Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_09-cv-00510/USCOURTS-azd-4_09-cv-00510-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:205 Denial Social Security Benefits

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“Tr.” refers to the official transcript of the administrative record.

UNITED STATES DISTRICT COURT

DISTRICT OF ARIZONA

Elizabeth K. Grimes, )

) No. CIV 09-00510-TUC-CKJ (JM)

Plaintiff, )

)

v. ) REPORT AND

) RECOMMENDATION

Michael J. Astrue, Commissioner of Social )

Security, )

)

Defendant. )

_______________________________________)

Plaintiff Elizabeth K. Grimes (“Plaintiff”) brings this action pursuant to 42 U.S.C. §

405(g), seeking judicial review of the final decision of the Commissioner of Social Security.

This Social Security Appeal has been referred to the United States Magistrate Judge pursuant

to Local Rule – Civil 72.2(a)(10) of the Rules of Practice of this Court. Based on the parties’

cross motions of summary judgement and the record submitted to the Court, the Magistrate

Judge recommends that the District Court, after its independent review, deny Plaintiff's

Motion for Summary Judgment (Doc. 16) and affirm the decision of the Commissioner.

I. Procedural Background 

On December 22, 2006, Plaintiff filed her application for disability insurance benefits

under Title II of the Social Security Act, alleging a disability onset date of January 1, 2007.

(Tr. 12).1

 Her application was denied initially and upon reconsideration. (Tr. 55-59, 76-78).

Plaintiff then requested a hearing before an administrative law judge ("ALJ") which was held

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on June 30, 2008. (Tr. 73, 23-54). In a decision dated February 20, 20096, the ALJ found

that Plaintiff was not disabled. (Tr. 9-22). Plaintiff requested review of the ALJ's decision

which was denied by the Appeals Council on August 6, 2009. (Tr. 1-4). Accordingly, the

ALJ's decision became the final decision of the Commissioner of Social Security. (Tr. 2).

On September 9, 2009, Plaintiff filed a complaint with this Court seeking judicial review of

the ALJ's decision pursuant to 42 U.S.C. § 405(g). (Doc. 1). 

II. Record on Appeal

A. Plaintiff's Testimony

At the time of the hearing, Plaintiff was 60 years old. (Tr. 27). She is a high school

graduate and attended some college which primarily consisted of technical training. (Tr. 28).

She lives alone and gets help with cleaning from her grand daughter about once a month. (Tr.

33). She has a driver’s license and can go to the grocery store. (Id.). She watches television

during the day. (Tr. 34). 

She was not working at the time of the hearing and in her most recent job she worked

part-time for two years as an associate in the men’s department at Macy’s until June 1, 2007.

(Tr. 28-29). At the time she quit, she was “in a lot of pain,” and her husband was sick and

died on July 30, 2007. (Tr. 29). Prior to working at Macy’s, she worked for 15 years writing

software for Verizon in Fort Wayne, Indiana. (Tr. 29-30). Before Verizon, she had worked

for a mortgage company and had done insurance work. (Tr. 30).

The medications she was taking at the time of the hearing included Norvasc for high

blood pressure, Lyrica for pain, Chantix to help her stop smoking, and an anti-anxiety

medication. (Tr. 30-31, 34-35). She described her pain as follows:

– in my, all my muscles. It’s mostly located on the right side of

my body. I have arthritis in my spine, and I have arthritis in, you

know, I’m getting that age, my hands [and] feet. But I have

fibromyalgia so the pain is a shooting pain, and then it’s just a

nagging pain on some days, but I’m always in pain.

(Tr. 32). She can stand approximately 30 minutes before having to sit, and sit for 30 minutes

before she needs to stand. (Tr. 32-33). She reports having trouble concentrating and loses

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her train of thought. (Tr. 36). She is unable to lift her grandchildren. (Id.). She is often

fatigued and once a week will sleep all day and night. (Id.). 

B. Vocation Expert’s Testimony

The ALJ asked Ruth Van Vleet, a vocational expert (“VE”), to assume a hypothetical

individual, of Plaintiff’s age, education, and work experience with limitations as follows:

[S]he can only lift about 20 pounds on an occasional basis and

ten pounds on a frequent basis, but she should, she should be able

require [sic] an ability to sit and stand at her option at a minimum

of about an hour each just to change position. And this

hypothetical person could only climb, she could only

occasionally climb, stoop, kneel, crouch, and crawl, and she can

avoid, she should avoid climbing ladders, ropes, and scaffolds.

This hypothetical person uses a cane for, occasionally using a can

for uneven surfaces. She’s got problems with her shoulders so

she should avoid working above shoulder heights. She should

avoid working at unprotected heights and hazardous moving

machinery. She should, even though she smokes, I will still give

her the benefit of the doubt that she should avoid where there are

working, there might be excessive amounts of dust, fumes, and

gases. Also, she should avoid working where there are extreme

vibrations, and she should avoid where there is extreme cold

temperatures. Now, this hypothetical has various parts of, she

has pain in various parts of her body, in both her joints and

muscles, that are primarily in her back, her hands, her feet, her

right hip, and she’s got some, in her abdomen, she’s got some

irritable bowel syndrome problems. She also has restless leg

syndrome. And for the first hypothetical, I want you to assume

that the pain level, the pain level that this hypothetical person has

would be of a slight nature and would have a slight effect on her

ability to do basic work activities or that condition is or can be

controlled by appropriate medication or treatment without any

significant or adverse side effects. This hypothetical person also

has some other problems. She’s got very slight obesity. She’s

got fibromyalgia. She’s got hypertension. She’s got occasional

dizziness and tremors, also some occasional numbness or tingling

on her feet and hands, but I’ve already considered these factors

in the other portions of this hypothetical or to the extent that if

they are in excess thereof, then these hypotheticals’

miscellaneous impairments would be of a slight nature and would

have a slight effect on her ability to do basic work activities or

that condition is or can be controlled by appropriate medication

without significant adverse side effects. All right. This

hypothetical person also has some psychiatric problems in the

form of depression and anxiety. She’s got some symptoms of

decreased, memory loss, and decrease in concentration. She’s

got some substance abuse in the form of smoking which is, I will

not consider that portion other than I’ve already taken into

consideration of all these other factors in this hypothetical. All

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right. These psychiatric problems then would be of, first of all,

would be of a slight nature and would have a slight effect on her

ability to do basic work activities, or that condition is or can be

controlled by appropriate medication with significant side effects.

All right. Basically with all those problems, could that

hypothetical person do any of the past work that was done by Ms.

Grimes?

(Tr. 44-46). After confirming with the ALJ that the hypothetical person’s limitations could

be controlled with medication without significant adverse side-effects, the VE opined that

such an individual could perform the Plaintiff’s past relevant work as a translation design

analyst. (Tr. 46). 

The ALJ then asked the VE to assume that the hypothetical person also had moderate

pain that could be controlled by appropriate medication without significant side-effects. (Tr.

47-48). With this additional limitation, the VE opined that if the pain could be controlled,

“they could still do the past job of translation design analyst. (Tr. 48). If the pain was severe

and uncontrolled with medication, the VE indicated that such a person would not be able to

perform the translation design analyst job or any other work. (Tr. 48-49). 

C. Medical Evidence

The records indicate that Plaintiff began seeing Netley D’Souza, M.D., in 2006. In

April 2006, Dr. D’Souza saw Plaintiff for bronchitis and “some [lower back pain] that radiates

down R[ight] leg.” He described Plaintiff as an “alert female who appears mildly

uncomfortable,” and referred her to physical therapy for low back pain. (Tr. 256). 

On August 16, 2006, Plaintiff presented complaining of lower back and right hip pain.

(Tr. 252). She had gone to physical therapy, but after no improvement, she reported that the

therapists felt she should see a pain specialist. (Id.). She also reported that she has a history

of fibromyalgia which bothered her periodically. (Id.). On examination, Dr. D’Souza noted

that there was no acute inflammation, but the right hip showed limited range of motion and

was causing “discomfort with extreme positioning.” (Tr. 253). She had previously been

denied an MRI, but the doctor felt her symptoms were progressing and resubmitted the

request. (Id.). 

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MRIs of Plaintiff’s right hip and lumbar spine were performed on August 21, 2006.

The impression of the right hip was negative with findings reported as normal bilateral hips

and musculature. (Tr. 273). The impression of the lumbar spine was of “[m]inimal multilevel

disc degeneration,” and otherwise negative. (Tr. 274). These findings were consistent with

a previous radiograph taken on April 25, 2006, which showed “[n]o significant radiographic

abnormality of the lumbar spine.” (Tr. 275). 

A week later, on August 23, 2006, Plaintiff presented complaining that the left side of

her face was swollen and numb. (Tr. 249). Dr. D’Souza’s assessment was “[p]robable Bell’s

Palsy” based on her symptoms and suggested further testing if there was no improvement.

(Tr. 250). He also noted that Plaintiff was to see an orthopedist regarding her right hip pain

and reported that her MRI was read as being normal. (Id.). She was seen again two days later

for the facial swelling, the symptoms of which were reported to have decreased. Dr. D’Souza

advised her to go to the emergency room, but she declined as she did not want to have to wait

there.” He sent her for an MRI of her head. (Tr. 247). An EKG “showed an incomplete right

bundle branch but otherwise negative.” (Id.) 

On August 25, 2006, Plaintiff had an MRI of her brain and inner auditory canals. The

findings reflected the ventricles and cerebral sulci were within normal limits, no abnormal

intracranial enhancement, and the orbits and osseous structures appeared normal. (Tr. 272).

The impression was “[m]ild chronic ischemic white matter changes, without evidence of acute

intracranial abnormality,” and “no evidence of abnormal enhancement along the left facial

nerve to suggest left Bell’s palsy.” (Id.). 

Plaintiff next presented on August 30, 2006, for follow-up. The doctor reviewed the

results of her MRI, which were negative, and stated that “[h]er MRI did not show any

enlargement of the nerve, but it could still be possible, though she seems to be doing well

symptomatically and on exam.” (Tr. 244-45).

/ / /

/ / /

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From September to December 2006, Plaintiff saw Randall Prust, M.D., who diagnosed

sacroiliac joint pain, lumbar degenerative disc disease, hypertension, and right hip pain and

administered a series of steroid injections. (Tr. 257-67, 279-92, 293-97). 

On September 26, 2006, Plaintiff returned for follow-up of her back problems. Dr.

D’Souza reported that she had an injection done by Dr. Prust, but was not sure it helped. (Tr.

240). Plaintiff believed “a lot of her symptoms may be due to fibromyalgia.” The doctor

indicated that he would discuss treatment plans per Dr. Prust, continue with the injections, and

refer her back to physical therapy. (Tr. 241). He noted that, “[s]he also raises questions about

disability as she has not improved a whole lot.” (Id.). 

On October 25, 2006, Plaintiff returned for follow-up on her back pain. She reported

that “the pain has progressively gotten worse since her corticosteroid injection performed by

Dr. Prust 5 wks ago.” She reported that her lower back pain level was “5/10,” but her hip pain

was better. (Tr. 238). The doctor assessed her lower back pain as chronic and prescribed

Naprosyn and Flexeril and injected 60 mg of Toradol for acute pain relief. (Tr. 239). 

She was next seen on December 13, 2006 for back pain and an ear ache. She had three

injections from Dr. Prust, which seemed to help, but reported that the pain “starting to recur.”

 (Tr. 235). She reported thinking of going on disability and again expressed that her

symptoms may be due to fibromyalgia. (Id.). The doctor noted that they discussed disability

and stated that, “I think she would qualify as she has been trying diligently to try to go back

and maintain her regular work schedule.” (Tr. 236). On February 13, 2007, she returned for

follow-up and the assessment was largely unchanged. (Tr. 232-33). She was put on Lyrica

to see if it would help with her pain. (Tr. 233). 

In a Medical Source Statement prepared for the Arizona Department of Economic

Security on March 8, 2007, Dr. D’Souza noted a diagnosis of “lower back & hip pain/lumbar

disk disease.” (Tr. 228). He reported lifting restrictions of less than 10 pounds frequently,

standing limitations of at least 2 hours but less then 6 hours in an 8 hour day, and no sitting

laminations. (Tr. 229). The doctor based his opinions on “history/exam/MRI findings.” (Tr.

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228-29). 

On April 3, 2007, a bone densitometry test was normal and indicated the Plaintiff’s risk

of fracture was low. (Tr. 354-361). 

On April 13, 2007, Plaintiff was seen for a routine check-up and for right hand and

wrist pain. (Tr. 347). Dr. D’Souza described Plaintiff’s history as including hypertension,

chronic back pain, fibromyalgia, osteopenia, anxiety, and depression. He continued with the

same management of her historical problems and attributed the wrist pain as most likely due

to repetitive stress at work and cane use. He recommended a more stable cane and a wrist

brace. (Tr. 348). 

On May 1, 2007, Plaintiff reported to Dr. Prust that, since she last saw him, her pain

was 75% better overall and that four month intervals seem to work for her. Dr. Prust

diagnosed lumbar degenerative disc disease, lumbar bulging disc, sacroiliac joint pain,

fibromyalgia, hypertension, and right hip pain. He administered an epidural steroid injection.

(Tr. 365-66). 

On May 15, 2007, John Fahlberg, M.D., a State agency physician, prepared a Physical

Residual Functional Capacity Assessment based on his review of Plaintiff’s medical records.

He concluded that Plaintiff could perform light work that did not require more than occasional

climbing, stooping, kneeling, couching and crawling. He also found that Plaintiff should

avoid concentrated exposure to extreme cold, vibration and hazards. He indicated that his

conclusions were significantly different from Dr. D’Souza’s, explaining that Dr. D’Souza’s

opinions were “based on subjective pain without much objective by MRI or exam.” (Tr. 326-

32). 

On June 6, 2007, Plaintiff presented to Dr. D’Souza complaining of not feeling well

for a week and needing to talk about her husband and disability forms. (Tr. 343). The doctor

noted that most of her problems were related to the stress and anxiety associated with the

hospitalization of her husband. That same day, Dr. D’Souza completed a Fibromyalgia

Questionnaire indicating Plaintiff experienced widespread skeletal pain with tender point pain

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in the occiput, trapezius, supraspinatus, lateral epicondyle, gluteal, greater trochanter, and

knees. (Tr. 165). Her symptoms were described as including multiple tender points, nonrestorative sleep, chronic fatigue, morning stiffness, muscle weakness, subjective swelling,

irritable bowel syndrome, frequent severe headaches, numbness and tingling, breathlessness,

difficulty concentrating, and vestibular dysfunction. The doctor reported the fatigue as

incapacitating. (Tr. 167). At the same time, Dr. D’Souza completed a Pain Questionnaire

indicating Plaintiff’s pain was severe– described as “extreme impairment of ability to

function”– such that it constantly interfered with Plaintiff’s ability to maintain attention and

concentration. (Tr. 168). Dr. D’Souza reported that both of these conditions had existed at

least since November 2003. 

On September 6, 2007, Plaintiff saw Dr. Prust with complaints of low back pain. Dr.

Prust found she was neurologically unchanged. He diagnosed lumbar degenerative disk

disease, lumbar bulging disk, sacroiliac joint disease, fibromyalgia, hypertension, and right

hip pain and administered an epidural steroid injection. (Tr. 415-16). 

On October 16, 2007, Plaintiff saw Dr. D’Souza about left knee pain and requesting

lab work. (Tr. 404). She could not associate her knee pain with any injury or trauma. She

was also dealing with the death of her husband and had just returned from Indiana where his

services were held. She had left knee tenderness, very minimal swelling and tenderness with

pressure in that area, and positive crepitus. Dr. D’Souza diagnosed left knee pain and

bereavement and recommended a knee x-ray. He also prescribed medication. (Tr. 404-05).

On October 30, 2007, Anita Stafford, M.D., a State agency physician, reviewed the

medical evidence and concluded that “[t]here is no clear evidence that [Plaintiff] has

fibromyalgia. The [treating source] completed a [medical source statement] indicating this

diagnosis but this form is not supported by his clinical notes.” (Tr. 369). On October 31,

2007, Eugene Campbell completed a Psychiatric Review Technique for the State and found

Plaintiff’s impairments “not severe,” finding her depressive disorder secondary to her general

medical condition. (Tr. 373). 

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On November 14, 2007, Plaintiff visited Dr. D’Souza to follow-up on her labs and for

grief counseling. (Tr. 401). She was having problems dealing with issues related to the loss

of her husband, including crying without specific reason. She also reported having been

turned down for disability benefits and having financial difficulty. (Id.) The doctor advised

her to attend a bereavement and support group. The doctor also advised her to volunteer at

a local hospital, “so that she can find something to keep her busy.” (Tr. 402). Her knee pain

was reported as improving. Her x-rays were negative and normal and she did not want any

treatment of follow-up. (Tr. 403). 

On February 4, 2008, Plaintiff presented to Dr. D’Souza complaining of dizzy spells.

He treated her dizziness with medication and noted that “she feels her symptoms are better.”

The doctor also noted hat she was doing better in relation to her bereavement from the loss

of her husband. (Tr. 398-400). She returned two days later reporting that she had one dizzy

spell the day before, but was feeling better. (Tr. 395). She also reported that she planned to

do some volunteer work with the national forest in Oregon beginning in June. (Id.). She

followed-up on February 13, reporting her dizziness had improved. (Tr. 392). She did not

want any testing, but the doctor recommended testing if her dizziness persisted. (Tr. 393). 

In a series of questionnaires dated February 25, 2008, Dr. D’Souza addressed

Plaintiff’s spinal disorders, fibromyalgia, and exertional limitations. He reported her back

impairment involved her thoracic and lumbar spine without compression of a nerve root with

persistent muscle spasm, limitation of motion, muscle weakness and reflex loss. (Tr. 406).

He reported that she had diminished circulation, dizziness, tremors, weakness/pain, slow gait,

and diminished sensation and reflexes. He reported she had no atrophy or signs of

radiculopathy and had minimal loss of muscle strength. (Tr. 407-08). He noted that her MRI

findings did not support surgical intervention. (Tr. 408). Dr. D’Souza anticipated that her

condition would cause her to be absent from work more than two days a month. (Tr. 409).

In the fibromyalgia questionnaire Dr. D’Souza stated that plaintiff experienced widespread

pain and axial skeletal pain. He said she had tenderness at the following sites: occiput, low

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cervical, trapezius, supraspinatous, lateral epicondyle, gluteal, greater trochanter, and knee.

He said that Plaintiff’s pain and fatigue were incapacitating to the point she could not perform

activities involving attention, concentration, memory, or reliability at least 50 percent of a

workday. He said her symptoms were consistent with clinical findings and she had

experienced changes in mood and thought. (Tr. 410-12). He stated that she required complete

freedom to rest frequently without restriction. (Tr. 413). He stated that Plaintiff was

incapable of sedentary work on a sustained and full-time basis. (Tr. 414).

On February 27, 2008, Dr. D’Souza referred Plaintiff to Mitchell Halter, M.D., Ph.D.,

for pain management. Dr. Halter prescribed medication. (Tr. 420-21). On March 24, 2008,

she returned to Dr. D’Souza to evaluate the side effects of the medications prescribed by Dr.

Halter. He diagnosed bronchitis/history of tobacco use and prescribed medication. (Tr. 390).

On April 21, 2008, Dr. Halter administered an epidural steroid injection. (Tr. 417-18).

On May 9, 2008, Plaintiff saw Dr. D’Souza for epigastric discomfort. The doctor

indicated that if the symptoms persisted, he would do an ultrasound and consider doing a CT

scan. (Tr. 426). 

D. ALJ's Findings and Decision

On February 20, 2009, the ALJ made the following findings: 

1. The claimant meets the insured status requirements of the

Social Security Act through March 31, 2011.

2. The claimant has not engaged in substantial gainful activity

since January 1, 2007, the alleged onset date (20 CFR 404.1571

et seq.).

3. The claimant has the following severe impairments:

degenerative disc disease, chronic low back pain, slight obesity,

left knee pain, fibromyalgia, hypertension, occasional dizziness

and tremors, irritable bowel syndrome, chronic illnesses

including tobacco use, and nicotine abuse, depression, and

anxiety (20 CFR 404.1521 et seq.).

4. The claimant does not have an impairment or combination of

impairments that meets or medically equals one of the listed

impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20

CFR 404.1525 and 404.1526). 

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5. After careful consideration of the entire record, the

undersigned finds that the claimant has the residual functional

capacity to perform light work as defined in 20 CFR

404.1567(b), except with a sit/stand option at a minimum of one

hour each, and is further limited to occasional climbing, stooping,

kneeling, crouching, and crawling, but never climb ladders,

ropes, and scaffolds. The claimant requires the occasional use of

a cane for uneven surfaces. The claimant is precluded from

working above shoulder [height], and should avoid working at

unprotected heights and around hazardous moving machinery,

and working around excessive amount of dust, fumes, and gases,

and avoid working with extreme vibrations and extreme cold

temperatures. Te claimant’s moderate pain level and psychiatric

problems are controllable with appropriate medications and

treatment without any significant adverse side effects.

6. The claimant is capable of performing past relevant work as

a translation design analyst. This work does not require the

performance of work-related activities precluded by the

claimant’s residual functional capacity (20 CFR 404.1565).

7. The claimant has not been under a “disability” as defined in

the Social Security Act from March 20, 2005 through the date of

this decision (20 CFR 404.1520(g) and 416.920(g)). 

(Tr. 14-22). 

III. Standard of Review

A court reviews the Commissioner’s final decision to determine whether the factual

findings are supported by substantial evidence and whether the proper legal standards were

applied in weighing the evidence and making the decision. Flake v. Gardner, 399 F.2d 532,

540 (9th Cir. 1968). “Substantial evidence” means such relevant evidence as a reasonable

mind might accept as adequate to support a conclusion. Burch v. Barnhart, 400 F.3d 676, 679

(9th Cir. 2005). Where evidence is susceptible to more than one rational interpretation, a court

must uphold the ALJ’s conclusion. Id.

The standard of review in social security appeals is the same whether the case involves

a denial of disability insurance benefits or a denial of supplemental security income. 42

U.S.C. §§ 405(g) and 1383 (c)(3). The definition of disability is also the same: whether the

claimant became unable to engage in substantial gainful activity by reason of any medically

determinable physical or mental impairment that can expect to result in death or which has

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lasted or can be expected to last for a continuous period of at least twelve months. 20 C. F.R.

§§ 404.1505 and 416.905.

IV. Discussion

A. Evaluation Process

The Social Security Regulations establish a five-step sequential evaluation process to

be followed by the ALJ in a disability case. 20 C.F.R. § 404.1520. At step one of the

process, the ALJ must determine whether the claimant is currently engaged in substantial

gainful activity; if so, a finding of non-disability is made and the claim is denied. 20 C.F.R.

§ 404.1520(b). 

When the claimant is not currently engaged in substantial gainful activity, the ALJ, in

step two, must determine whether the claimant has a severe impairment or combination of

impairments significantly limiting her from performing basic work activities; if not, a finding

of non-disability is made and the claim is denied. 20 C.F.R. § 404.1520(c). A severe

impairment or combination of impairments exists when there is more than a minimal effect

on an individual's ability to do basic work activities. 20 C.F.R. § 404.1521(a); Smolen v.

Chater, 80 F.3d 1273, 1290 (9th Cir. 1996). Basic work activities are "the abilities and

aptitudes necessary to do most jobs," including physical functions such as walking, standing,

sitting, lifting, pushing, pulling, reaching, carrying or handling, as well as the capacity for

seeing, hearing and speaking, understanding, remembering and carrying out simple

instructions, use of judgment, responding appropriately to supervision, co-workers and usual

work situations, and dealing with changes in a routine work setting. 20 C.F.R. § 404.1521(b).

At the third step, the ALJ must compare the claimant's impairment to those in the

Listing of Impairments, 20 C.F.R. § 404, Subpart P, App. 1; if the impairment meets or equals

an impairment in the Listing, disability is conclusively presumed and benefits awarded. 20

C.F.R. § 404.1520(d). 

When the claimant's impairment does not meet or equal an impairment in the Listing,

in the fourth step, the ALJ must determine whether the claimant has sufficient RFC despite

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the impairment or various limitations to perform her past work; if so, a finding of nondisability is made and the claim is denied. 20 C.F.R. § 404.1520(e). 

When the claimant shows an inability to perform past relevant work, a prima facie case

of disability is established and, in step five, "the burden shifts to the Commissioner to show

that the claimant can perform some other work that exists in 'significant numbers' in the

national economy, taking into consideration the claimant's residual functional capacity, age,

education, and work experience." 20 C.F.R. § 404.1520(f). 

B. Analysis

Here, the ALJ resolved Plaintiff’s claim at step four and found that Plaintiff “is capable

of performing past relevant work as a translation design analyst.” (Tr. 21).

Plaintiff raises two objections to the ALJ's findings and disability determination: 1)

that the ALJ erred by rejecting the opinion of her treating physician without providing

adequate reasons; and 2) that the ALJ erred by rejecting Plaintiff’s testimony without

providing adequate reasons. Both arguments are evaluated below.

1. Dr. D’Souza’s opinion is not well-supported and is contradicted by

other evidence in the record.

The Plaintiff takes issue with the ALJ’s determination that Dr. D’Souza’s opinion that

she is disabled “conflicts with other substantial evidence of record,” and that Dr. D’Souza

failed to “consider the entire record, including the statements of collateral sources and the

objective findings of other treating physicians.” (Tr. 20-21). The Commissioner argues the

Plaintiff’s arguments are without merit and the ALJ’s decision is supported by substantial

evidence.

If a treating or examining doctor's opinion is contradicted by another doctor's opinion,

an ALJ may only reject it by providing specific and legitimate reasons that are supported by

substantial evidence. Lester v. Chater, 81 F.3d 821, 830-31 (9th Cir. 1995). The Ninth

Circuit’s standards for evaluating opinions from treating physicians are as follows:

By rule, the Social Security Administration favors the opinion of

a treating physician over non-treating physicians. See 20 C.F.R.

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§ 404.1527. If a treating physician’s opinion is “well-supported

by medically acceptable clinical and laboratory diagnostic

techniques and is not inconsistent with the other substantial

evidence in [the] case record, [it will be given] controlling

weight.” Id. § 404.1527(d)(2). If a treating physician’s opinion

is not given “controlling weight” because it is not “wellsupported” or because it is inconsistent with the other substantial

evidence in the record, the Administration considers specified

factors in determining the weight it will be given. Those factors

include the “[l]ength of the treatment relationship and the

frequency of examination” by the treating physician; and the

“nature and extent of the treatment relationship” between the

patient and the treating physician. Id. § 404.1527(d)(2)(i)-(ii).

Generally, the opinions of examining physicians are afforded

more weight than those of non-examining physicians, and the

opinions of examining non-treating physicians are afforded less

weight than those of treating physicians. Id. § 404.1527(d)(1)-

(2). Additional factors relevant to evaluating any medical

opinion, not limited to the opinion of the treating physician,

include the amount of relevant evidence that supports the opinion

and the quality of the explanation provided; the consistency of

the medical opinion with the record as a whole; the specialty of

the physician providing the opinion; and “[o]ther factors” such as

the degree of understanding a physician has of the

Administration’s “disability programs” and their evidentiary

requirements’ and the degree of his or her familiarity with other

information in the record. Id. § 404.1527(d)(3)-(6).

Orn v. Astrue, 495 F.3d 625, 631 (9th Cir. 2007).

In her motion, Plaintiff focuses on her physical limitations and contends that Dr.

D’Souza’s findings of muscle spasm, limitation of motion, muscle weakness, reflex loss,

positive straight leg raising, inability to heal and to walk, lower extremity pain and sensory

radiculopathy, chronic dizziness, tremor and decreased sensory response are supported by the

opinions and treatment rendered by Dr. Halter and Dr. Prust. Motion, p. 8. Plaintiff contends

that the ALJ’s reasons for rejecting the opinions are vague and inaccurate, and therefore not

subject to adequate review. While Plaintiff may find some support for this argument when

considering the treatment rendered by the pain physicians to whom she was referred, her

argument does not withstand scrutiny when evaluated based on other considerations cited by

the ALJ in his decision.

The ALJ noted that “[p]hysical examinations were generally unremarkable with few

minimal abnormal findings.” (Tr. 19). The ALJ supported this statement by citing the records

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of Dr. D’Souza which “reported from April 21, 2006 through May 19, 2008 that the claimant

had continuing complaints of low back pain, however, practically all examinations of the back

(approximately 15) were unremarkable with findings of no external bruising, no erythema,

no tenderness to palpation, and usually normal range of motion and negative straight leg raise

testing.” (Tr. 19). A review of the record establishes this finding is legitimate. Although Dr.

D’Souza characterized Plaintiff’s maladies as completely disabling when completing

disability forms, his records suggest otherwise. As the Commissioner points out, in February

2007, Dr. D’Souza found the Plaintiff had no acute joint inflammation, erythema, or warmth

and had only “mild subjective” right hip discomfort. (Tr. 232-34). In April 2007, she was

again reported to have no acute inflammation, erythema, or warmth in her joints. She had

normal range of motion in her back with no tenderness to palpation and could lie down and

rise from that position. (Tr. 346-48). In June, she had only “mild discomfort” on palpation

of the muscles around the neck and again was reported with no acute inflammation, erythema,

or warmth in her joints and only “mild” subjective discomfort in her right hip, and “some”

discomfort to muscle palpation. (Tr. 343-45). Additionally, although not specifically cited

by the ALJ, Plaintiff’s 2006 MRI showed only minimal multilevel disc degeneration with no

herniated disks or stenosis. (Tr. 274). 

The ALJ also addressed Plaintiff’s knee complaints, noting that when Plaintiff

complained of knee pain, Dr. D’Souza found she had “very minimal” knee swelling and

tenderness. (Tr. 404-05). A subsequent x-ray of the knee was “negative and normal.” (Tr.

402). In fact, virtually every objective diagnostic procedure failed to support the existence

or extent of the condition for which it was ordered. Her brain MRI did not support a finding

of Bell’s palsy. (Tr. 272). An MRI of her hips was normal with “no DJD, malalignment,

fracture, bone bruise, bone marrow edema, joint effusion, or bursal enlargement.” (Tr. 273).

An MRI of her lumbar spine showed only “mild, multilevel anterolateral disc bulge

throughout the lumbar spine but no significant posterior or neural foraminal disc bulge,” no

significant muscle atrophy, no compression deformity, no significant disc height loss, no

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central canal stenosis or neural foraminal stenosis and no significant facet degeneration, and

the impression was “[m]inimal multilevel disc degeneration. No HNP, central canal stenosis,

or neural foraminal stenosis.” (Tr. 274). An x-ray of the lumbar spine showed “[n]o

significant radiographic abnormality of the lumbar spine.” (Tr. 275). Her EKG “showed an

incomplete right bundle branch but otherwise negative.” (Tr. 247). 

Considering the evidence of the record, Dr. D’Souza’s disability opinion is not “wellsupported by medically acceptable clinical and laboratory diagnostic techniques” and is

inconsistent with other substantial evidence in the record. SSR96-2p at *1, 61 Fed.Reg.

34,490, 34, 491, 1996 WL 374188 (July 2, 1996). As discussed above, and as determined by

the ALJ, Dr. D’Souza’s opinions “did not adequately consider the entire record.” (Tr. 20).

The ALJ’s decision not to afford any significant weight to those opinions was supported by

the objective evidence. As the ALJ concluded:

In sum, the lack of objective medical evidence, the conservative

nature of the treatment provided and multiple examinations

performed, which revealed generally normal findings with

subjective complaints of pain, showed little evidence of

impairment, much less a disabling impairment.

(Tr. 21). As Dr. D’Souza’s opinion was contradicted by those of Dr. Fahlberg and Dr.

Stafford, the ALJ was permitted to find that the opinions of the non-examining doctors

constituted substantial evidence because they were consistent with and supported by other

independent evidence in the record. Lester, 81 F.3d at 830-31. Because the evidence is

readily susceptible to the interpretation of the ALJ, the decision must be upheld. Morgan v.

Comm’r, 169 F.3d 595, 599 (9th Cir. 1999).

2. The ALJ’s credibility determination must be upheld.

Plaintiff argues that the ALJ, rather than first determining the credibility of Plaintiff’s

subjective complaints of pain, instead first determined her Residual Functional Capacity and

“then compared the Plaintiff’s symptoms to it to determine whether or not the Plaintiff’s

symptoms are credible.” Motion, p. 10. However, Plaintiff’s argument ignores the bulk of

the ALJ’s analysis of Plaintiff’s credibility and the determination must be upheld. 

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"Questions of credibility and resolution of conflicts in the testimony are functions

solely of the Secretary." Sample v. Schweiker, 694 F.2d 639, 642 (9th Cir. 1982). The ALJ's

credibility findings must be supported by specific, cogent reasons. See Rashad v. Sullivan,

903 F.2d 1229, 1231 (9th Cir. 1990). When the credibility of pain testimony is at issue, and

there is medical evidence of an underlying impairment, the ALJ may not discredit a claimant's

testimony as to the severity of symptoms merely because they are unsupported by objective

medical evidence. See Bunnell v. Sullivan, 947 F.2d 341, 347-48 (9th Cir. 1991). Rather, the

ALJ must identify what testimony is not credible and what evidence undermines the

claimant's complaints. Lester v. Chater, 81 F.3d 821, 834 (9th Cir. 1995). The ALJ’s findings

must be supported by clear and convincing reasons why a claimant’s testimony of excess pain

is not credible and must be supported by substantial evidence in the record as a whole. 

Johnson v. Shalala, 60 F3d. 1428, 1433 (9th Cir. 1995).

In reviewing the medical evidence as a whole, the ALJ determined that her treatment

was conservative and that the clinical and laboratory findings did not support the severity of

pain reported by the Plaintiff. (Tr. 19). As discussed at length above, this finding is

supported by the evidence in the record. Additionally, the ALJ found that Plaintiff “describes

an active lift that includes handling her personal needs, maintaining her household while

living alone, attending multiple medical appointments, and doing recent volunteer work.” (Tr.

19). Plaintiff disputes none of these findings, nor could she. In fact, Dr. D’Souza, despite

opining that she was incapacitated and “required complete freedom to rest frequently without

restriction” (Tr. 410-13), only a few months before was advising her to volunteer at a local

hospital, “so that she can find something to keep her busy.” (Tr. 402). The fact that Plaintiff

was able to perform limited activities of daily living such as driving, shopping and personal

grooming, and that her treating physician was telling her to find volunteer work, provided

legitimate support to the ALJ’s credibility finding. Bunnell, 947 F.2d at 346.

This Court finds that the ALJ’s findings are both supported by substantial evidence and

free of legal error. 

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V. RECOMMENDATION FOR DISPOSITION BY THE DISTRICT JUDGE

Based on the foregoing and pursuant to 28 U.S.C. § 636(b) and Local Rule 1.17(d)(2),

Rules of Practice of the United States District Court, District of Arizona, the Magistrate Judge

recommends that the District Court, after an independent review of the record, DENY

Plaintiff's Motion for Summary Judgment (Doc. 16) and uphold the final decision of the

Commissioner.

This Recommendation is not an order that is immediately appealable to the Ninth

Circuit Court of Appeals. Any notice of appeal pursuant to Rule 4(a)(1), Federal Rules of

Appellate Procedure, should not be filed until entry of the District Court's judgment. 

However, the parties shall have fourteen (14) days from the date of service of a copy

of this recommendation within which to file specific written objections with the District

Court. See 28 U.S.C. § 636(b)(1) and Rules 72(b), 6(a) and 6(e) of the Federal Rules of Civil

Procedure. Thereafter, the parties have fourteen (14) days within which to file a response to

the objections. If any objections are filed, this action should be designated case number: CV

09-510-TUC-CKJ. Failure to timely file objections to any factual or legal determination of

the Magistrate Judge may be considered a waiver of a party's right to de novo consideration

of the issues. See United States v. Reyna-Tapia 328 F.3d 1114, 1121 (9th Cir. 2003) (en banc).

DATED this 2nd day of August, 2010.

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