily used [in social 

25 security cases], and even requested by the Court, such motions merely serve as vehicles 

26 for briefing the parties' positions, and are not a prerequisite to the Court's reaching a 

27 decision on the merits." Kenney v. Heckler, 577 F.Supp. 214, 216 (D.C. Ohio 1983). 

28 / / / 

3 

JScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 3 of 31
1 Title 42, United States Code, Section 405(g), provides as follows: "Any individual, 

2 after any final decision of the Commissioner of Social Security made after a hearing to 

3 which he was a party ... may obtain a review of such decision by a civil action ... 

4 brought in the district court of the United States .... The court shall have power to enter, 

5 upon the pleadings and transcript of the record, a judgment affirming, modifYing or 

6 reversing the decision ofthe Commissioner of Social Security, with or without 

7 remanding the cause for a rehearing. The findings of the Commissioner ... as to any fact, 

8 if supported by substantial evidence, shall be conclusive." 42 U.S.C. § 405(g). 

9 III. Evidence in the Administrative Record. 

10 A. Education. Work History. and Medical Information Included in Plaintiff's 

11 Application and Related Forms. 

12 Plaintiffs application states that he was born on July 9, 1957. [Doc. No. 12-6, at 

13 p.2.] Therefore, at the time of the hearing before the ALJ on April16, 2013, plaintiff 

14 was 55 years old. Plaintiff received his GED (i.e., a high school equivalency certificate) 

15 in May 1984 and also received training in basic office skills. [Doc. No. 12-6, at pp. 6, 9.] 

16 Shortly after submitting his application, plaintiff included the following 

17 information on a detailed Work History form dated May 23, 2011. [Doc. No. 12-6, at pp. 

18 38-45.] As reflected therein, most recently, from November 2009 through April of201O, 

19 plaintiff worked as a clerk in a grocery store bagging groceries, greeting customers, and 

20 retrieving shopping carts from the parking lot. [Doc. No. 12-6, at pp. 38-39.] From May 

21 2001 through March 2006, plaintiff worked as an office clerk in a real estate office doing 

22 data entry, copying, mailing, and delivering paperwork to his supervisors. [Doc. No. 12-

23 6, at pp. 38, 40.] From November 1996 through March 1999, plaintiff worked for the 

24 California Department ofFish and Game. His duties included data entry, filing licenses, 

25 copying, and helping with packaging in themailroom.This job also involved lifting and 

26 carrying file boxes. [Doc. No. 12-6, at pp. 38,41.] 

27 On May 23, 2011, plaintiff completed a Function Report form stating that he was 

28 "very tired" as a result of a heart attack. Plaintiff also stated he has difficulty handling 

4 

lScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 4 of 31
1 stress; high blood pressure; a herniated disk in his lower back; trouble hearing in one ear; 

2 serious headaches; depression; and anxiety_ His daily activities included walking service 

3 dogs; doing "small chores" around his apartment, such as laundry and emptying the trash; 

4 watching television; browsing the internet; chatting with friends on the computer; and 

5 making simple meals. He cannot do heavy lifting and cannot sleep very long when his 

6 back hurts. Once a month, plaintiff shops for groceries. He does not drive because his 

7 license is suspended but he uses public transportation and goes shopping and to medical 

8 appointments with friends. Plaintiff also represented that he did not have a problem 

9 paying attention or following written instructions. However, he did report having trouble 

10 completing tasks and concentrating because of headaches. Plaintiff reported that his 

11 medical problems limited his ability to lift, bend, stand, walk, and climb stairs. He must 

12 rest for about ten minutes after walking two or three blocks. [Doc. No. 12-6, at pp. 21-

l3 28.] 

14 Plaintiffs friend and housemate, Stephen Hernandez, also completed a Function 

15 Report on May 23, 2011. The responses by Mr. Hernandez are similar to responses on 

16 the above-referenced Function Report completed by plaintiff. However, Mr. Hernandez 

17 stated that the only household chore plaintiff is able to do is "dust" and it can take him 

18 over two hours because he needs to rest. Because of his back problems, Mr. Hernandez 

19 reported that plaintiff has trouble pushing a vacuum cleaner or standing for a long period 

20 of time. Mr. Hernandez also said plaintiff can be very irritable when he is in pain. [Doc. 

21 No. 12-6, at pp. 30-37.] 

22 On May 25, 2011, when contacted by an SSA agent, plaintiff stated he had not 

23 seen a physician since 2005 because of "financial embarrassment" and "lack of 

24 insurance." [Doc. No. 12-6, at p. 46.] However, in a Disability Report submitted on 

25 March 15,2012, plaintiff stated he was having ongoing appointments with Dr. David 

26 White for severe low back pain. [Doc. No. 12-6, at p. 69.] 

27 On May 2, 2012, about one year after he submitted his application for disability 

28 insurance benefits, plaintiff submitted an application for supplemental security income 

S 

lScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 5 of 31
1 and stated his disability began on January 1, 2009. [Doc. No. 12-5, at p. 9.] In the 

2 application, plaintiff represented that his only income was $200 in food stamps. He was 

3 living with two non-relatives who paid the rent and other living expenses. At this time, 

4 plaintiff also stated that he did not need help with personal care, hygiene, or upkeep of 

5 the home. [Doc. No. 12-5, at pp. 10-12.] 

6 In a Disability Report dated October 16, 2012, plaintiff reported that his medical 

7 condition had worsened. At this time, plaintiff said he was taking medications for his 

8 heart, high blood pressure, pain and headaches, and that the Vicodin he was taking for 

9 pain and headaches was making him tired. [Doc. No. 12-6, at pp. 87-94.] 

10 B. Chronological Summary of Medica I Records. 

11 On March 18,2006, plaintiff had a cervical spine x-ray. The x-ray showed he had 

12 "moderately advanced degenerative change mid-to-lower cervical spine" and "[a]dvanced 

13 disk space narrowing C4 through C7 with associated osteophytes and probable foraminal 

14 narrowingC5-6andC6-7." [Doc. No. 12-7,atp. 123.] 

15 Plaintiff went to the hospital on March 30,2006 with chest pain and was admitted 

16 for "presumed acute coronary ischemia" or reduced blood flow to the coronary arteries. 

17 [Doc. No. 12-7, at pp. 13, 18-19.] Diagnostic cardiac catheterization was performed and 

18 revealed "evidence of "triple vessel disease." [Doc. No. 12-7, atpp. 9,11-12.] 

19 Myocardial revascularization or bypass surgery was recommended. [Doc. No. 12-7, at p. 

20 9.] The surgery was performed on April 1, 2006. A Discharge Summary states that 

21 plaintiff "received coronary artery bypass graft x4." [Doc. No. 12-7, at p. 2.] Plaintiff 

22 was released from the hospital on April 5, 2006. [Doc. No. 12-7, at pp. 2-7.] 

23 A post-surgical cardiology examination was completed on April 27, 2006. 

24 Plaintiff had a treadmill test and the results were "negative for any evidence of ischemia 

25 or arrhythmias." [Doc. No. 12-7, at p. 72.] Additional follow-up notes from 2006 

26 indicate plaintiff "had no complications recovering from his surgery." [Doc. No. 12-2, at 

27 p. 42; Doc. No. 12-7, at pp. 55-59,64-65.] However, he did complain of neck and back 

28 pain and was referred to physical therapy. [Doc. No. 12-7, at pp. 70-71.] 

6 

JScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 6 of 31
1 As noted above, plaintiff filed his application for disability insurance benefits on 

2 May 3, 2011. At the request of the Department of Social Services, Disability Evaluation 

3 Department, plaintiff was examined by Dr. Noli A. Cava, an internist, on August 13, 

4 2011. [Doc. No. 12-7, at pp. 86-88.] Plaintiff told Dr. Cava he could not work because 

5 of a herniated or "worn disc in his lower back" that causes low back pain with occasional 

6 radiation down to his left calf. Although he said he was offered surgery, plaintiff said he 

7 refused and elected to manage the problem with physical therapy and medication. In 

8 addition, plaintiff reported to Dr. Cava that he had bypass surgery and still gets 

9 intermittent shortness of breath, has a history of high blood pressure that is controlled 

10 with medication, anxiety, depression, deafness in his right ear since birth, headaches, and 

11 fatigue. [Doc. No. 12-7, at p. 86.] 

12 In his evaluation, Dr. Cava noted that plaintiff could still walk several blocks 

13 before he needed to rest, had a normal range of motion, and did not have any problems 

14 with squatting, kneeling, or crouching. [Doc. No. 12-7, at pp. 86-88.] Based on his 

15 examination, Dr. Cava concluded that plaintiff could stand, walk, and sit for six hours in 

16 an eight-hour day; lift and carry 25 pounds frequently and 50 pounds occasionally; and 

17 had no limitations for stooping, crouching, reaching, and handling. Dr. Cava confirmed 

18 that plaintiff is deaf in his right ear but had no visual limitations. [Doc. No. 12-7, at p. 

19 88.] 

20 On June 24,2011, plaintiff had an initial visit with Lindsey C. Yung, a nurse 

21 practitioner ["NP Yung"] at Linda Vista San Diego Family Care. l [Doc. No. 12-7, at pp. 

22 144, 130.] He was seeking a refill for his blood pressure medication and said he had last 

23 seen a cardiologist in 2007. He also said he had shortness of breath and "very mild" 

24 

25 

26 

27 

28 

SSA regulations list "nurse practitioners" as examples of a number of "acceptable 

medical sources." 20 CFR 404.1513( d)(l). The ALJ must evaluate each medical opinion 

received "[r]egardless of its source." 20 CFR 404.1 527(c). The opinions oftreating and 

examining medical sources are afforded "more weight" than non-treating, non-examining 

sources. 20 CFR § 404.1 527(c)&(e). 

7 

l5cv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 7 of 31
1 chest pain that lasts less than a minute. In addition, he told NP Yung that his lower back 

2 pain was getting worse and the pain sometimes radiates down his left leg. He was taking 

3 over-the-counter pain medications. [Doc. No. 12-7, at pp. 144-145.] NP Yung 

4 prescribed medication to treat plaintiffs hypertension (Lisinopril and aspirin) and acid 

5 reflux (Prilosec). NP Yung also prescribed pain medication to treat plaintiffs low back 

6 pain (Tramadol) and a muscle relaxant to address muscle spasms (Cyclobenzaprine). 

7 [Doc. No. 12-7, at p. 145.] 

8 On July 19,2011, plaintiff had an appointment with NP Yung for "fasting labs." 

9 [Doc. No. 12-7, at p. 140.] Plaintiff told NP Yung that Tramadol was helping his lower 

10 back pain but he was still having shooting pains into his legs and some numbness and 

11 tingling. [Doc. No. 12-7, at p. 140.] NP Yung noted that an x-ray showed degeneration, 

12 osteophytes, and disc narrowing. Prescriptions for pain medications were continued and 

13 an MRI ofplaintiffs spine was requested. [Doc. No. 12-7, at pp. 142-143.] 

14 Plaintiff had a follow-up appointment with NP Yung on August 15,2011 about his 

15 "[l]ab results." [Doc. No. 12-7, at p. 137.] NP Yung's notes indicate plaintiff was being 

16 treated for hypertension, back pain, and elevated cholesterol. His heart rate was "mildly 

17 elevated" and his blood "platelet count" was "a little low." [Doc. No. 12-7, at pp. 137-

18 138.] For plaintiffs back pain, NP Yung discontinued plaintiffs prescriptions for 

19 Tramadol and Cyclobenzaprine and replaced it with Naprosyn. [Doc. No. 12-7, at p. 

20 139.] 

21 At the request ofthe Department of Social Services, Dr. Jaga Nath Glassman, a 

22 psychiatrist, interviewed plaintiff on August 24,2011 and prepared a written psychiatric 

23 evaluation. [Doc. No. 12-7, at pp. 91-94.] Based on the August 24,2011 interview, 

24 Dr. Glassman reported there were "no signs of depression or anxiety"; plaintiff 

25 "ambulated without apparent difficulties;" and plaintiff "sat throughout the examination 

26 without apparent discomfort." [Doc. No. 12-7, at p. 93.] Dr. Glassman concluded there 

27 was "no evidence of impairment on a psychiatric basis." [Doc. No. 12-7, at p. 94.] 

28 Plaintiffs mental status examination was "completely without abnormality." [Doc. No. 

8 

15cv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 8 of 31
1 12-7, at p. 93.] In addition, plaintiff told Dr. Glassman "he could work at ajob at a desk 

2 ifhe were able to move around and shift position." [Doc. No. 12-7, at p. 93.] 

3 A report by Dr. Lori L. Baker dated August 30, 2011 states than an MRI of the 

4 lumbar spine was completed based on plaintiffs complaints of chronic low back pain. 

5 [Doc. No. 12-7, at p. 121.] The report notes there is a "3 mm posterior osteophyte/disc 

6 complex at L5-S1 which mildly impinges upon the Sl nerve roots bilaterally." [Doc. No. 

7 12-7, at p. 121. In addition, the reports states that there are "[m]ild disc bulges at 

8 remaining levels ... with no associated nerve root impingement." [Doc. No. 12-7, at p. 

9 122.] 

10 Progress Notes from an appointment with NP Yung on October 14, 2011 state that 

11 plaintiff complained of back pain which is not relieved with Naprosyn, daily headaches, 

12 dizziness, memory loss, and numbness where the vein was taken from his leg for his 

13 heart surgery. He also said his left knee has been "giving out" and has caused "difficulty 

14 with gait for the last couple months." [Doc. No. 12-7, at p. 133.] NP Yung noted that 

15 plaintiff would be seen by neurology in December and that a "pain clinic referral is 

16 pending." [Doc. No. 12-7, at pp. 133-134.] An x-ray of plaintiffs left knee and a CT 

17 scan of plaintiffs head were ordered. NP Yung prescribed Vicodin for back pain and 

18 also continued a prescription for Naprosyn. [Doc. No. 12-7, at pp. 133-134.] 

19 A CT scan ofplaintiffs head was performed by Dr. Gregg Anderson on 

20 October 25,2011 based on plaintiffs complaints of headache and memory loss. [Doc. 

21 No. 12-7, at pp. 120,130.] However, there were "[n]o acute findings." [Doc. No. 12-7, 

22 at p. 120.] 

23 NP Yung's medical notes from an appointment on December 16,2011 state that an 

24 x-ray ofplaintiffs left knee was "completely normal," but he continued to complain of 

25 numbness in his lower leg that began after a vein was taken during his heart bypass 

26 surgery. [Doc. No. 12-7, at p. 130.] He complained of chronic headaches and had been 

27 referred to neurology but a CT scan ofthe head showed "no acute findings." [Doc. No. 

28 12-7, at p. 130.] To treat lower back pain, plaintiff had been taking Vicodin, but he said 

9 

lScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 9 of 31
1 he stopped taking it because "it made him feel in a daze." [Doc. No. 12-7, at p. 130.] 

2 According to plaintiff, he had previously consulted with a neurosurgeon about his back 

3 pain but was told that surgery would only cause more pain. [Doc. No. 12-7, at pp. 130-

4 131.] NP Yung requested a consultation with a neurosurgeon, because plaintiff wanted a 

5 second opinion. Plaintiff was referred to the pain clinic and physical therapy. His blood 

6 pressure medication and prescriptions for pain medications, Tramadol and Naprosyn, 

7 were continued, but NP Yung discontinued the prescription for Vicodin. [Doc. No. 12-7, 

8 atpp.130-131.] 

9 On December 23,2011, plaintiff returned to NP Yung for a "potassium recheck 

10 and EKG after potassium returned mildly elevated." [Doc. No. 12-7, at p. 125.] 

11 Although there were "[n]o acute findings," the Electrocardiogram or EKG was "non12 specifically abnormal." [Doc. No. 12-7, at p. 125.] Based on the abnormal findings and 

13 plaintiff s history of "quadruple bypass," it was recommended that plaintiff establish care 

14 with a specialist in cardiology, Dr. Tri Nguyen. [Doc. No. 12-7, at p. 125.] 

15 On January 25, 2012, a medical consultant, K. Vu, prepared a Physical Residual 

16 Functional Capacity Assessment form based on the evidence in plaintiffs file. [Doc. No. 

17 12-7, at pp. 172-176.] The form states that plaintiff is able to lift and carry 20 pounds 

18 occasionally and 10 pounds frequently; stand, walk, and sit with normal breaks for 6 

19 hours in an 8-hour workday; and climb, stoop, kneel, crouch and crawl occasionally. 

20 [Doc. No. 12-7, at pp. 172-176.] The only limitation included on the form is that plaintiff 

21 could not do work requiring acute hearing in his right ear. [Doc. No. 12-7, at p. 175.] 

22 The same medical consultant, K. Vu, also prepared a Case Analysis on January 25, 

23 2012. Based on the evidence in the file, the Case Analysis states that "fully disabling 

24 severity [was] not established by objective findings" and "[t[he severity ofthe 

25 impairments in the allegations [was] disproportionate to the objective findings." [Doc. 

26 No. 12-7, atpp. 177-178.] 

27 Plaintiff had another EKG in the offices of Dr. Tri T. Nguyen on January 27,2012. 

28 [Doc. No. 12-7, at pp. 184-187.] Dr. Nguyen also prepared a detailed report of his 

10 

JScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 10 of 31
1 evaluation of plaintiff in a letter dated March 31, 2012. [Doc. No. 12-7, at pp. 182-183.] 

2 Dr. Nguyen's examination ofplaintiffinc1uded the results of several tests: (1) The 

3 electrocardiogram (EKG) "showed normal sinus rhythm and no significant abnormality." 

4 [Doc. No. 12-7, at p. 183.] (2) An exercise treadmill test showed that plaintiff had 

5 "normal exercise tolerance." [Doc. No. 12-7, at p. 183.] During the treadmill test, 

6 plaintiff had no significant chest pain but did have pain in his right calf. (3) "A Holter 

7 recording showed occasional premature atrial contractions and premature ventricular 

8 contractions, otherwise unremarkable." [Doc. No. 12-7, at p. 183.] (4) A "Carotid 

9 Doppler study showed mild plaques only. No significant common carotid artery or 

10 internal carotid artery narrowing was present. The vertebral arterial flow was normal 

11 bilaterally." [Doc. No. 12-7, at p. 183.] Dr. Nguyen's report concluded that plaintiff was 

12 "doing well from a cardiac standpoint." [Doc. No. 12-7, at p. 183.] 

13 At an appointment with NP Yung on July 24,2012, plaintiff complained of chronic 

14 headaches, fatigue, and spasms in his calves. He said he could not walk very far without 

15 getting "very winded." [Doc. No. 12-7, at p. 222.] NP Yung prescribed an inhaler and 

16 ordered testing to determine if plaintiffs complaints offatigue were related to heart 

17 function. [Doc. No. 12-7, at p. 223.] 

18 On August 6, 2012, plaintiff met with a therapist for an "intake evaluation" and 

19 reported anxiety, panic attacks, low energy, restlessness, excessive worry, compulsive 

20 behaviors, depression, and sleep issues. A year before the appointment, plaintiff lost a 

21 partner of 25 years and had been living with another couple. He reported medical issues 

22 that made it difficult for him to work and said he must depend on friends for money and a 

23 place to live. Continued therapy was recommended. [Doc. No. 12-7, at pp. 219-220.] 

24 On October 26,2012, plaintiff had an appointment with NP Yung and reported he 

25 had been to see a neurosurgeon, who told him that his back pain was "secondary to old 

26 age and that his only option [was physical therapy] and injections." [Doc. No. 12-7, at p. 

27 216.] He had also been referred to neurology for a CT scan of his head but said he forgot 

28 to call for the appointment. [Doc. No. 12-7, at p. 216.] Medications were continued for 

11 

J5cv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 11 of 31
1 hypertension, back pain, muscle spasms, and elevated cholesterol. There was a lesion on 

2 plaintiff's lower left cheek that would not heal, so he was referred to dermatology. [Doc. 

3 No. 12-7,atpp.216-217.] 

4 During a follow-up appointment on November 27,2012 with NP Yung, plaintiff 

5 had "[ n]o new complaints" but said he was awaiting results of a biopsy of an un-healing 

6 lesion on his left cheek. He also requested a cane to aid with ambulation, because he has 

7 back pain and has "had some 'almost' falls." [Doc. No. 12-7, at pp. 212,214.] 

8 Medications were continued to address back pain, hypertension, and elevated cholesterol. 

9 [Doc. No. 12-7, at pp. 213-214.] 

10 On December 14,2012, plaintiff had an initial evaluation for physical therapy at 

11 Sharp Healthcare to address his lower back pain, and he was placed on a home treatment 

12 plan. [Doc. No. 12-7, at pp. 191-193.] He was walking 10 to 15 minutes every 2 hours 

13 but complained of cramping in his calves, burning on the bottom of his feet, and pain in 

14 his neck. He told the therapist he was not working because of lower back pain and 

15 headaches. [Doc. No. 12-7, at pp. 190-191.] His prescription for Naprosyn was 

16 "helpful." [Doc. No. 12-7, at p. 191.] 

17 On January 9, 2013, plaintiff was discharged from physical therapy at Sharp 

18 Healthcare because his functional goals had been achieved. His strength and pain had 

19 improved, and he was able to walk for 30 minutes without difficulty. However, plaintiff 

20 continued to report fatigue and calf cramping with prolonged walking, so further medical 

21 evaluation was recommended. [Doc. No. 12-7, at p. 190.] 

22 On January 16,2013, plaintiff had a follow up appointment with NP Yung, who 

23 reported in his Progress Notes that the lesion on plaintiff's cheek "turned out to be basal 

24 cell carcinoma," so he was awaiting approval from his insurance to begin radiation 

25 treatment. [Doc. No. 12-7, at p. 209.] Medications were continued for hypertension, 

26 back pain, and depression. [Doc. No. 12-7, at p. 210.] 

27 Plaintiff had a neurology consultation with Dr. Geoffrey Lyle Sheean at UC San 

28 Diego Healthcare System on February 5, 2013. Testing completed during the 

12 

15cv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 12 of 31
1 consultation included an EMG (Electromyography). The interpretation section ofthe test 

2 results state as follows: "The study is ABNORMAL. 1. There is chronic axonal loss 

3 affecting the left L4-S 1 myotomes, especially L5, almost certainly due to chronic 

4 radiculopathy. There is no evidence of recent or ongoing axonal injury. A limited study 

5 suggests similar, probably less severe, pathology on the right. 2. There is no evidence of 

6 large sensory fiber polyneuropathy in the feet." [Doc. No. 12-7,atpp. 196-197.] In 

7 addition, the consultation report includes the following differential diagnosis: "1. LIS 

8 radiculopathy and neurogenic claudication (spinal stenosis?); 2. Polyneuropathy, inc!. 

9 small fibres." [Doc. No. 12-7, at pp. 194-206.] 

10 Progress notes from a follow-up appointment with NP Yung on February 27, 2013 

11 state that plaintiff was having neck pain and some nerve studies had been ordered. His 

12 lower back pain was "well-controlled with Vicodin." [Doc. No. 12-7, at p. 207.] 

13 Although he had been referred to the pain clinic, plaintiff said he had not been contacted 

14 for an appointment and did not want to go because "his pain is controlled with oral 

15 medications." [Doc. No. 12-7, at p. 207.] Medications were continued for hypertension, 

16 elevated cholesterol, depression, and pain. [Doc. No. 12-7, at p. 208.] Plaintiff reported 

17 that he started radiation therapy for basal cell carcinoma on his left cheek near his 

18 jawline. [Doc. No. 12-7, at p. 207.] A letter dated March 18, 2013 from Genesis 

19 Healthcare states that plaintiff completed radiation therapy. [Doc. No. 12-7, at p. 248.] 

20 C. Hearing Testimonv. 

21 1. Plaintiff. 

22 When questioned at the hearing by the ALJ, plaintiff testified that he was not 

23 presently working and had not worked since 2009. In 2009, he worked for six months as 

24 a greeter in a grocery store. [Doc. No. 12-2, at pp. 58-59.] Prior to that, he worked as an 

25 office clerk for over five years and as a clerk in the back office at the Department ofFish 

26 and Game. [Doc. No. 12-2, at p. 59.] He decided to quit the job as greeter in the grocery 

27 store because standing for eight hours was making his back stiff and sore. After that, he 

28 did not look for other work. [Doc. No. 12-2, at p. 60.] 

13 

JScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 13 of 31
1 Plaintiff appeared at the hearing using a cane that was prescribed by "Dr. Michelle 

2 Young."z He had been using the cane off and on for about two months. The cane was 

3 prescribed in February 2013. [Doc. No. 12-2, at p. 65.] When asked what had changed 

4 to prompt him to return to the doctor since "last summer," plaintiff explained that he 

5 started having neck pain and his back pain was moving from side to side. At the time of 

6 the hearing, plaintiff said his back pain was "just hurting all the way across." [Doc. No. 

7 12-2, at p. 66.] In addition, he has noticed more calf pain in both calves while walking 

8 less than a half of a block. [Doc. No. 12-2, at p. 68.] 

9 Plaintiff further testified that he gets "very stiff and sore" when sitting for 10 to 30 

10 minutes while watching a television program, and he then has to get up and move around 

11 for 10 minutes before he can sit down again. [Doc. No. 12-2, at p. 70.] On the morning 

12 of the hearing, plaintiff did not take any pain medication. However, he takes Vicodin 

13 every day in the morning for pain. Previously, he took Vicodin every 6 hours for pain, 

14 but he cut back. The reason he takes the Vicodin in the morning is that he is "really stiff 

15 and sore" first thing in the morning and the Vicodin helps him to get moving for the day. 

16 [Doc. No. 12-2, at pp. 71-72.] Later in the day he takes aspirin or Excedrin but it 

17 provides "very little" pain relief. The Excedrin does help with his headaches. [Doc. No. 

18 12-2, at p. 72.] 

19 When questioned by his attorney during the hearing, plaintiff testified that his neck 

20 pain radiates down his right arm to his elbow and his middle finger. His whole arm "goes 

21 numb." [Doc. No. 12-2, at p. 73.] He has a headache every morning that lasts all day. 

22 The Excedrin helps but he does not get complete relief from the headaches. As a result, 

23 

24 

25 

26 

27 

28 

2 The physician's name appears to be a stenographic error. As noted above in the 

chronological summary of plaintiff s medical records, plaintiff received his primary 

medical care through Lindsey C. Yung, a nurse practitioner. [Doc. No. 12-7, pp. 144 et 

seq.] Plaintiffs medical records indicate that he requested a cane to aid ambulation 

during his appointment with NP Yung on November 27,2012. [Doc. No. 12-7, at pp. 

212,214.] The Court was unable to locate any medical notes from a Dr. Michelle Young. 

14 

15cv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 14 of 31
1 his doctor suggested a neurology consult [Doc. No. 12-2, at p. 73.] His low back pain 

2 also radiates down both legs but mostly on the left side. [Doc. No. 12-2, at p. 74.] The 

3 Vicodin makes him "groggy." [Doc. No. 12-2, at p. 75.] He can stand for about 10 or 15 

4 minutes before he has to sit down and can only lift 5 to 10 pounds. [Doc. No. 12-2, at pp. 

5 75-76.] After walking a half a block, plaintiff feels exhausted and out of breath. [Doc. 

6 No. 12-2, at p. 76.] He no longer drives because of the medications and because his 

7 license was suspended some time ago because of drunk driving. [Doc. No. 12-2, at pp. 

8 77-78.] 

9 Plaintiff also testified he lives with two roommates. One of the roommates does 

10 the cooking and the laundry. He tries to pick things up around the house and do 

11 vacuuming but must take frequent breaks to rest They all help with grocery shopping. 

12 However, the third roommate is older and does not do much. They have three service 

13 dogs that need to be taken outside every two hours, so that keeps plaintiff going. [Doc. 

14 No. 12-2, at pp. 79-80.] The dogs help to keep them calm. Plaintiff has a fear of crowds 

15 and close environments. They take the dogs wherever they go. [Doc. No. 12-2, at pp. 

16 80-81.] 

17 2. Medical Expert. 

18 Dr. Pella, a medical expert, testified that plaintiff's medical records show the 

19 following: (1) Plaintiff had a heart attack in 2006 and then had "coronary artery bypass 

20 grafting" in "four vessels." [Doc. No. 12-2, at p. 61.] However, Dr. Pella said, "Recent 

21 studies have shown adequate function .... " [Doc. No. 12-2, at p. 61.] Testing indicated 

22 he was capable of light activity. [Doc. No. 12-2, at pp. 61,63.] (2) Plaintiff has a long 

23 standing history of low back pain "with more recent exacerbation" that prompted an MRI 

24 in August 2011. "He was found to have mild to moderate bulging primarily degenerative 

25 disc disease that has worsened .... " [Doc. No. 12-2, at p. 62.] There was also some 

26 evidence of nerve compression (radiculopathy). [Doc. No. 12-2, at p. 62.] (3) Plaintiff 

27 is congenitally deaf in his left ear. [Doc. No. 12-2, at p. 62.] (4) Plaintiff has systemic 

28 hypertension without organ damage. (5) Plaintiff is taking medication for migraine 

IS 

IScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 15 of 31
1 headaches. (6) Plaintiff had knee surgery on his right leg. (7) There are some 

2 indications in the record indicating plaintiff has had some issues with anxiety, depression, 

3 and prior drug and alcohol use but these are outside Dr. Pella's area of expertise. [Doc. 

4 No. 12-2, at p. 62.] 

5 Based on the records he reviewed, Dr. Pella testified it was his opinion that 

6 plaintiffs impairments, whether viewed separately or in combination, did not met or 

7 equal the severity of any of the listed impairments in the Social Security regulations. 

8 [Doc. No. 12-2, at p. 62.] Based on plaintiffs cardiac history alone, which indicates he 

9 had "adequate function" following his bypass surgery, Dr. Pella said plaintiff was 

10 "capable oflight exertion." [Doc. No. 12-2, at pp. 61-63.] With the combination of his 

11 cardiac condition, back issues, and postural limitations, Dr. Pella believes plaintiffs 

12 activity level was reduced to sedentary as of August 2011. At this time, plaintiff s back 

13 pain was severe enough to warrant imaging studies, and an MRI indicated there was mild 

14 bilateral impingement of nerve roots. [Doc. No. 12-2, at pp. 63-64.] Although this was 

15 "too mild a finding" to equal a Listing, Dr. Pella said plaintiff was "close to a listing in 

16 February 2013" after additional findings were made based on the results ofEMG testing. 

17 [Doc. No. 12-2, at p. 64.] 

18 3. Vocational Expert. 

19 The vocational expert testified that plaintiffs former job as a license clerk with the 

20 Department ofFish and Game is considered semi-skilled, light work. [Doc. No. 12-2, at 

21 p. 82.] The job of grocery clerk/greeter is unskilled, medium work, and the job of real 

22 estate clerk is sedentary work. [Doc. No. 12-2, at p. 83.] Plaintiffs past relevant work as 

23 a license/administrative clerk and a real estate clerk would be appropriate for someone of 

24 plaintiffs age, education, work experience, and limitations who is capable of a "light 

25 level of exertion." [Doc. No. 12-2, at p. 83.] Plaintiffs past relevant work as a real 

26 estate clerk would also be appropriate for someone with plaintiffs age, education, work 

27 experience, and limitations who is capable of a "sedentary level of exertion." [Doc. No. 

28 12-2, at p. 84.] Plaintiffs past relevant work would be ruled out if additional conditions 

16 

15cv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 16 of 31
1 and limitations are imposed, including frequent stand and sit option; frequent balance; 

2 "occasional for the remaining posturals;" no work requiring acute hearing in the right ear; 

3 no concentrated exposure to certain environments; and ability to understand, remember, 

4 perform simple work instructions and tasks. There would still be unskilled work 

5 available at a sedentary level for such an individual with transferable skills. However, 

6 without transferable skills, an individual would "GRID rule at age 50." [Doc. No. 12-2, 

7 at p. 85.] 

8 IV. 

9 

The ALJ's Five-Step Disability Analvsis. 

To qualify for disability benefits under the SSA, an applicant must show that he or 

10 she is unable to engage in any substantial gainful activity because of a medically 

11 determinable physical or mental impairment that has lasted or can be expected to last at 

12 least 12 months. 42 U.S.C. § 423(d). The Social Security regulations establish a five13 step sequential evaluation for determining whether an applicant is disabled under this 

14 standard. 20 CFR § 404.1 520(a); Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). 

15 At step one, the ALJ must determine whether the applicant is engaged in 

16 substantial gainful activity. 20 CFR § 404.1 520(a)(4)(I). "Substantial gainful activity is 

17 work activity that is both substantial and gainful." 20 CFR § 416.972. Here, the ALJ 

18 concluded plaintiff had not engaged in substantial gainful activity since March 30, 2006 

19 (i.e., the date plaintiff claims he became disabled). [Doc. No. 10-2, at pp. 25-26.] 

20 At step two, the ALJ must determine whether the applicant is suffering from a 

21 "severe" impairment within the meaning of Social Security regulations. 20 CFR 

22 § 404.1 520(a)( 4)(ii). "An impairment or combination of impairments is not severe if it 

23 does not significantly limit [the applicant's] physical or mental ability to do basic work 

24 activities." 20 CFR § 404.1521(a). For example, a slight abnormality or combination of 

25 slight abnormalities that only have a minimal effect on the applicant's ability to perform 

26 basic work activities will not be considered a "severe" impairment. Webb v. Barnhart, 

27 433 F.3d 683, 686 (9th Cir. 2005). Examples of basic work activities include walking, 

28 standing, sitting, lifting, pushing, pulling, reaching, carrying, handling, seeing, hearing, 

17 

IScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 17 of 31
1 speaking, understanding, carrying out and remembering simple instructions, use of 

2 judgment, responding appropriately to supervision, co-workers and usual work situations, 

3 and dealing with changes in a routine work setting. 20 CFR § 404.1521(b)(I)-(6). "Ifthe 

4 ALI finds that the claimant lacks a medically severe impairment, the ALI must find the 

5 claimant not to be disabled." Webb v. Barnhart, 433 F.3d at 686. 

6 At step two, the ALI concluded plaintiff has the severe impairments of "coronary 

7 artery disease, status post bypass grafts; [and] degenerative disc disease of the cervical 

8 spine and the lumbar spine." [Doc. No. 12-2, at p. 39.] These impairments are severe 

9 because they "significantly limit his physical ability to do basic work activities." [Doc. 

10 No. 12-2, at p. 41.] Based on the record, the ALI also concluded plaintiff does not have 

11 any mental or psychiatric impairments that are severe enough to impact his ability to 

12 work. [Doc. No. 12-2, at pp. 39-41.] 

13 If there is a severe impairment, the ALI must then determine at step three whether 

14 it meets or equals one ofthe "Listing ofImpairments" in the Social Security regulations. 

15 20 CFR § 404. 1520(a)(4)(iii). Ifthe applicant's impairment meets or equals a Listing, he 

16 or she must be found disabled. Id. In this case, the ALI concluded at step three that 

17 plaintiff does not have an impairment or combination of impairments that meets or 

18 medically equals the severity of one of the listed impairments in 20 CFR Part 404, 

19 Subpart P, Appendix 1. [Doc. No. 12-2, at p. 41.] Specifically, the ALI concluded based 

20 on the medical evidence in the record that plaintiff's degenerative disc disease and 

21 ischemic heart disease are not severe enough to meet a Listing. [Doc. No. 12-2, at p. 41.] 

22 If an impairment does not meet or equal a Listing, the ALI must make a step four 

23 determination of the claimant's residual functional capacity based on all impairments, 

24 including impairments that are not severe. 20 CFR § 404.1520( e), § 404.1545(a)(2). 

25 "Residual functional capacity" is "the most [a claimant] can still do despite [his or her] 

26 limitations." 20 CFR § 404.1 545(a)(I). The ALI must determine whether the applicant 

27 retains the residual functional capacity to perform his or her past relevant work. 20 CFR 

28 § 404.1520(a)(4)(iv). 

18 

15cv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 18 of 31
1 Here, plaintiff objects to the ALl's findings at step four. At step four, the ALI 

2 concluded plaintiff has the residual functional capacity to perform his past relevant work 

3 as a license clerk and/or administrative/real estate clerk.3 According to the ALI, these 

4 positions are considered light, semi-skilled work that plaintiff is able to do despite his 

5 heart and back conditions. With respect to plaintiff's back condition, the ALI found that 

6 plaintiff's "allegations of disabling pain are out of proportion with the record." [Doc. No. 

7 12-2, at p. 45.] The ALI also rejected a portion ofthe opinion of the testifying medical 

8 expert, Dr. Pella, that plaintiff's functional capacity "decreased to sedentary in August 

9 2011 due to a lumbar radiculopathy." [Doc. No. 12-2, at p. 46.] Plaintiff now challenges 

10 the ALl's reasons for rejecting this portion of Dr. Pella's opinion testimony. [Doc. No. 

11 13-1, at pp. 6-9.] According to plaintiff, the ALI committed legal error by failing to 

12 articulate good reasons for not fully crediting the opinion testimony of Dr. Pella. [Doc. 

13 No. 20, at pp. 4, 8.] 

14 Alternatively, the ALI concluded plaintiff would not be disabled even if full credit 

15 was given to Dr. Pella's opinion that his functional capacity "decreased to sedentary in 

16 August 2011 due to a lumbar radiculopathy." [Doc. No. 12-2, at p. 46.] The ALI 

17 

18 

3 Since the ALI concluded plaintiff has the residual functional capacity to perform 

19 past relevant work, it was unnecessary for the ALI to complete step five of the disability 

20 analysis. If the applicant cannot perform past relevant work, the AU-at step five-must 

consider whether the applicant can perform any other work that exists in the national 

21 economy. 20 CFR § 404. 1520(a)( 4)(v). While the applicant carries the burden of 

22 proving eligibility at steps one through four, the burden at step five rests on the agency. 

Celaya v. Halter, 332 F.3d 1177, 1180 (9th Cir. 2003). The ALI must consider all of 

plaintiff's medically determinable impairments, including any pain that could "cause a 

24 limitation of function" and any impairments that were not "severe," and then determine 

plaintiff's residual functional capacity to perform other work in the national economy. 

20 CFR §§ 404.1520; 404.1545; 416.929. "In determining [the claimant's] residual 

23 

25 

26 functional capacity, the ALI must consider whether the aggregate of [the claimant's] 

mental and physical impairments may so incapacitate him that he is unable to perform 

available work." Light v. Soc. Sec. Admin., 119 F.3d 789, 793 (9th Cir. 1997). As noted 

above, "residual functional capacity" is "the most [an applicant] can still do despite [his 

or her] limitations." 20 CFR § 404. 1545(a)(I). 

27 

28 

19 

IScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 19 of 31
1 reasoned that plaintiff could still return to his past relevant work as a real estate clerk, 

2 which is classified as sedentary, skilled work [Doc. No. 12-2, at p. 47.] However, citing 

3 the Dictionary of Occupation Titles ("DOT"), plaintiff contends that the testifying 

4 vocational expert mischaracterized his prior work as a real estate clerk. According to 

5 plaintiff, this position could not be characterized as a sedentary, skilled position. Instead, 

6 plaintiff states that he worked as a generic office clerk in a real estate office, which could 

7 only be characterized as a semi-skilled position requiring light exertion. [Doc. No. 13-1, 

8 at pp. 4-5.] 

9 Since he contends that he does not have any past relevant work at a sedentary, 

10 skilled level, plaintiff believes the ALJ's alternative conclusion is incorrect. According 

11 to plaintiff, if Dr. Pella's opinion was fully credited, the ALJ would have been obligated 

12 to conclude he was not able to perform any of his past relevant work [Doc. No. 13-1, at 

13 pp.5-6.] Citing Medical-Vocational Guideline Rule 201.14,20 CFR, Part 404, Subpart 

14 P, Appendix 2 (the "grid rule"), it is plaintiffs view that he would only be able to 

15 perform sedentary work if he has transferable skills. If he does not have transferable 

16 skills, plaintiff believes he would be considered disabled under the "grid rule.,,4 [Doc. 

17 No. 13-1, at p. 11.] 

18 Plaintiff s view is that there is no evidence in the record to show whether he has 

19 transferable skills to perform other sedentary work. Because he contends his past 

20 relevant work "falls on the low end ofthe semi-skilled range of work," plaintiff believes 

21 he does not have transferable skills, particularly because he attained the age of 55 on 

22 July 9, 2012 while his claim for benefits was pending. As a result, plaintiff argues that 

23 the Court should reverse the SSA's decision and award benefits or remand the matter for 

24 further administrative proceedings. [Doc. No. 13-1, at pp. 3-11.] 

25 

26 

4 Section 201.14 indicates that an individual closely approaching advanced age with 

27 the residual functional capacity for sedentary work would be considered disabled ifhe or 

she had a high school education but no transferable skills. 20 CFR, Part 404, Subpart P, 

Appendix 2. 28 

20 

15cv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 20 of 31
1 V. 

2 

Discussion. 

A. The ALJ's Rejection ora Portion orDr. Pella's Opinion. 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

Plaintiff argues that the ALI provided insufficient reasons for rejecting the portion 

of Dr. Pella's testimony that indicates his residual functional capacity was reduced from 

the "light" work category to the "sedentary" work category as of August 2011. [Doc. No. 

13-1, at pp. 6-9.] The ALJ's decision discusses his rejection of this portion of Dr. Pella's 

opinion in a single paragraph which states as follows: 

[P]artial weight is given to impartial medical expert, John Pella, M.D., 

who indicated the claimant's coronary artery disease limited him to light 

exertion, and that his condition decreased to sedentary in August 2011 due to 

a lumber radiculopathy. While the claimant does have radicular pain, he 

has never demonstrated motor or sensory abnormalities. As noted above, 

his admitted activities are greater than sedentary. Dr. Pella also opined 

that from his 2006 bypass to August 2011, the claimant was able to lift and 

carry 10 pounds frequently and 20 pounds occasionally; he could stand and 

walk up to 6 hours out of an 8-hour day and he could sit up to 6 hours out of 

an 8-hour day. Consequently, the undersigned accepts the opinion that the 

claimant has been limited to light work since 2006, but not the opinion that 

the claimant's function has reduced further to sedentary. 

[Doc. No. 12-2, at p. 46.] 

"Light work involves lifting no more than 20 pounds at a time with frequent lifting 

or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be 

20 very little, ajob is in this category when it requires a good deal of walking or standing, or 

21 

22 

23 

24 

25 

26 

27 

28 

when it involves sitting most of the time with some pushing and pulling of arm or leg 

controls. To be considered capable of performing a full or wide range of light work, [the 

claimant] must have the ability to do substantially all of these activities. If someone can 

do light work, we determine that he or she can also do sedentary work, unless there are 

additional limiting factors such as loss of fine dexterity or inability to sit for long periods 

of time." 20 C.F.R. § 404.1567; 20 CFR § 419.967. 

To determine a claimant's residual functional capacity based on all impairments, 

including impairments that are not severe, an ALJ must consider all relevant medical 

21 

15cv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 21 of 31
1 opinions and other evidence in the record; the claimant's testimony "in conjunction with 

2 the medical evidence;" and "the effects of symptoms, including pain, that are reasonably 

3 attributed to a medically determinable impairment." Chaudhry v. Astrue, 688 F.3d 661, 

4 670 (9th Cir. 2012); Robbins v. Soc. Sec. Admin., 466 F.3d 880, 883 (9th Cir. 2006). 

5 "Medical opinions are statements from physicians and psychologists or other acceptable 

6 medical sources that reflect judgments about the nature and severity of [a claimant's] 

7 impairment(s), including [] symptoms, diagnosis and prognosis, what [the claimant] can 

8 still do despite impairment(s), and [the claimant's] physical or mental restrictions." 20 

9 CFR § 404.l527(a)(2). 

10 The opinions of treating and examining medical sources are afforded "more 

11 weight" than non-treating, non-examining sources, such as Dr. Pella. 20 CFR 

12 § 404.l527(c)&(e). SSA regulations require a treating physician's opinion to be given 

13 "controlling weight" ifit is "well-supported by medically acceptable clinical and 

14 laboratory diagnostic techniques and is not inconsistent with the other substance 

15 evidence" in the record. 20 CFR § 404.1527( c )(2). The opinions of a treating or 

16 examining physician, can only be rejected ifthe ALJ sets forth "specific and legitimate 

17 reasons that are supported by substantial evidence in the record." Lester v. Chater, 81 

18 F .3d 821, 831 (9th Cir. 1995). 

19 "The opinion of a non-examining physician cannot by itself constitute substantial 

20 evidence that justifies the rejection of the opinion of either an examining physician or a 

21 treating physician." Id. In other words, the opinion of a non-examining physician, such 

22 as Dr. Pella, is generally entitled to less weight. On the other hand, the ALJ must 

23 "evaluate every medical opinion" received "[r]egardless of its source." 20 CFR 

24 § 404.1 527(c). See also 20 CFR § 404. 1545(a)(3). In assessing a claimant's residual 

25 functional capacity, the ALJ "must always consider and address medical source opinions" 

26 and explain why an opinion was not adopted. SSR 96-8P (S.S.A. July 2, 1996). 

27 "Generally, the more consistent an opinion is with the record as a whole, the more 

28 weight [the ALJ] will give to that opinion." 20 CFR § 404.1 527( c)( 4). In addition, an 

22 

lScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 22 of 31
1 ALJ will "generally give more weight to the opinion of a specialist about medical issues 

2 related to his or her area of specialty than to the opinion of a source who is not a 

3 specialist." 20 CFR § 404.l527(c). "[T]he final responsibility for deciding" the 

4 claimant's residual functional capacity "is reserved to the Commissioner." 20 CFR 

5 § 404. 1527(d)(2). 

6 In his Motion for Summary Judgment, plaintiff cites two main reasons why he 

7 believes the ALJ did not provide sufficient reasons for rejecting the portion of Dr . Pella's 

8 opinion indicating his functional capacity was reduced to sedentary based on an MRI in 

9 August 2011. First, plaintiff argues that the ALJ "was plainly wrong for stating that the 

10 record does not contain any evidence of decreased motor strength and sensation." [Doc. 

11 No. 13-1, at p. 7.] In support of this argument, plaintiff cites minor notations made in a 

12 December 14,2012 Charting Report [Doc. No. 12-7, at pp. 192-193] and a January 9, 

13 2013 Charting ReportlDischarge Summary [Doc. No. 12-7, at pp. 190-191] from his 

14 participation in a physical therapy program through Sharp Healthcare and a February 5, 

15 2013 Consultation Form completed in connection with a neurology consultation by Dr. 

16 Sheean at UC San Diego Healthcare System. [Doc. No. 12-7, at pp. 190,192,193.] 

17 However, a review of these medical records as a whole indicate that any findings related 

18 to decreased motor strength and sensation were mild and, without more, do not appear 

19 serious enough to be considered outside the normal range of someone who, as the ALJ 

20 acknowledged, does have "mild degenerative disc disease in the cervical spine, as well as 

21 moderate findings in the lumbar spine at L4-L5 and L5-Sl." [Doc. No. 12-2, at p. 45.] 

22 As a result, the minor notations referenced by plaintiff do not in any way negate the 

23 ALJ's ultimate conclusion that plaintiff does have pain but the pain is not severe enough 

24 to be disabling. 

25 Second, plaintiff also argues that, contrary to the statement made by the ALJ in 

26 support of his rejection of Dr. Pella's opinion, his reported daily activities do not indicate 

27 that he has the residual functional capacity to perform work light work or that he is 

28 capable of anything greater than a sedentary level of exertion. [Doc. No. 13-1, at p. 8.] 

23 

JScv669·BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 23 of 31
1 According to plaintiff, his admitted activities do not "rise to the level of substantial 

2 evidence." [Doc. No. 13-1, at p. 10.] Standing alone, it is true that plaintiffs admitted 

3 daily activities are not enough to constitute substantial evidence to support the ALJ's 

4 residual functional capacity assessment. See, e.g., Vertigan v. Halter, 260 F.3d 1044, 

5 1049-1050 (9th Cir. 2001) (indicating the AU erred in rejecting the claimant's subjective 

6 complaints of pain and limitations based on her reported physical activities because they 

7 only represented a "scintilla of evidence" that the claimant lacked credibility). However, 

8 in this case, plaintiff s admitted daily activities only represent one of a number of factors 

9 that the ALJ actually considered to evaluate the extent of plaintiffs pain and limitations 

10 from his heart and back conditions. As discussed more fully below, when all of the 

11 factors considered by the ALJ are added together, they are enough to constitute 

12 substantial evidence of a residual functional capacity for light work. 

13 While it is true that the ALJ could have provided better or more detailed reasons 

14 for rejecting a portion of Dr. Pella's opinion, his failure to do so is not fatal to his 

15 ultimate determination about plaintiffs residual functional capacity. In addition to the 

16 reasons discussed above, Dr. Pella's opinion is entitled to less weight than that of 

17 plaintiffs treating and/or examining physicians. As discussed more fully below, when 

18 viewed as a whole, the ALJ's ultimate conclusion about plaintiff s residual functional 

19 capacity is supported by substantial evidence in the record 

20 B. The ALJ's Residual Functional Capacity Assessment. 

21 The final decision of the Commissioner must be affirmed if it is supported by 

22 substantial evidence and ifthe Commissioner has applied the correct legal standards. 

23 Batson v. Comm'r o/the Social Security Admin., 359 F.3d 1190, 1193 (9th Cir. 2004). 

24 Under the substantial evidence standard, the Commissioner's findings are upheld if 

25 supported by inferences reasonably drawn from the record. Id. Ifthere is evidence in the 

26 record to support more than one rational interpretation, the District Court must defer to 

27 the Commissioner's decision. Id. Substantial evidence means "such relevant evidence as 

28 a reasonable mind might accept as adequate to support a conclusion." Osenbrock v. 

24 

15cv669·BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 24 of 31
1 Apfel, 240 F.3d 1157, 1162 (9th Cir. 2001). "In determining whether the 

2 Commissioner's findings are supported by substantial evidence, we must consider the 

3 evidence as a whole, weighing both the evidence that supports and the evidence that 

4 detracts from the Commissioner's conclusion." Smolen v. Chater, 80 F.3d 1273, 1279 

5 (9th Cir. 1996). 

6 "Pain of sufficient severity ... may provide the basis for determining that a 

7 claimant is disabled." Light v. Soc. Sec. Admin., 119 F .3d at 792. "[A] claimant need not 

8 present clinical or diagnostic evidence to support the severity of his pain." Id. In tum, an 

9 ALJ may not reject "excess pain testimony" based solely on a lack of objective medical 

10 support in the record. Id. at 792-793. 

11 "In assessing the credibility of a claimant's testimony regarding subjective pain or 

12 the intensity of symptoms, the ALJ engages in a two-step analysis. [Citation omitted.] 

13 First, the ALJ must determine whether there is 'objective medical evidence of an 

14 underlying impairment which could reasonably be expected to produce the pain or other 

15 symptoms alleged.' [Citations omitted.] Ifthe claimant has presented such evidence, and 

16 there is no evidence of malingering, then the ALJ must give 'specific, clear and 

17 convincing reasons' in order to reject the claimant's testimony about the severity of the 

18 symptoms. [Citations omitted.] At the same time, the ALJ is not 'required to believe 

19 every allegation of disabling pain, or else disability benefits would be available for the 

20 asking, a result plainly contrary to 42 U.S.C. § 423(d)(5)(A).' [Citation omitted.] In 

21 evaluating the claimant's testimony, the ALJ may use 'ordinary techniques of credibility 

22 evaluation.' [Citation omitted.] For instance, the ALJ may consider inconsistencies 

23 either in the claimant's testimony or between the testimony and the claimant's conduct, 

24 [such as] ... 'whether the claimant engages in daily activities inconsistent with the 

25 alleged symptoms.' [Citation omitted.] While a claimant need not 'vegetate in a dark 

26 room' in order to be eligible for benefits, [citation omitted], the ALJ may discredit a 

27 claimant's testimony when the claimant reports participation in everyday activities 

28 indicating capacities that are transferable to a work setting. [Citation omitted.] Even 

25 

15cv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 25 of 31
1 where those activities suggest some difficulty functioning, they may be grounds for 

2 discrediting the claimant's testimony to the extent that they contradict claims of a totally 

3 debilitating impairment. [Citation omitted.]" Molina v. Astrue, 674 F.3d 1104, 1112-

4 1113 (9th Cir. 2012). 

5 If the ALJ's decision and the record are viewed as a whole, it is this Court's view 

6 that substantial evidence supports the ALJ's conclusion that plaintiff retains the residual 

7 functional capacity to perform his past relevant "light" work as a license and/or 

8 administrative clerk even though Dr. Pella testified that plaintiff's level of exertion was 

9 reduced to sedentary based on the results of an MRI from August 2011. The ALJ's 

10 decision in this regard is based in large part on medical notes and reports by plaintiff's 

11 treating and examining physicians and those ofNP Yung which were made close in time 

12 to the August 2011 MRI, and more recent records from 2012 and 2013. The ALJ's 

13 conclusion about plaintiff's residual functional capacity is also based in part on plaintiff's 

14 credibility, and the ALI provided a number of reasons for his conclusion that plaintiff's 

15 "allegations of disabling pain [were] out of proportion with the record." [Doc. No. 12-2, 

16 at p. 45.] 

17 First, the ALJ acknowledged that plaintiff has "mild degenerative disc disease in 

18 the cervical spine," as well as moderate findings in the lumbar spine at L4-L5 and L5-S 1. 

19 [Doc. No. 12-2, at p. 45.] The ALJ also acknowledged that plaintiff has "radicular pain 

20 at the level of L4 to S 1 ," and, as a result, should be "limited to lighter lifting in order to 

21 avoid exacerbations of back pain." [Doc. No. 12-2, at p. 46.] However, the ALJ said 

22 plaintiff had "few objective findings of the lower extremities consistent with 

23 radiculopathy." [Doc. No. 12-2, at p. 45.] 

24 Specifically, the ALJ cited a consultative examination by Dr. Cava on August 13, 

25 2011, shortly before the MRI was completed on August 30,2011. [Doc. No. 12-2, at p. 

26 45; Doc. No. 12-7, at pp. 121-122.] The ALJ's decision notes that Dr. Cava reported as 

27 follows: "[T]he claimant was noted to have no trouble with sitting, standing, or walking. 

28 There was only 'mild' right paralumbar tenderness to palpation without significant spinal 

26 

15cv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 26 of 31
1 tenderness. Additionally, he had full range of motion of the lumbar spine, without 

2 spasm." [Doc. No. 12-2, at p. 45.] In addition, as noted above, Dr. Cava further stated 

3 that plaintiff could still walk several blocks before he needed to rest and did not have any 

4 problems with squatting, kneeling, or crouching. [Doc. No. 12-7, at pp. 86-88.] As a 

5 result of his examination, Dr. Cava concluded that plaintiff could stand, walk, and sit for 

6 six hours in an eight-hour day; lift and carry 25 pounds frequently and 50 pounds 

7 occasionally; and had no limitations for stooping, crouching, reaching and handling." 

8 [Doc. No. 12-7, at p. 88.] However, the ALJ gave this portion of Dr. Cava's report "little 

9 weight" because later medical records (i.e., the August 30, 2011 MRI) indicated that 

10 plaintiff should be limited to lighter lifting than that recommended by Dr. Cava in order 

11 to avoid exacerbating his back pain. [Doc. No. 12-2, at p. 46; Doc. No. 12-7, at p. 121.] 

12 Although plaintiff attacks the ALJ's reliance on Dr. Cava's report and the reports of other 

13 medical professionals, his arguments are largely speculative and unconvincing based on a 

14 review ofthe record. [Doc. No. 20, at pp. 4-6.] 

15 Second, citing progress notes from plaintiff's visits with his primary medical 

16 provider during 2011 and 2012, the ALJ stated that he had "not demonstrated signs of 

17 symptoms of severe spinal nerve root impingement (such as asymmetric reflexes, sensory 

18 or motor loss, or a positive straight leg raising sign)" during his visits with his treating 

19 physicians. [Doc. No. 12-2, at p. 45.] In December 2012, physical examination findings 

20 were "very soft" for objective signs ofradiculopathy. Plaintiff had normal movements in 

21 all extremities, his gait was stable and narrow but slow, stiff and careful. [Doc. No. 12-2, 

22 at p. 45.] 

23 Third, the ALJ cited conservative treatment evidence in the record. Based on his 

24 testimony during the hearing, plaintiff was taking only one Vicodin tablet for pain in the 

25 morning and was otherwise using Naprosyn for pain. [Doc. No. 12-2, at p. 45, citing Doc. 

26 No. 12-2, at pp. 71-72.] In addition to these medications, plaintiff was referred to 

27 physical therapy. [Doc. No. 12-2, at p. 45. See also Doc. No. 12-7, at p. 190 (stating that 

28 plaintiff was discharged from physical therapy on January 9, 2013, because his strength 

27 

J5cv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 27 of 31
1 and pain had improved and he could walk for 30 minutes without difficulty but still 

2 complained about fatigue and calf cramping with prolonged walking).] Plaintiff has not 

3 required increasing doses or stronger medications and has not had referrals for epidural 

4 injections, acupuncture, a TENS unit, or pain patches. Surgery has not been 

5 recommended and plaintiff was told that he was not a surgical candidate. The ALJ 

6 reasonably concluded from this evidence that plaintiff has "fair control" of his pain with a 

7 moderate amount of medication. [Doc. No. 12-2, at p. 45.] Although not specifically 

8 cited by the ALJ, Progress Notes from a follow up appointment with NP Yung on 

9 February 27,2013 further state that plaintiffs lower back pain was "well-controlled with 

10 Vicodin" and that plaintiff did not want to go to the pain clinic because "his pain is 

11 controlled with oral medications." [Doc. No. 12-7, atp. 207.] 

12 Fourth, it was the ALJ's view that plaintiff described daily activities that were not 

13 consistent with disabling pain. He was able to cook, do laundry, empty the trash, and 

14 make minor household repairs. [Doc. No. 12-2, at p. 45.] The record also indicated he 

15 walked the dogs, shopped, and dusted. [Doc. No. 12-2, at p. 46.] On March 31,2012, 

16 plaintifftold his cardiologist he was walking 20 minutes, six days per week for exercise, 

17 and the cardiologist encouraged him to walk even longer, stop smoking, and follow a 

18 restricted diet. [Doc. No. 12-2, at p. 45.] 

19 Finally, the ALJ gave "some weight" to the opinion of Dr. Vu, a non-examining 

20 state agency medical consultant who reviewed plaintiffs medical records and prepared a 

21 Case Analysis dated January 25, 2012. [Doc. No. 12-2, at p. 46; Doc. No. 12-7, at 

22 pp. 177-178.] In the ALJ's view, Dr. Vu's analysis was entitled to some weight even 

23 though he was not a treating or examining physician, because his opinions were timely 

24 and consistent with the record as a whole. Essentially, Dr. Vu concluded that plaintiff 

25 was capable of light work, because he could lift and carry 10 pounds frequently and 20 

26 pounds occasionally, stand and walk up to 6 hours out of an 8-hour day, and sit up to 6 

27 hours out of an 8-hour day. [Doc. No. 12-2, at p. 46; Doc. No. 12-7, at pp. 177-178.] 

28 In sum, substantial evidence in the record supports the ALJ's conclusion that 

28 

JScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 28 of 31
1 plaintiff does not qualify for disability benefits, because he retains the residual functional 

2 capacity for light work and is therefore capable of performing his past relevant work as a 

3 license or administrative clerk. In reaching this conclusion, the ALJ relied on substantial 

4 evidence in the record; did not inappropriately reject a portion ofthe medical opinion by 

5 Dr. Pella, the testifying medical expert; and provided clear, convincing, and specific 

6 reasons for rejecting plaintiff's testimony indicating that he cannot work because he 

7 suffers from severe, disabling pain in excess of that indicated by objective medical 

8 evidence. 

9 C. The ALJ's Alternative Residual Functional Capacity Finding. 

10 As noted above, plaintiff also challenges the ALJ's alternative finding that he 

11 would not be disabled even if full credit was given to Dr. Pella's opinion that his 

12 functional capacity was reduced to sedentary in August 2011. In this regard, the ALJ 

13 concluded plaintiff could still return to his past relevant work as a real estate clerk, 

14 because this position was classified as sedentary, skilled work. Generally, if a claimant 

15 can do light work, he or she can also do sedentary work, "unless there are additional 

16 limiting factors such as loss of fine dexterity or inability to sit for long periods of time." 

17 20 C.F.R. § 404.1567; 20 CFR § 419.967. Plaintiff believes the ALJ's alternative 

18 conclusion is incorrect, because the vocational expert mischaracterized his prior work as 

19 a real estate clerk as a sedentary, skilled position. If Dr. Pella's opinion was given full 

20 credit, plaintiff argues that the ALJ could only find him disabled. [Doc. No. 13-1, at pp. 

21 3-11.] 

22 As plaintiff contends, it does appear from the record that the vocational expert may 

23 have mischaracterized his prior work as an office clerk in a real estate office as both 

24 sedentary and skilled. In a Work History form plaintiff completed on or about May 23, 

25 2011, plaintiff stated he worked as an office clerk in a real estate office doing data entry, 

26 copying, mailing, and delivering paperwork to his supervisors. [Doc. No. 12-6, at pp. 38, 

27 40.] 

28 Based on the definitions provided in plaintiff's moving papers from the Dictionary 

29 

lScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 29 of 31
1 of Occupational Titles, the vocational expert may have confused plaintiff s former 

2 position of office clerk in a real estate office performing basic clerical duties with the 

3 skilled, sedentary job of "real estate clerk." [Doc. No. l3-1, at pp. 4-5.] However, if the 

4 ALl's alternative finding is error, it is harmless because the ALl's finding that plaintiff 

5 retains the residual functional capacity for light work is supported by substantial 

6 evidence. See, e.g., Tommasetti v. Astrue, 533 F.3d 1035, 1042-1043 (9th Cir. 2008) 

7 (holding that an error is harmless if it is inconsequential to the ultimate disability 

8 determination). Under the circumstances presented, reversal or remand for additional 

9 administrative proceedings on this issue is unnecessary. See, e.g., Ludwig v. Astrue, 681 

10 F.3d 1047, 1055 (9th Cir. 2012) (indicating that a remand is unnecessary unless the 

11 claimant is able to establish a "substantial likelihood of prejudice"). 

12 VI. Conclusion. 

13 Based on the foregoing, this Court concludes that substantial evidence in the 

14 Administrative Record supports the ALl's May 14, 20 l3 decision that plaintiff does not 

15 qualify for disability or supplemental security income benefits because he retains the 

16 residual functional capacity to perform his past relevant work as a license or 

17 administrative clerk, both of which are considered semi-skilled, light work under SSA 

18 regulations. 

19 IT IS THEREFORE RECOMMENDED THAT THE DISTRICT COURT: 

20 

21 

1. 

2. 

DENY plaintiffs Motion for Summary Judgment [Doc. No. 13]; and 

GRANT defendant's Cross-Motion for Summary Judgment [Doc. No. 18]. 

22 This Report and Recommendation is submitted to the United States District Judge 

23 assigned to this case, pursuant to the provisions of28 U.S.C. § 636(b)(1) and Civil Local 

24 Rule n.1(d). Within fourteen (14) days after being served with a copy ofthis Report and 

25 Recommendation, "any party may serve and file written objections." 28 U.S.C. § 

26 636(b)(1)(B)&(C). The document should be captioned "Objections to Report and 

27 Recommendation." The parties are advised that failure to file objections within this 

28 / / / 

30 

15cv669·BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 30 of 31
1 II I 

2 specific time may waive the right to raise those objections on appeal ofthe Court's order. 

3 Martinez v. Ylst, 951 F.2d 1153, 1156-57 (9th Cir.1991). 

4 IT IS SO ORDERED. 

5 Dated: July Z.~2016 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

Hon. Kar raw ord 

United States Magistrate Judge 

31 

IScv669-BEN(KSC) 

Case 3:15-cv-00669-BEN-KSC Document 21 Filed 07/28/16 Page 31 of 31