Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_09-cv-01257/USCOURTS-caed-2_09-cv-01257-3/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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IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF CALIFORNIA

STSIAPAN LAYSHEVICH,

Plaintiff, No. CIV S-09-1257 GGH

vs.

MICHAEL J. ASTRUE, ORDER

Commissioner of 

Social Security,

Defendant. 

 /

Plaintiff seeks judicial review of a final decision of the Commissioner of Social

Security (“Commissioner”) denying his application for Supplemental Security Income (“SSI”)

under Title XVI of the Social Security Act (“Act”). For the reasons that follow, plaintiff’s

Motion for Summary Judgment is granted in part, the Commissioner’s Motion for Summary

Judgment is denied, and this matter is remanded to the ALJ for further findings as directed in this

opinion. The Clerk is directed to enter judgment for plaintiff.

BACKGROUND

Plaintiff, born June 8, 1948, applied on November 16, 2006 for disability benefits. 

(Tr. at 26, 51.) Plaintiff alleged he was unable to work due to low back pain, chest pain, knee

pain, and left leg pain and numbness. (Id. at 51.) In a decision dated July 23, 2008, ALJ L. Kalei

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 Disability Insurance Benefits are paid to disabled persons who have contributed to the 1

Social Security program, 42 U.S.C. § 401 et seq. Supplemental Security Income is paid to

disabled persons with low income. 42 U.S.C. § 1382 et seq. Both provisions define disability, in

part, as an “inability to engage in any substantial gainful activity” due to “a medically

determinable physical or mental impairment. . . .” 42 U.S.C. §§ 423(d)(1)(a) & 1382c(a)(3)(A). 

A parallel five-step sequential evaluation governs eligibility for benefits under both programs. 

See 20 C.F.R. §§ 404.1520, 404.1571-76, 416.920 & 416.971-76; Bowen v. Yuckert, 482 U.S.

137, 140-142, 107 S. Ct. 2287 (1987). The following summarizes the sequential evaluation: 

Step one: Is the claimant engaging in substantial gainful

activity? If so, the claimant is found not disabled. If not, proceed

to step two. 

Step two: Does the claimant have a “severe” impairment? 

If so, proceed to step three. If not, then a finding of not disabled is

appropriate. 

Step three: Does the claimant’s impairment or combination

of impairments meet or equal an impairment listed in 20 C.F.R., Pt.

404, Subpt. P, App.1? If so, the claimant is automatically

determined disabled. If not, proceed to step four. 

Step four: Is the claimant capable of performing his past

work? If so, the claimant is not disabled. If not, proceed to step

five. 

Step five: Does the claimant have the residual functional

capacity to perform any other work? If so, the claimant is not

disabled. If not, the claimant is disabled. 

Lester v. Chater, 81 F.3d 821, 828 n.5 (9th Cir. 1995). 

The claimant bears the burden of proof in the first four steps of the sequential evaluation

process. Bowen, 482 U.S. at 146 n.5, 107 S. Ct. at 2294 n.5. The Commissioner bears the

burden if the sequential evaluation process proceeds to step five. Id.

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Fong determined that plaintiff was not disabled. (Id. at 13-21.) The ALJ made the following

findings:1

1. The claimant has not engaged in substantial gainful activity

since November 16, 2006, the application date (20 CFR

416.920(b) and 416.971 et seq.).

2. The claimant has the following medically determinable

impairments: low back pain, left knee pain, and depression

(20 CFR 416.920(c)).

3. The claimant does not have an impairment or combination

of impairments that has significantly limited (or is expected

to significantly limit) the ability to perform basic workrelated activities for 12 consecutive months; therefore, the

claimant does not have a severe impairment or combination

of impairments (20 CFR 416.921).

4. The claimant has not been under a disability, as defined in

the Social Security Act, since November 16, 2006 (20 CFR

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416.920(c)), the date the application was filed.

(Tr. at 13-21.)

ISSUES PRESENTED

Plaintiff has raised the following issue: Whether the ALJ’s Step Two Finding was

Error.

LEGAL STANDARDS

The court reviews the Commissioner’s decision to determine whether (1) it is

based on proper legal standards pursuant to 42 U.S.C. § 405(g), and (2) substantial evidence in

the record as a whole supports it. Tackett v. Apfel, 180 F.3d 1094, 1097 (9th Cir.1999). 

Substantial evidence is more than a mere scintilla, but less than a preponderance. Connett v.

Barnhart, 340 F.3d 871, 873 (9th Cir. 2003) (citation omitted). It means “such relevant evidence

as a reasonable mind might accept as adequate to support a conclusion.” Orn v. Astrue, 495 F.3d

625, 630 (9 Cir. 2007), quoting Burch v. Barnhart, 400 F.3d 676, 679 (9 Cir. 2005). “The ALJ th th

is responsible for determining credibility, resolving conflicts in medical testimony, and resolving

ambiguities.” Edlund v. Massanari, 253 F.3d 1152, 1156 (9th Cir. 2001) (citations omitted). 

“The court will uphold the ALJ’s conclusion when the evidence is susceptible to more than one

rational interpretation.” Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 2008). 

ANALYSIS

Plaintiff contends that the ALJ refused to find plaintiff’s back and leg pain, and

carpal tunnel syndrome to be severe impairments at step two.

At the second step of the disability analysis, an impairment is not severe only if it

“would have no more than a minimal effect on an individual’s ability to work, even if the

individual’s age, education, or work experience were specifically considered.” SSR 85-28. The

purpose of step two is to identify claimants whose medical impairment is so slight that it is

unlikely they would be disabled even if age, education, and experience were taken into account. 

Bowen v. Yuckert, 482 U.S. 137, 107 S. Ct. 2287 (1987). “The step-two inquiry is a de minimis

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screening device to dispose of groundless claims.” Smolen v. Chater, 80 F.3d 1273, 1290 (9th

Cir. 1996). At this step, the ALJ may decline to find a severe impairment “only if the evidence

establishes a slight abnormality that has no more than a minimal effect on an individual’s ability

to work.” Webb v. Barnhart, 433 F.3d 683, 686-87 (9 Cir. 2005) (emphasis in original). th

The ALJ only found plaintiff’s low back pain, left knee pain and depression to be

medically determinable impairments, but did not find them to be severe, and found no severe

impairments whatsoever. (Tr. at 15.) Back and leg pain are by themselves only symptoms.

Plaintiff can only establish an impairment if the record includes signs – the results of “medically

acceptable clinical diagnostic techniques,” such as tests – as well as symptoms, i.e., plaintiff’s

representations regarding his impairment. Ukolov v. Barnhart, 420 F.3d 1002, 1004-1005 (9th

Cir. 2005). Here, an EMG dated January 26, 2007 indicated left lumbar radiculopathy. (Tr. at

108.) Although this study would tend to indicate a severe impairment, it is the only objective

record of radiculopathy. It is impossible to determine if it lasted for at least twelve months, or

whether it was only a passing irritant. 

An x-ray of the lumbar spine, dated January 26, 2007, showed a mild degree of

spondylosis, mild disc thinning at L4-5, and mild right convex thoracolumbar scoliosis. The SI

joints and paraspinous soft tissues were normal. The right hip was normal. (Tr. at 112.) 

Another lumbar x-ray dated approximately a year later, on January 17, 2008, was not negative as

to the lumbar spine as defendant asserts, but repeated the earlier findings and added a finding of

disc degeneration at L4-5. It also indicated that the SI joints were normal. (Id. at 182.)

Treating records indicate that although plaintiff complained of back pain, exams

indicated full range of motion on December 11, 2006. (Id. at 119.) Another undated report

indicates a normal back, despite back pain. (Id. at 128.) On November 8, 2006, plaintiff

complained of back pain radiating down the left leg and numbness, yet his treating physicians

ordered no treatment other than the aforementioned diagnostic studies until January 26, 2007,

when physical therapy was planned and a note was made to “consider MRI.” (Id. at 129, 113.) It

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does not appear that plaintiff ever went to physical therapy. On January 20, 2007, low back pain

was diagnosed and a neurology consult was ordered. It appears that plaintiff was prescribed

Naproxen at this time but the treating notes are difficult to decipher. (Id. at 114.) 

The ALJ mainly relied on the consultative report of Dr. Seu, who examined

plaintiff on June 29, 2007, without the benefit of any medical records. (Tr. at 167.) The

regulations require that a consultative examiner be given any necessary background information

about the plaintiff’s condition. 20 C.F.R. § 404.1517. Background information is essential

because consultative exams are utilized “to try to resolve a conflict or ambiguity if one exists.” 

20 C.F.R. § 404.1519a(a)(2). 

Here, Dr. Seu diagnosed low back pain and left knee pain. (Tr. at 170.) He

thought plaintiff could work without any limitations. (Id.) The ALJ relied heavily on this

assessment, and erred in doing so based on Dr. Seu’s lack of access to any records. Where there

are EMG studies and x-rays available, it is important for a consultant to have access to them. In

fact, even the state agency doctor had better access to plaintiff’s medical records than did this

examining internist. Additionally, both the SSA examiners and the ALJ did not have access to

the MRI submitted to the Appeals Council; see infra. (Tr. at 172-75.) For these reasons, this

consultant report should not have been given significant weight. 

When considered with the ALJ’s credibility analysis, it is clear that this case must

be remanded. The ALJ’s credibility analysis is somewhat confusing. She states:

After considering the evidence of record, the undersigned finds that

the claimant’s medically determinable impairments could

reasonably be expected to produce the alleged symptoms; however,

the claimant’s statements concerning the intensity, persistence and

limiting effects of these symptoms are not credible to the extent

they are inconsistent with finding that the claimant has no severe

impairment or combination of impairments for the reasons

explained below. 

(Tr. at 16.)

These statements are inconsistent in finding that plaintiff’s impairments could

produce the symptoms that plaintiff claims, yet on the other hand finding that plaintiff is not

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 The undersigned will infer that this MRI was provided to the Appeals Council and is 2

therefore not considered new evidence, as the Commissioner suggests. Ligenfelter v. Astrue, 504

F.3d 1028, 1030 (9 Cir. 2007) citing Ramirez v. Shalala, 8 F.3d 1449, 1451-52 (9 Cir. 1993). th th

It is already part of the record, and although the transcript does not contain the MRI itself, the

letter submitted by plaintiff’s counsel at the time of the appeal is the same one attached to the

MRI as an exhibit to plaintiff’s current motion. (Tr. at 8.) It is dated November 28, 2008, and

refers to an MRI result from Dr. Rafanov. (Tr. at 3, 192-93.) The MRI result attached to the

same letter and plaintiff’s motion is dated October 27, 2008, one month before the letter, and is

Dr. Rafanov’s report, as the letter suggests. (Pl.’s Mot., Ex. at 1-2.) 

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credible because he has no severe impairment. If the impairment is reasonably expected to

produce the alleged symptoms, then by definition it must be a severe impairment. Because there

are now x-rays, MRIs, and EMGs which support a finding of severe impairment as to plaintiff’s

back and leg pain, the level of severity of these problems and to what extent they are disabling is

dependent in large part on plaintiff’s credibility. The ALJ’s credibility analysis, as described

above, is flawed. 

Also attached to plaintiff’s motion as “new evidence” is an MRI submitted to the

Appeals Council after the hearing. (Pl.’s Mot., Ex. at 2.) Its findings include mild disc bulging 2

at L1-2, L3-4 and disc bulging at L4-5 and L5-S1. Spondylosis was present but there was no

high grade lumbar canal stenosis. The report additionally found “asymmetric narrowing of the

left neural foramen at L5-S1, there is also mild narrowing of the right inferior neural foramina at

L4-5 and L5-S1.” (Id.) ALJs have regularly found disc bulging and spondylosis to be severe

impairments. Preston v. Secretary of Health and Human Services, 854 F.2d 815, 817 (6 Cir. th

1988) (bulging disc); Larry v. Astrue, 2010 WL 1038554, *1 (M.D. Ala. March 19, 2010) (slight

disc bulge, spondylosis); Woody v. Astrue, 357 Fed. Appx. 765, 2009 WL 4884541 (9 Cir. th

2009) (spondylosis).

This objective study is further evidence indicating that plaintiff’s back problem

was a severe impairment. The ALJ had not seen the MRI even though it is technically part of the

record, and on remand she will be able to consider this evidence in conjunction with further

development of the record by obtaining a consultation with a specialist who has access to all of

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 The ALJ noted all of the unremarkable or minimal findings in the record, and the lack 3

of treatment in light of the alleged degree of pain. She also observed that although an MRI was

considered, it was never performed. (Tr. at 16-17.) Examination by Dr. Seu showed full range

of motion and no physical discomfort. Plaintiff had also complained of a disabling mental

impairment; however, a psychiatric evaluation was normal. (Id. at 17.) Plaintiff’s demeanor and

appearance at the hearing was also unpersuasive. (Id. at 18.) Plaintiff’s daily activities were also

not significantly limited, allowing him to take short walks to the store, do chores around the

house, go to church, and socialize with his four children. (Id. at 20.) 

7

plaintiff’s medical records. 

In making this determination, the undersigned is by no means instructing that an

outcome of disability result from the remand. In fact, it is quite apparent that since immigrating

to the United States in 2006, plaintiff has developed very little in the way of a medical record. 

He has no records from Belarus despite his claims that his medical impairments began there,

where he was allegedly hospitalized three times a year when he was unable to walk due to back

problems. Furthermore, as discussed throughout this opinion, the nature of plaintiff’s alleged

disability appears somewhat suspicious. 

Here, the ALJ found plaintiff to be not entirely credible for many reasons, and

plaintiff does not contest those findings. For example, the ALJ specifically pointed out that the 3

plaintiff reported to Dr. Seu that he had endured low back pain for fifteen years prior to the 2007

exam with this doctor, and had had left knee pain for the previous ten years. (Tr. at 18, 167.) 

The ALJ pointed out, however, that plaintiff last worked as a taxi driver in Belarus in 2005. 

Furthermore, in May, 2007, plaintiff told Dr. Cheema that he could not work since he came to the

United States due to pain, but in Belarus he had always been employed. (Id. at 18, 152.) In any

event, plaintiff apparently did his past work for years with this alleged pain.

Also submitted at the hearing was another report by plaintiff’s treating physician,

Dr. Rafanov at Manzanita Medical Clinic, dated April 11, 2008. It diagnoses lumbar

radiculopathy on the left and carpal tunnel syndrome. (Id. at 184.) This report concludes that

plaintiff can do less than sedentary work. (Tr. at 184-85.) “A statement by any physician that the

claimant is disabled or unable to work is a conclusion on the ultimate issue to be decided . . . and

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 Evidence is not deemed immaterial solely by the date it was created. Later dated 4

evidence may have substantive impact on a preceding period. 

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is not binding on the [ALJ] in reaching his determination as to whether the claimant is disabled

within the meaning of the [Act].” Murray v. Heckler, 722 F.2d 499 (9th Cir. 1983), (citing

Burkhart v. Bowen, 856 F.2d 1335 (9th Cir. 1988), 20 C.F.R. §§ 404.1527 and 404.927); accord,

Magallanes v. Bowen, 881 F.2d 747, 750-51 (9th Cir. 1989). The ALJ discounted this opinion

because it conflicted with the remainder of the record, and the objective evidence did not support

the level of severity assigned by this physician. (Id. at 19.) It should be noted that plaintiff does

not dispute the ALJ’s decision to give this report less weight. 

Contrary to the ALJ’s assertion that this report does not contain a reference to

objective testing to support these diagnoses, and defendant’s parroting of the ALJ’s finding, the

report specifically states that it relies on an abnormal x-ray and EMG, as outlined above. (Id. at

184.) Those diagnostic studies do not address plaintiff’s alleged carpal tunnel syndrome, but

plaintiff has provided new evidence in the form of an EMG study with his motion, dated April

11, 2008, which does indicate an abnormal study of mild median neuropathy at the wrist and

ulnar sensory neuropathy. (Pl.’s Mot., Ex. at 3-4.)

This EMG was not included in the record and therefore it must be determined

whether it should be considered new evidence. New evidence is “material,” if the court finds a

reasonable possibility that considering the evidence would have changed the disability

determination. See Booz v. Secretary of Health and Human Services, 734 F.2d 1378, 1380- 4

1381 (9th Cir. 1984). Unless it is probative of plaintiff’s condition at or before the disability

hearing, new evidence is not material. See 42 U.S.C. § 416(i)(2)(G); Sanchez v. Secretary of

Health and Human Services, 812 F.2d 509, 511-12 (9th Cir. 1987) (holding that new evidence

was not material because it related to a medical condition not significantly at issue at time of

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 When new evidence reflects plaintiff’s current condition but is not probative of a 5

condition at the time of the initial determination, the correct procedure is to reapply for benefits. 

See Ward v. Schweiker, 686 F.2d 762, 765-66 (9th Cir.1982).

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 hearing).

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“Good cause” requires more than “simply . . . obtaining a more favorable report

from an expert witness once [a] claim is denied. The claimant must establish good cause for not

seeking the expert’s opinion prior to the denial. . . .” Clem v. Sullivan, 894 F.2d 328, 332 (9th

Cir. 1990) (citing Key v. Heckler, 754 F.2d 1545, 1551 (9th Cir.1985)). For example, good

cause exists if new evidence earlier was unavailable, in the sense that it could not have been

obtained earlier. Embrey v. Bowen, 849 F.2d 418, 423-24 (9th Cir.1988). 

The EMG is probative of plaintiff’s condition on April 11, 2008, three months

prior to the ALJ’s decision and about a month before the administrative hearing. Plaintiff has not

submitted a reason why this report was not submitted earlier, other than to state that it “did not

make it into the record.” (Pl.’s Mot. at 4 n. 2.) Plaintiff has not provided an acceptable reason

why this report was not previously submitted to the ALJ. 

Pursuant to 20 C.F.R. § 404.1512(d), the ALJ will make “every reasonable effort”

to obtain evidence from medical sources. The record will be kept open after the hearing for

submission of post-hearing evidence known to be in existence. 1 Soc. Sec. Disab. Claims Prac.

& Proc. § 16:57 (2 Ed.) “Even if the ALJ does not hold a record open for submission of new nd

evidence, evidence can be submitted up to the date a hearing decision is issued.” Id. 

In this case, the hearing occurred on May 21, 2008, over a month after the EMG

study was completed. At that time, the ALJ told plaintiff that he could always re-open or re-file

more records. (Id. at 202.) Plaintiff did not submit the EMG report to the ALJ or the Appeals

Council, despite its prior existence. The ALJ’s decision, issued July 23, 2008, fails to refer to

this EMG, and in fact states that there is no objective evidence to support the treating physician’s

diagnosis of carpal tunnel syndrome. (Id. at 19.) 

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 Although he reported to Dr. Seu that he had experienced left knee pain for ten years and 6

that it was “sharp,” plaintiff had never obtained an x-ray for it, and reported that he “had no

specific medical treatment” for it. (Id. at 167.) Plaintiff reported to Dr. Seu that he had

undergone physical therapy for his back; however, there are no records of such treatment. He also

received no cortisone injections or other treatment. Plaintiff testified at the hearing that in

America he does “therapy by myself. I stay home, and lay down, and do – I buy special herbs

and do massage to my legs.” (Tr. at 201.) 

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As the EMG was in existence at the time of the hearing, it is probative of

plaintiff’s condition at the very end of the pertinent time period. Nevertheless, plaintiff’s casual

statement that the report did not make it into the record does not show good cause, especially in

light of the two month delay after the hearing before the ALJ issued her decision. 

More importantly, the remainder of the record does not evidence a carpal tunnel

problem. In fact, when plaintiff saw consulting physician Seu, he did not complain of this

problem at all. (Tr. at 167.) The SSA examiners had no record of complaint of this problem

either. (Id. at 172-75.) Furthermore, carpal tunnel syndrome was not raised as an impairment by

plaintiff until the administrative hearing when he submitted the April 11, 2008 report by

Manzanita Medical Clinic. (Id. at 26, 92, 184-87.) From November, 2006, when plaintiff filed

his application, until April, 2008, plaintiff did not complain of this problem, receive a diagnosis

of CTS, or seek treatment for this problem. Plaintiff has failed to show good cause why this

report should be considered. The best recourse is for plaintiff to file a new application for

benefits in this regard, but only if the problem is severe enough under guiding standards.

In sum, despite a real lack of treatment in comparison to the alleged degree of 6

pain, the ALJ erred in relying on Dr. Seu’s opinion because this consultant had no access to

plaintiff’s medical records. On remand, the ALJ shall consider plaintiff’s back and knee

problems to be severe impairments. The ALJ shall further develop the record in regard to these

impairments, including obtaining a consultative exam which has the benefit of all the medical

records, including the MRI before the Appeals Council. The ALJ shall then complete the

sequential analysis. Plaintiff’s carpal tunnel syndrome is not considered a severe impairment,

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and shall not be considered on remand, but plaintiff has the prerogative to file a new claim for

benefits on this impairment as he sees fit. 

CONCLUSION

For the reasons stated herein, IT IS ORDERED that: plaintiff’s Motion for

Summary Judgment is GRANTED in part pursuant to Sentence Four of 42 U.S.C. § 405(g), the

Commissioner’s Cross Motion for Summary Judgment is DENIED, and this matter is remanded

for further findings in accordance with this order. The Clerk is directed to enter Judgment for

plaintiff.

DATED: 08/09/2010 /s/ Gregory G. Hollows

 

 GREGORY G. HOLLOWS

U.S. MAGISTRATE JUDGE

GGH/076

Layshevich1257.ss.wpd

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