Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_11-cv-02579/USCOURTS-casd-3_11-cv-02579-1/pdf.json

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

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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

ERNESTO AZADA MANGAT,

Plaintiff,

CASE NO. 11cv2579-GPC(BGS)

ORDER ADOPTING REPORT

AND RECOMMENDATION

GRANTING PLAINTIFF’S

MOTION FOR SUMMARY

JUDGMENT; DENYING

DEFENDANT’S MOTION FOR

SUMMARY JUDGMENT AND

REMANDING MATTER TO

COMMISSIONER OF SOCIAL

SECURITY

vs.

MICHAEL J. ASTRUE,

Commissioner of Social Security,

Defendant.

Plaintiff Ernesto Azada Mangat (hereinafter “Plaintiff”) brings this action

pursuant to § 405(g) of the Social Security Act (hereinafter “Act”) to obtain judicial

review and remedy of the final decision of the Commissioner of the Social Security

Administration (hereinafter “Defendant”) in a claim for disability insurance benefits

under Title II of the Act. 42 U.S.C. § 405(g). Before the Court are the parties’ cross

motions for summary judgment. On January 2, 2013, Magistrate Judge Skomal filed

a report and recommendation granting Plaintiff’s motion for summary judgment and

denying Defendant’s motion for summary judgment. (ECF No. 23.) The Magistrate

Judge recommended that the matter be remanded to the Commissioner for further

proceedings. (Id.) On January 18, 2013, Defendant filed objections to the report and

recommendation. (ECF No. 24.) Plaintiff filed a reply to Defendant’s objections on

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February 5, 2013. (ECF No. 26.) Based on the reasoning below, the Court ADOPTS

the report and recommendation granting Plaintiff’s motion for summary judgment and 

denying Defendant’s motion for summary judgment. The Court REMANDS the

matter to the Commissioner of Social Security for further proceedings. 

Background

The Magistrate Judge’s report and recommendations provides a factual

background that is not objected to by the parties. Accordingly, the Court adopts the

factual background of the Magistrate Judge and recites them below. 

1

Plaintiff filed an application for a period of disability and disability insurance

benefits on January 22, 2009, alleging disability beginning on December 10, 2008.

(Administrative Record (“AR”) 18, 41.) Plaintiff’s application was based on, but not

limited to, insulin-dependent diabetes mellitus, back pain from kidney stones, chest

pain and gout. (AR 24, 42.) Plaintiff’s application was denied initially and upon

reconsideration. (AR 18.) Thereafter, he requested a hearing before an ALJ. (Id.) 

ALJ Parker held a hearing on November 10, 2010. (Id.) Plaintiff appeared and

testified at the hearing, represented by his attorney Harold O. McNeil, Esq. (Id.) John

R. Morse, M.D., a medical expert, and Gloria J. Lasoff, M.A., a vocational expert, also

appeared and testified. (Id.)

A. Relevant Medical Records / Diagnoses Submitted to ALJ Prior to Hearing

1. Insulin Dependent Diabetes Mellitus With Mild Sensory Neuropathy

Plaintiff has a ten year history of treatment for diabetes: originally being treated

with oral medications, and later, in approximately 2008, being treated with insulin. 

(AR 337.) Throughout these ten years, Plaintiff “has never been hospitalized for out

of control blood sugar . . . ”, and has never suffered from diabetic ulcers or lesions. 

(AR 337, 480.) 

Yet, on November 30, 2009 the consultative examiner, (“CE”), Phong T. Dao,

D.O., noted that Plaintiff’s glucose level was high, and that his blood sugar was not

The Court has added some facts for clarity. 

1

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controlled. (AR 341-342.) Further, progress notes from Operation Samahan, a

community health clinic, show that, as of April 2, 2010, Plaintiff’s diabetes was in fair

to poor control with an elevated blood sugar level at 130 mg/dL. (AR 443.) In

addition, various medical records evidence that Plaintiff has never complied with his

diet restrictions or medication instructions. (AR 231, 246, 264, 268, 280, 281, 387.)

2. Renal Insufficiency

Plaintiff has renal insufficiency. On December 18, 2009, Sharp Chula Vista

Medical Center noted that after Plaintiff’s bypass surgery his renalsymptoms were not

significantly changed frombefore. (AR 363.) Further, medicalrecords fromPlaintiff’s

treating physician, Dr. Elena Maria Bautista-Sacamay (“Dr. Sacamay”), at Balboa

Nephrology Medical Group on March 31, 2010 and May 27, 2010, show that although

Plaintiff did notrequire hemodialysus or peritoneal dialysis, Plaintiffreceived specialty

care for his renal insufficiency. (AR 405-413.) Also, lab resultsfrom June 9, 2010 and

September 25, 2010, establish that Plaintiff’s creatinine levels were elevated. (AR

475-476.) Most recently, in a discharge summary fromMarch 3, 2010, Paradise Valley

Hospital confirmed Plaintiff’s chronic kidney disease, as well as the presence of

hematuria (presence of red blood cells) in his urine. (AR 450-451.)

3. Polyarticular Gouty Arthritis (“Gout”)

As a consequence of his diabetes, Plaintiffsuffers fromgout. For example, signs

of gout and accompanying pain were evidenced at the outset of Plaintiff’s medical

records, namely in the Kaiser medicalrecords from March 3, 2008 to October 18, 2008. 

(AR 236-237.) Specifically, the Kaiser medical records state: (1) on October 9, 2009,

“[l]eft hand mild tenderness in his hand with TOM no edema or erythema present,”

(AR 247), (2) on September 14, 2008, left hand and left finger numb, and wrist pain

“likely due to uncontrolled gout,” (AR 274, 276), and (3) on December 10, 2008,

“[n]umbness and tingling of bilateral feet” but no foot lesions.” (AR 280.)

Moreover, on November 30, 2009, the CE noted that Plaintiff “has a history of

diabetic peripheral neuropathy [and] [o]n today’s examination, his sensation to light

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touch in the extremities was in tact.” (AR 342.) The CE also acknowledged that

Plaintiff “has intermittent burning pain in the feet.” (AR 338.) Further, Samahan

Medical Center noted on February 5, 2010, that Plaintiff suffered from joint swelling

with pain for a week. (AR 374.) And, between May 21, 2009 and August 25, 2010,

Operation Samahan indicated in its progress notes that Plaintiff complained of: (1) arm

swelling on February 5, 2010, (AR 436), (2) right foot and shoulder pain on February

25, 2010, (AR 433), (3) left elbow and right foot pain on April 16, 2010, (AR 429), and

(4) left knee swelling on September 16, 2010. (AR 430.) 

More recently, on March 3, 2010, the Paradise Valley Hospital stated that

Plaintiff was admitted to the Emergency Room in February for polyarthralgias (pain

in two or more joints). (AR 450-451.) During his admittance, Plaintiff had an elevated

blood cell count and a positive antinuculear antibody (“ANA”) test, but negative RH

factor. (Id.) A positive ANA test is an indication of an autoimmune disorder.

Consequently, Plaintiff was provided a steroid taper, responded positively, and was

discharged with referrals for follow-up care. (Id.) Last, in its progress notes from

September 3, 2010 to September 25, 2010, Operation Samahan noted that both of

Plaintiff’s feet were swollen and as a result, Plaintiff suffered from left leg pain. (AR

480-81.)

4. Coronary Artery Disease, Bypass Surgery, and Congestive Heart

Failure

Plaintiff has coronary artery disease and underwent three-vessel coronary artery

bypass surgery in November 2009. On November 30, 2009, the CE wrote: 

The claimant has no history of stroke but he did have a history of

myocardial infarction recently, on November 12, 2009. His myocardial

infarction was so severe that he had to have a three vessel cardiac

bypass. Since the bypass, about two weeks ago, he continues to have

midsternal chest pain especially with coughing, sneezing, deep breaths

or bending down to pick up objects. The pain can also occur while he

is sitting or lying down resting. He can now only walk about one block

before getting shortness of breath and experience midsternal chest

pain. When pain occurs, he denies any pain radiation and denies any

nausea or vomiting. The pain can last anywhere from a few minutes to

several hours. He is currently taking pain medication to help with the

chest pain. 

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(AR 338.)

Since the bypass surgery, Plaintiff has experienced intermittent chest pain. For

instance, at Sharp Chula Vista Medical Center on December 18, 2009, after bypass

surgery, Dr. Ali noted “no shortness in breath or chest pain.” (AR 362.) And on March

31, 2010 and May 27, 2010, Dr. Sacamay indicated that Plaintiff “denies chest pain nor

[sic] shortness or breath.” (AR 405, 408.) Yet, between May 21, 2009 and August 25,

2010, Operation Samahan wrote in its progress notes that Plaintiff complained of chest

pain three times. (AR 417, 419, 427.) Moreover, on March 3, 2010, Paradise Valley

Hospital’s discharge summary stated that Plaintiff was admitted to the Emergency

Room for polyarthralgias, but emphasized Plaintiff had an “atypical chest pain episode

during his hospital stay.” (AR 450-451.)

Last, Dr. Fernandez’s progress notes about Plaintiff’s recovery from December

31, 2009 to September 14, 2010, noted that Plaintiff (1) recovered but continued to

receive follow up care, (AR 464), (2) stabilized, (AR 464), and (3) experienced the

occasional chest pain, (AR 464), but his lungs were clear and there were no episodes

of arrhythmia. (AR 464-469.)

5. Relevant “Lesser” Diagnoses

Plaintiff has also suffered from:

a. Back Pain

On November 30, 2009, the CE diagnosed Plaintiff with back pain. (AR 340.) 

And on October 18, 2010, Dr. Sacamay diagnosed Plaintiff with back pain. (AR 493.) 

Dr. Sacamay indicated that the pain wasfrom kidney stones, (AR 340), whereasthe CE

did not specify, he simply wrote the pain was in the lumbar region. (AR 340.)

b. Kidney / Renal Stones

Paradise Valley Hospital indicated in its March 3, 2010 discharge summary that

Plaintiff had “[m]ultiple shadowing left renal stones without hydronephrosis.” (AR

461.) And on March 31, 2010 and May 27, 2010, Dr. Sacamay noted Plaintiff had

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“nonobstructing multiple renal stones.” (AR 405, 408.)

c. Dizziness

Plaintiff was treated for dizziness at Sharp Chula Vista Medical Center on

December 18, 2009. (AR 353, 362.) On January 4, 2010, however, a progress note

from Samahan Medical Group indicated that Plaintiff no longer felt dizzy. (AR 377.)

B. Hearing Testimony

Plaintiff testified that he has had approximately 12 years of formal education. 

(AR 41.) His alleged disability arose on December 10, 2008, and since that date

Plaintiff has not worked. (AR 42.) Plaintiff is about 5'7" and 172 pounds. (Id.) His

body mass index is 27—indicating Plaintiff is overweight, but not obese. (Id.) When

Plaintiff’s attorney asked Plaintiff about his problems, he stated that he suffers from(1)

kidney stonesspecifically causing him pain at night, (2) gout as a result of his diabetes

for which he takes medication and wasrecently prescribed a cane for balance, (3) chest

pain for which he takes medications, (4) anxiety and depression for which he neither

2

takes medication nor sees a psychiatrist, (5) dizzy spells caused by his medicine, (6)

back pain from his kidney stones and back curvature for which he takes medication,

and (7) uncontrollable diabetes. (AR 47-56, 59.)

Further, when Plaintiff’s attorney asked about his physical abilities, Plaintiff

explained that he (1) does not live alone and that his brothers and mother assist him,

(2) can carry no more than 10 pounds, (3) experiences no pain when he sits, (4) can

stand for lessthan 30 minutes due to his back pain and back curvature, (5) needs to rest

and lie down for approximately 20 minutes three times a day, (6) can drive only to and

from the doctor, and (7) takes all his medications consistently and according to the

label’s instruction. (AR 56-60.)

The medical expert (“ME”), John R. Morse, also testified. (AR 42.) Prior to

commencing his testimony, the ME did not ask Plaintiff any questions concerning his

Plaintiff suffers from coronary heart disease, and consequently, underwent coronary bypass 2

surgery in November 2009 and has since recovered from his surgery. (AR 43.) His chest pains appear 

to be related to this disease and surgery. (See AR 338.)

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injuries and treatment. (AR 42-43.) The ME testified that based on the medical

evidence of record, Plaintiff suffered from impairments, but they were neither severe

nor met the impairments listed in 20 C.F.R. Pt. 404, Subpt. P, App. 1. (AR 43.) The

ME listed the following impairments: (1) insulin-dependent diabetes, (2) mild

peripheral bilateral neuropathy as a result of diabetes, (3) mild chronic renal

insufficiency as a result of diabetes, (4) coronary artery disease, (5) high blood pressure

that is presently under control, (6) a form of polyarthralgias, polyarthritis, or transient

arthritis, and (7) renal stones. (AR 43-44.)

The ALJ asked the ME to render a residual functional capacity (“RFC”) for

3

what Plaintiff could do despite his limitations. (AR 44.) Prior to providing an RFC,

the ME disclaimed Plaintiff’s previous RFC rendered in November 2009 by the CE

because that RFC was conducted approximately two or three weeks after Plaintiff’s

coronary bypass surgery and “making any kind of assumptions about a postoperative

coronary patient within the first two to three months . . . is probably not valid.” (Id.) 

As such, based on the remaining medical evidence of record, the ME suggested that

Plaintiff:

[C]ould lift 10 pounds on a frequent basis, and 20 pounds occasionally.

That he

should be able to sit for six hours out of an eight hour day. That he

should be able

to stand and walk for six hours out of an eight hour day, and that there

would be no

additional push/pull limitation. Fromthe non-exertional standpoint, he

would be

limited to occasional climbing. That includes ramps, stairs, ladders,

ropes, scaffolds, balancing, stooping, kneeling, crouching, and

crawling.

(AR 45.)

Next, Plaintiff’s attorney questioned the ME. Here, the ME explained that

Plaintiff’s alleged dizziness and sensory neuropathy were taken into account when

Although later discussed in more detail, for clarity, an RFC “is the most [the claimant] can 3

still do despite [his or her] limitations.” 20 C.F.R. § 404.1545(a)(1). An RFC “is used at step four of

the sequential evaluation process to determine whether an individual is able to do past relevant work,

and at step five to determine whether an individual is able to do other work, considering his or her age,

education, and work experience.” Social Security Ruling (“SSR”) 96-8p. 

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issuing the RFC. (Id.) The ME further explained that because no medical records were

provided as to why Plaintiff was prescribed a cane, he could not say how this would

affect his assessment. (Id.) Yet, the ME opined that from the medical evidence of

record, Plaintiff’s diabetes was not severe enough to warrant the use of a cane. (AR

47.)

Lastly, the ALJ called a vocational expert (“VE”) to testify during the

administrative hearing. (AR 61-64.) The ALJ asked the VE to consider a hypothetical

claimant with restrictionssimilar to those formulated for Plaintiffin the ME’s RFC, but

not according to the CE’s RFC. (AR 62.) The VE replied that a person with those

restrictions would be unable to perform Plaintiff’s past work as an electrician, but

would be able to perform the lesser job as an electrician for manufactured buildings.

(Id.)

C. ALJ’s Findings

On November 17, 2010, the ALJ issued his decision denying benefits. (AR

18-27.) In arriving at his decision, the ALJ applied the Commissioner’s five-step

sequential disability determination process set forth in 20 C.F.R. § 404.1520. The ALJ

agreed that Plaintiff had not engaged in substantial gainful activity during the relevant

period. (AR 20.) Accordingly, the ALJ found that Plaintiff satisfied step one. (Id.) 

At step two, the ALJ found that Plaintiff suffered from the following severe

impairments: (1) insulin dependent diabetes mellitus with mild sensory neuropathy, (2)

mild renal insufficiency, (3) coronary artery disease status post three-vessel coronary

artery bypass graft, and (4) arthralgias(i.e. gout). (Id.) Also atstep two, the ALJ found

that Plaintiff’s alleged impairments of depression and anxiety were unsupported by the

record. (Id.) Thus, with regards to the listed impairments above, the ALJ found that

Plaintiff satisfied step two. (Id.) 

At step three, the ALJ found that Plaintiff did not have an impairment or

combination of impairments that met or medically equaled one of the listed

impairments. (AR 21-22.) The ALJ, therefore, proceeded to step four. The fourth and

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fifth steps require the ALJ to determine how the claimant’s impairments affect the

claimant’s ability to perform work. To make this determination, the ALJ formulates

the claimant’s RFC. An RFC “isthe most [the claimant] can still do despite [his or her]

limitations.” 20 C.F.R. § 404.1545(a)(1). An RFC “is used at step four of the

sequential evaluation process to determine whether an individual is able to do past

relevant work, and at step five to determine whether an individual is able to do other

work, considering his or her age, education, and work experience.” Social Security

Ruling (“SSR”) 96–8p. The ALJ found that Plaintiff had an RFC to perform light

work, provided that Plaintiff limit his climbing, balancing, stooping, kneeling,

crouching, crawling, and concentrated exposure to fumes, odors, dusts, gases, poor

ventilation as well as unprotected heights and machinery. (AR 22.) The ALJ partially

came to this decision regarding Plaintiff’s RFC by dismissing the conclusion drawn in

November 2009 by the CE that “claimant waslimited to sedentary activities” since the

CE’s exam was only weeks after Plaintiff’s bypass surgery. (AR 25.) As such, the

ALJ’s determination was largely based on the ME’s testimony. 

After the ALJ formulatesthe claimant’s RFC, the ALJ must consider whether the

claimant can, in light of that RFC, perform past or other work. To do so, the ALJ may

rely on the testimony of a vocational expert. 20 C.F.R. §§ 404.1560(b)(2) and

404.1566(e). Based on the VE’s testimony, the ALJ found that Plaintiff did not have

an RFC to perform his past relevant work, but that Plaintiff’s “past relevant work as an

electrician had transferable skillsto light work such as an electrician for manufactured

buildings.” (AR 26.) The ALJ thus concluded that Plaintiff was not disabled because

he could work as an electrician of manufactured buildings. (AR 27.) Plaintiff appealed

the ALJ’s decision to the Appeals Council and submitted additional medical records

in support of the appeal.

D. Additional Records Submitted to the Appeals Council After ALJ Hearing

On three separate occasions, between March and July 2011, Plaintiff’s new

counsel, Denise

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Haley, Esq., submitted additional medical records to the Appeals Council. (AR 9, 495,

497, 506.)

1. Dr. Sacamay’s Medical Report dated March 5, 2011

On March 5, 2011, Dr. Sacamay, Plaintiff’s treating physician, wrote on a

prescription pad, “[p]atient . . . has multiple medical problems. At this point I believe

patient would be unable and ineffective for employment. Any assistance afforded to

him would be much appreciated . . . .” (AR 495.) 

2. Dr. Sacamay’s RFC Questionnaire dated March 10, 2011

On March 10, 2011, Dr. Sacamay completed an RFC questionnaire regarding

what Plaintiff can do despite his limitations. The RFC outlines Plaintiff’s impairments,

which include but are not limited to, uncontrolled diabetes, chronic renal failure,

polyarticular gouty arthritis, coronary artery disease, bypass surgery, congestive heart

failure, hypertension and hyperlipidemic. (AR 499.) The RFC indicates that Plaintiff

does not sufferfromdepression, but continues to experience fatigue, jointswelling, and

joint pain. (AR 499-500.) The RFC statesthat Plaintiff often experiences pain or other

symptoms which interfere with his attention and concentration. (AR 500.) Although

Plaintiff only has a slight limitation in dealing with work stress, the RFC questionnaire

completed by Dr. Sacamay identifies the following functional limitations applicable to

Plaintiff: (1) he cannot walk more than two city blocks, (2) he cannot continuously sit

more than 45 minutes, (3) he cannot continuously stand more than 30 minutes, (4) he

cannot stand/walk more than two hours in an eight hour work day, (5) he cannot walk

more than 12 minutes every 45 minutes, (6) he cannot be restricted as to when he can

stand/walk, (7) he cannot be restricted from taking unscheduled breaks every hour for

15 minutes, (8) he cannot sit for prolonged periods without elevating his legs for two

to three hours out of an eight hour day, (9) he cannot lift more than 10 pounds, (10) he

cannot receptively reach, grasp, or manipulate items, and (11) he cannot be expected

to miss less than three days of work a month due to his impairments or treatment. (AR

501-503.)

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In sum, the RFC completed by Dr. Sacamay, a treating physician, concludes that

Plaintiff is not “fit to be employed in any way.” (AR 503.) Dr. Sacamay explained

Plaintiffsuffers from uncontrolled diabetes and polyarthritis, has a history of coronary

artery disease, and underwent bypass surgery. (Id.) In addition, “[m]ost of the

medications that can control his pain is [sic] contraindicated to his decreased renal

function.” (Id.) Also attached to the RFC was a second copy of the medical report

dated March 5, 2011, addressed above.

3. Alvarado Hospital Medical Report dated May 19, 2011

On May 19, 2011, Plaintiff underwent procedures for left heart catherization;

selective left and right coronary angiogram; left ventricular angiogram; thoracic

aotogram; saphenous vein graft angiography; left internal mammary artery

angiography; and percutaneous closure, right common femoral artery. (AR 510.) The

medical report for these procedures indicated that Plaintiff has “[c]ritical triple-vessel

coronary artery disease, patent SVG-RCA, patent mid body stent SVG-RCA, [and]

occluded distal LAD with patent LIMA to mid LAD.” (AR 508.) The treatment plan

wasto provide Plaintiff with medical therapy, IV hydration, and “continue with aspirin

and Plavix long-term.” (Id.) 

The Appeals Council accepted the new evidence and incorporated it into the

record, but ultimately denied the request for review. (AR 5-9.) The Appeal Council’s

denial made the ALJ’s denial of benefits the Commissioner’s final decision. (AR 5.)

Discussion

A. Standard of Review of Magistrate Judge’s Report and Recommendation

Federal Rule of Civil Procedure 72(b) and 28 U.S.C. § 636(b)(1) set forth a

district judge’s review of a magistrate judge’s report and recommendation. The district

judge must “make a de novo determination of those portions of the report to which

objection is made,” and “may accept, reject, or modify, in whole or in part, the finding

or recommendations made by the magistrate judge.” 28 U.S.C. § 636(b)(1); see also

United States v. Remsing, 874 F.2d 614, 617 (9th Cir. 1989). However, in the absence

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of timely objection(s), the Court “need only satisfy itself that there is no clear error on

the face of the record in order to accept the recommendation.” Fed. R. Civ. P. 72(b),

Advisory Committee Notes (1983); see also United States v. Reyna-Tapia, 328 F.3d

1114, 1121 (9th Cir. 2003) (district judge “must review the magistrate judge’s findings

and recommendations de novo if objection is made, but not otherwise.”).

B. Scope of Review of Commissioner’s Decision

Section 205(g) of the Act allows unsuccessful applicants to seek judicial review

of a final agency decision of the Commissioner. 42 U.S.C. § 405(g). The

Commissioner’s denial of benefits “will be disturbed only if it is not supported by

substantial evidence or is based on legal error.” Brawner v. Sec’y of Health and

Human Servs., 839 F.2d 432, 433 (9th Cir. 1988) (citing Green v. Heckler, 803 F.2d

528, 529 (9th Cir. 1986)).

Substantial evidence means “more than a mere scintilla” but less than a

preponderance. Sandgathe v. Chater, 108 F.3d 978, 980 (9th Cir. 1997). “[I]t is such

relevant evidence as a reasonable mind might accept as adequate to support a

conclusion.” Id. (quoting Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995)). 

The court must consider the record as a whole, weighing both the evidence that

supports and detracts from the Commissioner’s conclusions. Id. If the evidence

supports more than one rational interpretation, the court must uphold the ALJ’s

decision. Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005); Allen v. Heckler, 749

F.2d 577, 579 (9th Cir. 1984). Nevertheless, the Court “must consider the entire record

as a whole and may not affirm simply by isolating a specific quantum of supporting

evidence.” Robbins v. Soc. Sec. Admin., 466 F.3d 880, 882 (9th Cir. 2006).

C. Analysis

To qualify for disability benefits under the Act, an applicant must show that: (1)

he or she suffers from a medically determinable impairment that can be expected to

result in death or that has lasted or can be expected to last for a continuous period of

twelve months or more, and (2) the impairment renders the applicant incapable of

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performing the work that the applicant previously performed and incapable of

performing any other substantially gainful employment that exists in the national

economy. 42 U.S.C. § 423(d). The claimant’s impairment must result from

“anatomical, physiological, or psychological abnormalities which are demonstrable by

medically acceptable clinical and laboratory diagnostic techniques.” Drouin v.

Sullivan, 966 F.2d 1255, 1257 (9th Cir. 1992). 

The Social Security Regulations (hereinafter “Regulations”) employ a five step

process to determine whether an applicant is disabled under the Act. If an applicant is

found to be “disabled” or “not disabled” at any step, there is no need to proceed to the

subsequentsteps. 20 C.F.R. § 404.1520 (2007); Tackett v. Apfel, 180 F.3d 1094, 1098

(9th Cir. 1999). The applicant bears the burden of proof as to the first four steps. 

Tackett, 180 F.3d at 1098. If the fifth step is reached, the burden shifts to the

Commissioner. Id. The five steps are as follows:

Step 1. Is the claimant presently working in a substantially gainful

activity? If so, then the claimant is “not disabled” within the meaning of

the Social Security Act and is not entitled to disability insurance benefits. 

If the claimant is not working in a substantially gainful activity, then the

claimant’s case cannot be resolved atstep one and the evaluation proceeds

to step two.

Step 2. Is the claimant’s impairment severe? If not, then the claimant

is “not disabled” and is not entitled to disability insurance benefits. If the

claimant's impairment is severe, then the claimant's case cannot be

resolved at step two and the evaluation proceeds to step three.

Step 3. Does the impairment “meet or equal” one of a list of specific

impairments described in the regulations? If so, the claimant is “disabled”

and therefore entitled to disability insurance benefits. If the claimant’s

impairment neither meets nor equals one of the impairments listed in the

regulations, then the claimant's case cannot be resolved at step three and

the evaluation proceeds to step four.

 Step 4. Is the claimant able to do any work that he or she has done in

the past? If so, then the claimant is “not disabled” and is not entitled to

disability insurance benefits. If the claimant cannot do any work he orshe

did in the past, then the claimant’s case cannot be resolved at step four

and the evaluation proceeds to the fifth and final step.

Step 5. Is the claimant able to do any other work? If not, then the

claimant is “disabled” and therefore entitled to disability insurance

benefits. If the claimant is able to do other work, then the Commissioner

must establish that there are a significant number of jobs in the national

economy that claimant can do. There are two ways for the Commissioner

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to meet the burden of showing that there is other work in “significant

numbers” in the national economy that claimant can do: (1) by the

testimony of a vocational expert, or (2) by reference to the MedicalVocational Guidelines . . . . If the Commissioner meets this burden, the

claimant is “not disabled” and therefore not entitled to disability insurance

benefits. If the Commissioner cannot meet this burden, then the claimant

is “disabled” and therefore entitled to disability insurance benefits.

Id. at 1098-99 (footnotes and citations omitted).

D. ALJ’s Assessment of Treating Physician

The Magistrate Judge concluded that when the ALJ denied Plaintiff’s benefits,

the treating physician’s full opinion regarding Plaintiff’s medicalimpairments were not

part of the record for consideration and must be considered before it can be discounted

and not afforded controlling weight. (Dkt. No. 23. at 15.) 

On November 17, 2010, the ALJ issued a decision denying benefits. (AR 15.) 

Subsequently, on three separate occasions, between March and July 2011, Plaintiff’s

new counsel, Denise Haley, Esq. submitted additional medical records to the Appeals

Council. (AR 495, 497, 506.) These records provide direct medical opinions

concerning Plaintiff’s medical impairments and his ability to work. 

The Ninth Circuit has held that the district court must consider evidence

submitted for the first time to the Appeals Council as part of the administrative record

and assess whether the Commissioner’s decision is supported by substantial evidence. 

Brewer v. Comm. of Soc. Sec. Admin., 682 F.3d 1157, 1159-60 (9th Cir. 2012). The

Ninth Circuit distinguishes among the “opinions of three types of physicians: (1) those

who treat the claimant (treating physicians); (2) those who examine but do not treat the

claimant (examining physicians); and (3) those who neither examine nor treat the

claimant (nonexamining physicians).” Lester v. Chater, 81 F.3d 821, 830 (9th Cir.

1996). 20 C.F.R. § 404.1527 (d)(2) (2004) provides:

Generally, we give more weight to opinions from your treating sources,

since these sources are likely to be the medical professionals most able to

provide a detailed, longitudinal picture of yourmedical impairment(s) and

may bring a unique perspective to the medical evidence that cannot be

obtained from the objective medical findings alone or from reports of

individual examinations . . . .

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In general, more weightshould be given to the treating physician’s opinion than

to the opinion of doctors who do not treat the claimant. Id. (citing Winans v. Bowen,

853 F.2d 643, 647 (9th Cir. 1987)). The treating physician’s opinion is not, however,

necessarily conclusive asto either physical condition or the ultimate issue of disability. 

Magallanes v. Bowen, 881 F.2d 747, 750 (9th Cir. 1989). In addition, the ALJ need

not accept the opinion of the treating physician if it is conclusory, brief and

unsupported by clinical findings. Matney v. Sullivan, 981 F.2d 1016, 1019 (9th Cir.

1992). If the treating physician’s opinion is not contradicted by another doctor, the

ALJ must provide “clear and convincing” reasons to reject the opinion of the treating

physician. Lester, 81 F.3d at 830. If the treating doctor’s opinion is contradicted by

another doctor, the ALJ may not reject the opinion without providing “specific and

legitimate reasons” supported by substantial evidence. Id. 

Defendant objects to the Magistrate Judge’s conclusion that the case should be

remanded to further consider Dr. Sacamay’s opinion based on evidence that Plaintiff’s

submitted to the Appeals Council. Defendant argues that Dr. Sacamay’s medical

records submitted to the Appeals Council does not change the fact that substantial

evidence supports the ALJ’s decision because the ALJ noted inconsistencies with the

treating notes indicating no complaints of pain and medical opinion indicating

complaints of pain. Plaintiff contends that the Magistrate Judge properly concluded

that the matter should be remanded to the ALJ for consideration of medical evidence

provided by Dr. Sacamay. 

First, the Court questions the ALJ’s rejection of Dr. Sacamay’s opinion based

on inconsistencies. While the ALJ notes that Dr. Sacamay’s medical opinion dated

October 18, 2010 stating that Plaintiff experiences back pain related to his kidney

stones is in conflict with Dr. Sacamay’s treatment notes where the Plaintiff denies any

complaints, the CE, on November 30, 2009, noted that Plaintiff had bilateral back pain. 

(AR 340.) 

Moreover, Dr. Sacamay’s medical records before the ALJ were limited to

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Plaintiff’s kidney issues and not the other multiple medical issues concerning

Plaintiff’s alleged disability. The additional medical records submitted after the ALJ’s

decision provides a more comprehensive opinion of Plaintiff’s medical condition by

his treating physician. 

The Court agrees that the matter should be remanded to the ALJ to consider the

additional medical records where Dr. Sacamay provides specific opinions as to issues

relevant to determining whether Plaintiff is disabled under the Act. Since the

additional medical records by Plaintiff’s treating physician were not considered by the

ALJ and no “specific and legitimate reasons” were given to discount the treating

4

physician’s opinion, the Commissioner’s decision is not supported by substantial

evidence in the record. See Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th Cir. 2005)

(“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 . . . .”) Since Plaintiff submitted a more

comprehensive medical assessment by his treating physician, the ALJ must consider

the new medical records and reconsider the weight accorded to Dr. Sacamay’s opinion. 

E. Plaintiff’s Subjective Symptom Complaints

The Magistrate Judge concluded that the ALJ properly rejected Plaintiff’s

subjective complaint testimony; however, on remand, the Magistrate Judge directed

that the ALJ should reconsider the credibility determination after the ALJ reviews and

assesses the impact of the additional medical evidence. According to the ALJ’s

decision, he rejected Plaintiff’s subjective complaint testimony “to the extent it is

inconsistent with the Plaintiffs’ RFC.” (AR 24.) The Magistrate Judge concluded that

since the ALJ based the RFC based on the ME’s testimony, his decision may differ

after a review of the treating physician’s medical records. 

Assessing Plaintiff’s testimony regarding the severity of his impairments

depends on the medical evidence. See Chaudhry v. Astrue, 688 F.3d 661, 670 (9th Cir.

It appears that the treating physician’s opinion is contradicted by the ME’s opinion. 4

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2012) (“Because the RFC determination must take into account the claimant's

testimony regarding his capability, the ALJ must assess that testimony in conjunction

with the medical evidence.”). Therefore, since the ALJ, on remand, will consider the

additional medical records presented for the first time before the Appeals Council, the

ALJ’s determination of Plaintiff’s subjective symptom complaints for purposes of an

RFC assessment must be revisited. 

Conclusion

Based on the above,theCourt ADOPTS the report and recommendation granting

Plaintiff’s motion for summary judgment in part and denyingDefendant’s cross-motion

for summary judgment. The Court REMANDS the matter to the Commissioner of the

Social Security Administration for further proceedings consistent with this Order. 

IT IS SO ORDERED. 

DATED: April 4, 2013

HON. GONZALO P. CURIEL

United States District Judge

 

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