Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_18-cv-01720/USCOURTS-caed-1_18-cv-01720-3/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:402 Social Security Benefits

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UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

Thomas Joseph White asserts he is entitled to supplemental security income under Title XVI of 

the Social Security Act. Plaintiff seeks judicial review of the decision to deny his application for 

benefits, arguing the administrative law judge erred by not developing the record. In addition, Plaintiff 

contends the Appeals Council erred by not evaluating new evidence submitted with his request for 

review. For the following reasons, the administrative decision is AFFIRMED. 

BACKGROUND

In June 2014, Plaintiff filed an application for benefits, asserting he had been unable to work 

since May 1, 2011, due to depression, anxiety, back problems, and “[l]eft leg numbness and pain.” 

(Doc. 12-9 at 2; Doc. 12-10 at 6) The Social Security Administration denied the applications at the 

initial level on November 5, 2014, and upon reconsideration on December 1, 2015. (Doc. 12-3 at 33; 

see also Doc. 12-8 at 2-5, 10-15) Plaintiff requested a hearing and testified before an ALJ, without 

representation of counsel, on October 24, 2017. (See Doc. 12-6 at 43-46) The ALJ determined 

THOMAS JOSEPH WHITE,

 Plaintiff,

v.

COMMISSIONER OF SOCIAL SECURITY,

Defendant.

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Case No.: 1:18-cv-1720 - JLT

ORDER DIRECTING ENTRY OF JUDGMENT IN 

FAVOR OF DEFENDANT, THE COMMISSIONER 

OF SOCIAL SECURITY AND AGAINST 

PLAINTIFF THOMAS JOSEPH WHITE 

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Plaintiff was not disabled under the Social Security Act, and issued an order denying benefits on 

January 31, 2018. (Doc. 12-3 at 33-46) 

On February 14, 2018, Plaintiff filed a request for review of the ALJ’s decision with the 

Appeals Council. (Doc. 12-8 at 61) He requested the Appeals Council review the decision because he 

“suffer[ed] from schizophrenia, bipolar disorder, and lumbar spine pain.” (Id.) Plaintiff obtained 

representation, after which the Appeals Council granted a request for additional time before it acted on 

Plaintiff’s case. (See Doc. 12-3 at 9) The Appeals Council informed Plaintiff: 

You may send us a statement about the facts and the law in this case or additional 

evidence. We consider additional evidence that you show is new material and relates 

to the period on or before the date of the hearing decision. You must also show there 

is a reasonable probability that the additional evidence would change the outcome of 

the decision. You must show good cause for why you missed informing us about or 

submitting it earlier.

(Id.) 

Plaintiff submitted over 180 pages of evidence to the Appeals Council. (Doc. 12-3 at 3) The 

Appeals Council determined 68 pages of the records submitted did not relate to the period in issue, 

because they post-dated the ALJ’s decision. (Id.) The Appeals Council found the remaining additional 

evidence did “not show a reasonable probability that it would change the outcome of the decision.” 

(Id.) The Appeals Council denied Plaintiff’s request for review on October 25, 2018. (Id. at 2-5) 

Therefore, the ALJ’s determination became the final decision of the Commissioner of Social Security. 

STANDARD OF REVIEW

District courts have a limited scope of judicial review for disability claims after a decision by 

the Commissioner to deny benefits under the Social Security Act. When reviewing findings of fact, 

such as whether a claimant was disabled, the Court must determine whether the Commissioner’s 

decision is supported by substantial evidence or is based on legal error. 42 U.S.C. § 405(g). The ALJ’s 

determination that a claimant is not disabled must be upheld by the Court if the proper legal standards 

were applied and the findings are supported by substantial evidence. See Sanchez v. Sec’y of Health & 

Human Serv., 812 F.2d 509, 510 (9th Cir. 1987).

Substantial evidence is “more than a mere scintilla. It means such relevant evidence as a 

reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 

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389, 401 (1971) (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197 (1938)). The record as a whole 

must be considered, because “[t]he court must consider both evidence that supports and evidence that

detracts from the ALJ’s conclusion.” Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). 

DISABILITY BENEFITS

To qualify for benefits under the Social Security Act, Plaintiff must establish he is unable to 

engage in substantial gainful activity due to a medically determinable physical or mental impairment 

that 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). An individual shall be considered to have 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, regardless of whether such work exists in the immediate area in 

which he lives, or whether a specific job vacancy exists for him, or whether he would be 

hired if he applied for work. 

42 U.S.C. § 1382c(a)(3)(B). The burden of proof is on a claimant to establish disability. Terry v. 

Sullivan, 903 F.2d 1273, 1275 (9th Cir. 1990). If a claimant establishes a prima facie case of disability, 

the burden shifts to the Commissioner to prove the claimant is able to engage in other substantial 

gainful employment. Maounis v. Heckler, 738 F.2d 1032, 1034 (9th Cir. 1984).

ADMINISTRATIVE DETERMINATION

To achieve uniform decisions, the Commissioner established a sequential five-step process for 

evaluating a claimant’s alleged disability. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The process 

requires the ALJ to determine whether Plaintiff (1) is engaged substantial gainful activity, (2) had 

medically determinable severe impairments (3) that met or equaled one of the listed impairments set 

forth in 20 C.F.R. § 404, Subpart P, Appendix 1; and whether Plaintiff (4) had the residual functional 

capacity to perform to past relevant work or (5) the ability to perform other work existing in significant 

numbers at the state and national level. Id. The ALJ must consider testimonial and objective medical 

evidence. 20 C.F.R. §§ 404.1527, 416.927. 

A. Medical Evidence before the ALJ

On January 21, 2012, Plaintiff’s mother took him to the emergency department of Kaweah 

Delta Hospital, reporting “mood swings and threats.” (Doc. 12-13 at 6) Dr. Serena Puga noted 

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Plaintiff described a “longstanding history of anger management issues” and “had been spiraling 

downward in the context of recent homelessness and no where to turn.” (Id.) Dr. Puga noted that 

Plaintiff was “trying to get Mental Health Services from Kings County Clinic but he present[ed] so 

angry and verbally abusive that he ... alienated them” and was not getting the help Plaintiff believed he 

needed. (Id.) Dr. Puga observed that Plaintiff’s speech was “peppered constantly with angry expletives

and his tone [was] hostile and pressured,” and he made “provocative threats towards other patients in 

the hospital and veiled threats to murder others, such as his postman.” (Id.) Plaintiff admitted a history 

of methamphetamine use, but said it was “resolved,” and use of medical marijuana “to calm his anger.” 

(Id. at 7) Plaintiff was admitted for mental health treatment, and Dr. Puga opined his admission should 

be minimized “to avoid paradoxical reinforcement of maladaptive behavior.” (Id. at 8) Upon 

admission, the treatment goals included reduction of substance abuse side effects; lessening the risk of 

violence towards others, anxiety, and impulsivity; and improvement of mood. (Id. at 10) The 

following day, Plaintiff was observed to be alert, oriented, cooperative, calm and “not in any distress.”

(Id. at 12, 14) Plaintiff was discharged on January 24, 2012, with instructions to follow up with Kings 

View Mental Health. (Id. at 15)

In May 2013, Plaintiff visited a physician at Adventist Health Central Valley Network for 

medication management for his low back pain. (Doc. 12-12 at 16) Plaintiff reported his pain level at 

the time was a “0” on a scale of 10. (Id.) The treatment notes indicated Plaintiff’s condition was stable. 

(Id.)

In June 2013, Plaintiff described his low back pain as a “5.” (Doc. 12-12 at 15) Plaintiff’s 

musculoskeletal and neurological examinations were within normal limits, and he was directed to 

return on an as-needed basis. (Id.) 

Plaintiff returned to Adventist Health in September 2013. (Doc. 12-12 at 14) The treatment 

notes indicated Plaintiff had a history “of bipolar and anxiety disorder” schizophrenia, and chronic low 

back pain. (Id. at 13-14) Plaintiff requested a prescription of Vicodin. (Id. at 14) Dr. Reddy observed 

that Plaintiff was sweating and anxious. (Id.) Plaintiff’s range of motion was within normal limits and 

he had “intact sensation.” (Id.) Plaintiff received the requested Vicodin and was directed to return in 

five days. (Id.) At an appointment two days later, Plaintiff had a full range of motion in his neck and a 

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negative straight leg raise test. (Id. at 13) Dr. John Zweifler noted Plaintiff would be tapered off 

Norco, but would continue with Risperdal. (Id.)

In April 2014, Plaintiff visited Dr. Zweifler, who noted Plaintiff had not been evaluated for twoto-three months and was there for bipolar disorder management. (Doc. 12-12 at 10) Plaintiff told Dr. 

Zweifler that he was taking Risperdal daily and that it helped, but he was not seeing a psychiatrist. (Id.) 

Dr. Zweifler noted he directed Plaintiff to stop Vicodin in 2013, and Plaintiff said his pain was “eased 

with exercises from [physical therapy].” (Id.) Plaintiff reported he also heard voices. (Id.) Dr. 

Zweifler found Plaintiff had normal range of motion, strength, gait, and deep tendon reflexes. (Id. at

11) He indicated Plaintiff continued to have schizoaffective disorder, chronic back pain, and a problem 

relating to social and personal history, but was “[p]rogressing as expected.” (Id. at 11-12) 

In July 2014, Dr. Zweifler noted Plaintiff returned for medication management and reported 

occasional cramping in his hands and back pain. (Doc. 12-12 at 6) Plaintiff told Dr. Zweifler that his 

medication was “definitely helping” with his anger and he felt “more relaxed and calm.” (Id.) Plaintiff 

was “[r]equesting opioids,” which Dr. Zweifler advised Plaintiff are “addictive.” (Id. at 8) Dr. Zweifler 

refilled the prescription for risperdol and indicated Plaintiff could “[t]ry tramadol.” (Id.)

Dr. Lance Portnoff performed a comprehensive psychiatric evaluation on September 18, 2014. 

(Doc. 12-12 at 23) Plaintiff reported that he suffered from depression, anxiety, back problems, and left 

leg numbness and pain. (Id.) He told Dr. Portfnoff that he heard “audible voices of people talking to 

him, maybe lasting 3-5 minutes, 5-7 times a week, calling his name or having conversations among 

themselves.” (Id.) Plaintiff also stated he had mood swings, was quickly angered, and had “uncured 

panic attacks 5-8 times a week.” (Id.) Dr. Portnoff noted he could not “get a clear picture of discrete 

manic episodes or how long they last or how frequently they [occurred].” (Id.) Plaintiff attributed his 

depression to being homeless and unable to see his son as much as he wanted. (Id. at 24) Plaintiff said 

he did “not need help with bathing, dressing, and grooming, and [had] adequate motivation for them.” 

(Id.) He also stated he could travel alone, prepare food for himself, and manage money. (Id.) Plaintiff 

acknowledged a history of methamphetamine abuse and said he had been “clean for three years.” (Id.) 

He told Dr. Portnoff that he “use[d] medical cannabis for pain and stress.” (Id.)

Dr. Portnoff observed that Plaintiff appeared “casually-dressed, adequately groomed” and 

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maintained good eye contact. (Doc. 12-12 at 24) According to Dr. Portnoff, Plaintiff’s process of 

thought was “coherent but mildly rambling and occasionally tangential,” and the content of thought 

was “appropriate to the situation,” though Plaintiff seemed preoccupied. (Id. at 25) However, he 

believed Plaintiff “demonstrate[d] adequate concentration, persistence, and pace” during the exam. 

(Id.) Plaintiff was able to recall three words immediately and two out of three words after a delay of 

several minutes. (Id. at 25) Dr. Portnoff diagnosed Plaintiff with “Schizoaffective Disorder, Bipolar 

Type,” based upon his “available history and presentation.” (Id. at 26) Dr. Portnoff concluded Plaintiff 

was “able to perform simple and repetitive tasks,” but had “marked limitations in his ability to perform 

detailed and complex tasks due to deficit in mental focus and frequent hallucinations.” (Id.) He also 

opined Plaintiff had “has moderate limitations in his ability to work on a consistent basis without 

special or additional instruction due to psychiatric problems.” (Id.) Further, Dr. Portnoff believed 

Plaintiff had “marked limitations” with his ability to interact with the public and coworkers, and “to 

complete a normal workday or workweek without interruptions from a psychiatric condition due to 

schizoaffective symptoms.” (Id.)

Dr. Dale Van Kirk completed an orthopedic consultation on October 15, 2014. (Doc. 12-12 at 

30) Plaintiff reported pain in his neck and low back, which radiated down his left leg. (Id.) Plaintiff 

said his “neck pain increase[d] if he [had] to repetitively flex and extend at the neck, reach overhead, 

push, pull, or [make] rotary motions of the upper extremities. (Id. at 31) Also, his back pain increased 

if he had “to lift heavy objects, test, turn, climb, run, jump, squat, go up and down ladders, go up and 

down stars frequently, crouch, crawl or even attempt to do these activities.” (Id.) Plaintiff reported his 

treatment included chiropractic care and physical therapy, “both of which ... helped somewhat.” (Id.) 

Dr. Van Kirk observed that Plaintiff sat “comfortably in the examination chair” and “without 

difficulty” was able to get up and out of the chair, walk around the room, and get on and off the table. 

(Id. at 32) Dr. Van Kirk noted Plaintiff could “get up on his toes and heels” and “squat down and take 

a few steps... without difficulty.” (Id.) Plaintiff exhibited “slight pain” in the cervical spine, and Dr. 

Van Kirk noted Plaintiff “[s]lowly but surely ... [went] through a full range of motion of the cervical 

spine.” (Id.) Plaintiff’s range of motion of the lumbar spine was reduced from 90 degrees to 70 with 

flexion, from 25 degrees to 20 with extension, and from 25 degrees with lateral flexion to 20 degrees. 

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(Id.) He was able to rotate 30 degrees, while the normal was 25 degrees. (Id.) Dr. Van Kirk found 

Plaintiff had a “full range of motion without pain or difficulty” in his hip joints, knee joints, ankles, 

shoulders, elbows, [and] wrists.” (Id. at 33) He also determined Plaintiff’s grip strength was 5/5 

bilateral and his motor strength was 5/5. (Id.) He found Plaintiff’s deep tendon reflexes were “present 

only in the biceps reflexes in the upper extremities” and his patellar reflexes were 1+/4. (Id.) Dr. Van 

Kirk diagnosed Plaintiff with “[c]hronic cervical and lumbosacral musculoligamentous strain/sprain, 

possibly associated with degenerative disk disease.” (Id.) He concluded Plaintiff could “sit without 

restriction,” “stand and/or walk accumulatively six hours out of an eight hour day,” and “lift and carry 

frequently 25 pounds and occasionally 50 pounds.” (Id. at 34) Further, Dr. Van Kirk opined Plaintiff 

was “limited to frequent postural activities” and “should not be required to work an extremely cold 

and/or damp environment.” (Id.)

Dr. Dara Goosby completed a residual functional capacity assessment on October 24, 2014. 

(Doc. 12-7 at 8) Dr. Goosby noted Plaintiff’s impairments included “Schizophrenia and Other 

Psychotic Disorders” and “Substance Addition Disorder[].” (Id. at 7) Dr. Goosby observed that 

Plaintiff had been in the hospital “years ago,” and the recent medical record was “minimal.” (Id.) She 

found the record indicated “improvement of [symptoms]”—which appeared “in the moderate range of 

severity” —and that Plaintiff was independent with activities of daily living. (Id. at 7, 9) According to 

Dr. Goosby, Plaintiff had mild restriction of activities of daily living; moderate difficulties maintain 

social functioning; and moderate difficulties in maintaining concentration, persistence, or pace. (Id. at 

7) Dr. Goosby concluded Plaintiff was “capable of simple work in a setting with no public and limited 

peer contact.” (Id.)

Dr. A. Nasrabadi completed a physical residual functional capacity assessment on November 4, 

2014. (Doc. 12-7 at 9-10) According to Dr. Nasrabadi, “objective clinical findings were minimal” 

from the consultative examination. (Id.) Dr. Nasrabadi opined Plaintiff could lift and carry 25 pounds 

frequently and 50 pounds occasionally, stand and/or walk for about six hours in an eight-hour day, and 

sit about six hours in an eight-hour day. (Id. at 9-10) Dr. Nasrabadi found Plaintiff was “unlimited” 

with the ability to kneel, crouch, and crawl; and Plaintiff could frequently climb, balance, and stoop. 

(Id. at 10)

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In December 2014, Plaintiff visited United Health Centers of the San Joaquin Valley, seeking to 

“establish medical care.” (Doc. 12-12 at 38) Stacia Brandenburg, PA-C, noted Plaintiff requested 

medication refills, and said he had a history “of psychosis treated successfully with risperidone and 

benztropine.” (Id.) Plaintiff told Ms. Brandenburg that he also had back pain for which he “use[d] 

tramadol occasionally.” (Id.) Plaintiff requested a referral for physical therapy, which he said, “was 

helpful in the past.” (Id.) Ms. Brandenburg observed that Plaintiff’s musculoskeletal and psychiatric 

exams were normal, and he had an “[a]ppropriate mood and affect.” (Id. at 40) Ms. Brandenburg 

prescribed risperidone, tramadol, benztropine, and cyclobenzaprine to Plaintiff. (Id.) 

In March 2015, Plaintiff told Ms. Brandenburg that he was “still doing well on meds” and did 

not have any “new problems or questions.” (Doc. 12-12 at 44) Plaintiff denied feeling down, 

depressed, or hopeless; and Ms. Brandenburg determined Plaintiff’s psychiatric exam results were 

“normal.” (Id. at 45-46) She directed Plaintiff to continue the medications as prescribed and to return 

as needed or within three months. (Id. at 46)

Dr. Roger Izzi performed a psychiatric evaluation on November 2, 2015. (Doc. 12-12 at 53)

Plaintiff said he could not get along with others and suffered from depression. (Id.) He reported he 

continued to be homeless and would “stay with different family or friends.” (Id.) Plaintiff told Dr. Izzi 

that he had “occasional unprovoked crying spells” as well as difficulty sleeping because his mind was 

“always racing.” (Id.) Plaintiff described “auditory-type hallucinations,” including voices that called 

his name or yelled for help and said he saw shots. (Id. at 54) Dr. Izzi noted that “[a]uditory and visual 

hallucinations were not observed.” (Id. at 55) Dr. Izzi opined Plaintiff was “[e]ssentially... fully 

oriented” because he “could identify the year, month and date.” (Id. at 54) Plaintiff “was able to 

immediately recall three words without any obvious difficulty” and recalled one word after a delay. 

(Id. at 55) Dr. Izzi diagnosed Plaintiff with “Unspecified Depressive Disorder,” and noted “[h]is mood 

disorder will fluctuate as his subjective perception of pain fluctuates.” (Id.) Dr. Izzi opined:

The present evaluation suggests that the claimant does appear capable of performing a 

simple and repetitive type task on a consistent basis over an eight-hour period. His 

ability to get along with peers or be supervised in [a] work-like setting would be 

moderately limited by his mood disorder. The claimant’s mood disorder will fluctuate 

as his subjective perception of pain fluctuates. Any significant fluctuation of mood 

would limit the claimant’s ability to perform a complex task on a consistent basis over 

an eight-hour period. On a purely psychological basis, the claimant appears capable of 

responding to usual work session situations regarding attendance and safety issues. On 

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a purely psychological basis, the claimant appears capable of dealing with changes in a 

routine work setting.

(Id. at 55-56) 

On November 3, 2015, Plaintiff had an internal medicine consultation with Dr. Emmanuel 

Fabella. (Doc. 12-12 at 59) Plaintiff complained of pain in his left shoulder and “left lateral thigh... 

with prolonged walking of more than one quarter of a mile.” (Id.) He also told Dr. Fabella that he was 

taking “ benztropine for medication-induced movement disorder involving some clenching of the 

hand.” (Id.) Dr. Fabella found Plaintiff was “able to walk on his toes well” and had “a normal gait and 

balance.” (Id. at 61) He determined Plaintiff’s range of motion in his back and shoulders was “grossly 

within normal limits.” (Id. at 62-63) Plaintiff’s strength was “5/5... without focal motor deficits” and 

his deep tendon reflexes were “2/2.” (Id. at 63) Dr. Fabella opined Plaintiff had “[l]eft scapular pain of 

unclear etiology... which may be secondary to chronic strain and which [was] aggravated by lifting 

moderate to heavy weights.” (Id. at 64) He also indicated “mild iliotibial band syndrome” should be 

considered for Plaintiff’s mild lateral thigh pain. (Id.) Dr. Fabella concluded Plaintiff could “lift and 

carry 20 pounds occasionally and 10 pounds frequently, limited due to left scapular pain;” sit without 

restriction “walk and stand six hours out of an eight-hour day secondary to left thigh pain.” (Id.) He 

determined Plaintiff could occasionally climb, balance, kneel, crawl, walk on uneven terrain, climb 

ladders, and work at heights. (Id.) 

On November 17, 2015, Frances Gilbuena, PA, wrote a letter “to state that Mr. White [was] 

under the care of” Tulare Community Health Clinic. (Doc. 12-13 at 2) Mr. Gilbuena noted Plaintiff 

had been diagnosed with schizophrenia and low back pain, and his medications included risperidone, 

benztropine, tramadol, and ibuprofen. (Id. at 2-3)

Dr. Linda Kiger “reviewed the evidence in [the] file in November 2015, and affirmed the 

assessment of Dr. Nasrabadi, concluding Plaintiff could perform medium work with postural 

limitations. (Doc. 17-7 at 27-28)

Dr. Harvey Bilik reviewed the record related to Plaintiffs’ request for reconsideration on 

November 29, 2015, including available treatment notes and the consultative examination findings. 

(Doc. 12-7 at 24-26) Dr. Bilik also noted that a “prior folder” included a consultative examination in 

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August 2012 with Dr. Schmidt, who found “no sig[nificant] impairment from mental disorders.” (Id.

at 26) Dr. Bilik opined the record “suggest[ed] mild-moderate range of severity for any ongoing 

functional limitations resulting from mental disorders alone.” (Id. at 25) He determined Plaintiff had 

mild restrictions of activities of daily living; moderate difficulties in maintaining social functioning; 

and moderate difficulties in maintaining concentration, persistence, or pace. (Id.) Dr. Bilik gave 

“great weight” to the findings of Dr. Izzi and concluded Plaintiff could “carry out simple instructions 

over the course of a normal workweek.” (Id. at 26, 30)

B. Administrative Hearing

Plaintiff testified before an ALJ at a hearing on October 24, 2017. (Doc. 12-6 at 43) The ALJ 

informed Plaintiff of his rights to chose to postpone the hearing to appoint a representative or proceed 

at the hearing without a representative. (Id. at 45-46) Plaintiff elected to proceed without counsel and 

executed a “Waiver of Representation.” (Id. at 48) 

The ALJ confirmed that Plaintiff had submitted medical records and had received a copy on 

CD. (Doc. 12-6 at 58) Plaintiff reported he “had an opportunity” to review the record but “didn’t 

login properly” so he was unable to do so. (Id. at 48-49) The ALJ inquired whether Plaintiff was 

“aware of any additional information” that he needed to obtain, and Plaintiff stated: “Well pretty 

much, as long as you guys have all the information that I sent you, you should have just about 

everything ... except for ... a new medication, that they just put me on within the past couple months.” 

(Id. at 49) Plaintiff reported he was put on Neurontin and “sent that paper in,” but it was returned to 

Plaintiff. (Id. at 49-50) 

C. The ALJ’s Findings

Pursuant to the five-step process, the ALJ determined Plaintiff not engaged in substantial 

gainful activity since the application date of May 7, 2014. (Doc. 12-3 at 35) Second, the ALJ found 

Plaintiff’s severe impairments included “musculoligamentous strain/sprain of the lumbar spine, left 

scapular pain of unknown etiology, left thigh pain of unknown etiology, and unspecified depressive 

disorder, formerly diagnosed as schizoaffective disorder, bipolar type.” (Id.) At step three, the ALJ 

determined Plaintiff’s impairment did not meet or medically equal a Listing. (Id. at 35-37) Next, the 

ALJ found:

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[T]he claimant has the residual functional capacity to perform light work as defined in 

20 CFR 416.967(b), except the claimant can frequently climb ramps, stairs, ladders, 

ropes and scaffolds, and frequently balance, stoop, kneel, crouch, and crawl. The 

claimant must avoid concentrated exposure to extreme cold, wetness, or humidity, and 

the claimant’s work is limited to simple, routine[] instructions. The claimant is also 

limited to no overhead reaching with his dominant, left upper extremity. 

(Id. at 37) At step four, the ALJ noted Plaintiff had “no past relevant work at the level of substantially 

gainful activity.” (Id. at 44) At step five, with the above residual functional capacity, the ALJ 

determined there were “jobs that exist in significant numbers in the national economy that the claimant 

can perform.” (Id. at 45) Thus, the ALJ concluded Plaintiff had not been disabled as defined by the 

Social Security Act since May 7, 2014. (Id. at 46)

D. Evidence Presented to the Appeals Council 

Seeking review of the ALJ’s decision, Plaintiff submitted over 180 pages of evidence to the 

Appeals Council while his request for review was pending. The Appeals Council addressed the 

documents as follows:

You submitted medical records from Adventist Health dating from March 17 2011 to

December 5, 2016 (Pages - 39); from Ampla Health Lindhurst Medical dating from 

April 13, 2017 to April 25, 2017 (Pages - 11); from Altura Centers for Health dating 

from June 8, 2015 to September 29, 2017 (Pages - 52); and from Kaweah Delta 

Hospital dating from January 12, 2012 to January 24, 2012 (Pages - 25). We find this 

evidence does not show a reasonable probability that it would change the outcome of 

the decision. We did not exhibit this evidence1.

You also submitted Medical records from Kaweah Delta Health Care dating from 

February 18, 2018 to June 21, 2018 (Pages - 60); and medical records from Altura 

Centers for Health dated July 9, 2018 (Pages - 6). The Administrative Law Judge 

decided your case through January 31, 2018. This additional evidence does not relate 

to the period at issue. Therefore it does not affect the decision about whether you were 

disabled beginning on or before January 31, 2018.

(Doc. 12-3 at 3)

DISCUSSION AND ANALYSIS

Appealing the decision to deny his application for benefits, Plaintiff argues that “[t]he ALJ erred 

by failing to develop the record.” (Doc. 17 at 1, 10) In addition, Plaintiff contends the Appeals 

Council “erred by failing to weigh the new evidence submitted.” (Id.) The Commissioner asserts that 

 

1 The Court presumes this means the Council did not consider this evidence.

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the ALJ did not have a duty to further develop the record, and the additional evidence “did not affect 

the ALJ’s decision.” (Doc. 19 at 9-11, 12) 

A. Duty to Develop the Record

A claimant bears the burden to provide medical evidence that supports the existence of a 

medically determinable impairment. Bowen v. Yuckert, 482 U.S. 137, 146 (1987); see also Tidwell v. 

Apfel, 161 F.3d 599, 601 (9th Cir. 1998) (“At all times, the burden is on the claimant to establish [his]

entitlement to disability insurance benefits”). As the Supreme Court explained, it is “not unreasonable 

to require the claimant, who is in a better position to provide information about his own medical 

condition, to do so.” Bowen, 482 U.S. at 146 n.5. 

On the other hand, the law is well-established in the Ninth Circuit that the ALJ has a duty “to 

fully and fairly develop the record and to assure the claimant’s interests are considered.” Brown v. 

Heckler, 713 F.2d 441, 443 (9th Cir. 1983). The Ninth Circuit explained: 

The ALJ in a social security case has an independent duty to fully and fairly develop the 

record and to assure that the claimant’s interests are considered. This duty extends to the 

represented as well as to the unrepresented claimant. When the claimant is unrepresented, 

however, the ALJ must be especially diligent in exploring for all the relevant facts ... The 

ALJ’s duty to develop the record fully is also heightened where the claimant may be 

mentally ill and thus unable to protect her own interests.

Tonapetyan v. Halter, 242 F.3d 1144, 1150 (9th Cir. 2001) (citations and quotation marks omitted). 

Importantly, the law imposes a duty on the ALJ to develop the record only in limited 

circumstances. 20 C.F.R § 416.912(d)-(f) (recognizing a duty on the agency to develop medical 

history, contact medical sources, and arrange a consultative examination if the evidence received is 

inadequate for a disability determination). Accordingly, the duty to develop the record is “triggered 

only when there is ambiguous evidence or when the record is inadequate to allow for proper evaluation 

of the evidence.” Mayes v. Massanari, 276 F.3d 453, 459-60 (9th Cir. 2201); see also Tonapetyan, 242 

F.3d at 1150 (“[a]mbiguous evidence, or the ALJ’s own finding that the record is inadequate to allow 

for proper evaluation of the evidence, triggers the ALJ’s duty to conduct an appropriate inquiry”).

Plaintiff contends “[t]he ALJ erred by failing to develop the record and adjudicating [his] claim 

based on medical treatment notes that covered only 8 months of a 3-year and 7-month relevant 

period.” (Doc. 17 at 10) Plaintiff argues the ALJ erred by adjudicating his claim “based only upon 27 

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pages of medical treatment notes from the relevant period, and the opinions of one-time consultative 

examiners.” (Id.)

Despite Plaintiff’s statement that only eight months of relevant evidence were encompassed in 

the treatment records, the ALJ received—and reviewed—records relating to Plaintiff’s medical history

dated from January 2012 through November 2015. (See Doc. 12-3 at 38-44; see also Docs. 12-8, 12-

9) In addition, the ALJ specifically asked Plaintiff whether he was “aware of any additional 

information” that needed to be submitted for consideration at the hearing, and Plaintiff indicated that 

he “should have just about everything,” except for information regarding a new medication that he was 

put on in the past couple months. (Doc. 12-6 at 49) The ALJ’s reliance upon Plaintiff’s statement that 

he had submitted all relevant records was not improper.

Further, the record before the ALJ included the opinions of four physicians who examined 

Plaintiff and made objective findings regarding his physical and mental limitations following his 

application for benefits. (See Doc. 12-12 at 23-27, 30-35, 53-56, 59-65) Notably, the reports of 

consultative examinations are one method that may be used by the Agency to supplement an 

inadequate record. See 20 C.F.R. § 404.1519a(b), 416.919a(b) (“We may purchase a consultative 

examination to try to resolve an inconsistency in the evidence, or when the evidence as a whole is 

insufficient to allow us to make a determination or decision on your claim”). The findings of four 

consultative physicians were included in the record before the ALJ, who clearly considered the 

objective findings of Drs. Portnoff, Van Kirk, Izzi and Fabella in reaching his decision regarding 

Plaintiff’s residual functional capacity. (See Doc. 12-3 at 40-44) Plaintiff fails to demonstrate this 

evidence was ambiguous or insufficient for the ALJ to evaluate the abilities and limitations caused by 

his impairments.

Because the record before the ALJ was not inadequate for a decision to be made, the ALJ’s duty 

to further develop the record was not triggered. See Thomas v. Barnhart, 278 F.3d 947, 978 (9th Cir. 

2002) (duty not triggered when the medical report was adequate to make a disability determination); 

Mayes, 267 F.3d at 459-60. 

B. Review by the Appeals Council

The Regulations govern when Appeals Council must review additional evidence submitted 

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after the ALJ issues a decision. See 20 C.F.R. §§ 404.970, 416.1570 (effective January 17, 2017). The 

Regulations indicate that the Appeals Council “will review a case if ... the Appeals Council receives 

additional evidence that is new, material, and relates to the period on or before the date of the hearing 

decision, and there is a reasonable probability that the additional evidence would change the outcome 

of the decision.” 20 C.F.R. §§ 404.970(a)(5), 416.1470(a)(5). Evidence is new if it is not duplicative 

or cumulative. Meyer v. Astrue, 662 F.3d 700, 704-05 (4th Cir. 2011). In addition, evidence can be 

deemed new if it was not available when the ALJ made issued the decision. Threet v. Barnhart, 353 

F.3d 1185, 1191 (10th Cir. 2003). 

1. Consideration of evidence

The Ninth Circuit has distinguished between evidence the Appeals Council “considered” and 

evidence the Appeals Council merely “looked at” to determine whether the additional evidence was 

incorporated into the record. The Court explained that evidence the Appeals Council considered

becomes part of the administrative record as “evidence upon which the findings and decision 

complained of are based.” See Brewes v. Comm'r of Soc. Sec. Admin., 682 F.3d 1157, 1162 (9th Cir. 

2012). In contrast, where “the Appeals Council only looked at the evidence... the new evidence did not 

become part of the record.” Amor v. Berryhill, 743 F. App’x 145, 146 (9th Cir. 2018) (emphasis 

added); see also De Orozco v. Comm’r of Soc. Sec, 2019 WL 2641490 at*11 (E.D. Cal. June 26, 2019) 

(observing that the Ninth Circuit has distinguished between instances where the Appeals Council 

formally considered evidence and made it part of the administrative record with instances where the 

Appeals Council only looked at the evidence). Importantly, where the Appeals Council only looks at 

the evidence and it does not become part of the administrative record, the Court “may not consider it.” 

Amor, 743 F. App’x at 146; see also Lowry v. Barnhart, 329 F.3d 1019, 1024 (9th Cir. 2003). 

The Appeals Council indicated that it reviewed the new evidence from Plaintiff and 

determined it: (1) did “not show a reasonable probability that it would change the outcome of the 

decision” and (2) did “not relate to the period at issue.” (Doc. 12-3 at 3) Therefore, the Appeals 

Council indicated it “did not exhibit this evidence.” (Id.) Because the Appeals Council did not exhibit 

and consider the evidence but merely looked at it, the documents submitted were not incorporated to 

the administrative record subject to the Court’s review, unless Plaintiff meets his burden to 

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demonstrate the evidence should have been considered. See Amor, 743 F. App’x at 146; Lowry, 329 

F.3d at 1024. 

2. Plaintiff’s burden

When the Appeals Council fails to “consider” additional evidence that satisfies the 

requirements of Section 404.970(b) or 416.1570(b), a remand for further administrative proceedings is 

appropriate. Taylor v. Comm’r of Soc. Sec. Admin., 659 F.3d 1228, 1233 (9th Cir. 2011). A claimant 

has the burden to demonstrate the evidence should have been considered by the Appeals Council 

under the Regulations. See Hawks v. Berryhill, 2018 WL 6728037 at *4 (M.D.N.C. Dec. 21, 2018) 

(noting under the amended Regulations, “a claimant’s burden to have new evidence considered for the

first time at the Appeals Council level” includes “a requirement to show a reasonable probability of a 

different outcome”).

Plaintiff contends the Appeals Council should have considered the additional evidence 

submitted because it “supplemented the severely underdeveloped record before the ALJ.”2 (Doc. 17 at 

10) Plaintiff argues “the treatment records submitted ... show that his mental impairments persisted 

and worsened throughout the relevant period.” (Id. at 14) Plaintiff notes the records show he was

diagnosed with schizophrenia and referred for mental health care in June 2015, after which he had a 

consultation for services. (Id., citing AR 102, 109, 117 [Doc. 12-4 at 43, 50, 58]) Plaintiff reports that 

during the consultation, he “felt like a bomb that may explode; he endorsed hearing voices and was 

paranoid;” and was observed to be “unkempt, with intense eye contact, anxious and mistrustful attitude, 

constricted affect, incongruent smiles, rapid speech, tangential thought processes, paranoid and 

suspicious thought content, minimal insight, and impaired judgment.” (Id., citing AR 104 [Doc. 12-4 at 

45]) Plaintiff also observes: 

Subsequent psychotherapy treatment notes document a GAF of 41, and unimproved 

functional status in November and December 2015. Ar. 93-100. Consistent with 

Plaintiff’s subjective complaints and the opinions from Dr. Izzi and Dr. Portnoff, 

Plaintiff’s social difficulties were affirmed by treatment records in August 2016, 

documenting an altercation with his medical providers. Ar. 199. His medications were 

continued through 2016 Ar. 57-58, 197-98. In April 2017, he complained of down 

mood, apathy, anhedonia, decreased energy, decreased motivation, problems getting to 

 

2 Plaintiff does not dispute the Appeals Council’s finding that some of the evidence submitted failed to “relate to 

the period at issue,” as it post-dated the ALJ’s decision. (See id. at 6, n.1) Plaintiff’s argument focuses only on the 

evidence dated March 2011 through September 2017, which the Appeals Council did not exhibit. 

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and staying asleep, feeling tired, anxiety and nervousness, auditory hallucinations, and 

generalized paranoia. Ar. 51. Mental status examination revealed Plaintiff’s thought 

process was concrete and somewhat paranoid, and his mood and affect were anxious. 

Ar. 52. In September 2017, he displayed deficient fund of knowledge, forgetfulness, 

poor attention span, and disjointed concentration. Ar. 81.

(Doc. 17 at 14-15) The Commissioner argues that “the evidence submitted to the Appeals Council did 

not differ from diagnoses already in the record.” (Doc. 19 at 13) The Commissioner maintains, “There 

simply is no reason to believe that any of this information would make a difference to the ALJs 

findings.” (Id.)

Significantly, Plaintiff fails to identify objective findings in the additional records that 

undermine the ALJ’s findings regarding his mental abilities and limitations, or the conclusion that 

Plaintiff was capable of work that involved only “simple, routine[] instructions.” Indeed, Plaintiff has 

identified several subjective statements and observations regarding his demeanor but no new objective 

findings regarding his mental abilities and limitations. For example, though Plaintiff reports the new 

evidence shows his difficulties with social functioning and concentration, these difficulties were 

previously noted by Drs. Portnoff and Izzi at the consultative psychiatric examinations.

Dr. Portnoff believed Plaintiff appeared occupied and his thought process was “coherent but 

mildly rambling and occasionally tangential.” (See Doc. 12-12 at 25) Dr. Portnoff evaluated Plaintiff’s 

memory and concentration by asking him to recall three words immediately and after a delay, and 

concluded Plaintiff was “able to perform simple and repetitive tasks.” (Id. at 26) Likewise, Dr. Izzi 

tested Plaintiff’s concentration and found Plaintiff “was able to immediately recall three words without 

any obvious difficulty” and recalled one word after a delay. (Id. at 55) In addition, Plaintiff told Dr. 

Izzi that his mind was “always racing” and he could not get along with others. (Id. 53) Despite this, 

Dr. Izzi concluded Plaintiff was “capable of performing a simple and repetitive type task on a 

consistent basis over an eight-hour period.” (Id. at 55) Further, as the ALJ noted, Dr. Izzi opined 

Plaintiff had moderate limitations “in his ability to get along with work peers and supervisors,” but also 

indicated medication adherence and “staying on a proper regimen, ... would alleviate the claimant’s 

limitation to work with peers or the public.” (Doc. 12-3 at 41-42) Plaintiff fails to identify objective 

testing or evidence in the record that undermines these conclusions. Thus, the Appeals Council did not 

err in concluding Plaintiff failed to meet his burden to show “a reasonable probability that it would 

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change the outcome of the decision.” See Matthews v. Shalala, 10 F.3d 678 (9th Cir. 1993) (“mere 

existence of an impairment is insufficient proof of a disability”); see also Nottoli v. Astrue, 2011 WL 

675290, at *3 (E.D. Cal. Feb. 16, 2011) (“recitation of a medical diagnosis does not demonstrate how 

that condition impacts plaintiff’s ability to engage in basic work activities”).

Because Plaintiff fails to show the additional evidence was “new, material, and relates to the 

period on or before the date of the hearing decision” and that there was “a reasonable probability that 

the additional evidence would change the outcome of the decision,” he fails to demonstrate error by 

the Appeals Council in merely looking at the evidence and not incorporating it as exhibits into the 

administrative record. See 20 C.F.R. §§ 404.970, 416.1570.

CONCLUSION AND ORDER

For the reasons set forth above, the Court finds the ALJ did not have a duty to further develop 

the record, and Appeals Council did not err in declining to consider the additional evidence submitted 

by Plaintiff. Accordingly, the Court ORDERS:

1. The decision of the Commissioner of Social Security is AFFIRMED; and

2. The Clerk of Court is DIRECTED to enter judgment in favor of Defendant, the 

Commissioner of Social Security, and against Plaintiff Thomas Joseph White.

IT IS SO ORDERED.

Dated: February 27, 2020 /s/ Jennifer L. Thurston 

UNITED STATES MAGISTRATE JUDGE

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