Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_06-cv-00082/USCOURTS-casd-3_06-cv-00082-1/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)

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06cv82-WQH (BLM)

UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

MICHELLE D. SNOVELLE,

Plaintiff,

v.

MICHAEL J. ASTRUE, Commissioner of

Social Security,

Defendant.

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Case No. 06cv82-WQH (BLM)

ORDER DENYING PLAINTIFF’S

REQUEST FOR A DE NOVO HEARING

AND TO CONSIDER NEW EVIDENCE

AND 

REPORT AND RECOMMENDATION

FOR ORDER GRANTING IN PART

PLAINTIFF’S MOTION FOR SUMMARY

JUDGMENT AND DENYING

DEFENDANT’S CROSS-MOTION FOR

SUMMARY JUDGMENT

[ECF Nos. 44 & 50]

Plaintiff Michelle D. Snovelle brought this action for judicial review of the Social Security

Commissioner’s (Commissioner) denial of her application for disability insurance benefits and

supplemental security income. Before the Court are Plaintiff’s Motion for Summary Judgment

(ECF No. 44) and Defendant’s Cross-Motion for Summary Judgment (ECF No. 50). 

This Report and Recommendation is submitted to United States District Judge William Q.

Hayes pursuant to 28 U.S.C. § 636(b) and Civil Local Rule 72.1(c) of the United States District

Court for the Southern District of California. For the reasons set forth below, this Court

RECOMMENDS that Plaintiff’s Motion for Summary Judgment be GRANTED IN PART and

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

PROCEDURAL BACKGROUND

On April 28, 2003, Plaintiff applied for disability insurance benefits and supplemental

security income under Titles II and XVI of the Social Security Act. Administrative Record (AR) at

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3, 94-97. Plaintiff alleged a disability onset date of November 9, 2001. Id. at 94. The

Commissioner initially denied Plaintiff’s application, and again upon reconsideration, resulting in

Plaintiff’s February 17, 2004 request for an administrative hearing. Id. at 27-37.

On November 17, 2004, a hearing was held before Administrative Law Judge (ALJ) Jerry

F. Muskrat Id. at 14. Ansar Haroun, M.D., a board-certified specialist in the field of psychiatry,

John R. Morse, M.D., a diplomat of the American Board of Internal Medicine with a subspecialty

in cardiovascular disease, Plaintiff, and a vocational expert (VE) testified at the hearing. Id. In

a written decision dated February 2, 2005, the ALJ determined that Plaintiff was not disabled.

Id. at 14-24. Plaintiff requested review by the Appeals Council, but this request was denied,

making the ALJ’s decision the final decision of the Commissioner. Id. at 4-10; see also 20 C.F.R.

§ 404.981. 

On January 13, 2006, Plaintiff filed the instant federal action. ECF No. 1. In February of

2007, the parties filed a joint motion to remand based on the fact that the Commissioner had not

yet been able to locate the recording of the administrative hearing. ECF No. 14. The

Commissioner represented that if the recording could not be located within a reasonable time, the

Commissioner would remand the case to an ALJ for a de novo hearing. Id. On February 13,

2007, the district judge granted this request and remanded the matter to the Social Security

Administration. ECF No. 15. 

On July 2, 2010, the district judge reopened the case in response to a request by the

Commissioner wherein the Commissioner represented that he was prepared to file an

administrative record of the underlying proceedings. ECF Nos. 17, 18. After having been granted

five extensions of time in which to do so (totaling over five months of additional time), Plaintiff

filed a motion for summary judgment on March 28, 2011. ECF No. 44. On May 23, 2011,

Defendant filed a cross-motion for summary judgment and opposition to Plaintiff’s motion. ECF

Nos. 50 & 53. The Court granted Plaintiff’s first request for an extension of time to oppose

Defendant’s cross-motion for summary judgment but denied Plaintiff’s second request. ECF Nos.

58 & 61. While Plaintiff did not file an opposition to Defendant’s cross-motion for summary

judgment, she did filed a motion for remand. ECF No. 63. The motion for remand is addressed

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3 06cv82-WQH (BLM)

in a separate order filed today.

FACTUAL BACKGROUND

I. Plaintiff’s Education and Employment History

Plaintiff was born on December 16, 1971, and was 29 years old on November 9, 2001, the

alleged onset date of disability. AR at 94. Plaintiff has a high school education and completed

one year of college. Id. at 155 & 555. Prior to her alleged disability, Plaintiff worked as a pizza

maker, office clerk, secretary, waitress, cashier/receptionist, and most recently, as a field

representative for the Department of Motor Vehicles. Id. at 92, 114, 150, 555-63. 

II. Plaintiff’s Medical History

In March of 2001, Plaintiff underwent a sleep study and was diagnosed as having a mild

nocturnal obstruction. Id. at 490.

On July 15, 2001, Plaintiff went to Kaiser Urgent Care complaining of low back pain. Id.

at 490. She reported having no recollection of having recently increased her activity level or of

suffering any trauma. Id. Lumbar muscle spasm was diagnosed and short courses of Motrin and

Soma were prescribed. Id. About two weeks later, Plaintiff followed up with Tony Quan, M.D.,

regarding her back pain and it appears he prescribed Soma, Motrin, Prednizone, and Vicodin. Id.

at 491. On August 9, 2001, Plaintiff saw John Goetz, M.D., and complained that the acute back

pain was radiating from the lumbar area into the left buttock and posterior thigh, with associated

numbness and tingling in the left calf and outer border of the left foot. Id. at 487. Dr. Goetz

diagnosed an S1 radiculopathy (noting that the pathology most likely was at L4-5, though he did

not have the x-rays yet), and recommended a cautious trial of press-ups, anti-inflammatory

medication, and an epidural. Id. Plaintiff refused the epidural during the examination, stating

that she wanted to think about the treatment. Id. There is no evidence in the record that she

returned and received the epidural steroid.

During her initial consultation at Kaiser’s Department of Psychiatry and Addiction Medicine

on November 12, 2001, Plaintiff reported feeling depressed because of her health problems (citing

back pain and sleep apnea). Id. at 274-75. A mood disorder, secondary to a medical condition,

was diagnosed and Plaintiff was referred to a pain management program. Id. at 277. On

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 A few days later, Plaintiff underwent a third sleep study following reports of increased daytime fatigue.

AR at 228. The treating physicians increased her CPAP pressure. Id.

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November 16, 2001, Plaintiff underwent a second sleep study, at which time moderal obstructive

sleep apnea was diagnosed and a CPAP machine prescribed. Id. at 483. One month later,

Plaintiff was taking Prozac and attending a Depression Group and Adjusting to Medical Illness

Group. Id. at 270. On January 9, 2002, Plaintiff reported that the Prozac was not helping. Id.

at 268.

Michael Jaffe, D.O., conducted a physical medicine consultative examination on May 13,

2002, at which point Plaintiff complained of pain throughout her entire lumbar spine, with pain

shooting down her left leg. Id. at 458. Dr. Jaffe concluded that Plaintiff had severe degenerative

disc disease at L5-S1 (for her age) and might have a herniated disc. Id. at 459. He opined that

a significant amount of her pain was coming from muscle dysfunction of the lumbar spine and

that “contracture and deconditioning of the musculature ... is worsening her L5-S1 radicular

syndrome.” Id. He referred her for physical therapy and scheduled an appointment to review

her upcoming MRI. Id. An MRI performed on May 15, 2002, showed “likely conjoint nerve root

sheath involving left L5 and S1 never roots,” a disc hernia encroaching at the same location, and

“bilateral neural foramina mild to moderate stenosis.” Id. at 226. Meanwhile, Plaintiff attended

physical therapy and reported that the stretching exercises worked when she did them. Id. at

424.

On October 8, 2002, Plaintiff consulted with a pain management specialist, Lisa Phillips,

M.D., who ordered a lumbar diagnostic discogram to determine whether the L5-S1 disc was a

source of pain. Id. at 257-60. Dr. Phillips also encouraged Plaintiff to swim laps and stretch in

a warm water pool, and discussed the possible benefits of a referral for electrical acupuncture.1

Id. at 260. Clinical notes indicate that someone diagnosed Plaintiff with fibromyalgia in November

2002, but it is unclear from the records who did so. See id. at 253. Between December 30, 2002

and February 10, 2003, Plaintiff received six electroacupuncture treatments from Farshad

Ahadian, M.D. Id. at 210-11, 215-16, 219, 222-25. On January 24, 2003, one of Plaintiff’s Kaiser

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physicians noted 16/18 tender points and a depressed affect with tearfulness, and diagnosed

fibromyalgia and depression. Id. at 252, 404 (duplicate record). At the time, Plaintiff was taking

Flexeril, Vicodin, and Prozac, and the physician increased her Vicodin and Prozac doses following

the appointment. Id. 

On April 2, 2003, Dr. Phillips performed L4-L5, L5-S1 bilateral intra-articular facet joint

injections. Id. at 247-48. Plaintiff reported one day of complete pain relief from these injections,

but stated that the pain returned shortly thereafter. Id. at 241. Dr. Phillips then tried bilateral

diagnostic sacroiliac joint injections. Id. at 241-42. 

On July 7, 2003, Richard Heidenfelder, M.D., a board eligible psychiatrist, performed a

complete psychiatric evaluation and concluded that Plaintiff was not impaired in any work-related

way, except that she is “moderately impaired in her ability to respond to change in the normal

workplace setting.” Id. at 177-81. Dr. Heidenfelder opined that Plaintiff’s psychiatric prognosis

could be expected to improve in the next twelve months with active treatment. Id. at 181. 

On July 22, 2003, Thomas Sabourin, M.D., a board certified diplomate of the American

Board of Orthopaedic Surgeons, performed an orthopaedic consultation on Plaintiff and found that

Plaintiff had no restrictions. Id. at 182-86. He explained that:

This patient presents with pain syndrome, the severity and duration of which are

disproportionate to the physical findings on orthopedic examination. 

From the functional orthopedic point of view, this patient has very little in the way

of findings other than decreased range of motion in forward flexion. She has such

pain throughout the examination as she hyperventilates and when the exam was

done, she started crying.

Id. at 185-86.

On August 1, 2003, Plaintiff had an appointment with Dr. Jaffe, who noted that Plaintiff

has suffered chronic, daily low back pain (LBP) since 2001, had facet injections/SI injections that

did not help, and had a discogram that did not provide a good reproduction of her pain. Id. at

238. His notes further indicate that he observed “18/18 of FMS” (which seems to indicate 18/18

trigger points of fibromyalgia) and diagnosed fibromyalgia (among other things). Id. Dr. Jaffe

also signed off on Plaintiff’s application for disabled license plates, indicating on the form that

Plaintiff had “severe fibromyalgia.” Id. at 202.

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Plaintiff underwent an additional MRI scan of her lumbar spine on August 6, 2003, for

comparison to the May 15, 2002 study. Id. at 203-06, 525-26. The findings were similar to the

previous scan, with “evidence for severe degenerative disk disease at the L5/S1 disk, and the

presence of a small disk protrusion posteriorly and slightly off midline to the left with some

encroachment into the left neural foramina noted.” Id. at 526. 

Drs. Jaffe and Phillips referred Plaintiff to Sanjay Khurana, M.D., for an orthopedic

consultation and “evaluation of Plaintiff’s persistent low back pain and bilateral leg pain in the

setting of a diffuse fibromyalgia-type syndrome.” Id. at 230. On September 15, 2003, Dr.

Khurana examined Plaintiff and noted that she had somewhat limited mobility with pain generated

when she forward flexes. Id. at 231. He recommended purely conservative treatment because,

given her young age, surgical options were neither available nor advisable. Id. at 231-32. He

suggested weaning off the narcotics she had been taking, while taking anti-inflammatories

instead, and engaging in “any activity that she would like to do including aerobics, weights,

swimming, or any activity she desires.” Id. 

On November 20, 2003, Richard Hicks, M.D., a board certified psychiatrist, conducted a

comprehensive psychiatric evaluation of Plaintiff. Id. at 278-83. At that point, Plaintiff reported

suffering anxiety attacks, depression, insomnia, problems with concentration, fibromyalgia, and

disc pain. Id. at 278. She was taking Prozac for depression; Sulindac, Flexeril, and Vicodin (8 per

day) for pain; and Tranxene for panic attacks. Id. Dr. Hicks diagnosed a depressive disorder as

part of her overall physical picture and opined that she could do simple, repetitive tasks and could

take instruction from supervisors. Id. at 282. He felt that “[h]er interaction with coworkers and

the public would be very limited because of her preoccupation with her physical condition and her

pain. Her consistency and regularity would be questionable because of her pain.” Id. 

On April 4, 2004, Plaintiff was admitted to the County of San Diego’s Isis Center and

reported being suicidal. Id. at 318-24. She said that she had stopped seeing a therapist in 2003

because her insurance ran out and had stopped taking Prozac because she did not think it helped

her. Id. at 319. Plaintiff was diagnosed with major depressive disorder and referred for individual

therapy and medication management. Id. at 322-23. After being discharged from Isis, Plaintiff

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went for a follow-up appointment at South Bay Guidance on June 2, 2004. Id. at 331-38.

Following an evaluation, Donna Mills, M.D. observed that Plaintiff was positive for daytime

somnolence, low motivation, and low energy, had a panic episode three days prior, and had poor

concentration. Id. at 331, 335. Dr. Milla prescribed Neurontin and Paxil CR. Id. at 338. 

Doctors Janna Ropohl, MD. (attending) and Marianne McKennett, M.D. (supervising) at the

Chula Vista Family Clinic evaluated Plaintiff on August 24, 2004. Id. at 341-43. Plaintiff

complained of back pain, but stated that she had not taken any medications since January. Id.

at 341. Upon physical examination, the physicians noted tenderness to palpation in the lumbar

and thoracic spine, restricted range of motion in the thoracic spine, and less than 60E of flexion

on a left Straight Leg Raising Test, but otherwise reported normal findings. Id. at 342. They

prescribed naprosyn and Soma for back pain and referred Plaintiff for water exercise and physical

therapy. Id. at 343. 

Finally, in a mental impairment questionnaire dated October 27, 2004, Dr. Mills explained

that in addition to monthly doctor visits, Plaintiff attended weekly group therapy meetings and

weekly individual coaching. Id. at 533. On a checklist form, Dr. Mills indicated positive mental

status findings for: anhedonia or pervasive loss of interest, decreased energy, thoughts of suicide,

feelings of guilt or worthlessness, generalized persistent anxiety, mood disturbance, difficulty

concentrating, psychomotor agitation or retardation, paranoid thinking or inappropriate

suspiciousness, emotional withdrawal or isolation, disorientation to time and place, inflated selfesteem, easy distractibility, sleep disturbance, recurrent severe panic attacks, and a history of

multiple physical symptoms for which there ware no organic findings. Id. at 19, 534. When

asked to “[d]escribe the clinical findings including results of mental status examination that

demonstrate the severity of your patient’s mental impairment and symptoms,” Dr. Mills wrote

“[t]his client presented with severe depressed & anxious mood, insomnia, low energy, panic

attacks, chronic physical pain, thoughts of suicide and interpersonal relationship problems.” Id.

Dr. Mills then wrote in her diagnosis of “major depressive disorder, recurrent severe without

psychotic features” and noted that Plaintiff was not responding to Paxil and was starting

Wellbutrin and that Dr. Mills felt Plaintiff’s prognosis was poor. Id. at 533-38. In a checkbox-type

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 Plaintiff also explained that she suffers from sleep apnea, but had to stop using her CPAP machine when

her insurance ran out and she could not obtain a humidifier for it. Id. at 576-77. 

8 06cv82-WQH (BLM)

chart eliciting an evaluation of Plaintiff’s functional limitations, Dr. Mills indicated that Plaintiff had

“extreme” limitations in each of the following three areas: (a) restriction of activities of daily

living, (b) difficulties in maintaining social functioning, and (c) difficulties in maintaining

concentration, persistence or pace. Id. at 536. She further noted that Plaintiff had suffered four

or more episodes of decompensation within a twelve-month period. Id. 

III. Social Security Administration Hearing

During the November 17, 2004 hearing before the ALJ, Plaintiff, who was represented by

counsel, alleged a disability onset date of November 9, 2001. Id. at 564. However, upon learning

that Plaintiff went back to work part-time at the DMV for seven months, the ALJ amended

Plaintiff’s disability onset date to April 1, 2003. Id. at 565-67. 

During questioning from her attorney, Plaintiff explained that she could not currently

perform any of her past jobs due to her back pain, general body pain, and anxiety. Id. at 569.

She testified that she cannot sit or stand for more than a few minutes without extreme pain,

which comes in flares and spasms. Id. at 570, 577. She described her back pain as constant in

her lower back, though the degree of severity varies and sometimes radiates down her left leg

and up the middle of her back. Id. at 574-75. Plaintiff stated that her fibromyalgia causes

weakness and tenderness all over her body, with particular sensitivity in her shoulders, neck,

back, thighs, and calves. Id. at 575-76. Plaintiff also testified that her fear of being reprimanded

and resulting anxiety (in the form of shortness of breath, light-headedness, a rapid heart rate,

and feelings of tingliness and dizziness) prevented her from calling her employer to say that her

pain prevented her from working.2

 Id. at 571. 

As of the date of the hearing, Plaintiff claimed that she needed to rest for six hours in an

eight-hour day and was taking Paxil, Wellbutrin, Soma, and Naproxen. Id. at 572. However, she

stated that the medications she was taking did not help at all with her back pain. Id. She

explained that she used to take Sylindac and Flexoril, which provided some relief, but that she

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 The ALJ explained that he chose Dr. Morse, even though he is a cardiologist and Plaintiff has not alleged

cardiac issues, because the administration could not hire experts for each of Plaintiff’s diverse ailments and he

considered Dr. Morse a generalist. Id. at 551-52. Plaintiff’s attorney did not object to Dr. Morse offering testimony.

Id. at 553.

9 06cv82-WQH (BLM)

has not been able to get these medications since she lost her insurance. Id. at 572-73. Her

doctors have told her she was not a candidate for fusion surgery because it would cause the

degenerative disc disease to move up her spine and she would end up requiring multiple

surgeries. Id. at 574-75. The treatments doctors have tried—epidural shots, a discogram MRI,

and bilateral joint injections—have not helped. Id. at 575.

In regard to her depression, Plaintiff testified that she was diagnosed in 2001 and just

started taking the combination of Paxil and Wellbutrin a few weeks prior to the hearing. Id. at

579. She still had panic attacks, had no energy, preferred to be alone, cried and felt pitiful, had

trouble concentrating, and still sometimes felt suicidal. Id. at 580-81. As a result of these issues

and her physical pain, Plaintiff spent most days sleeping or lying down, listening to music, or

watching television. Id. at 582. She only went out for appointments and errands. Id. 

Dr. Morse then testified about Plaintiff’s physical ailments.3

 Id. at 583. He opined that

Plaintiff’s degenerative disc disease at the L5-S1 level, with some dessication at the L5 disc space,

was severe, but did not meet or equal a Social Security disability listing. Id. at 584-85. It would,

however, limit Plaintiff to lifting only twenty-five pounds frequently or fifty pounds occasionally,

sitting or standing for six hours in an eight-hour workday, and only crouching occasionally. Id.

at 585-86. He did not believe the diagnosis of fibromyalgia had been established by the medical

evidence. Id. at 584. And, though Plaintiff’s sleep apnea was medically established, he opined

that it should be non-severe with treatment. Id. 

On cross-examination by Plaintiff’s attorney, Dr. Morse disagreed with the treating

physician that Plaintiff’s MRI showed severe disc disease, instead relying on the opinion of a

consultative physician, who felt it was not severe because it did not show radiculopathy (which

causes motor weakness). Id. at 587-88. Dr. Morse felt that Plaintiff’s objective findings did not

correlate with many of her subjective symptoms. Id. at 591. 

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Dr. Haroun then testified about Plaintiff’s alleged mental impairments. Dr. Haroun did not

find that panic disorder had been established by the medical evidence, but did believe Plaintiff

suffered from a severe affective disorder (though not at a listing level). Id. at 592-94, 596.

Though different physicians classified this affective disorder differently, he felt it was most

accurately described as a depressive disorder, NOS. Id. at 594. While he acknowledged that

Plaintiff surely had real physical pain, he opined that Plaintiff’s mental impairment, standing alone,

would only limit her social functioning to a mild degree. Id. at 595-96. He felt that it would cause

mild impairment of her ability to do “super repetitive tasks,” mild to moderate impairment of

concentration, etc., and moderate impairment of her ability to engage in complex tasks. Id. at

596. He noted no repeated episodes of decompensation. Id. Given all of this, he opined that

Plaintiff’s residual functional capacity would be for “super repetitive tasks in a non-public setting.”

Id. During cross-examination, Dr. Haroun acknowledged that if all of the answers on the medical

impairment questionnaire completed by Plaintiff’s treating physician, Dr. Mills, were accepted,

Plaintiff would meet a Social Security disability listing. Id. at 598-99. 

Finally, the ALJ heard testimony from the VE. The ALJ asked the VE if Plaintiff could

perform any of her past relevant work if he were to find that Plaintiff retained a residual functional

capacity limited to a range of medium work with the additional non-exertional limitations that

Plaintiff could only occasionally climb, balance, stoop, crouch or crawl, and was limited mentally

to non-public simple, repetitive tasks. Id. at 601-02. The VE opined that she could not because

Plaintiff’s mental limitations alone precluded her from performing any of her past work. Id. at

602. The VE explained that the hypothetical limitations would put Plaintiff at vocational guideline

203.29 (younger individual, high school graduate or more, no direct entry into work, skilled or

semi-skilled, skills not transferrable) with her non-exertional (mental) limitations causing “severe

erosion” of the occupational list. Id. at 603-04. Nonetheless, the VE listed sweeper/cleaner,

textile stuffer, and bench hand as three jobs Plaintiff could perform. Id. at 604-05. However,

when Plaintiff’s attorney asked if the person in the hypothetical with the additional limitations that

Plaintiff testified to could work full-time, the VE answered “no.” Id. at 605. 

///

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STANDARD OF REVIEW

Section 405(g) of the Social Security Act permits unsuccessful applicants to seek judicial

review of the Commissioner’s final decision. 42 U.S.C. § 405(g). The scope of judicial review is

limited in that a denial of benefits will not be disturbed if it is supported by substantial evidence

and contains no legal error. Id.; Batson v. Comm’r Soc. Sec. Admin., 359 F.3d 1190, 1193

(9th Cir. 2004).

Substantial evidence is “more than a mere scintilla but may be less than a preponderance.”

Lewis v. Apfel, 236 F.3d 503, 509 (9th Cir. 2001) (citation omitted). It is “relevant evidence that,

considering the entire record, a reasonable person might accept as adequate to support a

conclusion.” Id. (citation omitted); see also Howard ex rel. Wolff v. Barnhart, 341 F.3d 1006,

1011 (9th Cir. 2003). Where the evidence reasonably can be construed to support more than one

rational interpretation, the court must uphold the ALJ’s decision. Batson, 350 F.3d at 1193. This

includes deferring to the ALJ’s credibility determinations and resolutions of evidentiary conflicts.

See Lewis, 236 F.3d at 509.

Even if the reviewing court finds that substantial evidence supports the ALJ’s conclusions,

the court must set aside the decision if the ALJ failed to apply the proper legal standards in

weighing the evidence and reaching his or her decision. See Batson, 359 F.3d at 1193. Section

405(g) permits a court to enter judgment affirming, modifying, or reversing the Commissioner’s

decision. 42 U.S.C. § 405(g). The reviewing court may also remand the matter to the Social

Security Administration for further proceedings. Id.

DISCUSSION

Plaintiff seeks a default judgment based on Defendant’s failure of consideration in

connection with the 2007 remand (i.e. in letting the case linger for three years). Pl.’s Brief and

Mot. for Summ. J. (Pl.’s Brief) at 2, 23. Alternatively, Plaintiff asks the Court to conduct a de novo

review of the entirety of the case records, including new evidence presented by Plaintiff. Id.

Plaintiff believes this review should lead to reversal of the ALJ’s decision and an award of benefits.

Id. at 23-24. Defendant argues the ALJ’s decision is based on substantial evidence and free of

legal error. Def.’s Mem. at 12-23.

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 Rule 37(b)(2)(A)(vi) also mentions the remedy of a default judgment, but this provision is not applicable

to the circumstances at bar because Rule 37 provides remedies for discovery violations. 

12 06cv82-WQH (BLM)

I. Plaintiff is Not Entitled to a Default Judgment

Plaintiff seeks a default judgment against Defendant based on Defendant’s failure of

consideration regarding the joint motion to remand that the parties filed in 2007. Pl.’s Brief at

2-6. Plaintiff explains that the she agreed to the joint motion because Defendant could not locate

the record from Plaintiff’s administrative hearing and Defendant told her that, if the record could

not be located within a reasonable amount of time, the Commissioner would remand the case to

an ALJ for a de novo hearing. Id. at 2-3. Ultimately, it took Defendant three years to locate the

record and reopen the case in federal court—a time period Plaintiff believes is unreasonable. Id.

at 3, 5. 

Though Defendant’s delay was lengthy and has never been explained, a default judgment

is not available as a remedy. Rule 55 of the Federal Rules of Civil Procedure provides that the

clerk of court may enter a default “[w]hen a party against whom a judgment for affirmative relief

is sought has failed to plead or otherwise defend, and that failure is shown by affidavit or

otherwise.” Fed. R. Civ. P. 55(a). That is not the case here. The parties filed the joint motion

to remand on the date Defendant’s answer to Plaintiff’s complaint was due. See ECF Nos. 13 &

14. Once the case was reopened, Defendant filed a timely answer to Plaintiff’s complaint. See

ECF Nos. 19 & 21. Since that time, Defendant has filed timely briefs and responses and otherwise

defended against Plaintiff’s case. Furthermore, Plaintiff has never asked the clerk to enter a

default, which is the precursor step to seeking a default judgment from the Court. Fed. R. Civ.

P. 55(a)-(b). For these reasons, the Court finds that a default judgment is not appropriate in this

case.4

 See Cmty. Dental Serv. v. Tani, 282 F.3d 1164, 1170 (9th Cir. 2002) (quoting Falk v. Allen,

739 F.2d 461, 463 (9th Cir. 1984) (per curiam)) (judgment by default is an extreme measure and

a case should, ‘whenever possible, be decided on the merits’”). The Court, therefore,

RECOMMENDS that Plaintiff’s request for a default judgment be DENIED.

///

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II. The Court Cannot Consider New Evidence or Conduct a De Novo Review

Plaintiff asks that the Court conduct a de novo review of the administrative record in her

case as well as the new evidence she submitted to the Court. Pl.’s Brief at 2. As this Court

explained in its April 21, 2011 order, the role of the district court is wholly appellate in social

security cases. ECF No. 47; 42 U.S.C. § 405(g) (“[t]he court shall have power to enter . . . a

judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security).

The district court may not consider new evidence in reviewing the decision of the Commissioner

of Social Security. See 42 U.S.C. § 405(g) (explaining that the court may consider only “the

pleadings and transcript of the record”); see also Ellis v. Bowen, 820 F.2d 682, 684 (5th Cir. 1987)

(expressly confirming that “[t]he courts may not take new evidence”); Carolyn A. Kubitschek &

Jon C. Dubin, Social Security Disability Law and Procedure in Federal Court § 9.57 (West, 2011

ed.) (“the District Court may not consider evidence outside of the administrative record in

reviewing a claim for benefits”). For the same reasons, the Court also lacks jurisdiction to

conduct a de novo review. See e.g. 42 U.S.C. § 405(g) (“[t]he findings of the Commissioner of

Social Security as to any fact, if supported by substantial evidence, shall be conclusive...”). The

Court, therefore, DENIES Plaintiff’s requests for a de novo hearing and consideration of new

evidence.

III. The ALJ’s Decision

Pursuant to Social Security Regulations, the ALJ followed a five-step sequential evaluation

process for determining whether Plaintiff was disabled. AR at 15-24; see also 20 C.F.R.

§ 416.920(a) (describing five-step assessment). 

A. Step One

 At the first step, the ALJ determined that Plaintiff had not engaged in substantial gainful

activity since the amended alleged onset date of disability of April 1, 2003. AR at 23; see also 20

C.F.R. § 416.920(a)(I). Plaintiff asserts that the correct disability onset date is November 9, 2001.

Pl.’s Brief at 7-8. Plaintiff explains that she did not work from November 10, 2001 to September

2002 and then she only worked part-time and sporadically from September 2002 to April 1, 2003.

Id.; AR at 564-67. Given the irregular and part-time nature of her work, Plaintiff believes this

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second period should qualify as an “unsuccessful work attempt.” Pl.’s Brief at 7-8. If so

classified, the correct alleged disability onset date would be November 9, 2011. Id.

“Work activity is ‘substantial’ if it ‘involves doing significant physical or mental activities.””

Corrao v. Shalala, 20 F.3d 943, 946 (9th Cir. 1994) (quoting 20 C.F.R. § 416.972(a)). Under this

definition, part-time work may be “substantial.” 20 CFR § 404.1572(a) (“work may be substantial

even if it is done on a part-time basis”); Keyes v. Sullivan, 894 F.2d 1053, 1056 (9th Cir. 1990).

The primary criterion for determining whether a claimaint’s work is substantial gainful activity is

the amount of the claimant’s earnings. See 20 CFR § 404.1574(a)-(b). If the claimant averaged

$700 or more per month in the year 2000, or more than the average monthly salary minimum for

each year thereafter (as adjusted based on the national average wage index), the presumption

is that the claimant engaged in substantial gainful activity. 20 CFR § 404.1574(b)(2)-(3); Keyes,

894 F.2d at 1056. This presumption is rebuttable, with the factors to be considered including “the

time spent working, quality of a person's performance, special working conditions, and the

possibility of self-employment.” Katz v. Sec’y of Health & Human Serv., 972 F.2d 290, 293 (9th

Cir. 1992). 

However, “substantial gainful activity means more than merely the ability to find a job and

physically perform it; it also requires the ability to hold the job for a significant period of time.”

Gatliff v. Comm’r of Soc. Sec. Admin., 172 F.3d 690, 694 (9th Cir. 1999). If an individual stops

working for a significant period of time due to his or her disability and then resumes working, only

to stop again, this may be considered an unsuccessful work attempt. See 20 CFR § 404.1574(c).

An unsuccessful work attempt does not affect the disability onset date. Id. Generally, if an

individual works less than three months, it constitutes an unsuccessful work attempt. 20 CFR

§ 404.1574(c)(3). More than six consecutive months of work, on the other hand, cannot be

considered an unsuccessful work attempt. 20 CFR § 404.1574(c)(5). If an individual worked

between three and six months, the Social Security Administration (SSA) applies the following rule:

We will consider work that lasted longer than 3 months to be an unsuccessful work

attempt if it ended, or was reduced below substantial gainful activity earnings level,

within 6 months because of your impairment or because of the removal of special

conditions which took into account your impairment and permitted you to work andCase 3:06-cv-00082-WQH-BLM Document 75 Filed 11/30/11 Page 14 of 37
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(i) You were frequently absent from work because of your impairment; 

(ii) Your work was unsatisfactory because of your impairment; 

(iii) You worked during a period of temporary remission of your impairment; or 

(iv) You worked under special conditions that were essential to your performance

and these conditions were removed. 

20 CFR § 404.1574(c)(4). 

In this case, Plaintiff did not work from November 10, 2001 to September 2002, and then

returned to work part-time from September 2002 to April 1, 2003. AR at 564-67. For the period

from September 2002 through March 30, 2003, the ALJ looked to Plaintiff’s earning records to see

if this work qualified as substantial gainful activity or an unsuccessful work attempt. See AR at

15. In calendar year 2002, Plaintiff earned $7,071.30 and in calendar year 2003, her earnings

were $3,469.01. Id. at 15, 98, 104. The ALJ concluded that because the monthly average of

these amounts fell above the minimums set forth in the regulations, Plaintiff was presumed to

have been engaged in substantial gainful activity for this seven-month period. Id. at 15, 564-67.

Plaintiff’s administrative counsel attempted to rebut this by arguing that Plaintiff’s earnings fell

below the minimum for some months, pointing to the Work Activity Report completed by an SSA

representative (Ex. 6E), which listed monthly totals for the period in question. Id. at 566-67

(referencing AR at 142). However, the ALJ rejected this argument because he did not know

where the figures in Exhibit 6E came from, whereas the detailed earnings report listing her annual

earnings came directly from the employers. Id. at 567. In her summary judgment motion,

Plaintiff points only to new evidence, which this Court cannot consider, to support her argument

that her work constituted an unsuccessful work attempt. Pl.’s Brief at 8. 

Having reviewed the evidence and argument before it, the Court finds no basis for

disturbing the ALJ’s decision. According to SSA regulations, Plaintiff’s monthly earnings may be

calculated by “averag[ing] [her] earnings separately for each period in which a different

substantial gainful activity earnings level applies.” 20 CFR § 404.1574a(b). The SSA’s guidelines

list the Substantial Gainful Activity (SGA) minimum for 2002 as $780 and the SGA minimum for

2003 as $800. See SSA’s Program Operations Manual System D1 10501.015, Table of SGA

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Earnings Guidelines and Effective Dates Based on Years of Work Activity (2010), available at

http://policy.ssa.gov/poms.nsf/lnx/0410501015. The monthly average of Plaintiff’s 2002 salary

is $1,767.83, which is well above the $780 minimum, and her monthly average for 2003 of

$1,156.34 is over the $800 minimum. Thus, the ALJ did not err in concluding that Plaintiff earned

over the minimum for seven consecutive months. Likewise, because Plaintiff worked more than

six consecutive months, her work could not be considered an unsuccessful work attempt. See

20 CFR § 404.1574(c)(5). Given that this Court also cannot ascertain the source of the figures

in Exhibit 6E and that the Court has no other rebuttal evidence or arguments before it, the Court

finds that the ALJ’s decision that Plaintiff engaged in substantial gainful activity from September

2002 through March 30, 2003 is supported by substantial evidence and not based on legal error.

In light of this conclusion, the Court further finds that the ALJ properly concluded that Plaintiff

could not be found disabled for the period from November 10, 2001 to September 2002 because

this period did not meet the SSA’s twelve-month durational requirement. See 20 CFR § 404.1509.

B. Step Two

At step two, the ALJ must determine whether the claimant has “a severe medically

determinable physical or mental impairment that meets the duration requirement in § 404.1509,

or a combination of impairments that is severe and meets the duration requirement.” 20 CFR

§ 404.1520(a)(4)(ii). An impairment or combination of impairments is considered severe if it

“significantly limits [the claimant’s] physical or mental ability to do basic work activities.” 20 CFR

§ 404.1520(c). As explained by the Ninth Circuit, this test is not intended to impose a high bar

on claimants:

An impairment or combination of impairments may be found “not severe only if the

evidence establishes a slight abnormality that has no more than a minimal effect on

an individual's ability to work.” Smolen [v. Chater], 80 F.3d [1273,] [] 1290 [9th Cir.

1996] (internal quotation marks omitted) (emphasis added); see Yuckert v. Bowen,

841 F.2d 303, 306 (9th Cir.1988). The Commissioner has stated that “[i]f an

adjudicator is unable to determine clearly the effect of an impairment or

combination of impairments on the individual's ability to do basic work activities, the

sequential evaluation should not end with the not severe evaluation step.” S.S.R. No. 85-28 (1985). Step two, then, is “a de minimis screening device [used] to

dispose of groundless claims,” Smolen, 80 F.3d at 1290, and an ALJ may find that

a claimant lacks a medically severe impairment or combination of impairments only

when his conclusion is “clearly established by medical evidence.” S.S.R. 85-28.

Thus, applying our normal standard of review to the requirements of step two, we

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must determine whether the ALJ had substantial evidence to find that the medical

evidence clearly established that Webb did not have a medically severe impairment

or combination of impairments. See also Yuckert, 841 F.2d at 306 (“Despite the

deference usually accorded to the Secretary's application of regulations, numerous

appellate courts have imposed a narrow construction upon the severity regulation applied here.”).

Webb v. Barnhart, 433 F.3d 683, 686-87 (9th Cir. 2005); see also Gardner v. Astrue, 257 Fed.

Appx. 28, 29 (9th Cir. 2007) (finding enough evidence of ankle impairment to “clear the low bar

at step two” and ordering the ALJ on remand to consider the impairment severe and incorporate

any limitations it caused into the claimant’s residual functional capacity assessment before

conducting the step-five determination). That being said, “[i]mpairments that can be controlled

effectively with medication are not disabling for the purpose of determining eligibility for SSI

benefits.” Warre v. Comm’r of Soc. Sec. Admin., 439 F.3d 1001, 1006 (9th Cir. 2006); but see

Gamble v. Chater, 68 F.3d 319, 321 (9th Cir. 1995) (“a disabled claimant cannot be denied

benefits for failing to obtain medical treatment that would ameliorate his condition if he cannot

afford that treatment”).

The ALJ determined at the second step that Plaintiff had the following “severe”

combination of impairments: lumbar degenerative disc disease and a depressive disorder, NOS.

AR at 23; see also 20 C.F.R. § 416.920(a)(4)(ii). Plaintiff argues that the ALJ’s findings at step

two are incomplete because the ALJ also should have included fibromyalgia, anxiety disorder with

panic attacks, and sleep apnea in his findings. Pl.’s Brief at 8. 

As Defendant points out, the ALJ found that Plaintiff had severe mental and physical

impairments, so technically Plaintiff prevailed at step two. See Def.’s Mem. at 15. This is true

because when an ALJ determines a claimant’s residual functional capacity (RFC) at step four, the

ALJ must consider the effects of all of the claimant’s impairments (including pain), not just those

which were determined to be severe at step two. See 20 CFR § 404.1545(e); Rhoades v.

Barnhart, 64 Fed.Appx. 76, 77 (9th Cir. 2003) (“[i]n determining a claimant's RFC, the ALJ must

consider the limiting effects of all of the claimant’s impairments, even those that were not

severe”); see also Robbins v. Soc. Sec. Admin., 466 F.3d 880, 883 (9th Cir. 2006) (quoting Soc.

Sec. Ruling 96-8p, 1996 WL 374184, at *5 (July 2, 1996)) (“[i]n determining a claimant's RFC,

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an ALJ must consider all relevant evidence in the record, including, inter alia, medical records, lay

evidence, and ‘the effects of symptoms, including pain, that are reasonably attributed to a

medically determinable impairment’”). Thus, at step four, the ALJ was required to consider

evidence of any limiting effects attributable to Plaintiff’s fibromyalgia, anxiety disorder with panic

attacks, and sleep apnea, even if he did not find these conditions to be severe at step two.

Nonetheless, the Court will consider Plaintiff’s objections to the ALJ’s findings at this step. 

With regard to fibromyalgia, Plaintiff objects that the ALJ overlooked evidence and failed

to consider the realities of her medical treatment. The ALJ made the following statements

pertaining to Plaintiff’s fibromyalgia,: 

Progress notes through November 3, 2003, document complaints of persistent low

back pain and bilateral leg pain. A diagnosis of diffuse fibromyalgia-type syndrome

was also reported. However, progress notes do not set forth an examination which

meets the criteria for a diagnosis of fibromyalgia. In particular, there is no

documentation of symptoms associated with trigger points, and the claimant has

not been referred to a rheumatologist or other specialist familiar with diagnosis

fibromyalgia. She was treated conservatively with Vicodin, physical therapy,

epidural injections, facet blocks, and bilateral sacroiliac blocks. 

...

On a DMV Application for Disabled Person Placard or Plates form completed on

August 1, 2003, Michael Jaffe, D.O. certified that the claimant was disabled due to

severe fibromyalgia. No specific objective findings were reported. 

AR at 16-17. Plaintiff rebuts the ALJ’s findings by pointing to medical evidence in the

administrative record that show she was diagnosed as having 16 of 18 tender points and

fibromyalgia. Pl.’s Brief at 9 (citing AR at 252). Additionally, Plaintiff points out that both when

she was insured and seeing physicians within the framework of Kaiser’s HMO and when she

became uninsured and was relying on County Medical Services, she was at the mercy of the

procedures of these organizations, which generally do not allow patients to see specialists before

meeting with a primary physician, having numerous tests, and trying several treatment

alternatives. Id. at 11. She explains that she was midway through this process at Kaiser when

her insurance ran out, so she had to start all over at County Medical Services. Id. In August of

2004, she was being treated at the Chula Vista Family Clinic, where the physician notes indicate

she had a history of fibromyalgia, and that the doctor referred her for a physical therapy

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evaluation and also provided the number for a local aquatic club so Plaintiff could do pool

exercises. AR at 343. The notes further indicate that Plaintiff requested a referral for

rheumatology, but that they “will try to focus on other 2 referals (sic) before this one” (apparently

referencing the physical therapy and aquatic club referrals). Id.

While the record is replete with evidence that Plaintiff experienced prolonged periods of

pain in her back and legs, which interfered with her ability to work, it is not clear from the record

that this pain was directly attributable to fibromyalgia as opposed to Plaintiff’s disc issues.

Because any impact the fibromyalgia had on Plaintiff’s ability to work, that was separate and apart

from the impact of the disc disease, bears more directly on the ALJ’s analysis at Step Four, the

Court will discuss this issue more thoroughly in it’s section addressing the ALJ’s Step Four

determination.

With regard to Plaintiff’s claimed diagnosis of anxiety disorder with panic attacks, Plaintiff

does not cite to evidence in the record where a physician made this diagnosis. The testifying

psychiatrist, Dr. Haroun, noted that Dr. Heidenfelder diagnosed “panic disorder without

agoraphobia” following his consultative examination, see AR at 180, 593, but Dr. Haroun did not

find that this diagnosis was sufficiently established in the record and it is unclear whether this is

even the diagnosis to which Plaintiff refers. Furthermore, Dr. Heidenfelder opined that Plaintiff

would be moderately impaired in her ability to respond to change in the normal workplace setting,

but otherwise concluded that all other work-related functions would be unimpaired. Id. at 181.

Thus, even if Plaintiff was diagnosed with a panic disorder, there is no evidence in the record that

it “significantly limits [her] physical or mental ability to do basic work activities.” 20 CFR

§ 404.1520(c). In other words, it fails to meet the Step Two severity threshold. The ALJ,

therefore, did not err in failing to include this diagnosis in his list of Plaintiff’s severe impairments.

Finally, the Court finds that Plaintiff has not presented evidence that her sleep apnea

qualifies as severe. As previously noted, the Social Security Administration does not consider

impairments that can be controlled effectively with medication to be disabling. Warre, 439 F.3d

at 1006. Plaintiff repeatedly has told her treating physicians that she sleeps better when she uses

it and feels less tired during the day. AR at 268, 426. However, she has discontinued using it,

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at least periodically, because it bothers her boyfriend. Id. at 134, 268. An impairment cannot

be considered severe where effective treatment exists and the claimant simply chooses not to

utilize it. 

Plaintiff could attempt to point to her hearing testimony in support of the argument that

she could not afford effective treatment. As previously noted, disability benefits cannot be denied

because a claimant did not obtain effective treatment if the claimant cannot afford the treatment.

Gamble, 68 F.3d at 321. Plaintiff claimed during the hearing that she discontinued using the CPAP

machine because it dried out her throat and she could not afford the prescription humidifier

necessary to make it tolerable after her insurance expired. AR at 576-77. However, it was the

ALJ’s responsibility to decide which of Plaintiff’s stories he believed — that she discontinued

treatment due to her boyfriend’s displeasure with the machine or due to the inability to make the

machine more comfortable through use of a humidifier. The law is clear that this Court must

defer to the ALJ’s credibility determinations and resolutions of evidentiary conflicts. See Lewis,

236 F.3d at 509. Therefore, the Court finds that ALJ’s decision to exclude sleep apnea as a severe

impairment was supported by substantial evidence. 

Accordingly, the Court finds that the ALJ did not err in making his determination at step

two that Plaintiff had the requisite severe combinations of impairments – lumbar degenerative disc

disease and a depressive disorder, NOS.

C. Step Three

At the third step, the ALJ found that Plaintiff’s impairments did not meet or medically equal

a listed impairment under Social Security Regulations. AR at 23; see also 20 C.F.R.

§ 416.920(a)(4)(iii). Listed impairments are those presumed to be disabling. See 20 C.F.R.

§ 404.1525. If any individual’s impairment meets a listing, the administration will find the

individual disabled without even considering the individual’s age, education, or work experience.

20 CFR § 404.1520(a)(4)(iii), (d). A claimant may also meet a listing if his or her impairment

equals a listed impairment (20 C.F.R. § 404.1520(d)) or if the claimant’s combination of

impairments is medically equal to a listed impairment (20 C.F.R. § 404.1526(a)-(b)).

Plaintiff contends that her degenerative disc disease, fibromyalgia, depression, and anxiety

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disorder with panic attacks all meet or equal a listing. Pl.’s Brief at 13-14. For each disorder, she

cites the listing she believes it meets or equals. Id. However, Plaintiff points to no medical

evidence in the record supporting her assertions and makes no arguments as to why the ALJ’s

conclusion that she did not meet a listing was in error. The Supreme Court has made clear that

the burden of showing a medically determinable impairment and providing medical and other

evidence in support thereof falls on the claimant. Bowen v. Yuckert, 482 U.S. 137, 146 and n.5

(1987); Roberts v. Astrue, 2011 WL 3501863, at *2 (C.D. Cal. Aug. 9, 2011) (“[t]he claimant

bears the burden of demonstrating that her impairments are equivalent to a listed impairment

that the Commissioner acknowledges are so severe as to preclude substantial gainful activity”);

see also Lewis, 236 F.3d at 514 (rejecting claimant’s argument that his disorders met or equaled

a listing where claimant “offered no theory, plausible or otherwise, as to how his seizure disorder

and mental retardation combined to equal a listed impairment” and pointed to no evidence

showing that his combined impairments equaled a listing). As Plaintiff has failed to offer any

evidence to the contrary, there is no basis for this Court to disturb the ALJ’s decision at step

three. D. Step Four

At the fourth step of the disability assessment, the ALJ determined that Plaintiff possessed

the “residual functional capacity” (RFC) to “perform a significant range of medium work.” AR at

21. More specifically, the ALJ found that Plaintiff retained the RFC to “lift and/or carry up to 25

pounds frequently or 50 pounds occasionally; to sit, stand, or walk about six hours each in an

eight-hour day; and to occasionally climb, balance, stoop, kneel, crouch, or crawl. She is further

limited to simple repetitive tasks in a non-public setting.” Id. at 20, 23; 20 C.F.R.

§ 416.920(a)(4)(iv). Given these limitations, the ALJ concluded that Plaintiff could not perform

any of her past relevant work. AR at 23; 20 C.F.R. §§ 404.1565 & 416.965. 

In evaluating Plaintiff’s physical limitations, the ALJ considered medical records and

opinions from Plaintiff’s treating physicians, Dr. Jaffe, Dr. Quan, and Dr. McKennett; consultative

examiners, Dr. Phillips, Dr. Sabourin, and Dr. Khurana; and the medical expert who testified at

the hearing, Dr. Morse. AR at 16-8. As the ALJ pointed out, none of Plaintiff’s treating physicians

provided a specific assessment of her physical functional limitations. Id. at 18. In evaluating

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 The ALJ mistakenly refers to Dr. Mills as “Dr. Miller” in his decision. 

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Plaintiff’s mental limitations, the ALJ considered medical records and opinions from Plaintiff’s

treating physicians at County of San Diego Mental Health Services and the South Bay Guidance

Center (in particular that of Donna Mills, M.D.); consultative psychiatrists, Dr. Heidenfelder and

Dr. Hicks; and the psychiatric medical expert who testified at the hearing, Dr. Haroun. Id. at 19-

20. Dr. Mills5

 did provide an assessment of Plaintiff’s mental limitations and how they impacted

her ability to work. See id. at 19, 533-38. 

Plaintiff challenges the ALJ’s assessment of her RFC generally on the grounds that it is

contradicted by her treating physicians and represents nothing more than a full adoption of the

consultative examiner’s “checklist,” which is not based on objective findings. See Pl.’s Brief at 21.

Plaintiff also objects to the ALJ’s bases for discounting her own testimony regarding her pain and

limitations. Id. at 14-21. Because the ALJ’s discounting of both the treating physician’s opinions

and Plaintiff’s credibility impacts this Court’s determination of whether his RFC decision is based

on substantial evidence, this Court addresses each issue below. 

1. Plaintiff’s Treating Physicians

The opinion of a treating physician generally should be given more weight than opinions

of doctors who do not treat the claimant. See Turner v. Comm’r. of Soc. Sec., 613 F. 3d 1217,

1222 (9th Cir. 2010) (citing Lester v. Chater, 81 F.3d 821, 830-31 (9th Cir. 1995)). If the treating

physician's opinion is not contradicted by another doctor, it may be rejected only for "clear and

convincing" reasons supported by substantial evidence in the record. Id. (citing Lester, 81 F.3d

at 830-31). Even when the treating doctor's opinion is contradicted by the opinion of another

doctor, the ALJ may properly reject the treating physician's opinion only by providing "specific and

legitimate reasons” supported by substantial evidence in the record for doing so. Id. (citing

Lester, 81 F.3d at 830-31). This can be done by “setting out a detailed and thorough summary

of the facts and conflicting clinical evidence, stating [his] interpretation thereof, and making

findings.” Tommasetti v. Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008) (citing Magallanes v.

Bowen, 881 F.2d 747, 751 (9th Cir. 1989). “The ALJ must do more than offer his conclusions.

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 The signature on the medical record is unclear, though Plaintiff states that it was Bill H. McCarberg, M.D.,

FABPM, a “Diplomate [of the] Americal Academy of Pain Medicine.” Pl.’s Brief at 9. 

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He must set forth his own interpretations and explain why they, rather than the doctors', are

correct.” Orn v. Astrue, 495 F.3d 625, 632 (9th Cir. 2007) (quoting Embrey v. Bowen, 849 F.2d

418, 421-22 (9th Cir. 1988)). 

In reviewing the ALJ’s decision, it is apparent that the only treating physicians’ opinions

that the ALJ expressly discounted were those of Dr. Jaffe and Dr. Mills. See AR at 16-20.

Because these treating physicians’ opinions were contradicted by those of other examining

physicians, the ALJ was required to provide specific and legitimate reasons, supported by

substantial evidence, for rejecting them. See Turner, 613 F.3d at 1222, and 20 CFR §

404.1527(d)(1) (2010).

As previously noted, the ALJ discounted Dr. Jaffe’s fibromyalgia diagnosis because his

medical records did not document symptoms associated with trigger points, Plaintiff was not

referred to a rheumatologist or other specialist familiar with diagnosing fibromyalgia, Plaintiff was

treated conservatively, and Dr. Jaffe did not report objective findings on the DMV form he

completed in order for Plaintiff to obtain a disabled placard. AR at 16-17. Preliminarily, Dr. Jaffe’s

conclusion on the DMV form that Plaintiff was disabled due to “severe fibromyalgia,” see AR at

202, was not a medical opinion at all, but an administrative finding reserved to the Commissioner.

20 CFR § 404.1527(e)(1). It is for the ALJ to decide the ultimate issue of whether the claimant

is or is not disabled. Id. Accordingly, the Court finds the ALJ properly discounted Dr. Jaffe’s

conclusion as set forth on the DMV form. However, the record does not support the ALJ’s

conclusions regarding lack of evidence of trigger points and objective findings. As Plaintiff points

out, the administrative record shows that on January 24, 2003, a treating physician6

 observed that

Plaintiff had 16 of 18 tender points and diagnosed fibromyalgia. Pl.’s Brief at 9 (citing AR at 252).

Dr. Jaffe’s August 1, 2003 notes indicate that he observed “18/18 of FMS” (which seems to

indicate 18/18 trigger points of fibromyalgia) and he specifically diagnosed fibromyalgia (among

other things). AR at 238. In this same record, Dr. Jaffe notes that Plaintiff has suffered chronic,

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daily low back pain (LBP) since 2001, saw Dr. McCarberg, had facet injections/SI injections that

did not help, and had a discogram that did not provide a good reproduction of her pain. Id. Dr.

Jaffe signed off on the DMV form the same day. AR at 202. Thus, there is evidence from treating

physicians and sources in the record demonstrating clinical findings and trigger point analysis

supporting a fibromyalgia diagnosis. 

However, the critical issue at this step is not whether Plaintiff has fibromyalgia but

whether the diagnosed firbromyalgia restricts Plaintiff’s ability to work. Plaintiff has not identified

(and the Court has not located) any evidence in the record indicating a specific restriction on

Plaintiff’s ability to work caused by the fibromyalgia. As such, Plaintiff fails to show that the ALJ’s

RFC determination is not based on substantial evidence. While it is true that an ALJ may only

reject a controverted opinion by a treating doctor by providing specific and legitimate reasons,

supported by substantial evidence, for doing so, see Turner, 613 F.3d at 1222 and 20 CFR §

404.1527(d)(1) (2010), an ALJ may properly reject a treating physician’s opinion where the

physician’s determination is “conclusory and unsubstantiated by relevant medical documentation,”

Johnson v. Shalala, 60 F.3d 1428, 1432 (9th Cir. 1995). 

In Benecke v. Barnhart, 379 F.3d 587, 594 (9th Cir. 2004), the Ninth Circuit acknowledged

that fibromyalgia is an elusive disease, which effectively evades objective measurement, but

nonetheless based its decision that the ALJ failed to provide legally sufficient reasons for rejecting

Benecke’s treating physicians’ opinions on an overwhelming amount of record evidence. The

claimant in Benecke consistently reported pain throughout her body, was diagnosed with

fibromyalgia by three rheumatologists and a pain management specialist, participated in a

fibromyalgia support group, and presented the ALJ with four RFC assessments from treating

rheumatologists, all of which concluded that Plaintiff could not sustain full-time work. Benecke,

379 F.3d at 590-91. A specialist in internal medicine who conducted a consultative examination

of Plaintiff also diagnosed fibromyalgia. Id. at 592. In light of this record, the Ninth Circuit

agreed with the district court that the ALJ failed to provide legally sufficient reasons for rejecting

Benecke’s treating physicians’ opinions that Plaintiff did not retain the RFC for full-time work. Id.

at 593-94. 

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7

 However, Dr. Sabourin did diagnose “pain syndrome, etiology undetermined” and noted that Plaintiff had

“such pain throughout the examination as she hyperventilates and when the exam was done, she started crying.”

AR at 185-86. He also took pains to note repeatedly that his opinion was based only on an orthopedic examination,

which was his only expertise. Id. at 186. 

8

 However, when asked by Plaintiff’s administrative counsel whether fibromyalgia could exacerbate Plaintiff’s

experience of pain in her back, Dr. Morse responded “I can’t comment.” AR at 591. 

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The generally inconclusive medical record presented in this case differs markedly from the

clear facts of Benecke. In this case, there is evidence that Plaintiff’s treating physicians diagnosed

her with fibromyalgia, but there is minimal, if any, evidence that any physician opined that

fibromyalgia limited Plaintiff’s residual functional capacity to work. On the other hand, there is

substantial evidence in the record supporting the ALJ’s RFC analysis. An examining physician, Dr.

Khurana, opined that Plaintiff’s pain was due to degenerative disc disease and that Plaintiff should

“stay active in regards to any activity that she would like to do including aerobics, weights,

swimming, or any activity she desires” in an attempt to alleviate this pain. AR at 348-49. Dr.

Khurana’s belief that Plaintiff was able to engage in these activities supports the ALJ’s RFC

findings. See Tonapetyan v. Halter, 242 F.3d 1144, 1149 (9th Cir. 2001) (an examining

physician’s opinion constitutes substantial evidence when it rests on his own independent

examination of the claimant). Likewise, Dr. Sabourin, another examining physician, found that

Plaintiff’s pain complaints were disproportionate to the physical evidence and opined that “[f]rom

the functional orthopedic point of view,” Plaintiff had minor limitations and no restrictions on her

abilities.7 AR at 186. Finally, the medical expert, Dr. Morse, concluded upon review of all of

Plaintiff’s medical records that she retained the RFC that the ALJ ultimately adopted. AR at 585-

868

; see Tonapetyan, 242 F.3d at 1149 (“[a]lthough the contrary opinion of a non-examining

medical expert does not alone constitute a specific, legitimate reason for rejecting a treating or

examining physician's opinion, it may constitute substantial evidence when it is consistent with

other independent evidence in the record”). As previously noted, the ALJ’s decision must be

supported by substantial evidence, which is “more than a mere scintilla but may be less than a

preponderance.” Lewis, 236 F.3d at 509 (substantial evidence is “relevant evidence that,

considering the entire record, a reasonable person might accept as adequate to support a

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9

 Dr. Mills, Plaintiff’s most recent treating psychiatrist, completed a Mental Impairment Questionnaire wherein

she set forth her observations and conclusions about Plaintiff’s symptoms and ability to work. AR at 533-38. Dr. Mills

opined that Plaintiff had “extreme” limitations in each of the following three areas: (a) restriction of activities of daily

living, (b) difficulties in maintaining social functioning, and (c) difficulties in maintaining concentration, persistence

or pace. Id. at 536. She further noted that Plaintiff had suffered four or more episodes of decompensation within

a twelve-month period. Id. When asked to describe any additional reasons why Plaintiff would have difficulty working

at a regular job on a sustained basis, Dr. Mills wrote “[t]he client is suffering mental problems, including depression

and anxiety. The client lacks appropriate interpersonal interaction skills.” Id. at 537. 

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conclusion”). The resolution of evidentiary conflicts is left to the ALJ and the Court must defer

to his determination. Id. And where, as here, the evidence reasonably can be construed to

support more than one rational interpretation, the court must uphold the ALJ’s decision. Batson,

350 F.3d at 1193. Given this standard, the Court concludes that it must defer to the ALJ’s

resolution of the conflicts in the medical evidence and his conclusion that Plaintiff retains some

residual functional capacity to work. The consulting and non-examining physician’s opinions

provide more than a “mere scintilla” of evidence in support of the ALJ’s RFC determination and

Plaintiff points to no treating physician records specifically refuting this determination. Therefore,

the Court finds that the ALJ’s physical RFC determination is supported by the requisite “substantial

evidence.”

With regard to the ALJ’s mental RFC determination, the ALJ rejected Dr. Mills’ “more

restrictive assessment”9

 and adopted the assessment of the testifying expert, Dr. Haroun. AR at

20. The ALJ rejected Dr. Mills’ assessment on the grounds that it “is supported only by checking

off of listed mental status findings on a single form, and is unsubstantiated by ongoing progress

notes.” Id. at 20. Neither of these constitute specific and legitimate reasons, supported by

substantial evidence, for rejecting Dr. Mills’ assessment. See Ryan, 528 F.3d at 1198. 

As an initial matter, the form Dr. Mills filled out appears to have been created and provided

by the Secretary. It seems disingenuous for the Secretary to provide physicians with an evaluation

form and then to hold that any evaluations provided thereon may be wholly discounted. While

Defendant is correct that there is Ninth Circuit precedent permitting an ALJ to reject check box

reports if they do not contain any explanation of the basis of their conclusions, Crane v. Shalala,

76 F.3d 251, 253 (9th Cir. 1996) (citing Murray v. Heckler, 722 F.2d 499, 501 (9th Cir.1983)

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(expressing preference for individualized medical opinions over check-off reports)), that is not the

case here. On the form, Dr. Mills explained that in addition to monthly doctor visits, Plaintiff

attended weekly group therapy meetings and weekly individual coaching. AR at 533. When

asked to “[d]escribe the clinical findings including results of mental status examination that

demonstrate the severity of your patient’s mental impairment and symptoms,” Dr. Mills wrote

“[t]his client presented with severe depressed & anxious mood, insomnia, low energy, panic

attacks, chronic physical pain, thoughts of suicide and interpersonal relationship problems.” Id.

Dr. Mills then wrote in her diagnosis of “major depressive disorder, recurrent severe without

psychotic features” and noted in the “prognosis” section of the form that “Paxil is not helping.

Her prognosis is poor.” Id. Furthermore, contrary to the ALJ’s statement, the South Bay

Guidance Center did provide records covering Plaintiff’s ongoing treatment, under the supervision

of Dr. Mills, from April 5, 2004 to July 7, 2004. AR at 330-38. Though the handwriting is difficult

to decipher, records from April 5, 2004 and June 2, 2004 both seem to reflect the major

depressive disorder diagnosis, and Dr. Mills observed in the June 2, 2004 record that Plaintiff is

positive for daytime somnolence, low motivation, and low energy, had a panic episode three days

prior, and has poor concentration. Id. at 331, 335. All of this refutes the ALJ’s conclusion that

Dr. Mills’ evaluation form is supported by nothing more than check box conclusions. Therefore,

the Court finds that the ALJ failed to provide the requisite specific and legitimate reasons,

supported by substantial evidence, for rejecting Dr. Mills’ assessment.

2. Plaintiff’s Credibility

One final factor Plaintiff asks the Court to consider in evaluating the ALJ’s conclusion at

Step Four is the ALJ’s discounting of Plaintiff’s subjective pain testimony. Pl.’s Brief at 14-21. 

“[T]he ALJ is responsible for determining credibility, resolving conflicts in medical

testimony, and for resolving ambiguities.” Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998)

(citing Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995)). However, “[f]or the ALJ to reject

the claimant’s complaints, [he] must provide ‘specific, cogent reasons for the disbelief.’” Lester

v. Chater, 81 F.3d 821, 834 (9th Cir. 1995) (quoting Rashad v. Sullivan, 903 F.2d 1229, 1231 (9th

Cir. 1990)). “Once the claimant produces medical evidence of an underlying impairment, the

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[ALJ] may not discredit the claimant’s testimony as to the severity of symptoms merely because

they are unsupported by objective medical evidence.” Reddick, 157 F.3d at 722 (citing Bunnell

v. Sullivan, 947 F.2d 341, 343 (9th Cir. 1991)); see also Swenson v. Sullivan, 876 F.2d 683, 687

(9th Cir. 1989) (“That a claimant testifies that his symptom is more disabling than would normally

be expected gives no valid reason to discount his testimony”). Moreover, “absent affirmative

evidence of malingering, an ALJ cannot reject a claimant’s testimony without giving clear and

convincing reasons.” Vertigan v. Halter, 260 F.3d 1044, 1049 (9th Cir. 2001) (citing Smolen v.

Chater, 80 F.3d 1273, 1283-84 (9th Cir. 1996)). As such, “the ALJ must identify what testimony

is not credible and what evidence undermines the claimant’s complaints,” because “[g]eneral

findings are insufficient.” Lester, 81 F.3d at 834; see also Vertigan, 260 F.3d at 1049 (“The fact

that a claimant’s testimony is not fully corroborated by the objective medical findings, in and of

itself, is not a clear and convincing reason for rejecting it”). 

An ALJ may, however, “disregard self-serving statements made by claimants if it finds them

to be incredible on other grounds.” Sousa v. Callahan, 143 F.3d 1240, 1243 (9th Cir. 1998)

(quoting Rashad, 903 F.2d at 1231). Relevant factors in assessing credibility include “the

claimant’s engagement in activities inconsistent with a claim of disability, an unexplained or

inadequately explained failure to seek treatment, or other ordinary methods of credibility

determination.” Sousa, 143 F.3d at 1243 (quoting Bunnell, 947 F.2d at 346); see also Smolen,

80 F.3d at 1284 (explaining that “ordinary techniques of credibility evaluation” include “the

claimant’s reputation for lying, prior inconsistent statements concerning the symptoms, and other

testimony by the claimant that appears less than candid”). Ultimately, in order to find Plaintiff’s

testimony unreliable, the ALJ is required to make “a credibility determination with findings

sufficiently specific to permit the court to conclude that the ALJ did not arbitrarily discredit

[Plaintiff’s] testimony.” Thomas v. Barnhart, 278 F.3d 947, 958 (9th Cir. 2002). The ALJ’s

credibility determination should be given “great weight,” Nyman v. Heckler, 779 F.2d 528, 531

(9th Cir. 1985), and the court may not engage in second-guessing if the ALJ’s finding is supported

by substantial evidence, Tommasetti v. Astrue, 533 F.3d 1035, 1039 (9th Cir. 2008), but it is error

for a district court to affirm an ALJ’s credibility decision based on evidence that the ALJ did not

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10 Plaintiff also objects to the ALJ’s fourth and sixth reasons, but references only inadmissible evidence (new

records the Court cannot consider) and evidence that she did not file with her motion in support of her arguments.

See Pl.’s Brief at 14-15. The Court, therefore, will not address these arguments. 

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discuss, Connett v. Barnhart, 340 F.3d 871, 874 (9th Cir. 2003).

In discounting Plaintiff’s pain allegations, the ALJ explained as follows:

Even though it is likely the claimant experiences some intermittent pain and

limitations, the undersigned finds the claimant’s allegations regarding the intensity,

persistence, and limiting effects of her pain to be in excess of the objective medical

findings, and not credible to the extent alleged, for the clear and convincing reasons

enumerated below. First, while the medical record does demonstrate the presence

of an underlying medically determinable impairment that could reasonably cause

mechanical pain, the objective findings with respect to the claimant’s

musculoskeletal complaints are not indicative of intractable pain. The claimant has

retained normal range of motion of all joints, and there is no neurological deficit or

spasm. Second, the claimant has required only conservative treatment, and has

achieved some relief with medication. There is no evidence of side effects from the

medications that she has been taking. Third, the claimant has not participated in

any significant pain regimen or therapy program. Fourth, there is no evidence that

she has needed assistance from others in attending to personal needs or in

performing essentially all normal activities of daily living. Fifth, there is no evidence

of severe weight loss because of loss of appetite from pain, and no evidence of

severe sleep deprivation because of pain. Sixth, the claimant has admitted in

statements about her daily activities that she remains capable of activities

consistent with medium work, in spite of her subjective complaints. Seventh, there

is no statement by a physician that the claimant has experienced severe and

unremitting pain. In fact, at least one examining physician has stated that the

claimant’s complaints are disproportionate to objective findings. Consequently, the

claimant’s allegations of disabling pain, excess pain, and limitation, when considered

pursuant to the law of the Ninth Circuit Court of Appeals, and Social Security Rule

96-7p, are not credible to the extent alleged. 

AR at 22. Plaintiff challenges the ALJ’s first, second, third, and seventh reasons for discounting

her testimony.10 

With regard to the ALJ’s conclusion that the objective findings as to Plaintiff’s

musculoskeletal complaints are not indicative of intractable pain, Plaintiff argues that Social

Security Ruling 96-7p counsels against using this as a basis for discounting her credibility. Pl.’s

Brief at 15. Within the fourth listed “Purpose” of the ruling, Social Security Ruling 96-7p states

“[a]n individual’s statements about the intensity and persistence of pain or other symptoms or

about the effect of the symptoms have on his or her ability to work may not be disregarded solely

because they are not substantiated by objective medical evidence.” SSR 96-7p (July 2, 1996).

While Plaintiff is correct that lack of objective findings cannot form the sole basis for rejecting pain

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11 Though the handwriting is difficult to read and the notes are cryptic, it appears Dr. Jaffe came to the same

conclusion, noting that Plaintiff’s “motor/sensory intact bilat.” AR at 250. 

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testimony, it is a factor the ALJ may consider in reviewing the record as a whole. See id. (under

the heading “Medical Evidence,” the ruling explains that “the absence of objective medical

evidence supporting an individual’s statements about the intensity and persistence of pain or

other symptoms is only one factor that the adjudicator must consider in assessing an individual’s

credibility and must be considered in the context of all the evidence”); Burch v. Barnhart, 400

F.3d 676, 681 (9th Cir. 2005). Here, substantial evidence in the record supports the ALJ’s

conclusion. For example, both Dr. Khurana and Dr. Sabourin observed that Plaintiff’s muscle

strength was normal11 (AR at 185, 348), which indicates that Plaintiff has not experienced

prolonged pain to a disabling degree. See Meanel v. Apfel, 172 F.3d 1111, 1114 (9th Cir. 1999)

(rejecting claimant’s claim that constant pain required her to lie in a fetal position all day where

claimant did not exhibit muscular atrophy, which would be a physical sign of a totally

incapacitated individual); see also AR at 343 (Dr. McKennett’s report indicates that no muscular

deterioration was noted). Likewise, despite Plaintiff’s complaints of significant pain, Doctors

Khurana, Sabourin, and McKennett all noted upon examination that Plaintiff was “in no acute

distress.” AR at 183, 342, 348. Given the totality of the record, the Court finds that substantial

evidence supported the ALJ’s decision.

Plaintiff’s objections to the ALJ’s other three conclusions interrelate. See Pl.’s Brief at 16-

18. The ALJ discounted Plaintiff’s testimony because she only required conservative treatment

and achieved some relief with medication, she has not participated in any significant pain regimen

or therapy program, and there is no statement by a physician that the claimant has experienced

severe and unremitting pain. AR at 22. In response, Plaintiff points out that she has tried a vast

array of medications and has undergone numerous pain therapies and treatments over the years

in an attempt to alleviate her pain. Pl.’s brief at 16-18. She also highlights that she was told that

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12 Plaintiff also alludes to references that explain that fibromyalgia’s cause is unknown and that is difficult

to treat. While this is true, see e.g. Benecke, 379 F.3d at 590 (explaining that “fibromyalgia’s cause is unknown, there

is no cure, and it is poorly-understood within much of the medical community”), there is no evidence in the record

that fibromyalgia affected Plaintiff’s RFC. 

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surgery was not an option because Dr. Khurana did not believe it would be effective.12 Pl.’s Brief

at 16-17. It is true that doctors have prescribed numerous pain medications and the record

reflects that Plaintiff’s pain was treated and/or examined with epidural steroid injections, physical

therapy, traction, use of a TENS unit, stretching exercises, discograms, electroacupuncture,

bilateral intra-articular face joint injections, a bilateral diagnostic sacroilac joint injection, and

MRIs. However, Plaintiff also has reported that some of the medications and treatments helped.

See e.g. AR at 230 (Plaintiff reported to Dr. Khurana that medications, including Vicodin, help her

symptoms and that “[s]he has had two epidurals, facet blocks and bilateral sacroiliac blocks which

provided some improvement”); AR at 572-73 (Plaintiff’s testimony that Sylindac and Flexoril

helped her back pain, though she has been unable to obtain these medications since her

insurance ran out). Additionally, Dr. McKennett’s records reflect that Plaintiff reported not taking

any pain medications at all between January of 2004 and August 24, 2004. AR at 341. What also

is evident from these records is that no doctor has concluded that no further treatment options

exist for Plaintiff. To the contrary, her treating physicians continue to try new medications and

treatments and, as the ALJ said, they continue to recommend conservative options such as

exercise and physical therapy. See e.g. AR at 348 (Dr. Khurana recommended weaning off

narcotics and trying swimming, aerobics, weights, etc.); AR at 343 (Dr. McKennett referred

Plaintiff for water exercise and physical therapy); AR at 238 (Dr. Jaffe recommended that Plaintiff

read John Sarno’s book Mind-Body Connection). Evidence of conservative treatment is a sufficient

basis for discounting a claimant's testimony regarding the severity of an impairment. Parra v.

Astrue, 481 F.3d 742, 751 (9th Cir. 2007) (citing Johnson v. Shalala, 60 F.3d 1428, 1434 (9th Cir.

1995) (finding that conservative treatment suggested “a lower level of both pain and functional

limitation”)). There also is no evidence that any physician has concluded that Plaintiff’s pain is

completely debilitating, such that a return to work would be impossible regardless of the

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13 Again, the ALJ determined that Plaintiff possessed the RFC to “lift and/or carry up to 25 pounds frequently

or 50 pounds occasionally; to sit, stand, or walk about six hours each in an eight-hour day; and to occasionally climb,

balance, stoop, kneel, crouch, or crawl.” AR at 23. He further found her “limited to simple repetitive tasks in a nonpublic setting.” Id.

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treatment. All of this supports the ALJ’s conclusion that while Plaintiff likely experiences some

intermittent pain and limitations, her allegations regarding the intensity, persistence, and limiting

effects of her pain are not wholly credible. See AR at 22. 

In view of the totality of the record, the Court finds that the ALJ provided clear and

convincing reasons for discounting Plaintiff’s testimony. As the Ninth Circuit clearly has explained,

It may well be that a different judge, evaluating the same evidence, would have

found [the claimant’s] allegations of disabling pain credible. But, as we reiterate in

nearly every case where we are called upon to review a denial of benefits, we are

not triers of fact. Credibility determinations are the province of the ALJ. (internal citation omitted). Where, as here, the ALJ has made specific findings justifying a

decision to disbelieve an allegation of excess pain, and those findings are supported

by substantial evidence in the record, our role is not to second-guess that decision.

Fair v. Bowen, 885 F.2d 597, 604 (9th Cir. 1989). The ALJ’s credibility determination is entitled

to “great weight,” Nyman, 779 F.2d at 531, and this Court finds no basis for disturbing the ALJ’s

conclusion in this case.

In summary, the Court finds that the ALJ did not err in handling Dr. Jaffe’s fibromyalgia

diagnosis and determining Plaintiff’s physical RFC or in discounting Plaintiff’s testimony regarding

her pain and limitations. However, the ALJ erred with regard to Plaintiff’s mental RFC because

he failed to provide the required “specific and legitimate reasons, supported by substantial

evidence” for discounting Plaintiff’s treating psychiatrist’s assessment. See Turner, 613 F.3d at

1222; 20 CFR § 404.1527(d)(1).

E. Step Five

At the fifth and final step of the disability determination, the ALJ assessed whether work

existed in the national and regional economy that, given her RFC13, Plaintiff could perform. 20

C.F.R. § 416.920(a)(4)(v). Based on the VE’s testimony, discussed supra, the ALJ held that

Plaintiff could work as a sweeper/cleaner, textile stuffer, or bench hand, and that thousands of

these positions existed in the San Diego region and tens of thousands to millions existed

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nationally. AR at 23. Thus, the ALJ concluded that Plaintiff was not disabled. 

In light of the Court’s conclusion that the ALJ improperly discounted Dr. Mills’ assessment

of Plaintiff’s mental limitations and that, therefore, the RFC determination was not supported by

substantial evidence, the Court finds that the ALJ’s step five conclusion, which relies on the RFC

determination, also is incorrect.

///

IV. Remand v. Reversal

“The decision whether to remand for further proceedings or simply to award benefits is

within the discretion of [the] court.” McAllister v. Sullivan, 888 F.2d 599, 603 (9th Cir. 1989).

“Remand for further administrative proceedings is appropriate if enhancement of the record would

be useful.” Benecke, 379 F.3d at 593. On the other hand, if the record has been fully developed

such that further administrative proceedings would serve no purpose, “the district court should

remand for an immediate award of benefits.” Id. “More specifically, the district court should

credit evidence that was rejected during the administrative process and remand for an immediate

award of benefits if (1) the ALJ failed to provide legally sufficient reasons for rejecting the

evidence; (2) there are no outstanding issues that must be resolved before a determination of

disability can be made; and (3) it is clear from the record that the ALJ would be required to find

the claimant disabled were such evidence credited.” Id. (citing Harman v. Apfel, 211 F.3d 1172,

1178 (9th Cir. 2000), McCartey v. Massanari, 298 F.3d 1072, 1076-77 (9th Cir. 2002), and

Smolen, 80 F.3d at 1292).

Where the ALJ’s error was in failing to offer sufficiently specific and legitimate reasons for

rejecting a treating physician’s opinion, the Ninth Circuit’s legal precedent is somewhat conflicting.

As a judge in the Central District of California has pointed out, 

The Ninth Circuit sometimes has directed the award of benefits where the

administrative decision has failed to provide sufficient justification for disregarding

a treating physician's opinion. See Smolen v. Chater, 80 F.3d 1273, 1291-92 (9th

Cir.1996); Lester v. Chater, supra, 81 F.3d at 834; Rodriguez v. Bowen, 876 F.2d

759, 763 (9th Cir.1989); Winans v. Bowen, 853 F.2d 643, 647 (9th Cir.1988);

Sprague v. Bowen, 812 F.2d 1226, 1232 (9th Cir.1987); Fife v. Heckler, 767 F.2d

1427, 1431 (9th Cir.1985); Bilby v. Schweiker, 762 F.2d 716, 719-20 (9th Cir.1985);

see also Pitzer v. Sullivan, 908 F.2d 502, 506 (9th Cir.1990) (directing award of

benefits where the administrative decision gave no reasons for disregarding an

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examining physician's opinions). Some of these decisions appear to acknowledge

the Court's discretion to remand for further administrative proceedings. Rodriguez,

supra; Winans, supra; Sprague, supra; Bilby, supra. The recent decisions in Lester

and Smolen do not do so, however. [footnote omitted] The Lester decision declares

that “[w]here the Commissioner fails to provide adequate reasons for rejecting the

opinion of a treating or examining physician, we credit that opinion ‘as a matter of

law.’ ” Lester, supra at 834. Yet, the Ninth Circuit did not credit the treating

physicians’ opinions as a matter of law in Salvador or McAllister, despite the

Administration’s failure to provide adequate reasons for rejecting the physicians’

opinions in those cases. Thus, the Ninth Circuit decisions conflict, leaving this Court

to “make the unsatisfactory choice between two opposing lines of authority, neither

of which has an unimpaired claim to being the law of the circuit.” Greenhow v.

Secretary, 863 F.2d 633, 636 (9th Cir.1988), overruled in part, United States v.

Hardesty, 977 F.2d 1347 (9th Cir.1992) ( en banc ), cert. denied, 507 U.S. 978, 113

S.Ct. 1429, 122 L.Ed.2d 797 (1993) (overruling Greenhow to the extent Greenhow

held that a Ninth Circuit panel may choose between the opposing lines of Ninth

Circuit authority without calling for en banc review).

The present case may be distinguished from those cases in which the ALJ

failed to state any reasons for rejecting the physician's opinion. See Pitzer, supra;

Winans, supra; Fife, supra. Here, the ALJ did not ignore the legal requirement of a

statement of reasons. The ALJ erred because at least some of the stated reasons

are legally insufficient. Such good faith errors inevitably will occur. Reasonable

judicial minds sometimes will disagree regarding proper application of the rather

imprecise standard of “specific, legitimate” reasons. The in terrorem impact of

automatic reversal [footnote omitted] would be misdirected in the present case.

In some cases, automatic reversal would bestow a benefits windfall upon an

undeserving, able claimant. The operative medical opinion may be flawed, baseless

or otherwise erroneous. Nevertheless, under the rule in Lester, the opinion will

trigger benefits whenever the ALJ's previously stated [footnote omitted] reasons for

rejecting the opinion fall short of the ill-defined “specific, legitimate” standard. A

reviewing court should have discretion to avoid this inequitable result by remanding

the case for further administrative proceedings. Remand necessitates delay, but the

cost of this delay should be balanced against the risk of an erroneous

determination.

Barbato v. Comm’r of Social Sec. Admin., 923 F. Supp. 1273, 1277-78 (C.D. Cal. 1996). And, the

Central District is correct that neither Salvador nor McAllister has been overruled. 

However, in a subsequent case addressing similar facts, the Ninth Circuit refused to

remand a case solely in order to allow the ALJ the opportunity to elucidate better reasons for

rejecting the treating physician’s testimony. See Harman, 211 F.3d at 1178-1179. Specifically,

the court explained:

[E]ven assuming arguendo that there is material in the record upon which the ALJ

legitimately could have rejected Dr. Fox's testimony, the Commissioner’s attempt

to distinguish Lester is not well founded. In Varney v. Secretary of Health and Human Services (Varney II), 859 F.2d 1396 (9th Cir.1988), this court addressed the

propriety of adopting the Eleventh Circuit's practice of accepting a claimant's pain

testimony as true when it is inadequately rejected by the ALJ. In language which

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is equally applicable here, we stated:

Requiring the ALJs to specify any factors discrediting a claimant at the

first opportunity helps to improve the performance of the ALJs by

discouraging them from reach[ing] a conclusion first, and then

attempt[ing] to justify it by ignoring competent evidence.... [¶ And]

the rule [of crediting such testimony] ensures that deserving

claimants will receive benefits as soon as possible....

.. Certainly there may exist valid grounds on which to discredit a

claimant's pain testimony.... But if grounds for such a finding exist, it

is both reasonable and desirable to require the ALJ to articulate them

in the original decision.

Id. at 1398-99. (Emphasis added; internal quotes and citation omitted).

Our reliance on Varney II to justify the current application of Smolen does

not obscure the more general rule that the decision of whether to remand for

further proceedings turns upon the likely utility of such proceedings. See Lewin v.

Schweiker, 654 F.2d 631, 635 (9th Cir.1981). Rather, the Smolen test14 still enables

only a limited exception to the general rule.

We conclude that if the Smolen test is satisfied with respect to Dr. Fox's

testimony, then remand for determination and payment of benefits is warranted

regardless of whether the ALJ might have articulated a justification for rejecting Dr.

Fox's opinion.

Id. (concluding that the Smolen test was not satisfied and that crediting Dr. Fox’s testimony did

not mandate an immediate award of benefits). While Harman left it somewhat unclear whether

the district court was required to credit the treating physician’s opinion before applying the

Smolen test or only required to credit the treating physician’s opinion if the Smolen test was

satisfied, subsequent cases have made clear that the Court retains discretion in this area. In

Vasquez v. Astrue, 572 F.3d 586, 593 (9th Cir. 2009), the Ninth Circuit acknowledged that there

is a split in authority in the Circuit over whether the “credit-as-true” rule is mandatory or

discretionary (though the Court declined at that time to resolve the split). Last year, the Ninth

Circuit specifically concluded that “applying the [“credit-as-true”] rule is not mandatory when,

even if the evidence at issue is credited, there are ‘outstanding issues that must be resolved

before a proper disability determination can be made.’” Luna v. Astrue, 623 F.3d 1032, 1035 (9th

Cir. 2010) (quoting Vasquez v. Astrue, 572 F.3d 586, 593 (9th Cir. 2009)); see also Shilts v.

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15 Dr. Haroun testified as follows under questioning from Plaintiff’s attorney: 

Q Dr. Haroun, you have reviewed the Exhibit 18F, the medical impairment questionnaire,

completed by Dr. Mills, is that correct?

A Yes, I have.

Q Okay. And Dr. Donna Mills is the treating psychiatrist, is that correct?

A Yes, she is. That’s correct, yes.

Q And she, she has spent a lot of — she has seen claimant many more times than the CE

[consultative examining] psychiatrist, is that correct?

A Yes, I’m sure she has.

Q Okay. And, according to the answers on this questionnaire, isn’t it true that claimant would

meet the listing for 1204?

A Yes, that’s true.

AR at 598-99.

36 06cv82-WQH (BLM)

Astrue, 400 Fed. Appx. 183, 184-85 (9th Cir. Oct. 18, 2010) (explaining that “evidence should be

credited as true and an action remanded for an immediate award of benefits only if [the Smolen

test is satisfied]”). The Court in Luna found that an outstanding question of when Luna’s

disability began remained, which the evidence she wanted credited did not answer, and that the

district court, therefore, did not err in remanding for further proceedings because the “application

of the [credit-as-true] rule would not result in the immediate payment of benefits.” Id. (quoting

Vasquez, 572 F.3d at 593). 

In the instant case, the Court does not find it appropriate to fully credit Dr. Mills’ opinion

and remand for an immediate payment of benefits because, even if Dr. Mills’ opinion were

credited, two outstanding issues remain. Specifically, it is not clear when Plaintiff became

disabled and whether she may still be expected to improve with treatment. While Dr. Haroun,

the psychiatric expert with whom the ALJ concurred in rejecting Dr. Mills’ assessment, testified

that Plaintiff would meet a listing if Dr. Mills’ opinion were credited15, neither he nor Dr. Mills

indicated at what point Plaintiff decompensated to this level. Dr. Mills only began treating Plaintiff

in April of 2004 (seven months before the hearing), so her decline to a listing level may have been

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28 16 At the hearing, Plaintiff testified that she only had been taking Wellbutrin for “a couple weeks.” AR at 579.

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fairly recent. Additionally, Dr. Mills indicated on the questionnaire that, though Paxil had not been

working, she was starting Plaintiff on Wellbutrin. AR at 533. There is no indication in the record

of whether the Wellbutrin caused improvement in Plaintiff’s condition.16 Thus, the evidence

before the Court does not make clear that Plaintiff’s condition satisfies the SSA’s twelve-month

durational requirement. Accordingly, this Court RECOMMENDS that the case be REMANDED

pursuant to sentence four of 42 U.S.C. § 405(g) for a new hearing before an administrative

law judge for further consideration consistent with this opinion. 

CONCLUSION

For the reasons set forth above, the Court RECOMMENDS that Plaintiff’s motion for

summary judgment be GRANTED IN PART, Defendant’s cross-motion for summary judgment

be DENIED, and the case be REMANDED pursuant to sentence four of 42 U.S.C. § 405(g)

for a new hearing before an administrative law judge. See 42 U.S.C. § 405(g). The Court also

DENIES Plaintiff’s requests for a de novo hearing and to have new evidence considered.

IT IS HEREBY ORDERED that any written objections to this Report and Recommendation

must be filed with the Court and served on all parties no later than December 21, 2011. 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 January 11, 2012. The parties are advised that failure

to file objections within the specified time may waive the right to raise those objections on appeal

of the Court’s order. Turner v. Duncan, 158 F.3d 449, 455 (9th Cir. 1998).

DATED: November 30, 2011

BARBARA L. MAJOR

United States Magistrate Judge

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