Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_14-cv-02265/USCOURTS-azd-2_14-cv-02265-0/pdf.json

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

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WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Haifa Mahdi, 

Plaintiff, 

v. 

Carolyn W. Colvin, 

Defendant.

No. CV-14-02265-PHX-JAT

ORDER 

 Plaintiff Haifa Mahdi appeals the Commissioner of Social Security’s (the 

“Commissioner”) denial of disability benefits. The Court now rules on her appeal. (Doc. 

13). 

I. Background 

A. Procedural Background

 On June 10, 2011, Plaintiff filed an application for supplemental security income 

under Title XVI of the Social Security Act, alleging a disability onset date of January 1, 

2009. (R. 155). The Commissioner denied benefits on September 21, 2011, (R. 58), and 

Plaintiff requested reconsideration, (R. 94). Plaintiff was again denied on April 6, 2012, 

(R. 73, 89), and she appealed. 

 On April 4, 2013, Administrative Law Judge (“ALJ”) Patricia A. Bucci held a 

hearing on Plaintiff’s claim. (R 31-57). At the hearing, Plaintiff amended her disability 

onset date to June 10, 2011. (R. 14, 182). Following the ALJ’s unfavorable decision, (R. 

14-26), Plaintiff appealed to the Appeals Council. After the Appeals Council denied 

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Plaintiff’s request for review, (R. 1), Plaintiff filed an appeal with this Court. (Docs. 1, 

13). Plaintiff argues that (1) the ALJ improperly rejected the opinions of examining 

physicians and (2) the ALJ failed to properly apply the Medical-Vocational Guidelines in 

finding Plaintiff to be not disabled. (Doc. 13 at 4). 

B. Medical Background

 The Court will briefly summarize Plaintiff’s medical history, which is recounted in 

the administrative record. Plaintiff’s medical history is not extensive, and begins in 2009, 

when an x-ray of her lumbar spine revealed first-degree degenerative spondylolisthesis 

and a narrowed L5-S1 disc space. (R. 241). Beginning in May 2011, Plaintiff was treated 

by 21st Century Family Medicine until February 2012. (R. 328-36). These treatment 

notes, which are largely illegible, appear to document lower-back pain, insomnia, and 

blurring vision. (Id.) In May 2011, a radiologic exam of Plaintiff’s spine revealed mild 

thoracic spondylitic disease, L4-L5 degenerative subluxation, and a transitional segment 

with partial sacralization of L5. (R. 245). Dr. Araghi, one of Plaintiff’s treating 

physicians, diagnosed Plaintiff with grade I spondylolisthesis of L4 on L5 with a partially 

sacralized L5-S1 and “[l]ow back pain with bilateral lower extremity radicular 

symptoms.” (R. 289, 302). 

 Plaintiff briefly treated with STI Physical Therapy & Rehabilitation, where she 

was prescribed treatment including stretching and icing. (R. 257). Plaintiff never returned 

for treatment. Plaintiff also treated for one appointment with Dr. Hennenhoefer, at which 

time Plaintiff reported 10/10 pain and taking tramadol and Vicodin to help with the pain. 

(R. 337). Plaintiff’s most recent treatment notes reflect that Plaintiff decided against local 

spinal injections in favor of pain medications, (R. 342), and is experiencing lower back 

and hip pain, (R. 344, 346, 348). Imaging of Plaintiff’s left hip revealed no fracture or 

degenerative change. (R. 354). Plaintiff has been diagnosed with hypertension, 

hyperlipidemia, diabetes, atherosclerosis, COPD, and backache. (R. 342). 

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II. Disability

A. Definition of Disability

 To qualify for disability benefits under the Social Security Act, a claimant must 

show, among other things, that she is “under a disability.” 42 U.S.C. § 423(a)(1)(E). The 

Act defines “disability” as the “inability to engage in any substantial gainful activity by 

reason of any medically determinable physical or mental impairment which can be 

expected to result in death or which has lasted or can be expected to last for a continuous 

period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). A person is: 

under a disability only if his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national 

economy. 

42 U.S.C. § 423(d)(2)(A). 

B. Five-Step Evaluation Process

 The Social Security regulations set forth a five-step sequential process for 

evaluating disability claims. 20 C.F.R. § 404.1520(a)(4); see also Reddick v. Chater, 157 

F.3d 715, 721 (9th Cir. 1998). A finding of “not disabled” at any step in the sequential 

process will end the inquiry. 20 C.F.R. § 404.1520(a)(4). The claimant bears the burden 

of proof at the first four steps, but the burden shifts to the Commissioner at the final step. 

Reddick, 157 F.3d at 721. The five steps are as follows: 

 1. First, the ALJ determines whether the claimant is “doing substantial gainful 

activity.” 20 C.F.R. § 404.1520(a)(4)(i). If so, the claimant is not disabled. 

 2. If the claimant is not gainfully employed, the ALJ next determines whether 

the claimant has a “severe medically determinable physical or mental impairment.” 20 

C.F.R. § 404.1520(a)(4)(ii). To be considered severe, the impairment must “significantly 

limit[] [the claimant's] physical or mental ability to do basic work activities.” 20 C.F.R. § 

404.1520(c). Basic work activities are the “abilities and aptitudes to do most jobs,” such 

as lifting, carrying, reaching, understanding, carrying out and remembering simple 

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instructions, responding appropriately to co-workers, and dealing with changes in routine. 

20 C.F.R. § 404.1521(b). Further, the impairment must either have lasted for “a 

continuous period of at least twelve months,” be expected to last for such a period, or be 

expected “to result in death.” 20 C.F.R. § 404.1509 (incorporated by reference in 20 

C.F.R. § 404.1520(a)(4)(ii)). The “step-two inquiry is a de minimis screening device to 

dispose of groundless claims.” Smolen v. Chater, 80 F.3d 1273, 1290 (9th Cir. 1996). If 

the claimant does not have a severe impairment, then the claimant is not disabled. 

 3. Having found a severe impairment, the ALJ next determines whether the 

impairment “meets or equals” one of the impairments listed in the regulations. 20 C.F.R. 

§ 404.1520(a)(4)(iii). If so, the claimant is found disabled without further inquiry. If not, 

before proceeding to the next step, the ALJ will make a finding regarding the claimant's 

“residual functional capacity based on all the relevant medical and other evidence in [the] 

case record.” 20 C.F.R. § 404.1520(e). A claimant's “residual functional capacity” is the 

most she can still do despite all her impairments, including those that are not severe, and 

any related symptoms. 20 C.F.R. § 404.1545(a)(1). 

 4. At step four, the ALJ determines whether, despite the impairments, the 

claimant can still perform “past relevant work.” 20 C.F.R. § 404.1520(a)(4)(iv). To make 

this determination, the ALJ compares its “residual functional capacity assessment . . . 

with the physical and mental demands of [the claimant's] past relevant work.” 20 C.F.R. 

§ 404.1520(f). If the claimant can still perform the kind of work she previously did, the 

claimant is not disabled. Otherwise, the ALJ proceeds to the final step. 

 5. At the final step, the ALJ determines whether the claimant “can make an 

adjustment to other work” that exists in the national economy. 20 C.F.R. § 

404.1520(a)(4)(v). In making this determination, the ALJ considers the claimant's 

“residual functional capacity” and her “age, education, and work experience.” 20 C.F.R. 

§ 404.1520(g)(1). If the claimant can perform other work, she is not disabled. If the 

claimant cannot perform other work, she will be found disabled. As previously noted, the 

Commissioner has the burden of proving that the claimant can perform other work. 

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Reddick, 157 F.3d at 721. 

 In evaluating the claimant’s disability under this five-step process, the ALJ must 

consider all evidence in the case record. 20 C.F.R. § 404.1520(a)(3); 20 C.F.R. § 

404.1520b. This includes medical opinions, records, self-reported symptoms, and thirdparty reporting. 20 C.F.R. § 404.1527; 20 C.F.R. § 404.1529; SSR 06-3p. 

C. The ALJ’s Evaluation Under the Five-Step Process

The ALJ applied the five-step sequential evaluation process using Plaintiff’s 

amended alleged onset date of June 10, 2011. (R. 14). The ALJ found in step one of the 

sequential evaluation process that Plaintiff has not engaged in substantial gainful activity 

since her amended alleged onset date of June 10, 2011. (R. 16). The ALJ then found 

Plaintiff to have the following severe impairments: lumbar degenerative disc disease and 

obesity. (R. 16). Under step three, the ALJ noted that none of these impairments met or 

medically equaled one of the listed impairments that would result in a finding of 

disability. (R. 19). The ALJ then determined that Plaintiff’s residual functional capacity 

(“RFC”) was the ability to “perform medium work as defined in 20 CFR 416.967(c) 

except the claimant is able to frequently balance, stoop, crouch, kneel, crawl, and climb 

ramps and stairs. The claimant should never be required to climb ladders, ropes or 

scaffolds. The claimant should also avoid concentrated exposure to non-weather related 

extreme cold, wet conditions, excessive vibration, dangerous with moving mechanical 

parts, and unprotected that are high, exposed.” (R. 20) (errors in original). Under step 

four, the ALJ determined that Plaintiff has no past relevant work. (R. 24). Under step 

five, the ALJ then considered Plaintiff’s age, education, work experience, and residual 

functional capacity to determine that Plaintiff could perform a number of jobs in the 

national economy. (R. 24). The ALJ concluded that Plaintiff was not disabled. (R. 25). 

D. Standard of Review

 A district court: 

may set aside a denial of disability benefits only if it is not 

supported by substantial evidence or if it is based on legal error. Substantial evidence means more than a mere scintilla 

but less than a preponderance. Substantial evidence is 

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relevant evidence, which considering the record as a whole, a reasonable person might accept as adequate to support a 

conclusion. Where the evidence is susceptible to more than one rational interpretation, one of which supports the ALJ’s decision, the ALJ’s decision must be upheld. 

Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002) (internal citation and 

quotation marks omitted). This is because “[t]he trier of fact and not the reviewing court 

must resolve conflicts in the evidence, and if the evidence can support either outcome, the 

court may not substitute its judgment for that of the ALJ.” Matney v. Sullivan, 981 F.2d 

1016, 1019 (9th Cir. 1992). Under this standard, the Court will uphold the ALJ’s findings 

if supported by inferences reasonably drawn from the record. Batson v. Comm’r of the 

Soc. Sec. Admin., 359 F.3d 1190, 1193 (9th Cir. 2004). However, the Court must consider 

the entire record as a whole and cannot affirm simply by isolating a “specific quantum of 

supporting evidence.” Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007) (internal 

quotation omitted). 

III. The Opinions of Examining Physicians

 A. Legal Standard 

“The ALJ is responsible for resolving conflicts in the medical record.” Carmickle 

v. Comm’r, Soc. Sec. Admin., 533 F.3d 1155, 1164 (9th Cir. 2008). Such conflicts may 

arise between an examining physician’s medical opinion and other evidence in the 

claimant’s record. An examining physician’s opinion is entitled to greater weight than the 

opinion of a nonexamining physician. 20 C.F.R. § 404.1527(c)(1); see also Lester v. 

Chater, 81 F.3d 821, 830 (9th Cir. 1995). The ALJ may reject the opinion of an 

examining physician, “if contradicted by another [physician],” only “for specific and 

legitimate reasons that are supported by substantial evidence in the record.” Lester, 81 

F.3d at 830-31; see also Moore v. Comm’r of Soc. Sec. Admin., 278 F.3d 920, 924 (9th 

Cir. 2002). Substantial evidence that contradicts an examining physician’s opinion may 

be either (1) an examining physician’s opinion or (2) a nonexamining physician’s opinion 

combined with other evidence. Id.

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B. Discussion

 Plaintiff argues the ALJ erred in rejecting the opinions of examining state agency 

physicians Dr. Monte Jones and Dr. Jeffrey Levison in favor of the opinion of 

nonexamining state agency physicians Dr. Jean Goerss and Dr. Mikhail Bargan. (Doc. 13 

at 4-5). 

 Dr. Jones was a state agency physician who examined Plaintiff on September 8, 

2011. (R. 266). Dr. Jones recorded Plaintiff’s primary complaints as left wrist pain and 

pain on the bottom of her feet. (R. 266). Dr. Jones noted back pain and diabetes among 

Plaintiff’s additional complaints. (R. 266). Plaintiff denied using tobacco to Dr. Jones. (R. 

266). Dr. Jones also recorded that Plaintiff had lost all vision in her left eye. (R. 267). At 

the examination, Plaintiff had a normal gait, normal posture, shook hands with “normal 

tension, “made positional changes without difficulty between sitting and standing,” sat in 

a chair, “was able to get up from an armless chair without difficulty,” “got up and down 

from the exam table without human assistance,” and “was able to lie down in the supine 

position on the exam table and recover without human assistance.” (R. 267). Plaintiff was 

also able to tandem walk, walk on her heels and toes, to squat and recover without 

assistance, and to kneel and recover without assistance. (R. 267). Plaintiff’s only mobility 

limitation was her fear to “try to hop on both feet.” (R. 267). 

 Dr. Jones noted that Plaintiff’s range of motion was within normal limits for her 

cervical spine, thoracic spine, lumbar spine, and pelvis. (R. 268). Plaintiff had full range 

of motion for her shoulder, elbow, wrist, hips, knees, and ankles with 5/5 muscle strength 

in all areas. (R. 268). Although Plaintiff complained of back pain, Dr. Jones noted no 

objective physical problems with her joints and normal reflexes. (R. 268). Yet, despite 

these findings, Dr. Jones rested his functional capacity assessment of Plaintiff on his 

diagnosis of degenerative disc disease in her lumbar spine and mild spondylitic disease in 

the thoracic spine. (R. 269-70). Dr. Jones apparently did so based on Plaintiff’s subjective 

reports of whole body pain. (R. 269). Dr. Jones assessed Plaintiff as only being able to 

perform light work. (R. 269-71). 

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 Dr. Jones’ functional capacity assessment is inconsistent with his own findings, 

including his findings showing a complete absence of objective limitations. The ALJ did 

not err in discounting Dr. Jones’ functional capacity assessment because although Dr. 

Jones’ objective findings are consistent with the record, his assessment that Plaintiff is 

capable of only light work is inconsistent with the balance of Plaintiff’s record evidence. 

The ALJ gave specific and legitimate reasons for discounting his opinion. For example, 

the ALJ noted that Plaintiff’s reports of pain are inconsistent with her diagnosis of only 

grade 1 spondylolisthesis and her engaging in only conservative treatment. (R. 21, 257). 

Plaintiff also twice failed to complete a course of physical therapy, attending only 

one appointment at STI Physical Therapy & Rehabilitation. (R. 21, 256). Plaintiff 

switched to the Core Institute, but after six therapy sessions Plaintiff stopped attending 

and was unreachable by the Core Institute staff. (R. 21, 304). Plaintiff also saw Dr. 

Hennenhoefer for a single visit, at which she complained of 10/10 pain but found 

physical therapy unhelpful and she stated she had not undergone injections. (R. 22, 337). 

Instead, Plaintiff took tramadol and Vicodin. (R. 337). Plaintiff admitted tobacco use to 

Dr. Hennenhoefer, which contradicts her denial to Dr. Jones and undermines Plaintiff’s 

credibility. (R. 339). Dr. Hennenhoefer found Plaintiff slow to rise from a chair, and 

noted mild to moderate restrictions in Plaintiff’s range of motion. (R. 339). Plaintiff never 

followed up with Dr. Hennenhoefer. (R. 22). 

 In addition to Plaintiff’s inconsistent statements regarding her tobacco use, the 

ALJ found Plaintiff’s credibility further compromised in that she complained of only 

being able to sit for twenty minutes at a time but sat through the forty-five minute ALJ 

hearing. (R. 22-23). More significantly, the ALJ noted that although Plaintiff had told Dr. 

Jones that she had lost her vision in her left eye, her left eye was tested at 20/15 vision by 

Dr. Levison. (R. 316). In fact, Dr. Levison reported that Plaintiff had told another doctor 

that she could not see out of her right eye. (R. 316). Thus, to the extent this evidence 

severely compromises Plaintiff’s credibility, the ALJ appropriately relied on it to 

discount Dr. Jones’ functional capacity assessment because that assessment was based on 

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Plaintiff’s subjective reports. 

 The ALJ also found Dr. Levison’s findings to be inconsistent with his functional 

capacity assessment of Plaintiff. Dr. Levison examined Plaintiff on March 28, 2012, and 

also reviewed her past medical records. (R. 315). Dr. Levison noted from Plaintiff’s 

records that she appeared to have age-appropriate narrowing of the central canal in her 

spine, as well as grade 1 spondylolisthesis. (R. 315). Dr. Levison noted that Plaintiff was 

“a very histrionic claimant” who displayed extremely poor effort during the exam, 

sighing frequently and making minimal effort. (R. 316). Dr. Levison found numerous 

Waddell’s signs (indicating a psychological component to chronic low back pain), and a 

“stark contrast” between direct and indirect observational findings. (R. 316). 

 Dr. Levison found Plaintiff’s gait, station, and coordination to be normal. (R. 316). 

Plaintiff refused during the exam to hop, squat, heel-toe stand, or use a tandem gait. (R. 

316). Dr. Levison noted during palpation of Plaintiff’s spine that Plaintiff’s tenderness 

was out of proportion to the actual intensity of palpation. (R. 316). Plaintiff also had a 

full range of motion of her cervical and thoracic spine and could sit on the examination 

table without difficulty, although Plaintiff would not bend forward “even 1 degree on 

formal testing.” (R. 316). Plaintiff had “about 0-1 strength” in her upper and lower 

extremities during formal testing, which Dr. Levison believed to be consistent with 

deception because Plaintiff was able to walk and maneuver. (R. 317). Dr. Levison also 

noted “give-way weakness,” which he believed was a further sign of deception. Overall, 

Dr. Levison concluded that he believed “there is marked malingering and deception on 

the claimant’s behalf.” (R. 317). Nevertheless, Dr. Levison assessed Plaintiff’s functional 

capacity as only light lifting. (R. 318). 

 The ALJ specifically discounted Dr. Levison’s functional capacity assessment as 

inconsistent with Dr. Levison’s own findings as well as other substantial record evidence. 

(R. 23-24). For the reasons already discussed with respect to Dr. Jones, the ALJ pointed 

to specific evidence in the record that undermined Plaintiff’s credibility and objectively 

contradicted Dr. Levison’s capacity assessment. 

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 Finally, the ALJ also pointed to the opinions of nonexamining physicians Dr. 

Goerss and Dr. Bargan as evidence contradicting Dr. Levison’s and Dr. Jones’ functional 

capacity assessments. (R. 23). Dr. Goerss reviewed Plaintiff’s records and found Plaintiff 

to be not credible because her reported symptoms were inconsistent with the objective 

findings. (R. 84). Similarly, Dr. Bargan found Plaintiff’s normal range of motion and 

strength in her extremities supported a functional capacity assessment of medium work. 

(R. 66-67). 

 In sum, the ALJ offered specific and legitimate reasons for discounting the 

functional capacity assessments of Drs. Jones and Levison. The ALJ pointed out that 

these capacity assessments were inconsistent with those doctors’ own treatment notes, the 

objective evidence in the record, and the findings of the nonexamining physicians. The 

ALJ also stated that Plaintiff’s impaired credibility negatively impacted the reliability of 

Dr. Jones and Dr. Levison’s capacity assessments because those assessments were based 

on Plaintiff’s subjective symptoms. These were specific and legitimate reasons for 

discounting these capacity assessments, and the ALJ did not err in doing so.1

IV. Medical-Vocational Guidelines

 Plaintiff’s second argument is that the ALJ did not properly consider “20 CFR 

404.1599 Subpart P, Appendix II at 202.09” in failing to find Plaintiff to be disabled. 

(Doc. 13 at 4). The Court presumes, as Defendant points out, that Plaintiff intended to 

cite to the Medical-Vocational Guidelines, 20 C.F.R. 404, Subpart P, Appendix 2. (Doc. 

16 at 10 n.1). Plaintiff argued in her opening brief that under the Medical-Vocational 

Guidelines, a person over 50 years of age who has an inability to communicate in English 

and has no skills is considered disabled. (Doc. 13 at 4). 

 In applying the Medical-Vocational Guidelines, the ALJ noted that “[i]f the 

claimant had the residual functional capacity to perform the full range of medium work, a 

 

1

 Plaintiff argues the ALJ erred in discounting the capacity assessments of Dr. Jones and Dr. Levison because, according to Plaintiff, even a healthy 60-year-old woman would have difficulty lifting fifty pounds occasionally. (Doc. 13 at 5). But a functional 

capacity assessment does not consider age, education, or work experience. See Bowen v. 

Yuckert, 482 U.S. 137, 148 (1987). 

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finding of ‘not disabled’ would be directed by Medical-Vocational Rule (“Rule”) 203.14. 

However, the claimant’s ability to perform all or substantially all of the requirements of 

this level of work has been impeded by additional limitations.” (R. 25). At the ALJ 

hearing, a vocational expert testified that given Plaintiff’s age, education, and limited 

English skills, there were jobs available in the national economy that required medium 

exertion and only the lowest level of language skills. (R. 25). The ALJ concluded that 

based on this testimony, Plaintiff was capable of making a “successful adjustment to 

other work that exists in significant numbers in the national economy” and was thus not 

disabled. (R. 25). Plaintiff does not challenge the vocational expert’s testimony on 

appeal. 

 Plaintiff’s argument fails because Medical-Vocational Rule 202.09, to which 

Plaintiff cites, applies only to claimants with a residual functional capacity for light work. 

The ALJ found Plaintiff to be capable of medium work. However, Plaintiff argues in her 

reply brief that because she is now over 60 years of age, Medical-Vocational Rules 

203.01 and 203.02 require a finding of disability even if Plaintiff is capable of medium 

work. (Doc. 17 at 2). Rules 203.01 and 203.02 apply when a claimant is over 60 years old 

and has a “limited” or “marginal” education. 20 C.F.R. pt. 404, subpt. P, app. 2. The ALJ 

found that Plaintiff has at least a high school education and is able to communicate in 

English. (R. 24); see also 20 C.F.R. § 414.964(b)(4). Accordingly, the applicable 

Medical-Vocational Rule is 203.06, which applies when the claimant is over 60, is a high 

school graduate, and has no previous work experience. Rule 203.06 directs a conclusion 

of “not disabled.” The ALJ did not err in applying the Medical-Vocational Guidelines 

V. Conclusion

 The ALJ did not err in finding Plaintiff to be not disabled. 

/ 

/ 

/ 

/ 

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 For the foregoing reasons, 

IT IS ORDERED that the decision of the Administrative Law Judge is affirmed. 

IT IS FURTHER ORDERED that the Clerk of the Court shall enter judgment 

accordingly. The judgment will serve as the mandate of this Court. 

 Dated this 22nd day of September, 2015. 

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