Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_10-cv-00163/USCOURTS-casd-3_10-cv-00163-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:405 Review of HHS Decision (DIWC)

---

1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10cv0163 1

UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

MARY A. ROCKETT,

Plaintiff,

v.

MICHAEL J. ASTRUE,

Respondent.

 

)

)

)

)

)

)

)

)

)

)

)

Civil No. 10-0163-DMS(WVG)

REPORT AND RECOMMENDATION:

DENYING PLAINTIFF’S MOTION FOR

SUMMARY JUDGMENT (DOC. # 23)

GRANTING DEFENDANT’S MOTION

FOR SUMMARY JUDGMENT 

(DOC. # 25)

I

INTRODUCTION

Plaintiff Mary A. Rockett (hereinafter “Plaintiff”), filed a

Complaint for Judicial Review and Remedy On Administrative Decision

Under the Social Security Act [42 U.S.C. §405(g)]. Defendant Michael

J. Astrue (hereinafter “Defendant”), filed an Answer to the

Complaint and the administrative record pertaining to this case.

Plaintiff has filed a Motion for Summary Judgement. Defendant has

filed an Opposition to Plaintiff’s Motion for Summary Judgment and

a Cross-Motion for Summary Judgment.

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 1 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10cv0163 2

The Court, having reviewed Plaintiff’s Motion for Summary

Judgment, Defendant’s Opposition to Plaintiff’s Motion for Summary

Judgment, Defendant’s Cross-Motion for Summary Judgment, the

supplemental briefing by both parties, and the administrative record

filed by Defendant, hereby finds that Plaintiff is not entitled to

the relief requested and therefore RECOMMENDS that Plaintiff’s

Motion for Summary Judgement be DENIED and Defendant’s Motion for

Summary Judgment be GRANTED.

II

PROCEDURAL HISTORY

Plaintiff filed concurrent applications for benefits based on

disability in July 2001. On August 9, 2002, the Honorable Peter J.

Valentino, Administrative Law Judge, denied Plaintiff’s application.

On February 22, 2005, Plaintiff filed subsequent applications. On

June 24, 2005, Plaintiff’s applications were denied. Plaintiff did

not appeal. (Administrative Record [hereinafter “AR”] at 11). 

In this case, on March 27, 2007, Plaintiff filed applications

for Supplemental Security Income benefits and Disability Insurance

Benefits, alleging that she had been disabled since January 31,

2007. (AR at 116-122). The Commissioner of Social Security denied

her application initially and upon reconsideration. (AR at 67-71,

77-81). On June 9, 2009, a hearing was held at which Plaintiff

appeared with counsel and testified before the Honorable Larry B.

Parker, Administrative Law Judge (hereinafter “the ALJ”). (AR at 18-

50). On June 30, 2009, the ALJ found that Plaintiff was not

disabled. (AR at 10-17). On July 13, 2009, Plaintiff’s attorney

filed a Request for Review of Hearing Decision. On November 20,

2009, the ALJ’s decision became the final decision of the CommisCase 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 2 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

1/ The Declaration of Service omits the method used by Plaintiff to serve

Defendant and the date on which service was accomplished.

2/ The additional evidence presented by Plaintiff primarily consists of medical

records dated after the ALJ’s decision. These records post-date the decision and

concern, in large part, injuries relating to a October 14, 2009 motor vehicle

accident. The additional evidence is not relevant to a discussion of whether or

not the ALJ’s determination was correct. Therefore, the Court will not address the

additional evidence.

10cv0163 3

sioner of Social Security when the Appeals Council denied Plaintiff’s request for review. (AR at 1-3). 

On January 20, 2010, Plaintiff filed her Complaint for

Judicial Remedy and Review on Administrative Decision (hereinafter

“Complaint”). On January 28, 2010, Plaintiff filed a supplemental

document with additional evidence. On September 9, 2010, Plaintiff

moved for Entry of Default. On September 14, 2010, the District

Judge assigned to this case denied the Motion, noting that Plaintiff

had not completed service upon Defendant. On September 21, 2010,

Plaintiff filed a Declaration of Service.1/

 On November 19, 2010,

Defendant filed an Answer to the Complaint (hereinafter “Answer”)

and the administrative record.

On December 29, 2010, Plaintiff filed a Motion for Summary

Judgment. On February 4, 2011, Defendant filed an Opposition to

Plaintiff’s Motion for Summary Judgment and a Cross-Motion for

Summary Judgment (hereinafter “Defendant’s Opposition”). On March 4,

2011, Plaintiff filed an Opposition to Defendant’s Motion for

Summary Judgment. On June 1, 2011, Plaintiff filed additional

evidence.2/ On June 16, 2011, Defendant filed a Supplemental Brief

Addressing Additional Evidence Plaintiff Submitted to the Court,

arguing such additional evidence is irrelevant to the determination

of the issues before the court. On June 27, 2011, Plaintiff filed a

supplemental briefing and additional evidence. 

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 3 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

3/ In a Disability Report completed by Plaintiff, she contradictorily reported

having completed the 12th grade. (AR at 167). At a psychiatric evaluation, she

reported having completed only 10th grade. (AR at 266).

4/ In a Disability Report completed by Plaintiff, she contradictorily reported

that she did not work subsequent to her disability onset of January 31, 2007. (AR

at 162).

10cv0163 4

III

STATEMENT OF FACTS

Plaintiff was born on July 30, 1957. (AR at 10, 25). She

completed only the 9th grade3/ and in the last fifteen years,

Plaintiff has worked as a security guard, an auto parts delivery

driver, and has cared for her grandchildren. (AR at 10, 25, 29-33,

209, 219). She claims that she became unable to work on January 31,

2007 due to fibromyalgia, heart problems, back problems, asthma,

migraines, dyslexia, stress, kidney problems, and blood in her

stool. In addition, Plaintiff complains of depression and anxiety.

(AR at 10, 27, 162). Plaintiff admits to working a limited number of

days subsequent to her alleged onset date of January 31, 2007.4/ (AR

at 150-155).

On March 27, 2007, a Disability Report regarding Plaintiff

was completed by A. Villasenor. (AR 160). Villasenor apparently

works for the Social Security Administration, although his or her

exact capacity is unspecified. (See AR 156). Villasenor noted that,

during the interview, Plaintiff did not display any difficulties,

and was difficult to interview as she was rude, arrogant, and

forgetful. (AR at 157-168).

On June 25, 2007, Plaintiff received a workers compensation

settlement of $25,100, after other expenses. (AR at 43-44).

On September 24, 2007, Plaintiff completed a Function Report.

She alleged that she could no longer cook, clean, play with her

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 4 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

5/ Plaintiff claims she cannot raise her arm over her head or neck to comb her

hair. Although she does not specify which arm she is referring, it is probably,

given the context, that Plaintiff’s claim is that she cannot so raise either of

her arms.

6/ Subluxation is an “incomplete luxation or dislocation; though a relationship

is altered, contact between joint surfaces remains.” Stedman’s Medical Dictionary,

27th Ed. (2000).

10cv0163 5

grandchildren, drive for a long time, or work her job. She also

alleged that she could not sleep, raise her arm above her head, or

dress herself.5/

 She further alleged that she needed reminders to

bathe, among other functional limitations. (AR at 201-207).

A. PHYSICAL MEDICAL HISTORY

1. DR. RICHARD SCOTT CAMPBELL, TREATING PHYSICIAN

Plaintiff initially visited Sharp Medical Group in November

2006 due to an alleged back injury resulting from lifting a 40-50

pound box at work on November 26, 2006. (AR at 228)

On this date, Plaintiff had “plain film radiographs” taken of

her lumbar spine. Five views of the lumbar spine showed no fracture

or subluxation6/ and that Plaintiff’s intervertebral disk spaces were

preserved. The results were deemed “negative examination” as read by

Dr. Peter Yang. (AR at 235).

Since this alleged injury, Plaintiff reported that she has

experienced constant pain in her lower back, radiating to her

buttocks. (AR at 228). Plaintiff received prescriptions for Vicodin

and Flexeril and was advised to follow up with Occupational Health

Services. (AR at 229).

On November 28, 2006, Plaintiff followed up with Occupational

Health Services. Dr. Campbell first evaluated Plaintiff on this

date. Plaintiff reported to Dr. Campbell that she had hurt her back

at work lifting a tub filled with parts. Plaintiff described the

pain as increasing, that she had pain to her left buttocks, and

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 5 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

7/ Myoflex Creme is an anti-inflammatory drug. See http://www.drugs.com/

cdi/myoflex-cream.html

8/ Toradol is a non-steroidal anti-inflammatory drug used to treat mild to

moderate pain. See Kristyn S. Appleby and Joanne Tarver, Medical Records Review, § 5.7 Medications, t.5-2.

9/ Radiculopathy is a “disorder of the spinal nerve roots.” Stedman’s Medical

Dictionary, 27th Ed. (2000).

10cv0163 6

numbness going down the left leg to her foot. (AR at 229). Dr.

Campbell examined Plaintiff and diagnosed her with lumbar strain,

thoracic strain, and left-sided sciatica. She was given prescriptions for ibuprofen, Myoflex Creme, Vicodin ES, and Valium.7/

Plaintiff was also given an injection of Toradol.8/ (AR at 229-230).

Plaintiff subsequently was seen by the Physician’s Assistant

at Sharp Medical Group. Plaintiff reported that her pain had not

gotten better and that she now had numbness in her feet and shooting

pain down her right leg. Plaintiff requested refills of her

medication. (AR at 230).

On January 2, 2007, Dr. Campbell re-evaluated Plaintiff.

Plaintiff reported that her pain seemed to be decreasing, although

after intercourse her pain increased significantly. (AR at 230).

Plaintiff complained of bilateral radiculopathy9/, described as

numbness, pain, and tingling. The examination showed that Plaintiff

had significant difficulty moving around. Plaintiff was to continue

with physical therapy, and continue using her ibuprofen, Vicodin,

and Valium. Plaintiff also received an injection of Toradol. (AR at

230).

On January 16, 2007, Plaintiff was seen again by Dr.

Campbell. Plaintiff reported that she was doing slightly better and

that her physical therapy was helping, although she was still taking

the Vicodin and Valium periodically and her pain level was still

quite high. Plaintiff’s examination was unchanged and she was to

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 6 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10/ A ten would indicate the highest level of pain.

11/ “Herniated nucleus pulposus” refers to a torn or damaged pulpy center (as

in the center of the discs of the spinal cord). See Stedman’s Medical Dictionary,

27th Ed. (2000) (entries for “nucleus pulposus”). “Thoracic strain” refers to a

strain of the upper part of the trunk, between the neck and abdomen. Id. (entries

for “thorax”).

12/ Stenosis is a “stricture of any canal or orifice.” Stedman’s Medical

Dictionary, 27th Ed. (2000).

13/ “Bilateral neural foraminal narrowing” refers to a narrowing of the natural

openings in the spine that allow the spinal cord to pass through.

10cv0163 7

continue with physical therapy. Plaintiff was referred for an MRI as

her symptoms indicated a possible herniated disc. She was given a

refill of Vicodin, Valium, and ThermaCare Patches. (AR at 231).

On January 30, 2007, Plaintiff reported that her pain had

increased, which Dr. Campbell thought was odd since she had

previously reported her pain was ten on a scale of one to ten.10/

Plaintiff stated that she hurt her back significantly at work

lifting a 25 pound box and that the lifting and driving requirements

of her job aggravated her back pain. Plaintiff’s diagnosis was

modified to lumbar strain with probable herniated nucleus pulposus,

thoracic strain, and bilateral radiculopathy.11/ (AR at 231).

On February 9, 2007, Plaintiff had an MRI of her lumbar

spine. Findings indicated (1) focal central disk protrusion at L4-5

measuring up to 5MM, (2) no central spinal stenosis12/, and (3) mild

bilateral neural foraminal narrowing13/ at L4-4 and L5-S1 as read by

Baseer Khan, M.I. (AR at 235).

On February 16, 2007, Plaintiff reported that she was doing

worse, despite having not worked for several days after being sent

home by her employer. Plaintiff stated that the last day she worked,

she lifted a 40 pound box, possibly explaining the increase in her

pain level. (AR at 231).

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 7 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10cv0163 8

On March 6, 2007, Plaintiff reported that she was doing a

little better and that she had been seen by Dr. John Serocki, an

orthopedic surgeon. Dr. Campbell spoke with Dr. Serocki, who

informed him that he did not feel as if Plaintiff were a candidate

for surgery or that corticosteroid injections would be helpful.

Plaintiff’s diagnosis was modified lumbar strain, thoracic strain,

bilateral radiculopathy, L4-5 central disk protrusion of 5mm, and

L4-5 neural foraminal narrowing. Plaintiff was sent back to work on

a modified status. (AR at 232).

On March 19, 2007, it was noted that Plaintiff had been

complaining of neck discomfort. Plaintiff was working as a cashier,

was not doing any heavy lifting, and was tolerating this work

well.(AR at 232).

On April 3, 2007, Plaintiff reported an increase in pain and

was upset because her chair was taken away at work, which was

helping her to be more comfortable at the register. Plaintiff

complained of more numbness in her foot and asked for temporary

totally disabled status but was refused. (AR at 232).

On April 10, 2007, Plaintiff had her permanent and stationary

evaluation. Plaintiff reported stabbing pain in her mid-lumbar

region. Plaintiff also complained of an inability to turn in bed and

continued leg numbness, pain, and tingling. She alleged that when

her back symptoms flare up, her leg symptoms do as well. Plaintiff

claimed that she occasionally lost her balance and had some tripping

and that her neck pain had begun with her initial injury. (AR at

232-233).

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 8 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

14/ Fibromyalgia is “a syndrome of chronic pain of musculoskeletal origin but

uncertain cause.” Stedman’s Medical Dictionary, 27th Ed. (2000).

15/ Antalgic gait is “a characteristic gait resulting from pain on weightbearing

[leg] in which the stance phase of gait is shortened on the affected side.”

Stedman’s Medical Dictionary, 27th Ed. (2000).

10cv0163 9

Plaintiff claimed to have been diagnosed with fibromyalgia

years earlier, initially causing pain in her hands and feet, and now

pain in her arms and hands.14/

 (AR at 233).

Plaintiff complained that she was having difficulty with

multiple activities, including (1) intercourse, (2) walking long

distances, (3) sitting for a long time, (4) cooking, (5) cleaning,

and (6) using stairs. Plaintiff alleged that she cannot even lift a

gallon of milk. (AR at 233-234).

Dr. Campbell found that Plaintiff was alert, was in no

apparent distress, but did appear to be sitting uncomfortably on the

examination table. Plaintiff moved around uncomfortably and had

difficulty lying down and getting up from a lying position. (AR at

233).

Examination of Plaintiff’s back showed no obvious abnormalities or deformities, but did reveal some tenderness to palpation at

various points. Plaintiff’s grip strength measured 0/0/0 on both

hands, although she reported no pain in her hands that day. (AR

at234). Dr. Campbell noted that Plaintiff got up from the examination table slowly and that her gait is slightly antalgic.15/

Dr. Campbell opined that Plaintiff’s condition had reached

permanent and stationary status because her symptoms had essentially

remained unchanged and she had achieved maximum medical improvement.

(AR at 237). Furthermore, he believed Plaintiff required work

restrictions in the open labor market as she could not sit for

longer than one hour, stand for longer than one hour, walk for

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 9 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

16/ For example, Mr. Iannazzo states “Plaintiff was unable to transfer self

without antalgia [antalgic gait] into a supine from sitting position, but able to

lift both legs without issue when placing bolster under legs...Grip strength is

so low that [Petitioner] would be essentially nonfunctional without documented

wrist or hand pathology. [Petitioner able to drive with extremely high pain

report. Finally, in regard to driving, [Plaintiff] would be a danger to self and

others if cervical and lumbar active range of motion was actually this restricted

since she is driving such a large vehicle. When stepping down from her truck, this

is at least a 21-inch rise from the ground to the step, but the patient reports

that she is unable to do a 7-inch step for stairs. [Petitioner] entered her truck

without antalgia at the end of the examination. This is observed from directly

from the window of the clinic that overlooks the parking lot.” (AR at 236).

10cv0163 10

longer than one hour, bend or twist repeatedly, lift more than 20

pounds, or push and pull more than 25 pounds. (AR at 238).

2. ADAM IANNAZZO, M.P.T.

On March 23, 2007, Adam Iannazzo performed a Functional

Capacity Examination on Plaintiff. Mr. Iannazzo’s evaluation aimed

to determine whether Plaintiff could meet the essential job

requirements of a delivery driver. (AR at 235). However, the

examination requested was a “fitness for duty” examination and was

not as thorough as Mr. Iannozzo would have done for a Functional

Capacity Examination. (AR at 235)

Mr. Iannazzo found that Plaintiff’s behavior reflected pain,

but felt she was giving sub-maximal and inconsistent effort.

Therefore, he was unable to determine her abilities. He did note

that Plaintiff was capable of walking without restriction, that she

was unable to squat, that she was able to stand for one hour during

the examination, and that she was able to lift a seven and one half

pound box, but could not lift a 10 pound box. However, she was able

to carry a 10 pound box 30 feet. Furthermore, Plaintiff was able to

carry 15 pounds but reported lower back pain upon doing so and

seemed to have “maxed out.” (AR at 235).

Mr. Iannazzo noted several inconsistencies between Plaintiff’s testing results and her reported abilities.16/ (AR at 235-

236). He concluded that “[t]he detailed inconsistencies above show

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 10 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10cv0163 11

that this client is fabricating her symptoms and lifting impairment

for secondary gains and magnifying her symptoms so as to remain out

of work, and further medical intervention should be based solely on

scientific objective findings since subjective reports are not

trustworthy or accurate of the client’s actual pain or ability.” (AR

at 236).

3. DR. G.G. SPELLMAN

On June 1, 2007, Dr. Spellman performed a Physical Residual

Functional Capacity Assessment (hereinafter “RFC”) with regard to

Plaintiff. Dr. Spellman opined that Plaintiff could (1) occasionally

lift/carry twenty pounds, (2) frequently lift/carry ten pounds, (3)

stand for six hours of an eight hour work day, (4) sit for six hours

of an eight hour work day, and (5) conduct unlimited pushing or

pulling (including hand/foot controls). (AR at 242). Additionally,

she could occasionally balance, stoop, kneel, crouch, crawl, and

climb, but not on ladders. (AR at 243).

4. DR. STEVEN GOODMAN

On July 4, 2007, Plaintiff was admitted to an emergency room

with a left-side migraine and was treated by Dr. Goodman. Her

migraine was characterized with sensitivity to light, extreme

nausea, and several episodes of vomiting. Dr. Goodman reported that

these symptoms are “pretty typical” of Plaintiff’s migraines,

although “[p]ossibly a little bit more severe than usual.” Plaintiff

had been outside on a hot day for a significant period of time when

the migraine began. Plaintiff reported being completely pain-free an

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 11 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

17/ Diluadid is an opiate analgesic, typically prescribed for therapeutic pain

relief. See Physicians Desk Reference (2005) (available at 2005 WL 4060823).

Phenergan is an antihistamine, typically prescribed to treat allergy symptoms. See

http://en.wikipedia.org/wiki/Phenergan; see also Wyeth v. Levine, 555 U.S. 555

(2009) (“Phenergan is Wyeth's brand name for promethazine hydrochloride, an

antihistamine used to treat nausea.”).

18/ Although the record states the pain begin in Plaintiff’s right shoulder, it

does not state which arm the pain radiated into.

19/ It is unclear when these x-rays were taken. Given the similarities as to

date, time, and issue, the Court will assume that the x-rays were taken during

Plaintiff’s emergency room visit that occurred on the same day.

10cv0163 12

hour after being given 2mg of Dilaudid and 12.5mg of Phenergan

intravenously.17/ (AR at 301).

5. JULY 24, 2008 EMERGENCY ROOM VISIT

On July 24, 2008, Plaintiff took a bus to the UCSD Medical

Center and was admitted to the emergency room for shoulder pain. The

triage nurse recorded that Plaintiff’s pain was dull and began in

her right shoulder before radiating to her arm.18/ Plaintiff reported

a pain level of ten out of ten, that the pain was not caused by a

work or domestic violence related injury, and that the pain had

existed for about three weeks. The treating physician, Dr. Angela

Pham, reported being unable to fully assess Plaintiff’s shoulder due

to pain. Plaintiff was given prescriptions for Vicodin and Motrin.

Upon discharge, she reported a pain level of two out of ten. (AR at

377-79, 387). 

6. JULY 24, 2008 X-RAYS

On July 24, 2008, Dawn Engelkemier and John Stassen reviewed

x-rays taken of Plaintiff’s right shoulder.19/ They found normal bone

alignment, no evidence of acute fracture, and nothing remarkable

about Plaintiff’s soft tissues. (AR at 385).

On the same day, Engelkemier and Stassen reviewed x-rays

taken of Plaintiff’s cervical spine. They found no evidence of acute

fracture, dislocation, or misalignment. However, they found

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 12 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

20/ Myofascial pain syndrome refers to pain in the fibrous tissue separating

muscles from each other and from the skin. See Stedman’s Medical Dictionary, 27th

Ed. (2000) (entries for “myofascial” and “fascia”).

21/ Lidocaine is a local anaesthetic. Stedman’s Medical Dictionary, 27th Ed.

10cv0163 13

“significant degenerative disc disease at C5-C6" and noted that

“[g]iven the severity of the disease at this single level, it is

likely secondary to prior trauma or prior infection.” (AR at 386).

7. FEBRUARY 7, 2009 EMERGENCY ROOM VISIT

On February 7, 2009, Plaintiff took a bus to the UCSD Medical

Center for an MRI and a medication refill. While at the hospital,

she was admitted to the emergency room at the UCSD Medical Center

due to leg pain. The triage nurse recorded that Plaintiff’s pain was

constant and began in her left buttock before radiating to her left

leg. Plaintiff reported a pain level of nine out of ten and that the

pain was not caused by a work or domestic violence related injury.

She was prescribed four medications. However, these medications are

not identified in the record. Plaintiff was accompanied by two

grandsons and identified herself as their primary caregiver. Upon

discharge, she reported a pain level of three out of ten. (AR at

377-79, 387).

8. DR. MICHAEL SCOTT JAFFE

On April 14, 2009, Plaintiff visited Dr. Jaffe, who specializes in osteopathic medicine. Her chief complaint was pain in her

neck, right shoulder, and right arm. Dr. Jaffe diagnosed myofascial

pain syndrome, carpal tunnel syndrome, and chronic pain syndrome.20/

He prescribed Lidocaine in 700mg topical patches.21/ Dr. Jaffe also

ordered an MRI of Plaintiff’s cervical spine and instructed

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 13 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

22/ On April 30, 2009, an MRI of Plaintiff’s cervical spine was performed by Dr.

Glenn H. Tsukada. He found “mild spinal stenosis” and “moderate ... foraminal

narrowing.” (AR at 355-56). On February 7, 2009, an MRI of Plaintiff’s lumbar

spine was performed by Dr. Jon M. Robins. He found a “[s]mall midline disc

protrusion with annular fissure. No compromise of the central canal or foramina.”

(AR at 376). An annular fissure is a ring-shaped fissure. See Stedman’s Medical

Dictionary, 27th Ed. (2000).

23/ Synovitis is an inflammation of the fluid-containing membranes of a joint.

It is often associated with or used to refer synonymously to arthritis. See

Stedman’s Medical Dictionary, 27th Ed. (2000) (entries for “synovitis” and

“synovial fluid”).

24/ The name “Dr. Jaffrey” has been written underneath the signature line on the

pages of this assessment. (See AR at 330, 332). The same name is typed on one

page. (See AR at 333). It is likely that Dr. Jaffrey is actually Dr. Jaffe.

10cv0163 14

Plaintiff to call him two days after the MRI to review the results.

(AR at 343-45).22/

Dr. Jaffe noted that Plaintiff was alert, had normal

sensation, normal strength, and normal reflexes. However, he also

noted that Plaintiff had “[g]reater than 11/18 tender points of

Fibromyalgia syndrome” with “no active synovitis”.23/ (AR at 346).

The nursing notes for this visit listed 40 prescribed medications.

(AR at 347-51).

9. DR. JAFFREY

On April 14, 2009 (the same day that Plaintiff visited Dr.

Jaffe), Dr. Jaffrey completed a “Physical Capacities Evaluation”

regarding Plaintiff.24/ This evaluation indicated that she could sit,

stand, or walk for zero hours at a time. Somewhat inconsistently,

Dr. Jaffrey reported that, out of an eight-hour workday, Plaintiff

was able to sit for two hours, stand for one hour, and walk for one

hour. (AR at 334).

In terms of lifting ability, Dr. Jaffrey indicated that

Plaintiff could occasionally lift 6-10 or 11-20 pounds but never

greater than 21 pounds. Dr. Jaffrey did not mark a box for the 0-5

pounds category. (Id.).

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 14 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

25/

 Qvar and albuterol are anti-inflammatory drugs typically prescribed to treat

the symptoms of asthma. See Physicians Desk Reference (2005) (available at 2005

WL 4061219); see also Stedman’s Medical Dictionary, 27th Ed. (2000). Nortriptyline

is an antidepressant. Id.

10cv0163 15

In terms of carrying ability, Dr. Jaffrey indicated that

Plaintiff could occasionally carry 6-10 pounds but never greater

than 21 pounds. Dr. Jaffrey did not mark a box for the 0-5 or 11-20

pound categories. (Id.).

In terms of using her hands, Dr. Jaffrey indicated that

Plaintiff could not push or pull arm controls but that should could

engage in fine manual manipulation. Dr. Jaffrey did not mark a box

for the “simple grasping” category. (Id.).

However, on the same day, Dr. Jaffrey completed a one-page

form that stated a diagnosis of “Chronic Pain Syndrome”. Dr. Jaffrey

noted that Plaintiff could occasionally engage in fine or gross

manipulative activities with her hands and could rarely engage in

“pushing/pulling activities”. (AR at 333).

Dr. Jaffrey indicated that Plaintiff could occasionally bend,

squat, or reach but could not crawl or climb. Additionally, Dr.

Jaffrey indicated that Plaintiff was totally restricted from

activities involving unprotected heights, driving automotive

equipment, and exposure to dust, fumes, and gases. (AR at 334).

10. DR. ERWIN GUZMAN

Two days later, on April 16, 2009, Plaintiff saw Dr. Guzman.

He diagnosed her with asthma, myofascial pain syndrome, and carpal

tunnel syndrome. Plaintiff requested that Dr. Guzman fit her with

wrist splints. He prescribed Qvar in an inhaler, albuterol in an

inhaler, and nortriptyline in 10mg doses.25/ Dr. Guzman also ordered

x-rays of Plaintiff’s knees and ankles. (AR at 353).

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 15 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

26/ Tramadol is an analgesic drug, typically prescribed to treat moderate to

severe pain. Stedman’s Medical Dictionary, 27th Ed. (2000).

27/ Hydrocodone-acetaminophen is the active ingredient in Vicodin. See

http://en.wikipedia.org/wiki/Hydrocodone/acetaminophen. Carisoprodol is a

skeletal muscle relaxant with abuse potential. Stedman’s Medical Dictionary, 27th

Ed. (2000). Prednisone is an anti-inflammatory drug. Id. Lexapro and Trazadone are

antidepressant drugs. See http://en.wikipedia.org/wiki/Lexapro; see

http://en.wikipedia.org/wiki/Trazadone.

10cv0163 16

On April 29, 2009, Plaintiff saw Dr. Guzman about her knee

pain. He prescribed Tramadol in 50mg oral tablets.26/ At this time,

Plaintiff was already taking the following pain and depression

medications: 1) nortriptyline in 10mg capsules, 2) Lipoderm in 700mg

patches, 3) hydrocodone-acetaminophen in 500mg oral tablets, 4)

carisoprodol in 350mg oral tablets, 5) prednisone in 10mg oral

tablets, 6) Lexapro in 10mg oral tablets, 7) Trazadone in 100mg oral

tablets.27/ Plaintiff was also taking medications for a cough and for

asthma. (AR at 336-37). On April 29, 2009, Plaintiff was given a

knee brace. (AR at 367).

11. DR. SANDRA CHRISTIANSEN

On May 6, 2009, Dr. Christiansen described Plaintiff’s asthma

and rhinitis in a letter addressed “[t]o whom it may concern”. In

this letter, Dr. Christiansen stated that Plaintiff’s respiratory

tract problems were “poorly controlled” and that her exercise was

therefore “limited”. (AR at 375).

12. NORM HARDMAN, THERAPY SPECIALIST

On June 3, 2009, Plaintiff saw Norm Hardman, a therapy

specialist. Plaintiff reported the following limitations: 1) ability

to sit limited to less than 30 minutes, 2) ability to walk limited

to less than 15 minutes, 3) inability to bend without pain. Mr.

Hardman recommended physical therapy twice a week for three to four

weeks. (AR at 410).

B. PSYCHIATRIC MEDICAL HISTORY

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 16 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

28/ Serial sevens are a diagnostic test in which the patient performs serial

substraction of sevens from one hundred. It is often used to assess mental status.

See http://en.wikipedia.org/wiki/Serial_sevens; see also 20 C.F.R. 404, Subpt. P,

App. 1, 12.00.

10cv0163 17

1. DR. MOUNIR SOLIMAN

On July 28, 2007, Dr. Soliman conducted a “Complete Psychiatric Evaluation” of Plaintiff at the request of the Department of

Social Services. Dr. Soliman noted Plaintiff brought herself to the

clinic by public transit and that her gait was normal. Plaintiff

reported using the public transit for her transportation needs.

Plaintiff complained of depression; “[d]espite medication, Plaintiff

report[ed] sadness, decreased energy and decreased concentration, as

well as anxiety and irritability.” She alleged that she was unable

to work as a result of her physical and psychiatric condition.

However, she reported being able to cook, clean, shop, run errands,

attend to her personal hygiene, and manage her finances. (AR at 266)

At the evaluation, Plaintiff’s immediate, recent, and remote

memory was tested and found intact. Specifically, she was oriented

to person, place, and time, she correctly recalled three of three

objects after five minutes, and was able to perform serial sevens

without errors.28/ Plaintiff’s abstract thinking was normal, her

insight and judgment were good, and her reality associations were

not loose. However, she did report auditory hallucinations.

Furthermore, Plaintiff’s mood and affect were depressed. (AR at 266-

67).

In terms of work, Dr. Soliman determined that Plaintiff was

able to comprehend, remember, and carry out instructions. She could

withstand the stress of a normal eight-hour workday on a day-to-day

basis. (AR at 268).

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 17 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

29/ As noted supra, it is likely that Dr. Jaffrey is likely the same doctor as

Dr. Jaffe. If they are the same physician, it is unclear what expertise Dr. Jaffe,

an osteopathic doctor, has in psychiatry. The paperwork signed by Dr. Jaffrey does

not list an associated clinic or hospital.

10cv0163 18

On August 3, 2007, Dr. K.J. Loomis summarized the evidence in

Plaintiff’s file, including Dr. Soliman’s evaluation, and completed

a Mental Residual Functional Capacity Assessment (hereinafter “First

MRFC”). Dr. Loomis found no significant limitations on Plaintiff’s

mental capacity except as to the “ability to understand and remember

detailed instructions” and “ability to carry out detailed instructions” categories. In these two categories, Dr. Loomis noted that

Plaintiff’s capacity was “moderately limited.” (AR at 280, 282).

2. DR. JAFFREY

On the same day (April 14, 2009) that Plaintiff visited Dr.

Jaffe, a second Mental Residual Functional Capacity Assessment

(hereinafter “Second MRFC”) was written by Dr. Jaffrey.29/ Like the

First MRFC, the Second MRFC summarized evidence in Plaintiff’s file.

The Second MRFC indicates that Plaintiff was moderately limited in

ten categories, including “ability to perform activities within a

schedule, maintain regular attendance, and be punctual within

customary tolerances” and “ability to maintain socially appropriate

behavior and to adhere to basic standards of neatness and cleanliness.” (AR at 330-31).

Furthermore, Dr. Jaffrey indicated in the Second MRFC that

Plaintiff was “markedly limited” in “the ability to complete a

normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an

unreasonable number and length of rest periods.” Unlike Dr. Loomis’

assessment in the First MRFC, Dr. Jaffrey did not complete the

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 18 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

30/ Buspar is used to treat generalized anxiety disorders. See

http://en.wikipedia.org/wiki/Buspar

10cv0163 19

narrative section entitled “Functional Capacity Assessment”. (AR at

331-32).

3. THIRD MRFC

On May 6, 2009, a third Mental Residual Functional Capacity

Assessment (hereinafter “Third MRFC”) was written by a therapist

whose signature is illegible. The Third MRFC was based on observations made at two appointments; April 30, 2009 and May 6, 2009. The

Third MRFC indicates that Plaintiff was moderately limited in ten

categories and markedly limited in four categories. Of the twenty

categories, the Third MRFC matches the First MRFC in seven categories and the Second MRFC in six categories. Although the Third MRFC

was 21 months after the First MRFC, it was less than 1 month after

the Second MRFC. (AR at 397-98; see also AR at 280-82, 330-32).

4. DR. SAMUEL ETCHIE

On May 18, 2009, Dr. Etchie confirmed Plaintiff’s diagnosis

of Major Depressive Disorder with Anxiety Features in a letter

addressed “To Whom It May Concern”. In this letter, Dr. Etchie noted

that Plaintiff had been prescribed Lexapro, Trazadone, and Buspar

for daily use.30/ (AR at 399).

IV

SUMMARY OF APPLICABLE LAW

Title II of the Social Security Act (hereinafter “Act”), as

amended, provides for the payment of insurance benefits to persons

who have contributed to the program and who suffer from physical or

mental disability. 42 U.S.C. § 423(a)(1)(D). Title XVI of the Act

provides for the payment of disability benefits to indigent persons

under the Supplemental Security Income (SSI) program. § 1382(a).

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 19 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10cv0163 20

Both titles for the Act define “disability” as the “inability to

engage in any substantial gainful activity by reason of any

medically determinable physical or mental impairment which can be

expected to last for a continuous period of not less than 12

months...” Id. The Act further provides that an individual: 

...shall be determined to be under a disability only

if his physical or mental impairment or impairments

are of such severity that he is not only unable to do

his previous work but cannot, considering his age,

education, and work experience, engage in any other

kind of substantial gainful work which exists in the

national economy, regardless of whether such work

exists in the immediate area in which he lives, or

whether a specific job vacancy exists for him, or

whether he would be hired if he applied for work. 42

U.S.C. § 423(d)(2)(a).

The Secretary of the Social Security Administration has established

a five-step sequential evaluation process for determining whether a

person is disabled. 20 C.F.R. §§ 404.1520, 416.920. 

Step one determines whether the claimant is engaged in

“substantial gainful activity.” If he is, disability benefits are

denied. 20 C.F.R. §§ 404.1520(b), 416.920(b). If he is not, the

decision maker proceeds to step two.

Step two determines whether the claimant has a medically

severe impairment or combination of impairments. That determination

is governed by the “severity regulation”. The severity regulation

provides in relevant part:

If you do not have any impairment or combination of

impairments which significantly limits your physical

or mental ability to do basic work activities, we will

find that you do not have a severe impairment and are,

therefore, not disabled. We will not consider your

age, education, and work experience. §§ 404.1520(c),

416.920(c).

The ability to do basic work activities is defined as “the abilities

and aptitudes necessary to do most jobs.” 20 C.F.R. §§ 404.1521(b),

416.921(b). Such abilities and aptitudes include “[p]hysica

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 20 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10cv0163 21

functions such as walking, standing, sitting, lifting, pushing,

pulling, reaching, carrying, or handling;” “[c]apacities for seeing,

hearing, and speaking;” “[u]nderstanding, carrying out, and

remembering simple instructions;” “[u]se of judgment;” “[r]esponding

appropriately to supervision, co-workers, and usual work situations;” and “[d]ealing with changes in a routine work setting.” Id.

If the claimant does not have a severe impairment or combination of

impairments, the disability claim is denied. If the impairment is

severe, the evaluation proceeds to step three.

Step three determines whether the impairment is equivalent to

one of a number of listed impairments that the Secretary acknowledges are so severe as to preclude substantial gainful activity. 20

C.F.R. §§ 404.1520(d), 416.920(d). If the impairment meets of equals

one of the listed impairments, the claimant is conclusively presumed

to be disabled. If the impairment is not one that is conclusively

presumed to be disabling, the evaluation proceeds to step four.

Step four determines whether the impairment prevents the

claimant from preforming work he has performed in the past. If the

claimant is able to perform his previous work, he is not disabled.

20 C.F.R. §§ 404.1520(e), 416.920(e). If the claimant cannot perform

his previous work, the evaluation proceeds to step five.

Step five, the final step of the process, determines whether

he is able to perform other work in the national economy in view of

his age, education, and work experience. The claimant is entitled to

disability benefits only if he is not able to perform other work.

[20 C.F.R. §§ 404.1520(f), 416.920(f)].

V

ALJ’S FINDINGS

The ALJ made the following pertinent findings:

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 21 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10cv0163 22

1. [Plaintiff] meets the insured status requirements

of the Social Security Act through December 31, 2012.

2. [Plaintiff] has not engaged in substantial gainful

activity since January 31, 2007, the alleged onset

date (20 CFR 404.1571 et seq., and 416.971 et seq.).

3. [Plaintiff] has the following severe impairments:

degenerative disc disease of the cervical and lumbar

spine, obesity, asthma, migraine headaches, an

adjustment disorder and an anxiety disorder (20 CFR

404.1520(c) and 416.920©)).

4. [Plaintiff] 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, 404.1526, 416.925 and

416.926).

5. After careful consideration of the entire record,

the undersigned finds that [Plaintiff] has the

residual functional capacity to perform light work as

defined in 20 CFR 404.1567(b) and 416.967(b) except

for any climbing of ladders, ropes or scaffolds and is

limited to occasional climbing of ramps and stairs and

occasional balancing, stooping, kneeling, crouching

and crawling; and more than simple, repetitive tasks

if she has minimal or no contact with the general

public.

6. [Plaintiff] is unable to perform any past relevant

work (20 CFR 404.1565 and 416.965).

7. [Plaintiff] was born on July 30, 1957 and was 49

years old, which is defined as a younger individual

age 18-49, on the alleged disability onset date.

[Plaintiff] subsequently changed age category to

closely approaching advanced age. (20 CFR 404.1563 and

416.963).

8. [Plaintiff] has a limited education and is able to

communicate in English (20 CFR 404.1564 and 416.964).

9. Transferability of job skills is not material to

the determination of disability because using the

Medical-Vocational Rules as a framework supports a

finding that [Plaintiff] is “not disabled,” whether or

not the claimant has transferable job skills (See SSR

82-41 and 20 CFR Part 404, Subpart P, Appendix 2).

10. Considering [Plaintiff’s] age, education, work

experience, and residual functional capacity, there

are jobs that exist in significant numbers in the

national economy that [Plaintiff] can perform,

including the following unskilled light occupations

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 22 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

31/ SVP stands for Specific Vocational Preparation. An SVP of 2 indicates an

unskilled task that requires less than 31 days of training. 20 C.F.R. § 656.3.

10cv0163 23

with an SVP of 231/: inspector (DOT No. 5459.687-074)

of which there are 8400 jobs in the regional economy

and 140,000 in the national economy and hand packer

(DOT No. 685.687-014) of which there are 3500 jobs in

the regional economy and 680,000 jobs in the national

economy. This finding, which is made within the

framework of Medical-Vocational Rules 202.18 and

202.11 of Table No.2 of Appendix 2 to Subpart P of

Regulations No. 4, is predicated on expert vocational

testimony (20 CFR 404.1569, 404.1569a, 416.969, and

416.969a).

11. The claimant has not been under a disability, as

defined in the Social Security Act, from January 31,

2007 through the date of this decision (20 CFR

404.1520(g) and 416.920(g)).

VI

STANDARD OF REVIEW

“The findings of the Commissioner of Social Security as to

any fact, if supported by substantial evidence, shall be conclusive.” 42 U.S.C. § 405(g). Substantial evidence is defined as

relevant evidence that a reasonable mind might accept as adequate to

support a conclusion. Richardson v. Perales, 402 U.S. 389, 401

(1971); Mathews v. Shalala, 10 F.3d 678, 679 (9th Cir. 1993)

(“Substantial evidence, considering the entire record, is relevant

evidence which a reasonable person might accept as adequate to

support a conclusion.”). A reviewing court’s role is not to

determine whether the record can support the claimant’s alternative

view of the evidence, but whether substantial evidence supports the

ALJ’s conclusions. Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir.

2005) (“Where evidence is susceptible to more than one rational

interpretation, it is the ALJ’s conclusion that must be upheld.”).

A district court may only disturb the Commissioner’s final

decision “if it is based on legal error or if the fact findings are

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 23 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28 32/ In fact, Plaintiff’s Motion for Summary Judgment appears to be a photocopy

of her Complaint with the words “MOTION FOR SUMMAY [sic] JUDGMENT” added

immediately after the caption and title.

10cv0163 24

not supported by substantial evidence.” Sprague v. Bowen, 812 F. 2d

1226, 1229 (9th Cir. 1987); see Villa v. Heckler, 797 F.2d 794, 796

(9th Cir. 1986). The court cannot affirm the Commissioner’s final

decision simply by isolating a certain amount of supporting

evidence. Rather, the court must examine the administrative record

as a whole. Gonzalez v. Sullivan, 914 F.2d 1197, 1200 (9th Cir.

1990). However, the Commissioner’s findings are not subject to

reversal simply because substantial evidence exists in the record to

support a different conclusion. See, e.g., Mullen v. Brown, 800 F.2d

535, 545 (6th Cir. 1986). The Commissioner’s decision must be set

aside, even if supported by substantial evidence, if improper legal

standards were applied in reaching that decision. See, e.g., Benitez

v. Califano, 573 F.2d 653, 655 (9th Cir. 1978).

VII

DISCUSSION

Plaintiff’s Complaint argues that Plaintiff’s “information

was not presented and the decision was unfair” and alleges that the

Defendants “didn’t send me to there [sic] doctor at all...”.

(Complaint at 1-2). Beyond these two contentions, the Complaint

appears to be a litany of Plaintiff’s alleged medical conditions.

(See Complaint).

Plaintiff’s Motion for Summary Judgment reiterates the

arguments made in the Complaint.32/ However, Plaintiff attaches a

copy of her Request for Review of Hearing Decision letter, originally sent by her attorney to the Appeals Council. The request

letter alleged that the “ALJ’s decision is not based on substantial

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 24 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10cv0163 25

evidence, and that [the ALJ] committed legal error.” On November 20,

2009, the Appeals Council denied this request. The Court presumes

that Plaintiff intends the argument presented in the letter to apply

to the Motion for Summary Judgment now before the Court.

On this basis, Plaintiff appears to argue that the ALJ erred

in rejecting the opinions of treating physicians in favor of

opinions from one-time examiners and that the ALJ’s decision was

therefore not based on substantial evidence.

Defendant argues that the ALJ’s decision was supported by

substantial evidence, noting that Plaintiff’s residual functional

capacity assessment found her able to “perform a range of simple,

repetitive light work...” Defendant notes that assessing residual

functional capacity is an administrative, rather than medical,

function and is the responsibility of the Commissioner. See 20

C.F.R. §§ 404.1427(e), 16.927(e)(2); see also Vertigan v. Halter,

260 F.3d 1044, 1049 (9th Cir. 2001) (“it is the responsibility of

the ALJ, not the claimant’s physician, to determine residual

functional capacity.”) Since the ALJ’s decision was based on

substantial evidence, Defendant contends that the ALJ did not commit

legal error.

A. SUBSTANTIAL EVIDENCE SUPPORTS THE ALJ’S DETERMINATIONS

Plaintiff argues that the ALJ erred in rejecting the opinions

of treating doctors in favor of opinions of one-time examiners. As

a matter of law, no error exists. ALJs are not required to give

controlling weight to a treating physician’s opinion unless it is

well-supported and not inconsistent with other substantial evidence

in the record. 20 C.F.R. §§ 404.1527(d)(2), 416.927(d)(2) (“If we

find that a treating source’s opinion... is well supported... and

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 25 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10cv0163 26

not inconsistent with the other substantial evidence... we will give

it controlling weight.”); see also Holohan v. Massanari, 246 F.3d

1195, 1202-03 (9th Cir. 2001)

As explained in Holohan, “[a]n ALJ may reject the uncontradicted medical opinion of a treating physician only for ‘clear and

convincing’ reasons supported by substantial evidence in the

record.” Id. at 1202 (internal quotation marks and citation

omitted). Alternatively, “[a]n ALJ may rely on the medical opinion

of a non-treating doctor instead of the contrary opinion of a

treating doctor only if she or he provides specific and legitimate

reasons supported by substantial evidence in the record.” Id.

(internal quotation marks and citation omitted).

An ALJ may reject subjective accounts “upon (1) finding

evidence of malingering, or (2) expressing clear and convincing

reasons for doing so.” Benton v. Barnhart, 331 F.3d 1030, 1040 (9th

Cir. 2003). Dr. Campbell’s report, summarized supra, is rife with

evidence of such malingering.

Here, opinions by Plaintiff’s treating doctors are contradictory. Even if they were not contradictory, the ALJ had clear and

convincing reasons, supported by substantial evidence in the record,

for not giving the treating doctors’ opinions controlling weight.

A. DR. CAMPBELL

Dr. Campbell, a treating physician, reported that he believed

Plaintiff was precluded from sitting, standing, or walking for

greater than one hour at a time. Also, he reported that she could

not do any repetitive bending or twisting and could not lift more

than 20 pounds. (AR at 238). However, his opinion notes that

Plaintiff had “four extremely positive Waddell tests for symptom

magnification.” (AR at 236) The opinion also quotes Mr. Iannazzo’s

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 26 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10cv0163 27

report of “inconsistencies... show[ing] that [Plaintiff] is

fabricating her symptoms and lifting impairment for secondary gains,

and magnifying her symptoms as to remain out of work... subjective

reports are not trustworthy or accurate of [Plaintiff’s] actual...

ability.” (Id.) Dr. Campbell concluded that Plaintiff’s “subjective

complaints have been out of proportion to physical examination

findings, and functional capacity examination showed inconsistent

and/or submaximal effort...” (AR at 237).

Dr. Campbell concludes that “[o]verall, [Plaintiff] is rated

as having a 6 percent impairment of the whole person.” (AR at 238).

Although Dr. Campbell believed Plaintiff was precluded from

standing, sitting, or walking for greater than one hour at a time,

a second doctor who reviewed Dr. Campbell’s report concluded

otherwise. Dr. Spellman concluded that Plaintiff could sit or stand

for six hours of an eight hour work day.

B. DR. JAFFE (JAFFREY)

On April 14, 2009, Plaintiff visited Dr. Jaffe, another

treating doctor. There are also several records from a Dr. Jaffrey

that are dated April 14, 2009. As noted supra, these appear to be

the same doctor and will be so addressed by the Court.

The opinions signed by Drs. Jaffe and Jaffrey are also

inconsistent and clearly controverted by other substantial evidence

in the record. Dr. Jaffe, an osteopathic specialist, recommended

that Plaintiff undergo an MRI and instructed her to call him two

days after the MRI to discuss the results. On April 30, 2009, the

MRI was completed. However, it appears that Dr. Jaffrey’s opinions

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 27 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

33/ These opinions are signed by Dr. Jaffrey, not Dr. Jaffe.

10cv0163 28

regarding Plaintiff’s physical and psychiatric limitations were

written on April 14, 2009.33/

Dr. Jaffrey’s opinion of Plaintiff’s physical limitations

were that she could sit, stand, or walk for zero hours at a time.

However, Dr. Jaffrey contradictorily noted that Plaintiff was able

to sit for two hours, stand for one hour, and walk for one hour out

of an eight-hour workday. Furthermore, several sections of the

opinion incorporated forms with check boxes for various weight

ranges. Dr. Jaffrey checked off boxes corresponding to higher weight

ranges but did not check off boxes for intermediate or lower

ranges. For example, Dr. Jaffrey indicated that Plaintiff could

occasionally carry 6-10 pounds but never greater than 21 pounds. Dr.

Jaffrey did not mark a box for the 0-5 or 11-20 pound categories.

The opinions signed by Drs. Jaffe and Jaffrey are therefore

contradictory and internally inconsistent.

Even if these opinions were not contradictory, they are

clearly controverted by other substantial evidence in the record,

including the opinion of Plaintiff’s earlier treating physician, Dr.

Campbell, as discussed supra. The opinions signed by Drs. Jaffe and

Jaffrey are also inconsistent with that given by Dr. Spellman, also

discussed supra.

Dr. Jaffrey also assessed Plaintiff’s psychiatric fitness and

recorded his results in Plaintiff’s Second MRFC. His reason for

doing so, and his ability to do so accurately, are unclear since his

area of expertise is osteopathic medicine. Three such MRFCs are in

the record; the First MRFC was conducted by Drs. Soliman and Loomis,

and the Third MRFC was conducted by a therapist whose name is

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 28 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

34/ The Second MRFC was conducted 20 months after the First MRFC and matches the

First MRFC in eleven categories.

10cv0163 29

illegible. Of the twenty categories, the Second MRFC matches the

Third MRFC, dated less than a month later, in just six categories.34/

The opinion of Dr. Jaffe/Jaffrey, Plaintiff’s treating

physician, as to Plaintiff’s physical limitations was internally

contradictory and inconsistent with other substantial evidence in

the record. Furthermore, the opinion of Dr. Jaffe/Jaffrey as to

Plaintiff’s psychiatric limitations were inconsistent with other

substantial evidence in the record. Therefore, the ALJ did not err

in electing not to give controlling weight to these opinions.

C. UNKNOWN THERAPIST / DR. ETCHIE

On May 6, 2009, a therapist whose name is illegible wrote the

above-mentioned Third MRFC. The ALJ apparently believed that this

therapist was associated with Dr. Etchie. The therapist noted that

he or she had only seen Plaintiff twice, once for 45 minutes and

once for 25 minutes. On May 18, 2009, Dr. Etchie, Plaintiff’s

treating psychiatrist, confirmed Plaintiff’s diagnosis of Major

Depressive Disorder with Anxiety Features in a letter addressed “To

Whom It May Concern”.

The ALJ noted that Dr. Etchie had only seen Plaintiff twice,

once for 45 minutes and once for 25 minutes, and therefore determined that Dr. Etchie had not established the type of physicianpatient relationship that would lend special weight to a treating

physician’s opinion. See 20 C.F.R. §§ 404.1527, 416.927(d)(2)(i)

(length of the treatment relationship and the frequency of examination are important factors in determining weight assigned to

resulting opinion).

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 29 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10cv0163 30

If the ALJ was correct in assuming that Dr. Etchie and the

therapist were associated, the ALJ’s determination that no special

physician-patient relationship existed between Plaintiff and Dr.

Etchie is correct. If the ALJ was incorrect, the determination would

apply to the therapist. Furthermore, if the ALJ was incorrect, the

lack of any records beyond Dr. Etchie’s “To Whom It May Concern”

letter clearly indicates that Dr. Etchie also lacked such a

physician-patient relationship with Plaintiff. 

Even if Dr. Etchie or the therapist had established such a

relationship with Plaintiff, the opinion expressed in the Third MRFC

was inconsistent with other substantial evidence in the record. For

example, Drs. Soliman and Loomis determined that Plaintiff had

essentially no psychiatric limitations preventing her from working,

as stated in the First MRFC. (See AR at 280-82). In fact, the Third

MRFC only matches the First MRFC in seven of twenty categories.

Since Dr. Etchie and the unknown therapist both failed to

establish a physician-patient relationship of the type entitling

resulting opinions to special weight, the ALJ did not err in

electing not to give such weight to their opinions. Furthermore,

because the opinion of Dr. Etchie or the unknown therapist as to

Plaintiff’s psychiatric limitations were inconsistent with other

substantial evidence in the record, the ALJ did not err in electing

not to give controlling weight to these opinions.

D. OPINIONS OF OTHER DOCTORS ARE SUBSTANTIAL EVIDENCE SUPPORTING THE

ALJ’S DECISION

The ALJ justifiably elected not to give controlling weight to

the opinions of either Plaintiff’s actual or purported treating

physicians. See Holohan, 246 F.3d at 1202. Furthermore, the ALJ

based that election on specific and legitimate reasons developed

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 30 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10cv0163 31

from substantial evidence in the record. See id. at 1203. Specifically, the opinions of Plaintiff’s physical limitations signed by

Drs. Jaffe and Jaffrey were controverted by the opinion of Plaintiff’s earlier treating physician, Dr. Campbell. Furthermore, the

opinions of Dr. Etchie and the unknown therapist were controverted

by the opinions of Drs. Soliman and Loomis.

Since the ALJ had specific and legitimate reasons for his

election and because that election was within the bounds of the

relevant law, the ALJ did not commit legal error as alleged by

Plaintiff.

For the aforementioned reasons, the Court RECOMMENDS

Plaintiff’s Motion for Summary Judgment be DENIED and Defendant’s

Motion for Summary Judgment be GRANTED. 

VI

CONCLUSION AND RECOMMENDATION

After a review of the record in this matter, the undersigned

Magistrate Judge RECOMMENDS that the Plaintiff’s Motion for Summary

Judgment be DENIED and Defendant’s Motion for Summary Judgment be

GRANTED.

This Report and Recommendation of the undersigned Magistrate

Judge is submitted to the United States District Judge assigned to

this case, pursuant to the provision of 28 U.S.C. § 636(b)(1).

IT IS ORDERED that no later than September 6, 2011, any party

to this action may file written objections with the Court and serve

a copy on all parties. The document should be captioned “Objections

to Report and Recommendation.”

IT IS FURTHER ORDERED that any reply to the objections shall

be filed with the court and served on all parties no later than

September 20, 2011. The parties are advised that failure to file

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 31 of 32
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10cv0163 32

objections within the specified time may waive the right to raise

those objections on appeal of the Court’s order. Martinez v. Ylst,

951 F.2d 1153 (9th Cir. 1991).

DATED: August 16, 2011

 Hon. William V. Gallo

 U.S. Magistrate Judge

Case 3:10-cv-00163-AJB-WVG Document 37 Filed 08/16/11 Page 32 of 32