Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_04-cv-01892/USCOURTS-casd-3_04-cv-01892-0/pdf.json

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

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 42 U.S.C. § 405(g) provides:

Any individual, after any final decision of the Commissioner of Social Security made

after a hearing to which he was a party . . . may obtain a review of such decision by a

civil action ... brought in the district court of the United States. . . . The court shall have

power to enter, upon the pleadings and transcript of the record, a judgment affirming,

modifying or reversing the decision of the Commissioner of Social Security, with or

without remanding the cause for a rehearing. The findings of the Commissioner . . . as

to any fact, if supported by substantial evidence, shall be conclusive.

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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

CANDICE A. HENRY, Civil No. 04cv1892-WQH (CAB)

Plaintiff,

REPORT AND RECOMMENDATION

TO DENY PLAINTIFF’S MOTION FOR

SUMMARY JUDGMENT AND GRANT

DEFENDANT’S MOTION FOR

SUMMARY JUDGMENT

v.

JO ANNE B. BARNHART, Commissioner of

Social Security,

Defendant.

I. Introduction

Plaintiff Candice A. Henry brings this action pursuant to 42 U.S.C. § 405(g)1, to obtain

judicial review of a final decision of the Commissioner of Social Security (“Commissioner”) on her

application for Supplemental Security Income (“SSI”) benefits under Title XVI of the Social

Security Act (“Act”). Plaintiff had been receiving SSI benefits, but on June 7, 2002, Plaintiff was

determined to be no longer disabled, and Plaintiff has filed this action challenging that decision. 

Pursuant to Southern District of California Local Civil Rule 7.1(d)(1), the Court finds the parties’

cross-motions for summary judgment can be decided on the papers and that no oral argument is

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necessary. After careful consideration of the papers, the administrative record, and the applicable

law, this Court RECOMMENDS that the Commissioner’s decision adopting the ALJ’s decision be

AFFIRMED, Plaintiff’s motion for summary judgment be DENIED, and Defendant’s cross-motion

for summary judgment be GRANTED.

II. Procedural History

In 1999, the Social Security Administration (“Administration”) determined that Plaintiff was

disabled, beginning on April 7, 1998, due to disorders of the back. (Administrative Record (“AR”)

at 45.) In June 2002, the Administration determined that Plaintiff’s disability had ceased on June 1,

2002 and informed her benefits would terminate on August 1, 2002. (AR at 46, 50-53.) The

Administration informed Plaintiff that, based on the medical evidence received in May 2002, she

was able to do light work activity, and while she could not return to her past jobs as she described

them, she could return to her past work as it is customarily performed in the national economy. (AR

at 51.) Plaintiff requested reconsideration, and the Administration denied benefits again after

reconsideration. (AR at 62-72.)

On January 8, 2003, Plaintiff requested a hearing before an Administrative Law Judge

(“ALJ”). (AR at 93.) On June 3, 2003, the ALJ conducted a hearing to consider the merits of

Plaintiff’s application. (AR at 28-44.) As a result of this hearing, the ALJ issued a written decision

dated October 22, 2003. (AR 19-27.) The ALJ found that Plaintiff’s disability ceased on June 1,

2002, and she was no longer eligible for SSI benefits. (AR at 27.) Plaintiff disagreed with the ALJ’s

decision and requested an Appeals Council Review of the decision. (AR at 14-15.) On June 25,

2004, the Appeals Council concluded there was no basis for granting Plaintiff’s request for review. 

(AR at 8-11.) Even though Plaintiff had submitted additional evidence after the administrative

hearing, and the additional evidence was made a part of the record, the Appeals Council concluded

the medical opinion submitted was not supported by any treatment or progress notes or records of

any clinical or laboratory tests. (AR at 9.) The Appeals Council affirmed the ALJ’s decision, which

then became the final decision of the Commissioner. (AR at 8.)

On September 20, 2004, after having exhausted all administrative remedies, Plaintiff initiated

this action challenging the proceedings in connection with the Commissioner adopting the ALJ’s

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decision. [Doc. No. 1.] Plaintiff filed a First Amended Complaint on November 7, 2005. [Doc. No.

13.] On January 5, 2006, the Commissioner filed an answer to the complaint. [Doc. No. 15.] On

June 12, 2006, Plaintiff filed a motion for summary judgment, requesting that the Court reverse the

ALJ’s decision and remand for payment of benefits. [Doc. No. 22-23.] On July 7, 2006, Defendant

filed a cross-motion for summary judgment, requesting that the ALJ’s decision be affirmed. [Doc.

No. 24-26.]

III. Factual Background

A. Plaintiff’s Testimony

Plaintiff was born on September 4, 1956. (AR at 45.) She has a high school education and

attended two years of college. (AR at 128.) She worked as a cashier at a gas station in 1988, did not

work at all between 1988 and 1995 (AR at 33), and worked as a tech support specialist in customer

relations between 1995 and 1998. (AR at 131.) At the administrative hearing on June 3, 2003,

Plaintiff testified that she stopped working in April 1998 due to a motor vehicle accident, in which

she injured her neck and back. (AR at 34.) In June 1999, she had fusion surgery. (Id.) Despite the

surgery, however, Plaintiff indicated she still suffered pain in her arms, fingers, back and legs. (Id.) 

On a scale of one to ten, Plaintiff described her pain as a seven or eight. (AR at 35.) She indicated

she was being treated at Neighborhood Healthcare, saw a chiropractor about once a week, and took

Naprosyn. (AR at 35-36.)

Plaintiff believed that she could lift with both hands no more than a gallon of milk,

equivalent to about five pounds. (AR at 36.) She stated that she had trouble using a mouse on a

computer or holding a book. (AR at 37.) She reported she was only able to move a computer mouse

for about 20 to 30 minutes before it became too painful, and she could sit comfortably for 15 minutes

and stand comfortably for five minutes. (Id.) Plaintiff testified that she could walk approximately

350 steps before it became uncomfortable. (Id.) Additionally, she indicated that it took her about

four to five hours to complete two loads of laundry. (Id.) She stated that she could maintain a task

for about 20-30 minutes before needing to rest, lie down or use ice-packs in order to resume again. 

(AR at 38.) Plaintiff also stated that she had to lie down and rest for up to half an hour, about 6

times during the day. (AR at 39.)

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Plaintiff testified that she had an 11-year-old son, who lived with her. (AR at 39.) She drove

him to school and picked him up. (Id.) She also indicated that she did the chores around the house,

including grocery shopping, cooking, laundry and cleaning. (Id.) Plaintiff indicated, however, that

she was embarrassed at the state of her home, because she was not able to maintain it the way she

would have liked. (AR at 40.) She indicated she was not seeing a mental health professional and not

taking any medication for depression. (AR at 39.)

B. Medical Evidence Presented

1. Before September 1999

Beginning in July 1998, Plaintiff saw Steven Horowitz, D.O., for treatment of discomfort in

her neck, right arm, right leg, and lower back and for intermittent headaches resulting from a car

accident in April 1998. (AR at 198-226.) An MRI of Plaintiff’s cervical spine revealed disc

protrusion and bulge at C5-6 and L4-5. (AR at 198, 239-40.) On June 16, 1999, Plaintiff had

anterior cervical discectomy and fusion surgery. (AR at 255.) X-rays taken on August 17, 1999

showed that the graft was in good position, with no evidence of migration, and fusion appeared to be

consolidating well. (AR at 284.) At that time, Plaintiff’s strength was good in the upper extremities

including hand grip, wrist extension, wrist flexion, biceps and triceps. (Id.) Plaintiff noted

improvement in left cervical radicular pains that she had been experiencing and a return of feeling in

her thumb and first finger. She also indicated that she continued to have some mild neck pain, and

her doctor recommended she wear a hard collar for three months. (Id.)

2. Chuck Grauerholtz, R.P.T.

Plaintiff began receiving physical therapy on November 1, 1999, after her fusion surgery. 

(AR at 345-46.) She reported moderate pain, sometimes as low as 2-3/10, but frequently reaching

8/10. (AR at 345.) Even though the surgery was four and a half months earlier, the physical

therapist noted that Plaintiff was fearful of performing exercises of her cervical spine, and as a result,

she reported decreased functional use of her bilateral shoulders and ability to perform any sustained

activity. (Id.) The physical therapist also noted that Plaintiff was right-handed and had an unusual

Bell Curve for grip strength, suggesting possible malingering. (Id.) The treatment plan involved two

more physical therapy sessions, as allowed by Plaintiff’s insurance, and a reevaluation from there. 

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(Id.) There is no evidence in the record to suggest treatment went beyond the two sessions.

3. Robert J. Santella, M.D.

Dr. Santella was a gynecologist and primary care physician, and it appears from the record

that he treated Plaintiff as early as January 1999. (AR at 347-58.) She saw Dr. Santella during

August 2000 for problems with abnormal menstrual bleeding. (AR at 327-32.) On August 9, 2000,

Plaintiff had a normal pelvic ultrasound. (AR at 328.)

4. Centro Medico Latino Clinic

The record contains notes from several visits Plaintiff made to the clinic in September 2001. 

(AR at 318-24.) The notes from the clinic indicate that Plaintiff had a tobacco addiction, a

hypothyroid condition and high cholesterol. On September 28, 2001, Plaintiff reported chronic neck

pain and reported that she saw a chiropractor, which helped a lot. (AR at 324.)

5. Marvan N. Sabbagh, M.D.

In May 2002, Plaintiff was referred to Dr. Sabbagh, a neurologist, for her neck pain. (AR at

337-38.) Three weeks before, Plaintiff had fallen and complained of severe pain in her left pectoral

region. (AR at 337.) She reported to the doctor that she was taking Levoxyl, Arthrotec and

Excedrin. (Id.) A motor examination revealed normal tone and no atrophy. Her motor strength was

5/5 in most extremities. (AR at 338.) She had decreased sensation to pin prick and hypoesthesia to

light touch in the right C-8 dermatomal distribution and left L-5 dermotomal distribution. (Id..) Her

gait was normal, and the doctor diagnosed her with back pain, neck pain, polyradiculopathy

involving the cervical and lumbosacral region. (Id.)

6. Neighborhood Healthcare

Plaintiff testified at the administrative hearing that Neighborhood Healthcare was her treating

source. (AR at 35.) The record contains progress notes of visits Plaintiff made to Neighborhood

Healthcare between September 2002 and May 2003. (AR at 404-05, 411-23.) During this time, she

occasionally complained of neck and/or back pain, but she was also being treated for her thyroid

condition.

7. Rajeswari Kumar, M.D.

At the request of the Department of Social Services, Plaintiff underwent an orthopaedic

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consultation with Dr. Kumar on April 28, 2002. (AR at 359-64.) At the examination, Plaintiff

reported to Dr. Kumar that while the fusion surgery improved her numbness in the right hand, the

pain in the neck and lower back persisted. (AR at 359.) She informed the doctor that she had been

diagnosed with arthritis in the neck and was receiving chiropractic treatment as needed. (Id.) 

Plaintiff reported that her neck pain was constant and radiated down to the right shoulder. (Id.) 

Plaintiff also said that her lower back pain was constant, and there was occasional numbness in the

right medial two fingers. (Id.) She described her pain as sharp and burning and aggravated with 20

minutes of standing, 30 minutes of walking, bending or lifting. (AR at 360.) She reported that she

took Excedrin four or five times a day and thyroid medication. (Id.)

On physical examination, Plaintiff’s gait was normal with a normal ability to toe-and-heel

walk. She also had normal swing and stance phases. (AR at 361.) There were no spasms or

tenderness in her paravertebral musculature and her spine contour was normal, but she had restricted

motion in her cervical spine and minimally restricted motion in her lumbar spine. (AR at 361,

363-64.) Plaintiff’s upper and lower extremity examinations did not reveal joint pathology, and she

had normal ranges of motion in her shoulders, elbows, wrists, hands, ankles, knees and hips, with no

tenderness. (AR at 361-62.) Her neurological examination was normal, except for reduced

sensation in the lateral aspect of her calves. (AR at 363.) Dr. Kumar concluded that because of

Plaintiff’s previous cervical spine surgery and limited ranges of motion in her spine, she was limited

to pushing, pulling and lifting 20 pounds occasionally and 10 pounds frequently; standing and

walking six hours; and unlimited sitting. (AR at 364.)

8. Mounir Soliman, M.D.

At the request of the Department of Social Services, Plaintiff underwent a psychiatric

evaluation with Dr. Soliman on May 6, 2002. (AR at 367-70.) Dr. Soliman indicated that Plaintiff

drove herself to the evaluation. (AR at 367.) He observed that her gait and posture were normal,

and he noted no involuntary movements on Plaintiff’s part. (Id.) He noted her chief complaint was

physical pain. (Id.) Plaintiff informed the doctor that she had been suffering from multiple physical

problems since 1998 and had not been able to work since. (Id.) She reported chronic pain, weakness

in her back, neck, arms and legs. (Id.) She denied any psychiatric condition, including mood

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symptoms, psychotic symptoms, or any alcohol or drug problems. (AR at 367-68.) She indicated

she was currently under no psychiatric treatment, and she related her current disability to her physical

condition. (AR at 368.) She indicated she was able to cook, clean, shop, do errands, take care of

personal hygiene and take care of financial responsibilities. (Id.) She also reported that she knew

how to drive a car. (Id.) She did, however, report that she was unable to concentrate on her daily

activities due to her physical pain. (AR at 369.)

Dr. Soliman concluded that Plaintiff had no psychiatric diagnosis, and she had a global

assessment functioning of 75. (AR at 369-70.) From a psychiatric standpoint, the doctor believed

Plaintiff was able to understand, carry out, and remember simple and complex instructions. (AR at

370.) She could interact with co-workers, supervisors and the general public. (Id.) He believed she

was able to withstand the stress and pressures associated with an eight-hour workday and day-to-day

activities. (Id.) Dr. Soliman concluded there was no evidence to indicate any limitation of

Plaintiff’s work ability based on her current psychiatric condition. (Id.)

9. Other Medical Evidence Presented

An MRI of the cervical spine taken on May 27, 2000 showed status post discectomy and

fusion at C5-6, with no significant focal disc herniations. (AR at 333.) An MRI of the lumbar spine

revealed degenerative disc disease at L4-5, with no focal disc protrusions, and facet arthropathy in

the lower lumbar spine. (AR at 334.)

A cervical spine x-ray taken September 21, 2001 revealed straightening of the cervical spine,

degenerative disc disease and anterior ligamentous ossification. (AR at 316.) An x-ray of the

thoracic spine showed early anterior osteophyte formation and normal soft tissues. (AR at 317.) 

Both x-rays showed normal mineralizations without evidence of fracture or sublugation, and no

arthritic changes.

10. Physical Residual Functional Capacity Assessment

On June 5, 2002, Don Jenkins, M.D., reviewed the medical records and conducted a Physical

Residual Functional Capacity Assessment of Plaintiff. (AR at 372-80.) The doctor concluded that

Plaintiff could occasionally lift and/or carry 20 pounds and frequently lift and/or carry 10 pounds;

stand and/or walk (with normal breaks) for a total of six hours in an eight-hour workday; and sit

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(with normal breaks) for a total of six hours in an eight-hour workday. (AR at 373.) Dr. Jenkins

believed Plaintiff had unlimited ability to push and/or pull. (Id.) As far as postural limitations were

concerned, Dr. Jenkins believed Plaintiff could frequently climb, balance, stoop, kneel, crouch and

crawl. (AR at 374.) The doctor also concluded that Plaintiff had no manipulative, visual,

communicative, or environmental limitations. (AR at 375-76.) Dr. Jenkins believed Plaintiff had

improved from her surgery, and she could do light work. (AR at 380.)

11. Roy C. Springer, M.D.

On February 13, 2004, after the ALJ issued his determination that Plaintiff was no longer

disabled, Plaintiff submitted a Physical Capacities assessment from Dr. Springer. (AR at 427-29.) 

Dr. Springer concluded that, due to Plaintiff’s chronic pain, she could stand/walk no more than two

hours in an eight-hour work day, and sit no more than two hours in an eight-hour workday. (AR at

427.) He believed she was restricted in using her hands and fingers for repetitive motions, because

she was unable to operate a mouse. (Id.) He also believed Plaintiff could never carry 15 pounds and

could constantly carry 10 pounds. (AR at 428.) Due to Plaintiff’s chronic soft tissue disease, Dr.

Springer believed Plaintiff could occasionally climb, balance, kneel, and crouch; could never stoop

or crawl; could constantly reach from waist to chest; could frequently reach below the knees, from

waist to knees, and from chest to shoulders; but could never reach above the shoulders. (Id.)

C. Vocational Evidence Presented

Gloria Lassoff testified at the administrative hearing as a vocational expert. (AR at 42-44.) 

Based on Plaintiff’s description of her past work, as a tech support specialist and a cashier, Ms.

Lassoff prepared a profile of Plaintiff’s prior work based on the Dictionary of Occupational Titles. 

(AR at 33, 186-87.) The profile classified Plaintiff’s prior work as that of a “salesperson, pts.” (AR

at 186.) The ALJ presented three hypotheticals encompassing various aspects of Plaintiff’s physical

and mental limitations.

The first hypothetical assumed the following facts and limitations: a younger individual with

14 years of education, past work as a parts salesperson, who could occasionally lift or carry 20

pounds, frequently lift or carry 10 pounds, stand or walk for a total of six hours in an eight-hour

workday, sit for six hours in an eight-hour workday, conduct unlimited pushing or pulling, and

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frequently climb, balance, stoop, kneel, crouch and crawl, with no medically determinable mental 

impairment. (AR at 42, 373-74, 388.) Ms. Lassoff found that, given those limitations, Plaintiff

would be able to do her former work. (AR at 42.)

The second hypothetical assumed the same age, education, and work experience as in the

previous hypothetical but incorporated the limitations from Dr. Kumar’s report that Plaintiff had the

ability to do light work and incorporated the psychiatric consultative exam that indicated Plaintiff

had no psychiatric diagnosis. (AR at 42.) With those limitations, Ms. Lassof determined that

Plaintiff could do her former work.

The third hypothetical again assumed the same age, education, and work experience but

incorporated the limitations Plaintiff laid out for herself: could lift five pounds with both hands,

difficulty gripping and grasping with the right upper extremity, could sit comfortably for 15 minutes,

stand for five minutes, comfortably walk for 350 steps, maintain laundry and cleaning for 20-30

minutes, and must rest about six times a day up to half an hour at a time. (AR at 42-43.) With those

limitations, Ms. Lassoff determined that Plaintiff would not be able to sustain her former work or

any other work. (AR at 44.)

D. Other Evidence Presented

Verna Hansen, Plaintiff’s friend, testified that she saw Plaintiff go from a “productive young

woman” to “practically nothing because of the pain.” (AR at 41.) She indicated she saw Plaintiff

about once a week, and she believed Plaintiff wanted nothing more than to work but had not been

able to do so. (Id.)

E. ALJ’s Findings

After a discussion of the evidence in the record, the ALJ determined that Plaintiff was no

longer under a disability as of June 1, 2002. (AR at 26.) The ALJ concluded that Plaintiff retained

the residual functional capacity to perform her past relevant work as a parts salesperson. (Id.) In

making this determination, he considered the State Agency consultative physicians’ opinions and

gave them significant weight, because they were consistent with the medical record as a whole. (AR

at 24.) The ALJ considered Verna Hansen’s testimony, but rejected her opinion regarding Plaintiff’s

disability because, because she did not have any medical training, and her testimony was inconsistent

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with the physicians’ records. (AR at 25-26.)

The ALJ found that Plaintiff’s allegations of disabling limitations were not credible to the

extent alleged. (AR at 24.) He provide 13 reasons for this conclusion, including: 1) Plaintiff was

only taking over-the-counter medication and not the type of pain medication associated with severe

disabling pain; 2) Plaintiff was not currently being treated by a physician for her alleged neck and

back pain and only saw a chiropractor; 3) Plaintiff’s treating records from June and September 2002

show that Plaintiff did not complain of back or neck pain, even though she testified that she had

severe pain daily; the ALJ noted that Plaintiff did not show complaints of back and neck pain until

benefits had ceased; and 4) there was no opinion of disability from a treating physician. (AR at 25.)

Specifically, the ALJ found that Plaintiff suffered from a severe neck impairment-status post

cervical fusion, back impairment and no mental impairment. (AR at 22.) Although her impairments

were severe, they did not meet or equal an impairment or combination of impairments listed in the

regulations. (Id.) Then, the ALJ determined Plaintiff had experienced medical improvement related

to her ability to work. (AR at 26.) The ALJ found that Plaintiff could lift and carry 20 pounds

occasionally and 10 pounds frequently; sit, stand and walk for six hours in an eight-hour day;

frequently climb, balance, stoop, kneel, crouch and crawl; and had no mental limitations. (AR at

24.) The ALJ then found Plaintiff could perform her past relevant work as a parts salesperson. (AR

at 26.) Therefore, he concluded, she was no longer under a disability as defined under the Act. (AR

at 22.)

IV. Discussion

A. Legal Standard

The Social Security Act authorizes payment of SSI benefits to individuals who have an

“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. § 1382c(a)(3)(A). 

The disabling impairment must be so severe that the claimant is not only unable to do her previous

work, but, considering age, education, and work experience, cannot engage in any kind of substantial

gainful work that exists in the national economy. § 1382c(a)(3)(B).

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1. Initial Five-Step Process

The Commissioner makes this assessment by a five-step analysis. First, the Commissioner

determines whether a claimant is engaged in “substantial gainful activity.” If so, the claimant is not

disabled. 20 C.F.R. § 416.920(b). Second, the Commissioner determines whether the claimant has a

“medically severe impairment or combination of impairments.” If not, the claimant is not disabled. 

§ 416.920(c). Third, the medical evidence of the claimant’s impairment is compared to a list of

impairments that are presumed severe enough to preclude work; if the claimant’s impairment meets

or equals one of the listed impairments, benefits are awarded. § 416.920(d). If not, the

Commissioner proceeds to the next step. Bowen v. Yuckert, 482 U.S. 137, 141 (1987). Fourth, if the

claimant can do her past work, benefits are denied. 20 C.F.R. § 416.920(e). If the claimant cannot

perform her past relevant work, the burden shifts to the Commissioner. In step five, the

Commissioner must establish that the claimant can perform other work. § 416.920(f). If the

Commissioner meets this burden and proves that the claimant is able to perform other work that

exists in the national economy, then benefits are denied. § 416.966.

Sections 405(g) and 421(d) of the Social Security Act allow unsuccessful applicants to seek

judicial review of a final agency decision of the Commissioner. 42 U.S.C. §§ 405(g), 421(d). The

scope of judicial review is limited, however, and the Commissioner’s denial of benefits “will be

disturbed only if it is not supported by substantial evidence or is based on legal error.” Brawner v.

Sec’y of Health and Human Servs., 839 F.2d 432, 433 (9th Cir. 1988) (citing Green v. Heckler, 803

F.2d 528, 529 (9th Cir. 1986)). Substantial evidence means “more than a mere scintilla” but less

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

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

Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995)). The court must consider the record as a

whole, weighing both the evidence that supports and detracts from the Commissioner’s conclusions.

Desrosiers v. Sec’y of Health & Human Servs., 846 F.2d 573, 576 (9th Cir. 1988). If the evidence

supports more than one rational interpretation, the court must uphold the ALJ’s decision. Allen v.

Heckler, 749 F.2d 577, 579 (9th Cir. 1984). When the evidence is inconclusive, “questions of

credibility and resolution of conflicts in the testimony are functions solely of the Secretary.” Sample

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v. Schweiker, 694 F.2d 639, 642 (9th Cir. 1982).

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

1978). Section 405(g) permits a court to enter a 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 Commissioner for further proceedings. Id.

The ALJ has a special duty in social security cases to fully and fairly develop the record in

order to make an informed decision on a claimant’s entitlement to disability benefits. DeLorme v.

Sullivan, 924 F.2d 841, 849 (9th Cir. 1991). Because disability hearings are not adversarial in

nature, the ALJ must “inform himself about the facts relevant to his decision,” even if the claimant is

represented by counsel. Id. (quoting Heckler v. Campbell, 461 U.S. 458, 471 n.1 (1983)).

2. Medical Improvement and Seven Step Re-Evaluation

Once a claimant is found disabled, a presumption of continuing disability arises. See Bellamy

v. Sec’y of Health & Human Servs., 755 F.2d 1380, 1381 (9th Cir. 1985). Although the claimant

retains the burden of proof, this presumption shifts the burden of production to the Commissioner to

produce evidence to meet or rebut this presumption. Id.

Disability benefits cannot be terminated unless substantial evidence demonstrates medical

improvement in the claimant’s impairment so that the claimant is able to engage in substantial

gainful activity. See 42 U.S.C. § 423(f); Murray v. Heckler, 722 F.2d 499, 500 (9th Cir. 1983). 

Medical improvement is defined as any decrease in the medical severity of the impairment that was

present at the time of the most recent medical decision favorable to the claimant, i.e., the most recent

decision that the claimant was disabled or continued to be disabled. See 20 C.F.R. §§

416.994(b)(1)(i) & (b)(2)(i).

In determining whether to discontinue disability benefits, the Commissioner applies a sevenstep sequential evaluation. First, if the claimant has an impairment or combination of impairments

that meets or equals a listing, disability continues. Second, if the claimant does not meet or equal a

listing, the ALJ will determine whether medical improvement has occurred. Third, if medical

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improvement has occurred, the ALJ will determine whether the improvement is related to ability to

work (i.e., to residual functional capacity (“RFC”)). Fourth, if no medical improvement--or no

improvement related to ability to work--has occurred, disability continues. Fifth, if there has been

medical improvement related to ability to work, the ALJ will determine whether all the current

impairments, in combination, are “severe,” and, if not, disability ends. Sixth, if the claimant meets

the “severity” criteria, the ALJ will determine the current RFC, and, if the claimant is able to do past

work, disability ends. Finally, if the claimant remains unable to do past work, the ALJ will

determine whether the claimant can do other work. See 20 C.F.R. § 416.994(b)(5).

B. Plaintiff’s Claim

Plaintiff argues several grounds for reversal of the ALJ’s decision: 1) the ALJ failed in his

duty to fully develop the record even though Plaintiff was unrepresented by counsel at the

administrative hearing; 2) the Appeals Council failed to remand the claim to the ALJ to consider the

new evidence from Dr. Springer; and 3) the ALJ failed to evaluate Plaintiff’s ability to perform all of

the duties of her past work. The Court considers each of these arguments below.

1. ALJ did not fail to develop the record

Plaintiff appeared at the administrative hearing without counsel. (AR at 31.) She now argues

it is unclear whether she willingly waived her right to counsel. In addition, she argues that because

she appeared at the administrative hearing without counsel, the ALJ had a heightened duty to

develop the record, and the ALJ erred by not doing so.

Lack of counsel does not in itself affect the validity of the hearing. Hall v. Secretary, 602

F.2d 1372, 1378 (9th Cir. 1979). When a claimant appears at a hearing without counsel, the ALJ

must “scrupulously and conscientiously probe into, inquire of, and explore for all the relevant facts. 

He must be especially diligent in ensuring that favorable as well as unfavorable facts and

circumstances are elicited.” Cox v. Califano, 587 F.2d 988, 991 (9th Cir. 1978) (citations and

internal quotations omitted). A claimant seeking relief by way of remand must demonstrate that the

absence of counsel resulted in prejudice or unfairness during the hearing. Hall, 602 F.2d at 1378.

In the instant case, when Plaintiff appeared at the administrative hearing without counsel, the

ALJ advised her of her right to be represented. (AR at 31.) Plaintiff indicated she had been trying

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for three months to find an attorney but was unsuccessful. (Id.) While the ALJ did note that

Plaintiff already had three months, which he believed to be a long time, he also did give her an

opportunity to postpone the hearing so she could have more time to seek counsel. (Id.) At that

point, Plaintiff clearly indicated she wanted to go forward with the hearing. (Id.) During the

hearing, the ALJ gave Plaintiff an opportunity to present her case and to add documents to the record

if she wanted. (Id.) After Plaintiff gave her testimony, the ALJ asked her if she had anything else to

tell him. (AR at 40.) The ALJ also gave Plaintiff’s friend, who accompanied her to the hearing, an

opportunity to discuss Plaintiff’s condition. (AR at 41.) At the end of Ms. Hansen’s testimony, the

ALJ again asked whether she had anything else to add, and Ms. Hanesen indicated she did not. (Id.) 

Plaintiff has not presented any evidence that indicates absence of counsel resulted in prejudice or

unfairness during the hearing.

It is true that the ALJ has a special duty in social security cases to fully and fairly develop the

record in order to make an informed decision on a claimant’s entitlement to disability benefits. 

DeLorme v. Sullivan, 924 F.2d 841, 849 (9th Cir. 1991). There is no evidence to indicate the ALJ

did not fully and fairly develop the record in this case. Plaintiff’s citation to Vidal v. Harris, 637

F.2d 710 (9th cir. 1981) is inapplicable here. In Vidal, the court found that the ALJ’s conclusion was

not supported by substantial evidence and that the ALJ’s examination of the vocational expert was

inadequate. As a result, that court found the ALJ had not met his burden of fully and fairly

developing the record. In this case, however, there is substantial evidence to support the ALJ’s

conclusion, as discussed below. Further, there was no “ambiguous evidence” which would have

triggered the ALJ’s duty to develop the record further. See Tonapetyan v. Halter, 242 F.3d 1144 (9th

Cir. 2001).

2. The Appeals Council properly rejected Dr. Springer’s opinion

Plaintiff also argues that the Appeals Council should have remanded her claim to the ALJ to

consider new medical evidence from her treating physician, Dr. Springer, submitted after the ALJ

issued his opinion. Specifically, Plaintiff argues that the Appeals Council failed to articulate specific

and legitimate reasons for rejecting Dr. Springer’s opinion and did not give proper weight to the

opinion.

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When physicians’ medical opinions are offered as evidence, the Ninth Circuit distinguishes

among three types of physicians and gives varying weight to their opinions. Lester v. Chater, 81

F.3d 821, 830 (9th Cir. 1995). The three types of physicians are the following: (1) those who treat

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

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

Id. The opinion of a treating physician receives greater weight than that of a non-treating physician,

because the treating physician “is employed to cure and has a greater opportunity to know and

observe the patient as an individual.” Andrews v. Shalala, 53 F.3d 1035, 1041 (9th Cir. 1995)

(citation omitted). Likewise, greater weight is accorded to the opinion of an examining physician

than a non-examining physician. Id.

An acceptable treating source is one who has provided the claimant with medical treatment or

evaluation and either has, or has had, an ongoing treatment relationship with the plaintiff. 20 C.F.R.

§ 416.902. If the frequency and nature of treatment or evaluation by an acceptable medical source is

typical for the plaintiff’s condition, the court will consider that relationship to be an ongoing

treatment relationship. Benton v. Barnhart, 331 F.3d 1030, 1034 (9th Cir. 2003). However, the

Ninth Circuit does not consider a medical source to be a treating source “if [the] relationship with the

source is not based on medical need for treatment or evaluation, but solely to obtain a report in

support of [a] claim for disability.” Id. In such case, the acceptable medical source is considered a

nontreating source. Id. Additionally, when a plaintiff provides new medical evidence from a

treating doctor, but it is obtained after the Commissioner’s denial of benefits, the Ninth Circuit has

held that the Appeals Council shall give it less weight in determining whether the ALJ’s decision is

contradicted by the weight of the evidence in the record. Macri v. Chater, 93 F.3d 540, 544 (9th Cir.

1996) (citations omitted).

Here, the Appeals Council rejected Dr. Springer’s opinion, because it was not supported by

any treatment or progress notes or records of any clinical or laboratory tests. (AR at 9.) The only

opinion Dr. Springer provided was by filling out a four-page Physical Capacities form. Assuming

Dr. Springer was a treating physician, the fact that his opinion is conclusory in nature, brief and

unsupported by clinical findings are valid reasons to reject an opinion of a treating physician. 

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Matney v. Sullivan, 981 F.2d 1016, 1019 (9th Cir. 1992). However, there is no evidence in the

record to indicate that Dr. Springer was Plaintiff’s treating physician.

At no time did Plaintiff submit progress notes or treatment records from Dr. Springer and at

no time during the administrative hearing did Plaintiff indicate that Dr. Springer was one of her

treating physicians. Therefore, the Appeals Council had no reason to give Dr. Springer’s opinion the

weight of a treating physician. See Benton v. Barnhart, 331 F.3d 1030, 1038 (9th Cir. 2003.) 

Finally, the probative value of Dr. Springer’s opinion is diminished by the fact that it was submitted

after the ALJ issued his opinion and determined Plaintiff was no longer eligible for SSI benefits. See

Macri, 93 F.3d at 544. As such, the Appeals Council was not required to remand the case to the ALJ

for consideration of the new medical evidence submitted by Dr. Springer.

3. ALJ properly found Plaintiff could return to her past relevant work

Plaintiff finally argues that the ALJ improperly evaluated whether she could return to her past

relevant work. Specifically, Plaintiff argues her past work was as a “tech support specialist in

customer service,” but the vocational expert classified the work as “parts salesperson.” In addition,

Plaintiff argues that her past work as a tech support specialist required medium work activity, but the

vocational expert indicated the work as a parts salesperson was classified as light work activity.

To determine whether plaintiff has the residual functional capacity to perform her past

relevant work, the ALJ in step four (or step six of the re-evaluation analysis) must evaluate the work

demands of the past relevant work and compare them to her present capacity. Villa v. Heckler, 797

F.2d 794, 797-98 (9th Cir. 1986). Plaintiff’s past relevant work is considered not only as she

actually performed it, but as it is ordinarily performed in the national economy. SSR 82-61. 

Although not required to do so, the ALJ in this case enlisted the services of a vocational expert to

assist in evaluating Plaintiff’s ability to perform her past work. The vocational expert, Ms. Lassoff,

heard Plaintiff’s testimony and prepared a profile of Plaintiff’s prior work based on the Dictionary of

Occupational Titles (“DOT”). (AR at 33.) While Ms. Lassoff did indicate that the job title was

different from what Plaintiff called it, there is no evidence to indicate that Ms. Lassoff’s assessment

was incorrect or that the job title of “parts salesperson” was not a job that had similar demands and

requirements as that of Plaintiff’s past relevant work.

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At this point in the analysis, the burden rests with the plaintiff, and she must establish her

inability to return to her former type of work and not just to her particular former job. Villa, 797

F.2d at 798. Plaintiff meets this burden and overcomes the presumption created by use of the DOT if

she can demonstrate that the duties in her particular work as actually performed were not

contemplated by the drafters of the DOT. Id. Plaintiff can also satisfy the burden by demonstrating

that the same type of work as performed in the national economy actually involves demands higher

than the DOT suggests. Id. at 799. Alternatively, plaintiff may challenge the ALJ’s classification of

her past relevant work according to the DOT; if the ALJ incorrectly categorized it, the job

description becomes irrelevant. Id. at 798.

Here, the ALJ properly developed the record by asking Plaintiff what her previous work as a

“tech support specialist” entailed. (AR at 32.) She responded that she worked in the Sears Repair

Center where she helped set up appointments on the phone, helped the technicians with the parts,

ordered the parts, and got the parts for the customers and technicians. (AR at 32-33.) Based on this

testimony, the vocational expert evaluated the demands of Plaintiff’s past relevant work and

prepared a profile of her prior work based on the DOT. (AR at 33, 186.) The ALJ concluded that

Plaintiff was capable of performing the full range of light work, and the exertional requirements of

her past work indicated she could return to her past relevant work. Plaintiff fails to overcome the

presumption created by use of the DOT. The standard is whether Plaintiff can return to the same

type of work, not the exact same job she was performing previously. While she challenges the

vocational expert’s classification of her past relevant work as “parts salesperson,” she does not

provide an alternative classification that would more closely meet the demands of her past relevant

work.

Even if the ALJ committed error at step four (or step six in the re-evaluation analysis), there

is substantial evidence to support his determination that Plaintiff could perform the full range of light

work. As such, if the ALJ had to proceed to the next step in the analysis, an individual of Plaintiff’s

age who can perform light work is not disabled at step five of the sequential analysis (or step seven

of the re-evaluation analysis). 20 C.F.R. Part 404, Subpart P, Appendix 2, 202.00 (“The functional

capacity to perform a full range of light work includes the functional capacity to perform sedentary []

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 Naprosyn appears to be a drug used for the management of mild to moderate pain, fever, and

inflammation. http://www.medicinenet.com/naproxen/article.htm.

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work. Approximately 1,600 separate sedentary and light unskilled occupations can be identified in

eight broad occupational categories, each occupation representing numerous jobs in the national

economy.”). Given that other reliable evidence exists to support the ALJ’s decision, even if the ALJ

committed error in determining Plaintiff could return to her past relevant work, it was harmless error. 

Matthews v. Shalala, 10 F.3d 678, 681 (9th Cir. 1993).

4. ALJ’s opinion is supported by substantial evidence and is not based on legal error

Despite Plaintiff’s claims of debilitating pain, her own testimony revealed she had not sought

treatment for the pain, other than visits to the chiropractor and taking Naprosyn.2 (AR at 35-36.) 

Even though chiropractic care was the main source of pain relief, the chiropractic office she visited

had no treatment records to submit for the disability review. (AR at 406-08.) The treatment notes

from Neighborhood Healthcare indicate that Plaintiff did complain about pain in her neck and back,

but that she also visited the clinic for other unrelated ailments. (AR at 404-05, 411-23.)

Plaintiff was receiving SSI benefits, because the Administration found she was unable to

work due to the injuries she suffered in a car accident and the subsequent fusion surgery. X-rays

taken after the surgery revealed Plaintiff was healing well. (AR at 284.) An MRI taken in 2000 and

x-rays taken in 2001 indicated no disc herniations or protrusions, a major improvement from the

MRI taken in 1998. (AR at 198, 239-40, 316-17, 333-34.) The record lacks objective evidence to

support the existence of and treatment for the debilitating pain Plaintiff currently alleges. In

addition, Dr. Kumar and Dr. Jenkins’s reports support the ALJ’s conclusion that Plaintiff was

capable of performing light work. As such, there was substantial evidence in the record to support

the ALJ’s decision.

Finally, because this is a case of disability cessation, the ALJ effectively met the burden of

production to rebut the presumption of Plaintiff’s continuing disability. Bellamy, 755 F.2d at 1381. 

The reports of Dr. Kumar, Dr. Jenkins and Dr. Solimar support the conclusion that Plaintiff’s

condition had improved since the last favorable disability decision, in which she was found to have

discogenic and degenerative disorders of the back. Further, the MRI taken in 2000 and x-ray taken

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in 2001 of Plaintiff’s back support the conclusion that Plaintiff’s back condition had improved. The

ALJ properly weighed the evidence, performed the seven-step re-evaluation analysis, and found

Plaintiff could return to her past work.

V. Conclusion

After a thorough review of the record and the papers submitted and based on the reasons set

forth above, this Court finds the ALJ’s decision that Plaintiff could return to her previous relevant

work was supported by substantial evidence in the record and was not based on legal error. 

Accordingly, this Court RECOMMENDS Plaintiff’s motion for reversal be DENIED and the

Commissioner’s cross-motion for summary judgment be GRANTED.

This Report and Recommendation is submitted to the United States District Judge assigned

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

and serve a copy on all parties on or before March 5, 2007. The document should be captioned

“Objections to Report and Recommendation.” Any reply to the objections shall be filed and served

no later than 10 days after being served with the Objections.

IT IS SO ORDERED.

DATED: February 16, 2007

CATHY ANN BENCIVENGO

United States Magistrate Judge

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