Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_15-cv-00631/USCOURTS-casd-3_15-cv-00631-0/pdf.json

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

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UNITED STATES DISTRICT COURT 

SOUTHERN DISTRICT OF CALIFORNIA 

VAL J. WALDON, 

Plaintiff,

v. 

CAROLYN W. COLVIN, Acting 

Commissioner of Social Security, 

Defendant.

 Case No.: 15cv631 AJB (NLS) 

REPORT AND 

RECOMMENDATION FOR ORDER:

(1) GRANTING PLAINTIFF’S 

CROSS MOTION FOR SUMMARY 

JUDGMENT [Dkt. No. 16]; and 

(2) DENYING DEFENDANT'S 

CROSS MOTION FOR SUMMARY 

JUDGMENT [Dkt. No. 20]. 

Plaintiff Val Waldon brings this action under the Social Security Act, 42 U.S.C. § 

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

Security Administration (“Commissioner” or “Defendant”) denying his claim for social 

security benefits. This case was referred for a report and recommendation on the parties’ 

cross motions for summary judgment. See 28 U.S.C. § 636(b)(1)(B). After considering 

the moving papers, the administrative record, and the applicable law, the court 

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RECOMMENDS that Plaintiff’s motion for summary judgment be GRANTED and the 

case be reversed and remanded to the Social Security Administration for the calculation 

of the award of benefits, and that Defendant’s cross motion for summary judgment be 

DENIED. 

I. BACKGROUND 

A. Procedural History. 

Waldon filed applications for a period of disability and social security disability 

insurance benefits (SSD) on August 27, 2008. Administrative Record (AR) 174-184. He 

alleges his condition rendered him unable to work on March 1, 1997. Id. An 

Administrative Law Judge (ALJ) held hearings on April 12 and August 30, 2010. AR 

59-67, 34-58. Waldon testified at the April hearing. AR 59-67. Waldon, medical expert 

Arvin Klein, and vocational expert John Kilcher testified at the August hearing. AR 34-

58. Based on the testimony and documentary evidence the ALJ issued a decision 

denying Waldon’s application for benefits. AR 18-33. Waldon filed an administrative 

request to review the decision. AR 16-17. The Appeals Council denied the request for 

review, and the ALJ’s decision became final. AR 1-6. 

 Waldon then filed a complaint for judicial review in this court. This court found 

legal error in the ALJ’s decision and reversed and remanded for further proceedings. AR 

1033-1058. An ALJ held another hearing on October 14, 2014. AR 956-999. On 

November 20, 2014, the ALJ again determined that Val Waldon was not disabled. AR 

897-919. 

B. Order Remanding this Action. 

In this court’s Report and Recommendation for Waldon’s first appeal (“R&R 1”), 

it found that the ALJ’s denial of benefits was unsupported because he did not cite clear 

and convincing evidence to reject either the opinion of Waldon’s treating physician for 

10 years, Dr. Sprague, or Waldon’s own testimony. The court ordered the ALJ, on 

remand, to properly consider the entire record when weighing the opinion of Dr. Sprague 

and the testimony of Mr. Waldon. See Waldon v. Astrue, 12cv1323 AJB (NLS). 

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C. Medical Evidence: Treating Physician Dr. Carol Sprague. 

Waldon has a history of insulin dependent diabetes mellitus, hypertension, 

depression, post traumatic stress disorder, substance, alcohol and Vicoden abuse, asthma, 

coronary artery disease, myocardial infarcation, peripheral neuropathy, cerebrovascular 

accident in 1996 with right lower extremity weakness, gastroesophageal reflux disease, 

and hypoglycemia. AR 23, 240-286, 380-851, 853-896. Those diagnoses are based on 

reports from several physicians. See R&R 1, pp.2-3. The ALJ found that during the time 

period in question, Waldon had severe diabetes mellitus, hypertension and substance 

abuse disorder. AR 26. 

One of the two major issues in this appeal concerns the opinion of Dr. Carol 

Sprague from the Veterans Affairs Medical Center, who treated Waldon from December 

2000 through March 2009. AR 289-348; 380-852. She diagnosed him as suffering from 

diabetes with significant peripheral neuropathy in his feet, significant numbness in his 

thighs with severe pain (meralgia paresthetica), distant history of a stroke with chronic 

right lower extremity numbness and mild weakness, high blood pressure, high 

cholesterol, obstructive sleep apnea, obesity, depression and PTSD symptoms. AR 852. 

She noted he takes the following medications: metformin, insulin, simvastatin, 

metoprolol, losartan, doxazosin, pantoprazole, testosterone, duloxetine, amitriptyline, 

trazodone and methadone. Id.

D. Waldon’s Testimony. 

At the first set of hearings, Waldon testified that various impairments prevented 

him from working since at least 1997. AR 26, 43-51. He testified that he broke his right 

wrist and had three operations on it. AR 26. While recovering from his wrist injuries he 

had a stroke followed by right sided weakness. AR 26, 43. He has used a cane since the 

late 1990s due to weakness on his right side. AR 41, 45. While he was treated at UCSD 

for the stroke, those records are no longer available. AR 43, 65-66. 

 Waldon was insulin-dependent due to his 1993 diagnosis of diabetes. AR 26. Diet 

and medicine helped his diabetes. AR 26. He stopped using cocaine in 1999, after he 

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was incarcerated. AR 26. Waldon said that he could not sustain an eight hour workday 

and 40 hour workweek due to his energy level and medication levels. AR 26. He said he 

could perform a full range of work with these nonexertional limitations: mild restrictions 

of activities of daily living, moderate difficulties maintaining social functioning, and mild 

difficulties maintaining concentration, persistence or pace, and the need to avoid hazards. 

AR 25. 

E. Residual Functional Capacity. 

After the first set of hearings, the ALJ concurred with RFC assessment by Dr. 

Klein, the state’s medical expert, and found that Waldon “had no exertional limitations 

and no postural limitations and is able to sit for six hours, stand for six hours, and walk 

for six hours in an eight hour workday, but should avoid hazards.” AR 27-28. After the 

hearing on remand, the ALJ changed the RFC and limited Waldon to perform sedentary 

work, except that he could lift and carry up to 10 pounds at one time, and never more. 

AR 905. He also found that he can sit for six hours in an eight hour work day, and can 

stand or walk for two hours in an eight hour work day. AR 905. 

F. The ALJ’s Decision. 

1. Evaluating Social Security Disability Claims. 

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

she cannot engage in any substantial gainful activity because of a medically determinable 

physical or mental impairment that has lasted or can be expected to last at least 12 

months. 42 U.S.C. §423(d). The Social Security regulations establish a five-step 

sequential evaluation for determining whether an applicant is disabled under this 

standard. 20 C.F.R. § 404.1520(a); Batson v. Comm’r of the Social Security Admin., 359 

F.3d 1190, 1194 (9th Cir. 2004). 

 At Step 1, the ALJ determines whether the applicant is engaged in substantial 

gainful activity. 20 C.F.R. § 404.1520(a)(4)(I). At Step 2, the ALJ determines whether 

the applicant suffers from a “severe” impairment within the meaning of the regulations. 

20 C.F.R. § 404.1520(a)(4)(ii). If the impairment is severe, the ALJ goes on to Step 3 to 

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decide whether the impairment meets or equals one of the “Listing of Impairments” in the 

Social Security regulations. 20 C.F.R. § 404.1520(a)(4)(iii). If it does, the applicant is 

found disabled, and benefits are awarded. Id. If the impairment does not meet or equal a 

Listing, the ALJ goes on to Step 4 to determine whether the applicant retains the residual 

functional capacity to perform his or her past relevant work. 20 C.F.R. § 

404.1520(a)(4)(iv). If the applicant cannot perform past relevant work, the ALJ–at Step 

5–must consider whether the applicant can perform any other work that exists in the 

national economy. 20 C.F.R. § 404.1520(a)(4)(v); Kennedy v. Colvin, 738 F.3d 1172, 

1175 (9th Cir. 2013); see Garrison v. Colvin, 759 F.3d 995, 1010-11 (9th Cir. 2014) 

(discussing the sequential process in greater length). 

 While the applicant carries the burden to prove eligibility at Steps 1 through 4, the 

burden at Step 5 rests on the agency. Celaya v. Halter, 332 F.3d 1177, 1180 (9th Cir. 

2003). Applicants not disqualified at Step 5 are eligible for disability benefits. Id.

2. Substance of ALJ Decision. 

The ALJ again determined that Waldon satisfied Step 1 of the evaluation because 

he met the insured status requirement of the Social Security Act through June 30, 2002 

and had not engaged in substantial gainful activity since March 1, 1997, the disability 

onset date. AR 903. At Step 2, the ALJ found that Waldon suffered from the following 

“severe” impairments as defined in the regulations: diabetes mellitus; peripheral 

neuropathy; history of cerebrovascular accident; gastroesophageal reflux disease; 

hypertension; dyslipidemia; right knee pain; possibly osteoarthritis and a history of 

alcohol and cocaine dependence. AR 903. He found that these impairments “cause more 

than a slight limitation of the claimant’s physical or mental ability to do basic work 

activities[.]” AR 903. The ALJ also found that Waldon’s post-traumatic stress disorder 

(PTSD) was non-severe and did not cause more than a minimal limitation in his ability to 

perform basic mental work activities. AR 903. 

Moving on to Step 3, the ALJ found Waldon did not suffer from an impairment or 

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

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Social Security Regulations. AR 905; see 20 C.F.R. §§ 404.1520(d), 404.1525, 

404.1526. The ALJ noted these findings: in a December 1, 2000 visit to the Veterans’ 

Affairs Medical Center, Waldon had not experienced symptoms of PTSD nor received 

treatment for it in the previous year; and at medical appointments in 1998 and in 2001 

and at the hearing before the ALJ, Waldon gave conflicting stories on his military 

service, combat history and source of PTSD, which the ALJ attributed to dishonesty 

rather than any other cause. AR 903-904. The ALJ then went on to address the four 

elements of the “paragraph B” criteria to evaluate mental disorders. He found that 

Waldon could perform all his activities of daily living; had only mild limitations in social 

functioning; and had only mild limitations in concentration, persistence and pace; and 

had not experienced any extended periods of decompensation. AR 904-905. 

In determining—at Step 4—whether Waldon retained the RFC to perform his past 

relevant work as a sheet metal production worker, truck driver or retails sales clerk, bank 

teller, the ALJ, relying on the opinion of the vocational expert, concluded that Waldon 

could not perform any of his past relevant work. AR 912. 

At Step 5, the ALJ considered Waldon’s RFC, age, education, work experience 

and RFC, all in conjunction with the medical-vocational guidelines, and found that he 

could successfully adjust to other work that exists in significant numbers in the national 

economy. AR 913. Some of the representative jobs include table worker and final 

assembler of optical goods. AR 913. 

II. DISCUSSION 

Waldon asserts the same challenges here as he did in his first appeal. He argues 

that the ALJ erred by failing to (1) give clear and convincing reasons for rejecting the 

opinions of Dr. Sprague, Waldon’s treating physician for 10 years; and (2) give clear and 

convincing reasons for rejecting Waldon’s testimony. These are the same two points that 

this court ordered the ALJ to address on remand. 

/ / / 

/ / / 

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A. Is There Substantial Evidence to Support the ALJ’s Decision to 

Reject Dr. Sprague’s Opinion? 

The Social Security Act provides for judicial review of a final agency decision 

denying a claim for disability benefits. 42 U.S.C. § 405(g). A reviewing court must 

affirm the denial of benefits if the agency’s decision is supported by substantial evidence 

and applies the correct legal standards. Batson v. Comm’r of the Social Security Admin., 

359 F.3d 1190, 1193 (9th Cir. 2004). Substantial evidence means “such relevant 

evidence as a reasonable mind might accept as adequate to support a conclusion.” 

Osenbrock v. Apfel, 240 F.3d 1157, 1162 (9th Cir. 2001) (citation omitted). Put another 

way, it is “more than a scintilla but less than a preponderance.” Thomas v. Barnhart, 278 

F.3d 947, 954 (9th Cir. 2002). If the evidence is susceptible to more than one reasonable 

interpretation, the agency’s decision must be upheld. Id.; Batson, 359 F.3d at 1193. 

Further, when medical reports are inconclusive, questions of credibility and resolution of 

conflicts in the testimony are the exclusive functions of the agency. Magallanes v. 

Bowen, 881 F.2d 747, 751 (9th Cir. 1989). The reviewing court cannot reinterpret or reevaluate the evidence however much a re-evaluation may reasonably result in a favorable 

outcome for the plaintiff. Batson, 259 F.3d at 1193. 

In the first appeal, the ALJ rejected Dr. Sprague’s opinion that Waldon was 

“‘disabled’, ‘unable to work’ [and] can or cannot perform a past job because they ‘are not 

medical opinions but are administrative findings dispositive of a case, requiring 

familiarity with the Regulations and legal standards set forth therein and in the Dictionary 

of Occupational Titles.’” R&R 1, p.10 (quoting AR 27). The only other reasons offered 

for rejecting Dr. Sprague’s opinion was reliance on the opinions of reviewing Drs. 

Steinberg, Hoskins, Klein and Tyutyulkova, who were “non-treating and non-examining 

physicians who did not have any relationship with Waldon and simply reviewed his 

medical records.” R&R 1, p.13. On remand, this court ordered the ALJ to “provide due 

consideration to Dr. Sprague’s findings and opinions with regard to these impairments: 

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diabetes, high blood pressure (hypertension), substance abuse,1

 significant numbness in 

thighs with severe pain (meralgia paresthetica), obstructive sleep apnea, obesity, 

depression and PTSD.” R&R 1, pp.13-14. 

1. Legal Standard for Rejecting Treating Physician Testimony. 

Where a treating doctor's opinion is not contradicted by another doctor, the 

commissioner can only reject the treating doctor's opinion for “clear and convincing” 

reasons. Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995). Where the treating doctor is 

contradicted by another doctor, the commissioner must provide “specific and legitimate” 

reasons based on “substantial evidence” to properly reject a treating physician's opinion. 

Id. at 830-831. The opinion of an examining physician alone can constitute “substantial 

evidence” because it rests on an independent examination. Tonapetyan v. Halter, 242 

F.3d 1144, 1149 (9th Cir. 2001). Moreover, “When confronted with conflicting medical 

opinions, an ALJ need not accept a treating physician's opinion that is conclusory and 

brief and unsupported by clinical findings.” Id. Finally, the “ALJ is the final arbiter with 

respect to resolving ambiguities in the medical evidence.” Tommasetti v. Astrue, 533 

F.3d 1035, 1041 (9th Cir. 2008.) 

Here, Waldon received his medical treatment through the VA. Dr. Sprague was 

his primary care physician at the VA for 10 years and referred him out to specialists. 

There are no other treating doctors or consultative examinations cited to in the record. As 

explained in R&R 1, this court found that the ALJ’s reasons to reject Dr. Sprague’s 

opinion based on the opinions of the Commissioner’s examining doctors did not 

constitute substantial evidence to support the ALJ’s initial decision. Now, because Dr. 

Sprague’s opinion is not contradicted by another doctor, the Commissioner can reject her 

opinion only for clear and convincing reasons. 

                                               

1

 The court notes that the ALJ already determined that Waldon suffers from diabetes, 

high blood pressure and substance abuse, and asked the ALJ to reconsider the impact of 

those diseases in combination with the other diagnoses on remand. 

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2. Did the ALJ Rely on Clear and Convincing Reasons to Reject Dr. 

Sprague’s Opinion? 

On April 8, 2010, Dr. Sprague described Waldon’s functional impairments as 

follows: 

Over the time that I treated Mr. Waldon he had significant 

functional impairment. This worsened over the time that I 

treated him. He was disabled when I first evaluated him in 

2000, and became increasingly disabled over time. His 

symptoms include significant depression and anhedonia, severe 

neuropathy and pain which limit his endurance and ability to do 

many activities. Mr. Waldon has marked limitation in his 

concentration due to pain and fatigue and marked impairment in 

his social functioning. He would not be able to work in even a 

sedentary job and it is very likely his medical and mental 

functioning would likely worsen if he was in a competitive 

work environment. Although he is able to perform his activities 

of daily living, he would be unable to work in any capacity due 

to his medical and medication side effects. In my opinion he 

was unable to work since at least 6/30/02 and likely before that. 

His condition is not reversible and is likely to be progressive 

and I consider him fully and permanently disabled. 

AR 852. 

 The ALJ considered Dr. Sprague’s report and rejected it because he found that (1) 

Waldon was non-compliant with his diabetes treatment; (2) Dr. Sprague’s pain reports 

were inconsistent with Waldon’s physical activity; (3) Dr. Sprague’s report of depression 

and PTSD were based on false information from Waldon; and (4) Dr. Sprague’s 

determination that Waldon was disabled is an issue reserved to the Commissioner. The 

court now evaluates whether those are clear and convincing reasons to reject Dr. 

Sprague’s opinion as to Waldon’s functional impairments. 

a. Waldon’s Compliance with Diabetes Medications. 

The ALJ pointed out that Dr. Sprague reported that Waldon had “very poorly 

controlled diabetes that required insulin.” AR 909. The ALJ then pointed out that 

treatment notes from Dr. Garniewski, a clinical pharmacist that Dr. Sprague referred 

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Waldon to, said that Waldon “had been only taking 5mg Glyburide once a day, although 

it was prescribed to be taken twice a day. Therefore, [Waldon’s] diabetes was likely 

uncontrolled because of his non-compliance with treatment.” AR 909. In support of this 

statement, the ALJ cites to Exhibit 14F, which is 472 pages long. 

Looking directly at Dr. Garniewski’s notes, it is inconclusive, at best, whether 

Waldon complied with his prescription regimen. It actually appears that Waldon did 

comply with the regimen, and that the more plausible explanation for the “noncompliance” statement is a possible mistake in transcription as to the Glyburide dosage 

prescribed for Waldon: 

 January 27, 1998: Waldon prescribed to take 2.5 mg Glyburide orally once 

a day. AR 875. 

 December 22, 2000: Dr. Sprague, in a consult request, noted that Waldon 

was taking 5 mg of Glyburide daily and “referred [him] to clinical pharmacy 

for adjustment of diabetes medication.” AR 511, 512 (emphasis added). 

 January 4, 2001: In making a further note regarding the consult request, a 

Christina Walters, who followed up on Dr. Sprague’s referral, wrote that 

Waldon was currently taking 5 mg of Glyburide twice a day instead of the 

once a day noted by Dr. Sprague. AR 514. 

 January 17, 2001: Pharmacist Dr. Garniewski, who took the referral and 

reviewed Ms. Walter’s note, said that Waldon was taking 5 mg once a day 

“instead of twice a day as prescribed by [Dr. Sprague]”. Dr. Garniewski 

advised Waldon to start taking 5 mg of Glyburide twice a day, which he said 

he would start doing that day. AR 515. 

 January 29, 2001: Dr. Garniewski noted Waldon was currently taking 5 mg 

Glyburide twice a day. AR 821. 

 March 8, 2001: Dr. Garniewski noted Waldon was currently taking 5 mg 

Glyburide twice a day. AR 811. 

 April 16, 2001: Dr. Garniewski noted that Waldon was “on glyburide for 9 

years and is most likely not achieving any benefit at this time. Will 

[discontinue] glyburide.” AR 806. 

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At no place in Dr. Sprague’s notes did she state that Waldon was to take 5 mg of 

Glyburide twice a day. Rather, a possible explanation for Dr. Garniewski’s notation that 

Waldon had been prescribed 5 mg of Glyburide twice a day was that Christina Walters, 

who worked in the pharmacy department and followed up on the referral, mistakenly 

transcribed twice a day (“bid”) instead of once a day (“qd”). Further, even if Dr. Sprague 

had prescribed Waldon to take 5 mg of Glyburide twice a day, the prescription would 

have come on or after December 22, 2000, which is less than a month before Waldon saw 

Dr. Garniewski, who adjusted the diabetes medication. It does not seem likely, though, 

that Dr. Sprague would have changed Waldon’s diabetes medication herself to twice a 

day because she referred Waldon to pharmacy expressly “for adjustment of diabetes 

medication.” AR 512. Finally, Dr. Garniewski noted that Waldon was “resistant to 

discussing initiation of insulin.” AR 515. If Waldon was trying to avoid taking insulin, 

he would have been motivated to comply with taking his oral diabetes medications. 

 Defendant also argues that on January 31, 1998, Dr. Kambhampati noted that 

Waldon was not compliant in taking his medications. AR 870. First, that statement 

misstates the record, as Dr. Kambhampati was only referring to “INH,” a medication used 

to treat tuberculosis. Second, in 1998 Waldon had only been prescribed to take 2.5 mg of 

Glyburide once a day, and as of 2001, Waldon had been more than compliant with that 

regimen. Defendant’s reliance on that statement by Dr. Kambhampati—which is taken 

out of context—does not support its argument that Waldon was non-compliant with his 

diabetes medication regimen. 

In sum, the record shows that the fact that Waldon’s diabetes was not controlled is 

more likely due to the lack of effectiveness of the medications as opposed to Waldon’s 

alleged failure to follow his prescription regimen. Based on the facts in the record, the 

ALJ’s statement that “[Waldon’s] diabetes was likely uncontrolled because of his noncompliance with treatment” is not a clear and convincing reason to reject Dr. Sprague’s 

opinion. See Reddick v. Chater, 157 F.3d 715, 720 (9th Cir. 1998) (requiring ALJs to 

view the record as a whole and not parcel out evidence). 

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b. Waldon’s Reports of Pain. 

The ALJ noted that there were several inconsistencies in Dr. Sprague’s opinion, 

including Dr. Sprague’s reports that Waldon suffered from pain “so severe that he took 

methadone for pain control” and had a distant history of a stroke. AR 909. The ALJ 

pointed out: 

[P]rogress notes dated January 17, 2001, report that [Waldon] 

was walking 1-1/2 to 2 hours every day; and on February 7, 

2001, he indicated that he was taking walks twice a day. This is 

not consistent with someone experiencing severe pain in his 

feet and does not take into account that this claimant has a 

substance dependence history that includes dependence on pain 

medications... 

AR 909. 

Waldon argues that his attempts at exercise complied with his doctor’s 

recommendation that he walk to combat his diabetes and that his walks do not 

demonstrate an inconsistency with Dr. Sprague’s pain evaluation. Here is just a sampling 

from the record that shows that Waldon’s doctors repeatedly ordered him to exercise: 

 January 29, 2001: Waldon has been “walking 20 minutes twice a day [and] 

[h]as not missed any medication doses. AR 821 (note by Dr. Garniewski). 

 February 7, 2001: “A daily routine of regular physical activity, as 

appropriate for this patient’s physical condition, was encouraged. The 

patient was given the opportunity to ask questions and was able to verbalize 

an understanding of the importance of regular exercise. AR 819 (note by 

Licensed Vocation Nurse Christopher Theonnes). 

 February 26, 2001: “The patient is walking 20 minutes to half an hour twice 

a day. Noted he get [sic] symptomatic when he walked for an hour-and-ahalf at a time.” AR 817 (note by Dr. Sprague). 

 May 30, 2001: “...has been walking as much as he always did.” AR 800 

(pharmacy note by Christina Walters). 

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 November 21, 2001: “Has not been walking as much. Walks about 20-30 

minutes 3 days a week. Used to walk every day.” Dr. Garniewski also 

“advised increase in walking during the holiday” season. AR 785-786 (note 

by Dr. Garniewski). 

 March 14, 2003: “Walking a little.” “Discussed the role of exercise in 

diabetes regimen.” AR 727-728 (notes by Judy McEuen, Diabetes Nurse 

Educator). 

Waldon’s attempts to exercise do not demonstrate an inconsistency in Dr. 

Sprague’s opinion. First, even though the ALJ complained that Waldon did not follow 

his doctor’s orders regarding diabetes medications, he now faults Waldon for trying to 

comply with his doctor’s orders to exercise. Second, just because Waldon walked does 

not mean he was without pain. In fact, Dr. Sprague knew that Waldon walked for 

exercise, and must have considered that in her April 8, 2010 opinion. Third, from 2001 

to 2003, the length of exercise steadily and significantly decreased, and in fact the one 

and a half hour walk made Waldon “symptomatic.” 

It seems that in this case, the ALJ substituted his lay opinion that walking was 

inconsistent with Waldon’s reported pain, which is not permitted. See Tackett v. Apfel, 

180 F.3d 1094, 1102-03 (9th Cir. 1999) (finding that an ALJ may not substitute his or her 

lay opinion for those of medical professionals). The ALJ’s noted “inconsistency” is 

therefore not a clear and convincing reason to reject Dr. Sprague’s opinion. 

c. Waldon’s PTSD. 

The ALJ rejected Dr. Sprague’s opinion for this reason: 

The doctor also reported that [Waldon] struggled with 

depression and PTSD symptoms since she had known him. 

However, this appears to be based on [Waldon’s] false 

allegation of being drafted into the service during the Vietnam 

War and seeing combat; which the claimant subsequently 

admitted, including during his testimony at the hearing, was not 

true (Exhibit 14F, 16F and claimant testimony). 

AR 909. 

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Waldon’s medical records from the VA include several statements regarding 

Waldon’s military experience. These statements are all recited by the medical providers 

in their notes; it is unclear in some of the statements whether the provider learned the 

information directly from Waldon or if any of the information comes directly from 

military records. The statements include: 

 “Are you a Vietnam-era veteran? Yes.” AR 659 (Jan. 23, 2004 Nursing 

Note by Deborah Vaughn). 

 “Waldon is a ... Coast Guard veteran who served during the Vietnam War.” 

*** 

He “is a Vietnam veteran having served 14 months in country as an aviation 

machinist mate. He was drafted shortly after graduation from high school at 

age 18.” 

*** 

“It should be noted that [Waldon] is a decorated Vietnam veteran, having 

received a head wound from shrapnel; he received a Purple Heart among 

other medals.” AR 688-690 (Oct. 8, 2003 Progress Note by Karen Inaba, 

Psychiatric Nurse Practitioner). 

 “After receiving his high school diploma, he was drafted into the service by 

lottery (period of service = 8/6/73 to 8/8/77, honorable discharge). He 

reported he had earned good grades, was student body president, and had 

planned to go to college but was drafted before he could get into college. He 

decided to enter the Coast Guard after assurances he would not have to go to 

Vietnam if he joined this branch. This was not correct, and Mr. Waldon was 

sent to Vietnam for 14 months where he worked on a PB4 small river boat 

and witnessed combat.” AR 815 (Feb. 28, 2001 Psychiatric Outpatient Note 

by Dr. Gonzales). 

 “MILITARY HISTORY: He served in the U.S. Coast Guard from 1972 to 

1977. His highest rank was an E5. This is also the rank he was discharged 

at. The patient saw combat during the Vietnam War and received a 

meritorious unit commendation with star.” AR 873 (Jan. 28, 1998 

Discharge Summary by Dr. Yoshimoto). 

Meanwhile, at the remand hearing, Waldon testified the following in response to 

questions from the ALJ: 

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Q: When did you go in the military? 

A: In 19 – August of 1973. 

Q: And when did you get out? 

A: On August 01 1977. 

Q: And what did you do in the military? 

A: I was an aviation machinist mate [phonetic]. 

Q: And where did you serve? 

A: I served in Sewick Bay [phonetic], the Philippines, also 

Panama. And then in San Diego Air Station, San Diego. 

Costguard [sic] Air Station, San Diego. 

Q: Now, tell me what was the last job you did? 

A: The last job was with George G. Sharp... 

AR 960. 

 Later, Waldon testified in response to further questions by the ALJ: 

Q. What did the PTSD – what was the root of the PTSD? 

A. Well...we would do the drug interdiction stuff with customs 

and...I fell over the side, and I just – I really thought I was 

dead[.] 

*** 

A. I worked in conjunction ... with US Customs while I was 

stationed here in San Diego [with the Coast Guard]. [W]e 

did drug interdiction...we went out and chased down drug 

people. 

Q. At the boarder [sic]? 

*** 

A. No, on the water. 

*** 

Q. And is this, in your mind, was this the cause or the 

beginning of your PTSD, the memories of this? 

A. Yeah, yeah. Yes it was. 

AR 983-984. 

The record also includes several references to Waldon’s PTSD and service during 

the Vietnam War, including: 

/ / / 

/ / / 

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 “[Waldon] receives a VA pension. ...Mr. Waldon reported experiencing 

depressed mood since his return from the Vietnam War in 1977. He 

reported that ... after the war he had ‘lost his zest for living.’ ... Among his 

past traumas are being shot, being stabbed, and two serious automobile 

accidents. ...During the war he experienced enemy fire and witnessed the 

death of friends. Mr. Waldon described symptoms consistent with PTSD: 

re-experiencing (nightmares, intrusive memories, flashbacks when 

triggered), hypervigilance/hyperarousal (exaggerated startle response, 

checking his environment, quick to lose temper), and avoidance (memories 

or movies about war, funerals). AR 813 (Feb. 28, 2001 Psychology 

Outpatient Note by Dr. Linda Gonzales). 

 “Impression: PTSD exacerbation.” AR 691 (Oct. 8, 2003 treatment note by 

Karen Inaba, Psychiatric Nurse Practitioner). 

 “Provisional Diagnosis: ptsd Vietnam.” AR 486 (Dec. 5, 2003 Mental 

Health Consult Request). 

The ALJ says that these statements about PTSD made throughout the record are 

really just “false allegation[s] of being drafted into the service during the Vietnam War 

and seeing combat” because when the ALJ asked Waldon where he served in the 

military, Waldon did not expressly mention Vietnam. AR 909, 960 (“I served in Sewick 

Bay2

 [phonetic], the Philippines, also Panama. And then in San Diego Air Station, San 

Diego. Costguard [sic] Air Station, San Diego”). 

The court is not convinced that Waldon’s failure to expressly mention Vietnam—

without any follow-up question by the ALJ—amounts to a “false allegation of being 

drafted into the service during the Vietnam War and seeing combat.” Such a statement 

would mean that Waldon’s omission of the word “Vietnam” is tantamount to an express 

admission that he lied to all service providers over decades about his military experience, 

                                               

2

 The mention of “Sewick Bay” could reference “Subic Bay” in the Philippines, which 

served as a U.S. Naval Base until 1992. “The Vietnam War was the period of peak 

activity” for Subic Bay. See 

https://en.wikipedia.org/wiki/U.S._Naval_Base_Subic_Bay#The_Vietnam_War (last 

visited May 5, 2016). 

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which would call into question all the “depression and PTSD symptoms” that Dr. 

Sprague and others noted over the 10 years that he was her patient at the VA. See AR 

909. Without any follow-up questioning or documentary evidence that Waldon did not 

serve during the Vietnam War, the court finds that the record does not support the ALJ’s 

conclusion. 

Further, the ALJ goes on to say that “during his testimony at the hearing, [Waldon] 

reported that he was not in Vietnam[.]” AR 911. This court has not identified any such 

testimony, and defense counsel has not pointed it out. It seems that the ALJ interprets 

Waldon’s statement that he got PTSD when he fell in the water during a Coast Guard 

interdiction of drug smugglers as tantamount to Waldon stating that he lied about service 

during the Vietnam War. See AR 911. Again, the court does not see any factual support 

for the ALJ’s conclusion here. 

d. Dr. Sprague’s Disability Determination. 

The ALJ again rejects Dr. Sprague’s opinion that Waldon is disabled because it is 

not a medical finding but an issue reserved to the Commissioner. AR 910. The court 

already rejected this rationale in R&R 1: 

The ALJ rejected the “statements that a claimant is ‘disabled’, 

‘unable to work’ [and] can or cannot perform a past job” 

because they “are not medical opinions but are administrative 

findings dispositive of a case, requiring familiarity with the 

Regulations and legal standards set forth therein and in the 

Dictionary of Occupational Titles.” AR 27. First, this court 

finds that Dr. Sprague was not trying to make an administrative 

decision but rather was offering her opinion. She couched her 

statements with, “In my opinion, he was unable to work . . .” 

and “I consider him fully and permanently disabled,” and 

therefore, she was not trying to substitute in her opinion for a 

definitive administrative decision. AR 852. 

Second, the ALJ’s rejection of her “administrative opinion” is 

not supported by specific and legitimate reasons, and cannot 

serve to reject all of Dr. Sprague’s clinical findings and 

evidence as to the nature and severity of Waldon’s impairments. 

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See Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998) 

(finding the ALJ could not reject the physicians’ 

uncontroverted opinion on the ultimate issue of disability 

without citing to clear and convincing reasons). The court 

notes that the ALJ’s rejection of Dr. Sprague’s conclusion 

simply highlights that the determination of whether Waldon is 

“disabled” is left to the Commissioner. See 20 C.F.R. 

404.1527(d)(2). 

R&R 1, p.10. 

 For the same reasons stated above, the court again rejects the ALJ’s statement that 

Dr. Sprague should not have opined on the ultimate question of Waldon’s disability 

because it is not a clear and convincing reason to reject Dr. Sprague’s opinion. 

B. Is There Substantial Evidence to Support the ALJ’s Decision to 

Reject Waldon’s Testimony? 

1. Legal Standard for Rejecting Claimant’s Testimony. 

An ALJ must determine the extent to which a claimant’s symptoms “can 

reasonably be accepted as consistent with the medical signs and laboratory findings and 

other evidence to decide how [those] symptoms affect [the claimant’s] ability to work.” 

20 C.F.R. § 404.1529(a). But those statements alone cannot be decisive on a disability 

claim. 42 U.S.C. § 423(d)(5)(A) (“[a]n individual’s statement as to pain or other 

symptoms shall not alone be conclusive evidence of disability”); 20 C.F.R. § 404.1529(a) 

(“statements about your pain or other symptoms will not alone establish that you are 

disabled”). 

A claimant’s subjective symptoms must be considered in a disability evaluation. 

20 C.F.R. § 404.1529; Smolen v. Chater, 80 F.3d 1273, 1291 (9th Cir. 1996). In deciding 

whether to credit a claimant’s testimony about subjective symptoms or limitations, the 

ALJ must engage in a two-step analysis. Batson, 359 F.3d at 1195; Smolen, 80 F.3d at 

1281. Under the first step, the claimant must produce objective medical evidence of an 

underlying impairment that could reasonably be expected to produce pain or other 

symptoms. Batson, 359 F.3d at 1195; Smolen, 80 F.3d at 1281. If this test is satisfied, 

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and there is no affirmative evidence that the claimant is malingering, then the ALJ must 

determine the credibility of the claimant’s subjective complaints. 

 In assessing the credibility of the claimant’s subjective complaints, the ALJ may 

consider such factors as the claimant’s reputation for truthfulness, any inconsistencies in 

the claimant’s statements, and the claimant’s daily activities. Tonapetyan, 242 F.3d at 

1148; Smolen, 80 F.3d at 1284; see Social Security Ruling 96-7p (credibility findings 

“must be sufficiently specific to make clear to the individual and to any subsequent 

reviewers the weight the adjudicator gave to the individual’s statements”); Bunnell v. 

Sullivan, 947 F.2d 341, 345-346 (9th Cir. 1991) (en banc) (ALJ cannot “arbitrarily 

discredit a claimant’s testimony regarding pain” (internal quotations omitted)). The ALJ 

may reject the claimant’s testimony about the severity of symptoms as long as he gives 

specific, convincing reasons for doing so. Batson, 359 F.3d at 1195; Lingenfelter v. 

Astrue, 504 F.3d 1028, 1036 (9th Cir. 2007). “General findings are insufficient; rather, 

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

claimant's complaints.” Lester, 81 F.3d at 834. If the ALJ’s interpretation of a 

claimant’s testimony is reasonable and supported by substantial evidence, courts may not 

“second-guess it.” Rollins v. Massanari, 261 F.3d 853, 857 (9th Cir. 2001). 

2. Did the ALJ Cite Clear and Convincing Reasons to Find 

Waldon’s Testimony Not Credible For a Second Time? 

Because there is objective medical evidence about the underlying impairments, the 

ALJ had to evaluate Waldon’s subjective symptoms or limitations. The ALJ cites these 

nine reasons for finding that Waldon is not credible in describing his pain and limitations. 

a. Activities of Daily Living. 

Because Dr. Sprague stated that Waldon could perform his activities of daily 

living, the ALJ finds Waldon not credible. But the full context of what Dr. Sprague said 

reads: 

/ / / 

/ / / 

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[Waldon] would not be able to work in even a sedentary job 

and it is very likely his medical and mental functioning would 

likely worsen if he was in a competitive work environment. 

Although he is able to perform his activities of daily living, he 

would be unable to work in any capacity due to his medical and 

medication side effects. 

AR 852. Thus, even though Waldon can perform his activities of daily living, his treating 

physician opined that he has several other limitations that affect his ability to function in 

a work environment. The ALJ does not point to substantial evidence in the record to 

negate this finding. Therefore, the court finds it is not a clear and convincing reason to 

find Waldon not credible. 

b. Discontinuance of Alcohol and Drug Treatment. 

The ALJ stated that Waldon discontinued his drug and alcohol rehabilitation in 

October 1997, and found this an independent reason to show he was not credible. AR 

910. In support, he said “there were no allowable reasons offered for discontinuing his 

alcohol and drug treatment regime[.]” AR 910. But Waldon eventually continued with 

the rehabilitation and was reported to be in remission from drug abuse prior to his date 

last insured. AR 814. Therefore, the court does not find this to be a clear and convincing 

reason to find Waldon not credible. 

c. Waldon’s Statements on Vietnam. 

The ALJ rejected Waldon’s testimony because he found that he made inconsistent 

statements about his military service. AR 910-911. As already explained, the court does 

not find substantial evidence in the record to support this assertion. This is not a clear 

and convincing reason to find Waldon not credible. 

d. Cardiac Catherization. 

The ALJ finds that Waldon was not credible because he did not show up for a 

cardiac catherization on June 25, 1999, so the doctor opined that Waldon did not have an 

acute illness. AR 911. But without further evidence as to what Waldon actually reported 

as his symptoms and if it was reasonable to schedule a cardiac catherization, this does not 

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constitute substantial evidence to support the ALJ’s determination that this was a reason 

to find Waldon not credible. 

e. Progress Notes re: Alcohol Use. 

The ALJ finds Waldon not credible because while on a medical visit to the VA on 

December 1, 2000, Waldon purportedly said, “alcohol products were not used.” AR 911 

(emphasis added). The ALJ then explains that this is inconsistent with what Waldon 

testified to at the remand hearing when he explained he had a history with alcohol and 

drug abuse. AR 911. But the actual progress note from December 1, 2000 says, “Patient 

states that alcohol products are not used.” AR 836 (emphasis added). That statement is 

quite different from what the ALJ quotes and more likely means that Waldon was not 

using alcohol at that time. The court finds that the ALJ’s twisting of Waldon’s words 

and using that misquote to imply that Waldon lied to the medical provider by saying he 

never abused alcohol is not a clear and convincing reason to find Waldon not credible. 

f. Waldon’s Exercise Habits. 

The ALJ found that Waldon’s exercise report did not correspond to his reports of 

debilitating pain. AR 911. As already explained, the court does not find substantial 

evidence to support this assertion. Waldon was following doctors’ orders by exercising, 

and his rate of exercise steadily decreased from 2001 to 2003. This is not a clear and 

convincing reason to find Waldon not credible. 

g. Diabetes Medication Regimen. 

The ALJ found Waldon not credible because he did not follow his diabetes 

medication regimen. AR 911. As already explained, the court does not find substantial 

evidence in the record to support this assertion. Therefore, it is not a clear and 

convincing reason to find Waldon not credible. 

h. Waldon’s Limitations. 

The ALJ says that no physician ever opined that Waldon’s ailments met or equaled 

a listing. AR 911. But Dr. Sprague described Waldon as having “marked limitation in 

his concentration due to pain and fatigue and marked impairment in his social 

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functioning.” AR 852. A marked limitation satisfies the criteria of the “Listing of 

Impairments.” See 20 C.F.R. § 404(p), Appendix 1 (Listing of Impairments) § 12.00 

Mental Disorders (“We assess functional limitations using the four criteria in paragraph B 

of the listings: Activities of daily living; social functioning; concentration, persistence, or 

pace; and episodes of decompensation.”). Based on the content of the opinion of Dr. 

Sprague, the court finds this is not a clear and convincing reason to reject Waldon’s 

testimony. 

i. Impairments and Pain. 

The ALJ found that the objective medical evidence does not support a finding of 

disability. AR 911. But the rejection of a claimant’s testimony based on a lack of 

objective evidence is legally insufficient because it requires the consideration of “excess 

pain,” and not simply the degree of pain established by the objective medical evidence. 

Bunnell, 947 F.2d at 345; 20 C.F.R. § 404.1529(c)(2) (“we will not reject your statements 

about the intensity and persistence of your pain or other symptoms or about the effect 

your symptoms have on your ability to work solely because the available objective 

medical evidence does not substantiate your statements”). Accordingly, the court does 

not find this to be a clear and convincing reason to find Waldon not credible. 

III. CONCLUSION 

A determination whether to reverse and award benefits or reverse and remand for 

further administrative proceedings is within the Court’s discretion. McAllister v. 

Sullivan, 888 F.2d 599, 603 (9th Cir. 1989). A finding of disability is warranted when 

further proceedings before the Commissioner on a fully-developed issue would be futile. 

Smolenr, 80 F.3d at 1292. Having already been remanded for a second set of 

proceedings, and now finding again that the record does not support the ALJ’s secondidentified set of “clear and convincing” reasons to reject the opinion of Dr. Sprague who 

treated Waldon for 10 years, the court finds that a second remand would be futile. In 

light of the above discussion, the court concludes that the ALJ erred in rejecting the 

opinion of treating physician Dr. Sprague and erred in not finding Waldon to be credible. 

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See Lester, 81 F.3d at 829-830 (finding a failure to properly consider the treating opinion 

is reversible error). 

Accordingly, the court finds that Waldon is entitled to disability benefits as of the 

date of his eligibility. Based on its review of the record and consideration of the briefs, 

the court RECOMMENDS that Plaintiff’s Motion for Summary Judgment be 

GRANTED and Defendant’s Cross-Motion for Summary Judgment be DENIED. This 

court RECOMMENDS that final decision of the Commissioner be REVERSED and 

REMANDED to the Social Security Administration for the calculation and award of 

benefits. 

This Report and Recommendation is submitted to the United States district judge 

assigned to this case pursuant to 28 U.S.C. § 636(b)(1). Any party may file written 

objections with the court and serve a copy on all parties on or before May 24, 2016. The 

document should be captioned “Objections to Report and Recommendation.” 

Any response to the objections shall be filed and served on or before June 1, 2016. 

The parties are advised that any failure to file objections within the specified time may 

waive the right to raise those objections on appeal of the Court’s order. Baxter v. 

Sullivan, 923 F.2d 1391, 1394 (9th Cir. 1991). 

IT IS SO ORDERED. 

Dated: May 10, 2016 

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