Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_11-cv-00459/USCOURTS-azd-2_11-cv-00459-0/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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IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Billy W. Martin, 

Plaintiff, 

vs.

Michael J. Astrue, Commissioner of

Social Security, 

Defendant. 

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No. CV 11-00459-PHX-NVW

ORDER

Billy W. Martin seeks review under 42 U.S.C. §§ 405(g), 1383(c)(3), of the final

decision of the Commissioner of Social Security (“the Commissioner”), which denied

him disability insurance benefits and supplemental security income under the Social

Security Act. Because the decision of the Administrative Law Judge (“ALJ”) is

supported by substantial evidence and is not based on legal error, the Commissioner’s

decision will be affirmed.

I. Background

A. Factual Background

Martin was born on March 20, 1971. He was 29 years old on July 1, 2000, the

alleged disability onset date, and 38 years old on the date of the ALJ’s decision. He has a

high school education (G.E.D.) and is able to communicate in English. He does not have

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a history of past relevant work. Martin has been diagnosed with major depressive

disorder and bipolar disorder.

Martin testified that he had difficulty associating with people when he was young

because his father moved at least once a year, sometimes two or three times a year. When

he was 18 or 19 years old, he quit living with his father and lived independently for

awhile. When he was 20 years old, he developed mental problems, quit socializing, and

moved in with his mother. He has lived with his mother ever since. He no longer has a

drivers license, so she drives him to go grocery shopping and to medical appointments. 

His mother reminds him to take his medications. He receives medical care through the

Arizona Health Care Cost Containment System.

Martin reports that he spends most days in his room, watching television with the

two family dogs. He goes outside to smoke every two or three hours. If he needs to go

somewhere, he will take a shower, but otherwise bathing seems like too much trouble. 

He has difficulty sleeping without medication, but when he takes sleep medication, he

usually sleeps almost 12 hours.

Martin does his own grocery shopping because he has food stamps. In 2009, he

testified that he does not help his mother with any of the cooking, housework, or yard

work. In 2008, both Martin and his mother reported that about three times a week he

would make sandwiches or simple meals and would take out the trash about once a week. 

Martin testified that he does not currently drink alcohol or use drugs. He said that

when he was in his mid-twenties he drank excessively and used methamphetamine.

When asked why he has not worked much in the past 20 years, Martin said he was

doing construction work and his knee buckled a couple of times, so he became afraid of

heights and could no longer do construction work. He also said he forgets things

constantly and would “mess up” on the job because of forgetfulness. He also reported

panic attacks and depression.

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The Court does not review issues raised only in a reply brief. Here, Martin raises for

the first time in his reply brief contentions that the residual functional capacity assessment

is deficient because it does not say how long it would take Martin to learn how to perform

his job or whether Martin has any limitation in his ability to deal with coworkers and

supervisors.

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B. Procedural History

On July 5, 2007, Martin applied for disability insurance benefits and supplemental

security income, alleging disability beginning July 1, 2000. The application was denied

on initial review and again on reconsideration, after which Martin requested that his claim

be heard by an ALJ. On August 13, 2009, an administrative hearing was held at which

Martin testified and was represented by counsel. George J. Bluth, an impartial vocational

expert, also appeared at the hearing. On November 6, 2009, the ALJ issued her decision

that Martin was not disabled within the meaning of the Social Security Act. 

On January 8, 2011, the Appeals Council denied Martin’s request for review of the

ALJ’s unfavorable decision, making that decision the final decision of the Commissioner. 

On March 9, 2011, Martin sought judicial review of the decision pursuant to 42 U.S.C.

§§ 405(g), 1383(c)(3).

II. Standard of Review

The district court reviews only those issues raised by the party challenging the

ALJ’s decision.1

 See Lewis v. Apfel, 236 F.3d 503, 517 n.13 (9th Cir. 2001). The court

may set aside the Commissioner’s disability determination only if the determination is not

supported by substantial evidence or is based on legal error. Orn v. Astrue, 495 F.3d 625,

630 (9th Cir. 2007). Substantial evidence is more than a scintilla, less than a

preponderance, and relevant evidence that a reasonable person might accept as adequate

to support a conclusion considering the record as a whole. Id. In determining whether

substantial evidence supports a decision, the court must consider the record as a whole

and may not affirm simply by isolating a “specific quantum of supporting evidence.” Id.

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As a general rule, “[w]here the evidence is susceptible to more than one rational

interpretation, one of which supports the ALJ’s decision, the ALJ’s conclusion must be

upheld.” Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002) (citations omitted).

The ALJ is responsible for resolving conflicts in medical testimony, determining

credibility, and resolving ambiguities. Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir.

1995). In reviewing the ALJ’s reasoning, the court is “not deprived of [its] faculties for

drawing specific and legitimate inferences from the ALJ’s opinion.” Magallanes v.

Bowen, 881 F.2d 747, 755 (9th Cir. 1989). 

III. Five-Step Sequential Evaluation Process

To determine whether a claimant is disabled for purposes of the Social Security

Act, the ALJ follows a five-step process. 20 C.F.R. § 404.1520(a). If the ALJ determines

that the claimant is disabled or not disabled at any step, the ALJ does not continue to the

next step. The claimant bears the burden of proof on the first four steps, but at step five,

the burden shifts to the Commissioner. Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir.

1999).

At the first step, the ALJ determines whether the claimant is engaging in

substantial gainful activity. 20 C.F.R. § 404.1520(a)(4)(I). If so, the claimant is not

disabled and the inquiry ends. Id. At the step two, the ALJ determines whether the

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

§ 404.1520(a)(4)(ii). If not, the claimant is not disabled and the inquiry ends. Id. At step

three, the ALJ considers whether the claimant’s impairment or combination of

impairments meet or equal an impairment listed in Appendix 1 to Subpart P of 20 C.F.R.

Pt. 404. § 404.1520(a)(4)(iii). If so, the claimant is automatically found to be disabled. 

Id. If not, the ALJ proceeds to step four. At step four, the ALJ assesses the claimant’s

residual functional capacity and determines whether the claimant is still capable of

performing past relevant work. § 404.1520(a)(4)(iv). If so, the claimant is not disabled

and the inquiry ends. Id. If not, the ALJ proceeds to the fifth and final step, where he

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determines whether the claimant can perform any other work based on the claimant’s

residual functional capacity, age, education, and work experience. § 404.1520(a)(4)(v). 

If so, the claimant is not disabled. Id. If not, the claimant is disabled. Id. 

IV. Analysis

At step one, the ALJ found that Martin has not engaged in substantial gainful

activity since July 1, 2000, the alleged onset date of disability. The ALJ also found that

Martin had acquired sufficient quarters of coverage to remain insured through June 20,

2007, but Martin believes the date last insured is June 30, 2001. At step two, the ALJ

found that Martin had the following severe impairment: bipolar disorder. At step three,

the ALJ found that Martin did not have an impairment or combination of impairments

that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404,

Subpart P, Appendix 1. Martin does not raise any issues related to the ALJ’s

determinations at the first three steps of the five-step sequential evaluation process. 

The ALJ determined that Martin:

has the residual functional capacity to perform a range of work at all

exertional levels but with the following nonexertional limitations: he can

perform simple, unskilled work with minimal contact with the general

public, and he is able to work independently once he learns how to perform

his job.

At step four, the ALJ determined that Martin does not have any past relevant work and

therefore is unable to perform past relevant work. At step five, the ALJ concluded that,

considering Martin’s age, education, work experience, and residual functional capacity,

there are jobs that exist in significant numbers in the national economy that Martin could

perform.

A. Weighing Medical Source Evidence

1. Legal Standard

In weighing medical source opinions in Social Security cases, the Ninth Circuit

distinguishes among three types of physicians: (1) treating physicians, who actually treat

the claimant; (2) examining physicians, who examine but do not treat the claimant; and

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(3) non-examining physicians, who neither treat nor examine the claimant. Lester v.

Chater, 81 F.3d 821, 830 (9th Cir. 1995). Generally, more weight should be given to the

opinion of a treating physician than to the opinions of non-treating physicians. Id. A

treating physician’s opinion is afforded great weight because such physicians are

“employed to cure and [have] a greater opportunity to observe and know the patient as an

individual.” Sprague v. Bowen, 812 F.2d 1226, 1230 (9th Cir. 1987). Where a treating

physician’s opinion is not contradicted by another physician, it may be rejected only for

“clear and convincing” reasons, and where it is contradicted, it may not be rejected

without “specific and legitimate reasons” supported by substantial evidence in the record. 

Lester, 81 F.3d at 830. Moreover, the Commissioner must give weight to the treating

physician’s subjective judgments in addition to his clinical findings and interpretation of

test results. Id. at 832-33.

Further, an examining physician’s opinion generally must be given greater weight

than that of a non-examining physician. Id. at 830. As with a treating physician, there

must be clear and convincing reasons for rejecting the uncontradicted opinion of an

examining physician, and specific and legitimate reasons, supported by substantial

evidence in the record, for rejecting an examining physician’s contradicted opinion. Id. at

830-31. 

The opinion of a non-examining physician is not itself substantial evidence that

justifies the rejection of the opinion of either a treating physician or an examining

physician. Id. at 831. “The opinions of non-treating or non-examining physicians may

also serve as substantial evidence when the opinions are consistent with independent

clinical findings or other evidence in the record.” Thomas, 278 F.3d at 957. Factors that

an ALJ may consider when evaluating any medical opinion include “the amount of

relevant evidence that supports the opinion and the quality of the explanation provided;

the consistency of the medical opinion with the record as a whole; [and] the specialty of

the physician providing the opinion.” Orn, 495 F.3d at 631. 

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Moreover, Social Security Rules expressly require a treating source’s opinion on

an issue of a claimant’s impairment be given controlling weight if it is well-supported by

medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent

with the other substantial evidence in the record. 20 C.F.R. § 404.1527(d)(2). If a

treating source’s opinion is not given controlling weight, the weight that it will be given is

determined by length of the treatment relationship, frequency of examination, nature and

extent of the treatment relationship, relevant evidence supporting the opinion, consistency

with the record as a whole, the source’s specialization, and other factors. Id.

Finding that a treating physician’s opinion is not entitled to controlling weight

does not mean that the opinion should be rejected:

[A] finding that a treating source medical opinion is not wellsupported by medically acceptable clinical and laboratory diagnostic

techniques or is inconsistent with the other substantial evidence in the case

record means only that the opinion is not entitled to “controlling weight,”

not that the opinion should be rejected. Treating source medical opinions

are still entitled to deference and must be weighed using all of the factors

provided in 20 C.F.R. §404.1527. . . . In many cases, a treating source’s

medical opinion will be entitled to the greatest weight and should be

adopted, even if it does not meet the test for controlling weight.

Orn, 495 F.3d at 631-32 (quoting Social Security Ruling 96-2p). Where there is a

conflict between the opinion of a treating physician and an examining physician, the ALJ

may not reject the opinion of the treating physician without setting forth specific,

legitimate reasons supported by substantial evidence in the record. Id. at 632. 

2. The ALJ Did Not Err in Weighing Medical Source Opinion

Evidence.

Martin contends the ALJ erred by giving greater weight to the opinion of the nonexamining physician Randall Garland, Ph.D., than to the opinions of treating psychiatrist

Leela Reddy, M.D., treating nurse practitioner Judy Yurgel, and examining state agency

consultative physician Joanne Smart, Ph.D. The ALJ gave “substantial weight” to the

opinion of Dr. Garland, the state agency psychologist, who completed both a mental

residual functional capacity and the psychiatric review technique form. The ALJ agreed

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that the evidence supported Dr. Garland’s mental residual functional capacity assessment,

but only gave “some consideration” to Dr. Garland’s conclusions with respect to the

psychiatric review technique form. The ALJ assigned “little weight” to the opinions of

Dr. Reddy, NP Yurgel, and Dr. Smart. 

Dr. Reddy’s July 2002 psychiatric evaluation states that Martin first sought

treatment in 2001, at which time his primary care physician prescribed Wellbutrin. After

three weeks, Martin discontinued taking Wellbutrin because he did not see any benefits. 

His primary care physician then prescribed Paxil, which Martin discontinued after three

weeks because he felt too tired. He reported being unable to work because of a knee

problem as a result of a high school football injury. Dr. Reddy observed that his “thought

processes were logical and goal directed without any evidence of looseness of association

or flight of ideas,” but his “cognition and concentration was significantly impaired.” She

assessed his intellectual functioning as average, his abstract ability as intact, and his

insight and judgment as fair. Dr. Reddy prescribed Zoloft and said “we will monitor

cautiously for compliance.” In March 2003, Martin was discharged from Dr. Reddy’s

care for failing to follow through with treatment, keep appointments, and respond to

appropriate notice. 

In September 2008 and July 2009, NP Yurgel completed medical assessments of

Martin’s ability to perform work-related activities. In both assessments she evaluated

Martin’s degree of restriction of daily activities as severe; his limitation in understanding,

carrying out, and remembering instructions as moderately severe; and his limitation in

performing simple, repetitive, or varied tasks as moderately severe. In 2008 NP Yurgel

wrote that a psychological evaluation had not been obtained at her agency because the

diagnosis of a schizoaffective disorder was clear, he had been ill for at least 15 years, and

the same level of severity had existed for five years. In 2009 she wrote that a psychiatric

evaluation had been done several years before and that the restrictions she assessed were

in existence since 1999.

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In June 2008, state agency consultative physician Dr. Smart assessed Martin based

on a clinical interview, Mini Mental Status Exam results, and a review of records. She

noted, “He reported that he is doing better since he has been on medications,” was able to

get his hair cut, and was bathing weekly now. She also noted, “His mother said he is

showing some emotion now, which he attributed to the medication he is taking.” He

reported to Dr. Smart that his worst problem was his difficulty being around people. Dr.

Smart said this “suggests the possibility, given his other symptoms, of Schizoid

Personality Disorder.” She concluded Martin “is severely depressed, but his depression

appears to be lifting somewhat.” Dr. Smart assessed Martin as likely to have a slight

impairment in work situations because of his long-term memory problems, no significant

short-term memory problems, and little problem with understanding. She assessed him as

likely to have moderate impairment maintaining concentration and focus and completing

tasks or normal workday schedules. She further opined that he is likely to have moderate

impairment in social interaction, which sometimes may be marked, and he is likely to

have moderate to marked difficulty adapting to changes needed to maintain employment.

In July 2008, Dr. Garland reviewed Martin’s medical record as of the alleged onset

date of disability, July 1, 2000, but noted that there was insufficient evidence regarding

July 1, 2000, to June 30, 2001. Dr. Garland made specific comments regarding the

treatment notes and evaluations by other medical sources. Dr. Garland assessed Martin’s

functional limitations as moderate in restriction of daily living activities, difficulties

maintaining social functioning, and difficulties in maintaining concentration, persistence,

or pace. He concluded that Martin:

is able to meet the basic mental demands of competitive, remunerative,

unskilled work on a sustained basis, particularly in settings of low social

contact, including the abilities to:

1. Understand, carry out, and remember simple instructions.

2. Make judgments commensurate with the functions of unskilled work,

i.e., simple work-related decisions.

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3. Respond appropriately to supervision, coworkers and work

situations.

4. Deal with changes in a routine work setting.

In order to reject a treating physician’s contradicted opinion, the ALJ is required to

provide specific and legitimate reasons supported by substantial evidence in the record. 

Lester, 81 F.3d at 830. Here, the ALJ did not give controlling weight to any provider’s

opinion or entirely reject any provider’s opinion. But, to the extent that the ALJ accepted

Dr. Garland’s opinion over that of another provider, she stated that the evidence

supported Dr. Garland’s opinions that Martin “has the ability to meet the basic mental

demands of competitive, remunerative, unskilled work on a sustained basis, particularly

in settings of low social contact” and is “able to understand, carry out, and remember

simple instructions, to make judgments commensurate with the functions of unskilled

work (i.e. simple work-related decisions), to respond appropriately to supervision,

coworkers, and work situations, and to deal with changes in a routine work setting.” The

ALJ further specifically found that the evidence supported Dr. Garland’s opinion that

Martin has “moderate limitations in social functioning and concentration, persistence, and

pace, but there is no evidence that the claimant has moderate limitations in activities of

daily living.”

The ALJ stated that she gave little weight to the opinions of Dr. Reddy, NP

Yurgel, and Dr. Smart because the assessments were extreme considering the overall

record and because NP Yurgel’s evaluation was “not only inconsistent with her treating

records but the overall evidence, including the fact that the claimant’s symptoms are

markedly improved when he complies with treatment.” Thus, the ALJ provided specific

and legitimate reasons supported by substantial evidence in the record and did not err in

weighing medical source opinion evidence.

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B. Subjective Symptom Testimony

1. Legal Standard

In evaluating the credibility of a claimant’s testimony regarding subjective pain or

other symptoms, the ALJ is required to engage in a two-step analysis: (1) determine

whether the claimant presented objective medical evidence of an impairment that could

reasonably be expected to produce some degree of the pain or other symptoms alleged;

and, if so with no evidence of malingering, (2) reject the claimant’s testimony about the

severity of the symptoms only by giving specific, clear, and convincing reasons for the

rejection. See Vasquez v. Astrue, 572 F.3d 586, 591 (9th Cir. 2009). To support a lack of

credibility finding, the ALJ is required to point to specific facts in the record that

demonstrate that Martin’s symptoms are less severe than he claims. Id. at 592. “Factors

that an ALJ may consider in weighing a claimant’s credibility include reputation for

truthfulness, inconsistencies in testimony or between testimony and conduct, daily

activities, and unexplained, or inadequately explained, failure to seek treatment or follow

a prescribed course of treatment.” Orn v. Astrue, 495 F.3d 625, 636 (9th Cir. 2007)

(internal quotation marks and citations omitted); see also Warre ex rel. E.T. IV v.

Barnhart, 439 F.3d 1001, 1006 (9th Cir. 2006) (“Impairments that can be controlled

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

SSI benefits.”). 

To be found credible regarding subjective pain or fatigue, a claimant is not

required to: (1) produce objective medical evidence of the pain or fatigue itself, or the

severity thereof; (2) produce objective medical evidence of the causal relationship

between the medically determinable impairment and the symptom; or (3) show that his

impairment could reasonably be expected to cause the severity of the alleged symptom,

only that it could reasonably have caused some degree of the symptom. Smolen v.

Chater, 80 F.3d 1273, 1282 (9th Cir. 1996). 

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2. The ALJ Did Not Err by Finding Martin’s Subjective Symptom

Testimony Not Fully Credible.

Martin contends that the ALJ erred by failing to set forth specific, clear, and

convincing reasons to reject his testimony about the severity of his subjective symptoms. 

However, the administrative hearing decision states:

After careful consideration of the evidence, the undersigned finds that the

claimant’s medically determinable impairment could reasonably be

expected to cause the alleged symptoms; however, the claimant’s

statements concerning the intensity, persistence and limiting effects of these

symptoms are not credited to the extent they are inconsistent with the above

residual functional capacity assessment.

The overall evidence does not support the severity of his symptoms and

work-related limitations. First, the claimant has neither consistently sought

treatment for his impairments nor complied with his plan of care. . . .

In response to his record of noncompliance, the claimant testified that he

relied on his mother to remind him about his medication and that he had

been waiting to receive a new appointment date. This merely indicates that

he abdicates responsibility for following through with his treatment. 

Moreover, his symptoms are evidently not as severe as alleged because he

has had periods of no treatment from January 2000 to July 2002, November

2003 to June 2005, and January 2006 to October 2007.

Second, when the claimant did receive treatment, the record shows that his

symptoms improved. . . .

Third, the claimant’s ability to work is further illustrated by his own

testimony. At the hearing, he did not indicate any specific work-related

limitations. Although he alleged the inability to associate with other people

and issues of anger management, he is able to go shopping and rely on his

mother for help. The record shows that, when compliant, he has been able

to control his symptoms with treatment, and he does not suffer from

significant adverse side effects from the medication.

The reasons stated for finding Martin’s testimony about the severity of his symptoms are

sufficiently specific, clear, and convincing.

C. Third-Party Reports

Martin contends the ALJ erred by rejecting lay witness testimony without

providing specific reasons relevant to each witness and supported by substantial evidence. 

The ALJ’s hearing decision does not explicitly mention the third-party function report

completed by Martin’s mother dated May 27, 2008, and did not implicitly reject it. The

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report is not only consistent with, but almost duplicates, Martin’s May 27, 2008 self

report. In fact, the record shows that, at times, Martin’s mother completed documents for

Martin and participated in his interviews with examining sources. Her “third-party”

report does not add any new information to be given or denied weight.

IT IS THEREFORE ORDERED affirming the final decision of the Commissioner

of Social Security denying Billy W. Martin disability benefits.

IT IS FURTHER ORDERED that the Clerk enter judgment in favor of Defendant

against Plaintiff and that Plaintiff take nothing. The Clerk shall terminate this action.

DATED this 17th day of February, 2012.

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