Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_15-cv-00009/USCOURTS-azd-4_15-cv-00009-0/pdf.json

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

---

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

WO

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Raymond S. Salinas,

Plaintiff, 

v. 

Carolyn W. Colvin, 

Defendant.

No. CV-15-00009-TUC-EJM

ORDER 

Plaintiff Raymond S. Salinas (“Salinas”) brought this action pursuant to 42 U.S.C. 

§ 405(g) seeking judicial review of a final decision by the Commissioner of Social 

Security (“Commissioner”). Salinas raises two general issues on appeal: 1) whether the 

Administrative Law Judge’s (“ALJ”) residual functional capacity (“RFC”) assessment is 

supported by substantial evidence, and 2) whether the ALJ’s Step Five finding that 

Salinas can perform work existing in the national economy is inconsistent with the 

evidence and the law. (Doc. 23 at 1–2). Salinas specifically contends that the ALJ erred 

in evaluating and weighing three of the medical expert opinions and that the ALJ failed to 

provide clear and convincing reasons for finding Salinas not credible. Id. at 2. 

Before the Court are Salinas’ Opening Brief and Defendant’s Response. (Docs. 23 

& 25). Salinas did not file a Reply. The United States Magistrate Judge has received the 

written consent of both parties and presides over this case pursuant to 28 U.S.C. § 636(c) 

and Rule 73, Federal Rules of Civil Procedure. The Court finds that the ALJ erred in 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 1 of 47
- 2 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

assessing Salinas’s activities of daily living and that she gave improper consideration to 

Salinas’s lack of treatment. These errors impacted the ALJ’s RFC assessment and the 

hypotheticals posed to the VE. Consequently, these errors were not harmless because 

they ultimately impacted the Step Five nondisability finding, and the Court finds remand 

for further proceedings is appropriate. 

I. Procedural History 

Salinas filed an application for Supplemental Security Income (“SSI”) and 

Disability Insurance Benefits (“DIB”) on February 21, 2012. (Administrative Record 

(“AR”) 159). Salinas alleged disability beginning March 20, 2011 (AR 159) based on an 

injury to his back and spine in a fall at work (AR 179). Salinas’s application was denied 

upon initial review (AR 60, 88) and on reconsideration (AR 70, 93). A hearing was held 

on June 6, 2013 (AR 31), after which ALJ Lauren R. Mathon found, at Step Five, that 

Salinas was not disabled because he was able to perform other work existing in the 

national economy (AR 25). On November 6, 2014 the Appeals Council denied Salinas’s 

request to review the ALJ’s decision. (AR 1). 

II. Factual History 

Salinas was born on January 15, 1959, making him 52 at the alleged onset date of 

his disability. (AR 159). Salinas has a high school education and completed one year of 

college. (AR 179). Salinas’s last job was with Olive Garden, from February through 

March 2011, where he worked as a prep cook. (AR 192). From 1997 to 2009, he worked 

as a lab technician for Baxter Health Care. Id. Salinas indicated that he lifted up to 50 to 

70 pounds at Olive Garden and walked and stood for 9–10 hours of his work day. (AR 

193). At Baxter Health Care, Salinas lifted up to 100 pounds or more and walked, stood, 

sat, and climbed for 10 hours a day. (AR 194). 

A. Treating Physicians 

Salinas had a CT of the lumbar spine on March 30, 2011. (AR 402). The findings 

were normal paraspinal area, normal bones, and “disc space narrowing, vacuum disc 

phenomenon, and small partially calcified right-sided herniated nucleus pulposus at L5–

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 2 of 47
- 3 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

S1, mildly posteriorly displacing the right S1 nerve root.”

Salinas was seen by Dr. Colin Bamford on June 22, 2011 with a complaint of neck 

and back pain. (AR 447). He reported that his back pops up and locks, and that he was 

not improving and some things were worsening. Salinas stated that staying in one 

position and washing dishes aggravated his pain, and changing activities relieved it. He 

reported that his medications made him nauseated and woozy and affected his sleep, so 

he stopped taking them. On examination Dr. Bamford noted Salinas had marked 

limitation of mobility in his neck and low back. (AR 448). Dr. Bamford also noted that 

Salinas got onto the examination table slowly using a step stool, and that he asked to be 

able to stand at one point during the interview and stood for one minute. Dr. Bamford 

found normal strength and tone in all four extremities, normal sensation in all four 

extremities, ability to toe walk, normal gait, and trouble heel walking requiring balance 

support from the doctor. (AR 449). Dr. Bamford’s impression was neck and back pain, 

and he noted that Salinas’ “limitation of mobility is extreme and suspect.” He also noted 

that Salinas had a small herniated disc “which is small enough that it could be 

asymptomatic” and that it was “partially calcified and consequently is probably old.” Dr. 

Bamford recommended a MRI and EMG/NCV study. 

 Salinas had a MRI on July 21, 2011. (AR 405). The impression was: 

1. L5–S1: Mild endplate degenerative changes, small Schmori’s node inferior endplate L5 with minimal 

retrolisthesis, disc desiccation and disc bulge extending 

posterior 3–4 mm asymmetric to the right result in mass effect at the ventral subarachnoid space, moderate right and 

mild-moderate left neural foraminal narrowing. 

2. L4–5: Disc desiccation and mild intraforaminal disc bulge results in mild bilateral neural foraminal narrowing. 

3. L3–4: Disc desiccation present. Left asymmetric disc bulge results in mild left neural foraminal narrowing. 

Salinas also had an EMG and NCV study of the lower extremities and paraspinals 

on July 21, 2011. (AR 407). Both tests were normal, and the impression was “no 

electrodiagnostic abnormalities in bilateral lower extremities.” (AR 408). 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 3 of 47
- 4 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

Dr. Bamford saw Salinas for a follow-up appointment on October 12, 2011. (AR 

444). Salinas reported he was doing the same, that nothing was working, and that he felt 

he was deteriorating. He complained of severe groin, knee, and back pain, and noted that

activity worsened his pain and muscle relaxants relieved it. He also complained of 

walking awkwardly, numbness and burning spine pain, and weakness in his arms and 

knees. Salinas also reported he was depressed due to weight gain. He rated his pain as a 

9/10. (AR 445). On examination Dr. Bamford noted Salinas had normal attention, 

concentration, mood, affect, speech and language. Dr. Bamford found normal strength in 

the upper extremities and left leg, but noted Salinas “provided a variable effort on 

strength testing of the right leg.” Pinprick sensation was normal in all four extremities, 

but light touch was absent in the right leg. Dr. Bamford observed that Salinas got up from 

his chair slowly and walked to the examination table slowly, laid back on the table with 

ease, and sat up from the exam table slowly using his arms. Dr. Bamford’s impression 

was possible neck and back pain, small herniated disc that is probably old, and symptom 

magnification. He recommended a physical medicine and rehabilitation consult, and that 

Salinas enroll in a work hardening program. (AR 446). 

Salinas saw Dr. Bamford for a follow-up on October 26, 2011 with a complaint of 

back, groin, and leg pain. (AR 441). He reported that the severity of his pain was 

unchanged, that activity made it worse, and that Diclofenac relieved it. Salinas rated his 

pain as a 8/10. (AR 442). Dr. Bamford observed that Salinas had an unmotivated, slightly 

blunted affect, and normal attention and concentration. On exam, Dr. Bamford found: 

slightly decreased right grip strength with variable effort, variable effort of the right leg, 

normal strength in left arm and leg, normal tone in all four extremities, vibration 

sensation decreased at right ankle, pinprick and light touch absent in the right foot, and 

position sense decreased in both feet. Dr. Bamford observed that Salinas walked upright 

but slowly, and was able to get onto the exam table and remove his socks and shoes 

without difficulty. Dr. Bamford’s impression was possible neck and back pain, small 

herniated disc that is probably old, and symptom magnification. He noted Liberty Mutual 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 4 of 47
- 5 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

had approved 6 work hardening visits for Salinas. 

Dr. Bamford saw Salinas for a follow-up on December 7, 2011. (AR 438). Salinas 

complained of burning and numbness up and down his spine and low back spasms. He 

reported that his symptoms were different every day, that sometimes the pain was in his 

low back, upper back, and neck, and that he felt a pull in his upper back, spasms and 

locking in his low back, and that his neck felt misaligned with his spine. Salinas rated the 

pain in his upper back at a 6–7/10 and a 6–8/10 in his low back. Activity, using his arms, 

and walking all aggravate his pain, and inactivity, medications, and popping his neck in 

alignment relieve his pain. Dr. Bamford observed that Salinas got onto the examination 

table and laid down with ease, and got up without being asked to and without asking for 

help. (AR 439). On examination of the back, Dr. Bamford noted: palpation of the low 

back revealed no spasm; Salinas could touch his ankles but had minimal movement of the 

low back in all other directions; when asked to rotate his low back, Salinas “instead 

rotated his neck with reasonable excursion;” and Salinas “exhibited no expression of pain 

and made no statement of pain when asked to move his low back.” On examination of the 

neck, Dr. Bamford noted that Salinas “had a fair range of motion in all directions.” Id. 

Dr. Bamford also observed “poor effort on extension of the right knee and plantar flexion 

of the right ankle,” and noted normal strength of the left leg and both arms, and normal 

tone in all four extremities. His impression was possible neck and back pain, small 

herniated disc that is probably old, symptom magnification, and somatization disorder. 

Dr. Bamford opined that Salinas “may return to work with the recommended work 

restrictions suggested by Karen Lumda which I feel are cautious and generous.” Id. 

On February 15, 2012 Dr. Bamford saw Salinas for a follow-up for back pain with 

numbness and tingling, and a new complaint of heel pain. (AR 435). Salinas reported that 

PT was not helping, that he tried to do his home exercises but they made his symptoms 

worse, and that Diclofenac temporarily relieved his pain. Salinas stated that he was doing 

worse and severe pain could hit him at any time, and that his pain is constantly a 5/10 but 

that he gets attacks twice per month lasting for a few minutes where it is a 10/10. Salinas 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 5 of 47
- 6 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

felt the heel pain was related to putting all of his weight on his heels to protect his back. 

Dr. Bamford observed that Salinas got up from his chair by holding onto the side bars, 

and that he walked with his back stiff. (AR 436). On the back exam, Dr. Bamford noted 

that Salinas could touch his toes, did not attempt to extend his back because he was 

worried it would increase his pain, could twist ok, side bends were mildly restricted due 

to pain, and there was tenderness of the right paraspinal muscles. On the neck exam, Dr. 

Bamford noted neck flexion, extension, and rotation were ok, and tilt was moderately 

restricted bilaterally due to pain between the shoulder blades. Dr. Bamford’s impression 

was neck and back pain after a fall at work, new onset of heel pain, and moderate right 

and mild-moderate left L5 neural formamina narrowing. (AR 437). He recommended a 

lumbar Velcro corset, referral to a pain clinic for a facet block, and a follow-up 

appointment after Dr. Ennabi’s evaluation, and renewed the Diclofenac prescription. 

On December 12, 2012 Salinas was seen by Dr. Michael Milazzo for a complaint 

of back pain, muscle spasms, and a burning sensation in the left L5–S1 area. (AR 542). 

Salinas reported he could not bend over or walk 50 yards, and that he was taking 

Diclofenac for pain. He also reported extremity weakness, gait disturbance, numbness in 

his extremities, and muscle weakness. (AR 543). On examination Dr. Milazzo 

documented “[m]oderate paravertebral muscle spasm noted [from] cervical region to 

lumbar area” and “[t]enderpoint left L5–S1 to palpation.” (AR 544). He also documented 

weakness on left foot dorsiflexion and diminished bilateral achilles deep tendon reflexes, 

and noted Salinas would not heel walk. Dr. Milazzo assessed herniated nucleus pulposus, 

L5–S1, left; muscle spasm of back; and obesity. He recommended a neurology 

reevaluation by Dr. Banford and prescribed Flexeril and Gabapentin. (AR 544–45). 

Dr. Milazzo saw Salinas on January 10, 2013 for lab results. (AR 556). Salinas 

reported that there was no change in his back condition and that he had not seen the 

neurology specialist in Tucson. Dr. Milazzo assessed hypertension, hyperlipidemia, and 

herniated nucleus pulposus, L5–S1, left. (AR 557). He noted Salinas never filled the 

Neurontin prescription because he could not afford it, and gave Salinas a refill 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 6 of 47
- 7 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

prescription for the Flexeril. 

Salinas saw Dr. Milazzo on February 20, 2013 for prescription refills. (AR 559). 

Salinas stated he had been summoned for jury duty but that he did not think he could not 

do it because he could not sit for an extended period of time. Dr. Milazzo noted Salinas 

complained of persistent muscle spasms in his back and pain, and on examination Dr. 

Milazzo indicated “[m]oderate paravertebral muscle spasm still noted” and “[t]enderness 

left L5–S1.” (AR 560–61). Dr. Milazzo also documented “[w]eakness still noted left foot 

dorsiflexion” and “[d]iminished achilles still noted.” (AR 561). Dr. Milazzo assessed 

hypertension and sciatica due to displacement of lumbar disc, and renewed Salinas’ 

prescription for Flexeril. (AR 562). He also noted that bed rest was not a recommended 

treatment for back pain and that Salinas should stay as active as possible and do exercises 

to strengthen his back and abdominal muscles. 

On April 3, 2013 Salinas saw Dr. Milazzo for prescription refills. (AR 563). 

Salinas reported he had been out of medication for 5 days and that he wanted to try the 

Gabapentin if he could afford it. Dr. Milazzo noted Salinas still had back pain and pain 

radiating down his left leg, and observed that Salinas “ambulates slowly because of back 

problems. (AR 564–65).” Dr. Milazzo documented normal deep tendon reflexes except 

for the left patellar, and weakness on the left foot dorsiflexion. He assessed 

hyperlipidemia, hypertension, and sciatica due to displacement of lumbar disc, and gave 

Salinas a prescription for Gabapentin. (AR 565–66). Dr. Milazzo also noted that Salinas 

could not afford to go see Dr. Bamford, and that he had disability and workman’s 

compensation hearings coming up. (AR 566). 

Salinas was seen on April 23, 2013 for a medication refill. (AR 568). Dr. Milazzo 

assessed sciatica due to displacement of lumbar disc, and noted that Salinas had not filled 

the Gabapentin prescription because he could not afford it. Dr. Milazzo also noted that 

Salinas refused to go to physical therapy. Dr. Milazzo prescribed Cymbalta. 

B. Physical Therapy 

Salinas was seen at Sierra Vista Regional Health Center Rehabilitation Services 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 7 of 47
- 8 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

for a physical therapy evaluation on January 16, 2012. Salinas reported that his current 

pain was a 7/10, that his pain at rest was a 7/10, and that his pain with activity was a 9/10. 

(AR 430). He noted that his symptoms were constant and come and go, and that they 

were worsening and not changing. Salinas stated that the following made his symptoms 

worse: walking/activity, sleeping, sitting, standing, lying down, turning/twisting, 

reaching, bending, gripping/grasping, stress, and work duties. He reported he was unable 

to engage in any activities and that after about 5 minutes of doing an activity his pain 

would increase and his back would lock up. (AR 474). The PT noted that Salinas 

currently had severe pain with activities of daily living, with a therapy goal of reducing 

that to moderate pain, and that Salinas was unable to perform specific work activity 

secondary to pain or limitation, with a therapy goal of reducing pain during or after work 

activity to a moderate level. (AR 475). Physical findings included: bilateral lumbar back 

pain, mild increased lordosis of the lumbar spine with stance, normal movement, and 

tenderness with palpation of the soft tissues throughout the mid and lower spine. (AR 

475). On the spinal assessment, the PT noted that Salinas was “able to grab both knees, 

[but] does not tolerate continued flexion of the spine” and “[h]e is very limited with side 

bending due to reported ‘locking’ of the trunk with very little pain.” (AR 476). Salinas 

was negative for all spine tests except one straight leg raise test, indicating hamstring 

tightness. The PT also noted that Salinas reported pain “to radiate into the right lower 

extremity but there is currently no signs or symptoms of progressive radiculopathy.” The 

PT observed that Salinas presented with impairments of: “1 weakness of the trunk and 

extremities, 2 decreased tolerance to sitting, standing, walking, reaching [and] 3 

decreased trunk movement due to pain and reported ‘locking’” and recommended 8 

weeks of PT. (AR 476–77). 

A progress note from January 19, 2012 notes that Salinas reported pain between 

his shoulder blades when doing chin tucks during his home exercise program. (AR 482). 

He agreed to continue to try to do the exercise with modifications for pain. The PT noted 

that exercised were modified to accommodate Salinas’ pain, and that Salinas reported 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 8 of 47
- 9 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

increased pain between his shoulders with activity. 

A progress note from January 24, 2012 notes that Salinas stated his pain was 

getting worse and that his home exercise program was too painful. (AR 483). The PT

commented that “Raymond has increased difficulty with today’s exercise session, he has 

pain with all activities and quits halfway through exercises stating they are too painful to 

continue.” 

A progress note from January 26, 2012 notes that Salinas reported he was doing 

better than at his last PT session and was performing his home exercise program to 

tolerance. (AR 484). The PT commented that Salinas demonstrated “improved activity 

tolerance” but “require[s] frequent rest breaks due to pain,” and “once he rests his pain 

levels decrease.” 

A progress note from January 31, 2012 notes that Salinas reported he was doing 

his home exercise program and had increased pain with prone extension exercises, and 

that he was still having significant pain. (AR 486). 

A progress note from February 20, 2012 states that “Raymond demonstrates 

improved activity tolerance today’s visit, he has no reports of pain throughout session.” 

(AR 487). 

A progress note from February 23, 2012 states that Salinas reported “no changes 

in his back symptoms since the start of therapy” and that “he reports completing his home 

program with no results.” (AR 488). Salinas also reported “he felt good prior to last 

session, has since been in significant pain through the back, continuing to have 6/10 

pain.” He further reported “getting occasional sharp pain in the back that has a stabbing 

pain in the past month,” that he continued to have an occasional locking sensation in his 

back, and that his pain is relieved with ice only. A reevaluation completed on February 

23, 2012 notes that Salinas was making steady progress towards his treatment goals. (AR 

490). However, Salinas had not yet met his short term goals of improving strength and 

range of motion or being independent with his home exercise program, nor had he met 

the following long term goals: stand and walk for 30 minutes with a pain level of 5/10, 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 9 of 47
- 10 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

reach forward and place a 5 pound object in a cabinet with pain at a 4/10, stand and was 

dishes for 15 minutes with pain at a 4/10, and sleep for 4 hours without interruption. (AR 

490–91). The PT noted that Salinas was going to see another specialist and would then 

contact the PT if he wanted to continue therapy, but that “[o]therwise there has not been 

consistent improvement to warrant continued treatment at this time.” (AR 492). 

A discharge summary dated April 19, 2012 notes that Salinas was seen for 8 visits 

for back pain, and that Salinas was to call after his last doctor’s appointment if further PT 

was needed. (AR 495). Salinas did not call and was administratively discharged from PT 

because: “1. Evaluation complete and plan of care established however, the patient did 

not return/complete therapy program 2. The patient did not comply with plan of care 

attendance policy failing to show or cancelling three or more consecutive appointments.” 

C. State-Agency Consulting Physicians 

Salinas was seen by Dr. Jeri B. Hassman, a certified independent medical 

examiner, for a physical medicine consultative examination (“CE”) and statement of 

ability to do work-related activities on November 10, 2012. (AR 525). Salinas reported 

that he was injured on the job on March 20, 2011 and “[s]ince then, he has had constant, 

severe midback pain and low back pain plus pain down both legs.” He also reported 

“worse pain in the legs, including the ankles and knees, with prolonged standing.” Salinas 

stated “he was feeling better when he was getting some therapy and was on pain 

medication, but his Workmen’s Compensation was closed in February 2012, and since 

then he has not had any treatment.” Further, Salinas “was supposed to get facet joint 

injections and a lumbosacral corset, but he never obtained either of those.” 

 On examination, Dr. Hassman observed the following: 

His gait was very abnormal. He took very tiny steps and he 

was very stiff. . . . He hardly moved his head at all when he walked. He could not stand or walk on his toes because, he 

said, it caused too much back pain. The same was true for 

heel walking. He also refused to hop for the same reason. He 

performed tandem walking very carefully, holding on for balance. He could not perform bending at all. . . . He seemed 

to have an unusual response to anything I asked him to do. He 

sort of smiled to himself and looked around, as if he were 

confused and distracted, and just could not perform anything. 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 10 of 47
- 11 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

He also could not perform kneeling. Taking off his shirt took 

a lot of time. . . . At least three times he started to sit down, 

but he never really sat down during the physical examination, 

even when I asked him to sit down, because, he said, sitting 

was more painful than standing. . . . 

I asked him to perform cervical flexion. He obviously heard 

me but he did not move his head. Instead, he moved his eyes 

in all directions . . . 

He had no tenderness over the cervical spine. However, he 

had moderate tenderness over the thoracic and lumbar spine. . 

. . 

He could not perform any trunk flexion. The most he could 

bend was 10 degrees. He had no trunk extension. He could 

not sit or get on the table for straight leg raising test. 

He had normal sensation of both lower extremities. . . . 

I could not formally test hip flexion or knee extension, since 

he would not sit down because of too much pain. 

He had full range of motion of both upper extremities without 

pain. 

(AR 527). Dr. Hassman’s diagnosis was: 

Severe back injury since a twisting injury to the spine on March 20, 2011. . . . He has a very antalgic, abnormal gait 

with tiny steps and keeps his trunk very stiff, and he has 

essentially no ability to perform any bending or kneeling and 

cannot perform any cervical range of motion either because of 

the pain. 

(AR 528). Dr. Hassman then completed a Medical Source Statement of Ability to do 

Work-Related Activities (Physical) (“MSS”). She opined that Salinas’ condition would 

impose limitations for 12 continuous months, that he could occasionally1 and frequently2

lift and carry less than 10 pounds, stand and walk at least 2 hours but less than 6 hours in 

an 8 hour workday, and sit for 3 hours. (AR 528–29). She opined that Salinas had no 

restrictions in seeing, hearing, speaking, handling, fingering, or feeling, that he could 

occasionally stoop and reach, and that he could never kneel, crouch, crawl, or climb 

 

1 The form defined “occasionally” as up to 1/3, or no more than 2 hours of an 8 hour workday. 

2

 “Frequently” was defined as 1/3 to 2/3 of an 8 hour workday. 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 11 of 47
- 12 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

ramps, stairs, scaffolds, or ladders. (AR 530). Dr. Hassman also stated Salinas could not 

work around heights, moving machinery, or extremes in temperature. 

Salinas was seen by Dr. Sloan King for a psychiatric CE on November 12, 2012. 

(AR 533). Salinas reported an unsteady gait, and requested assistance from the hotel staff 

and Dr. King when walking back to his car. Salinas “stood throughout his entire hour 

long appointment, stating that his back felt as though he were ‘being poked with nails,’ 

and he chose to save his stamina so he that he could sit in his car to drive” home. Dr. 

King noted that Salinas was not clean shaven, and Salinas explained that his fiancé was 

out of town and unable to assist him, and that he had difficulty lifting his arms and 

holding his hand steady to shave due to his pain. Salinas reported “significant pain as a 

result of his injury, which begins as a central pain down the middle of his back, moves to 

the left side of his waist, and feels as though many of his nerves are in a bundle and 

‘twisting.’” (AR 534). He also stated the pain causes swelling in his ankles and knees, 

especially after sitting or standing for any period of time. Salinas reported his pain was 

constant and that he typically lies on the couch most of the day. “He sleeps on the couch 

as well, ‘rolling off’ in the morning in order to wake up as the bed is too high and he 

cannot comfortably get in or out.” Dr. King noted Salinas had no history of mental health 

issues, but that “he reports symptoms of depression and anxiety as a result of the onset of 

his disabling condition.” (AR 535). 

Dr. King made the following notes regarding Salinas’ current level of daily 

functioning: 

Mr. Salinas is up by 4 or 5 in the morning. He tries to monitor 

his movements as to prevent spasms or acute flares . . . He is 

able to cook things in the microwave if his fiancé is not at 

home, but otherwise relies on her to do all of the cooking, yard work, chores, laundry, and driving. He has attempted to 

do things like wash dishes, but cannot stand longer than five 

minutes. . . . Mr. Salinas is inactive and expressed his 

frustration with a 30 to 40 pound weight gain since the time 

of his accident. Prior to his injury, he was able to play 

basketball, play physically with his dogs, do the dishes, and 

yard work. . . . Mr. Salinas demonstrates overall ability to 

independently maintain a household. He demonstrates 

compromised but minimally sufficient levels of 

concentration, persistence, and pace necessary to complete 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 12 of 47
- 13 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

domestic chores and engage in leisure pursuits. 

(AR 535–36). Dr. King noted that Salinas “presented with good interpersonal skills, 

although he appeared to be in significant pain, and was anxious for the appointment to be 

completed.” (AR 536). Dr. King observed the following regarding Salinas’ mental status: 

Mr. Salinas presented with a painful expression, but was able 

to smile appropriate to context, although his range of affect 

was fairly restricted overall. [He] reports a depressed mood, 

and had daily, passive thoughts of suicidal ideation in which 

he wishes to avoid the pain, even if it means ending his life. . 

. . He has noticed increased irritability, which he describes as 

‘snappiness’ and anger at others, based on his inability to 

work but desire to do so. His worries are fairly typical in 

nature, such as concern about finances and credit cards after 

his loss of income. . . . He reports low levels of energy, 

feeling drained and fatigued since the time of his accident. 

He had no problems with concentration in the past, but now 

has difficulty focusing. . . . Mr. Salinas has some problems 

with sleep since the accident, in that he is awake because of 

the pain and sleeps five hours on average. . . . Mr. Salinas 

demonstrated no significant problems with cognitive 

functioning . . . and appeared to be functioning in at least the 

average range of intelligence . . . Although he reports 

difficulty with concentration, his ability to focus appeared 

fairly intact as evidenced by a subtracting backwards on the 

serial sevens task. He demonstrated poor judgment in 

response to a scenario presented to him, and also appears to 

have a concrete thinking style. 

(AR 536–37). Dr. King’s diagnosis was: adjustment disorder with depressed mood 

(chronic), pain disorder associated with lower back injury/pain (chronic), occupational 

problems (unemployed since time of injury), economic problems (currently unable to pay 

many of his bills), inadequate access to healthcare services (uninsured since February 

2012, and unable to afford prescription medications or health care appointments). (AR 

537). Dr. King assessed a current GAF3 score of 55, and a GAF score of 50 for the past 

year.

Dr. King also completed a Psychological/Psychiatric MSS, and indicated that 

Salinas had a psychological diagnosis with limitations expecting to last 12 continuous 

months. (AR 538). Dr. King stated that “Mr. Salinas demonstrates the ability to 

 

3

 Global assessment of functioning 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 13 of 47
- 14 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

understand and remember detailed instructions.” Regarding sustained concentration and 

persistence, Dr. King noted that 

Mr. Salinas presents with moderate to marked limitations 

based on his reported level of chronic and persistent pain. 

Based on his reported presentation, he would have difficulty 

performing tasks within a normal work day due to significant 

interruptions and frequent rest periods. However, Mr. Salinas 

reports contradictory information from an independent 

medical examiner that apparently alleged the claimant was 

able to return to employment in February 2012. 

Id. Dr. King also opined that Salinas “should have no difficulty getting along with others 

within the realm of recent superficial contact” and that Salinas “demonstrates the ability 

to travel in unfamiliar places as well as utilize public transportation.” (AR 539). 

D. Additional Medical Information 

Salinas was seen by Karen Lunda, PT, for a functional capacity evaluation 

(“FCE”) on November 28 and 29, 2011. Lunda noted that Salinas was “pleasant and 

cooperative and put forth good effort over the two days of testing” (AR 418), and that he 

“demonstrated a consistent reliable performance (AR 422). The findings on exam 

included: 

Decreased hip and trunk rotation along with decreased arm 

swing during ambulation (consistent with decreased spinal 

mobility) 

Decreased intervertebral mobility during active trunk ROM 

testing 

Decreased intervertebral mobility with PA glides in the lower 

thoracic and lumbar spine with reproduction of the client’s 

reported pain 

Consistent palpation exam performed before and after both 

days of testing. The areas reported as symptomatic were 

marked with an ink pen. These areas were the same areas the 

client pointed to when reporting an increase in symptoms during functional testing. 

(AR 418). Lunda noted that Salinas scored 68 on the Oswestry Low Back Pain Scale, 

which falls in the “crippled” category and is defined as “back pain impinges on all 

aspects of the patient’s life.” (AR 419). Salinas reported that he had been placed on 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 14 of 47
- 15 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

multiple medications for his pain, none of which had helped except for Diclofenac, and 

that while the Diclofenac helped somewhat, it did not affect the cause of his pain. (AR 

422). Salinas also reported that any physical activity increases his symptoms, and that if 

he doesn’t stop what he is doing, his back will tighten up and may go into spasm and then 

lock up. Id. Lunda noted that Salinas’ “functional abilities and limitations were consistent 

with his diagnoses, his past medical history and objective physical examination findings” 

(AR 422), and that although he “was limited at times by a subjective report of an increase 

in symptoms,” his symptoms were consistent with his physical exam and his report was 

credible (AR 423). 

Regarding Salinas’ ability to return to work, Lunda made the following 

recommendations: 

Lift from floor to waist 10 pounds rarely and 5 pounds 

occasionally 

Lift from waist to overhead 10 pounds rarely and 5 pounds 

occasionally 

Horizontal lift 25 pounds rarely and 15 pounds occasionally 

Two hand carry 25 pounds rarely and 15 pounds occasionally 

One hand carry 15 pounds rarely and 10 pounds occasionally 

Push 87 pounds of force rarely and 65 pounds occasionally 

Pull 88 pounds of force rarely and 66 pounds occasionally 

Lifting, carrying, pushing and pulling should be performed to 

tolerance with positional/activity changes allowed as needed 

Crouching could be performed on a rare basis 

Kneeling, walking, stair climbing and ladder climbing could 

be performed occasionally if performed to tolerance with 

positional changes allowed as needed 

Repetitive squatting, elevated work and forward bending in 

standing could be performed frequently, and should be performed to tolerance with positional changes allowed as 

needed. 

(AR 424–25). Lunda recommended physical therapy to “address the decrease in vertebral 

mobility and the right hip adductor musculature.” (AR 418). 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 15 of 47
- 16 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

Salinas was seen by Dr. Jon Ostrowski on February 15, 2012 for an independent 

medical examination for his worker’s compensation claim. (AR 571). Salinas’ chief 

complaint was low back pain with radiation of pain up into the neck. He reported that he 

did not think the PT sessions were helping, and that every day he had different types of 

pain in different areas, including his neck, mid back, and low back. (AR 572). Salinas 

stated that he felt like there was a lump in his back that moved around to the right or left 

side, that he had burning pain radiating to his neck, and that he had episodes of very 

sharp pain in his upper and lower back. His back pain increases with prolonged standing 

or when he tries to walk more than 100 yards. He also reported recent onset of a 

throbbing pain in his heels. Dr. Ostrowski noted Salinas had been prescribed muscle 

relaxers, anti-inflammatories, and prednisone, and was currently taking Diclofenac but 

did not feel it was very effective. Salinas stated his lowest pain level was a 5/10, his 

highest pain level was 10/10, and that his current pain was a 5/10. Salinas reported he had 

just obtained a lumbar corset but hadn’t had a chance to use it yet, and also had a referral 

to be evaluated by a pain management specialist. 

 On physical examination, Dr. Ostrowski made the following observations: 

Gait is normal. He does not use an assistive device for 

ambulation. He is able to get on and off the examination table 

without difficulty or assistance. . . . 

Cervical spine range of motion is full and pain free. Cervical 

foraminal compression testing is negative bilaterally. Gentle 

axial compression does not produce any complaints of pain. 

Thoracic spine is nontender to percussion. Lumbar spine 

range of motion is full. He is able to get his fingertips within 

6 inches of the floor when bending forward. . . . 

Range of motion of the bilateral shoulders is full and pain 

free. . . . 

There is moderate tightness of the bilateral hamstring 

musculature. . . . Range of motion of the bilateral hips, knees 

and ankles are full. . . . There is mild tenderness to palpation 

of the mid right abductor musculature. 

Manual muscle testing is grade 5/5 in the bilateral upper and 

lower extremities. . . . He reports pain with palpation 

diffusely in the mid and low lumbar paraspinal musculature. . . . There was no involuntary muscle spasm noted in the 

cervical, thoracic or lumbar musculature. . . . 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 16 of 47
- 17 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

He is able to heel and toe walk without difficulty. Tandem 

gait is quite unsteady. Squat and return is full. 

(AR 573–74). Dr. Ostrowski’s impression was “[s]ubjective complaints of migratory and 

fluctuating levels of neck and back pain.” (AR 574). He further stated that: 

Mr. Salinas’ current subjective complaints are widespread 

and do not appear to have any specific relationship to the 

alleged industrial injury. There are no objective abnormal 

findings on physical examination which are consistent with a 

definable myofascial pain, orthopedic spinal problem or 

neurologic spine disorder. He does have the presence of an 

old calcified disk herniation at L5–S1 which does not 

correlate to any of his current symptomology nor does the 

disk herniation appear to be secondary to the industrial injury. 

(AR 574). Dr. Ostrowski noted Salinas was receiving PT but no progress was reported, 

and stated that he would not recommend any further treatment with PT or pain 

medications. (AR 574–75). Dr. Ostrowski further opined that no additional treatment was 

indicated, and that Salinas could return to work full time at regular duty and did not need 

permanent or temporary work restrictions. (AR 575). Dr. Ostrowski also stated that 

Salinas was not disabled and did not meet the criteria for a permanent impairment rating 

because he “did not have a defined etiology for his pain complaints and there has been a 

great deal of fluctuation in the nature and location of these complaints over time.” (AR 

575–76). 

On June 12, 2012 DDS physician Dr. Charles Fina made an initial determination 

that Salinas was not disabled. (AR 60). Dr. Fina completed a RFC assessment with the 

following limitations: occasionally lift and carry 20 pounds, frequently lift and carry 10 

pounds, stand and walk 6 hours, sit 6 hours, unlimited pushing and pulling, frequently 

kneel, balance, and climb ramps and stairs, and occasionally stoop, crawl, crouch, and 

climb ladders, ropes, and scaffolds. (AR 66). Disability examiner Ann Abyad noted that 

Salinas’ RFC was for light work and opined that he could return to his past work as a 

quality control technician as that job is typically performed in the national economy. (AR 

67–68). 

 On reconsideration, Salinas was again found not disabled on November 16, 2012. 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 17 of 47
- 18 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

(AR 70). Regarding Salinas’ mental impairments, Dr. Andres Kerns found that Salinas 

had mild restriction of activities of daily living, mild difficulties in maintaining social 

functioning, moderate difficulties in maintaining concentration, persistence, or pace, and 

no repeated episodes of decompensation of extended duration. (AR 79). Dr. Kerns made 

a mental RFC assessment and found Salinas was moderately limited in the following 

areas: ability to maintain attention and concentration for extended periods, ability to 

perform activities within a schedule, maintain regular attendance, and be punctual within 

customary tolerances, ability to complete a normal workday and workweek without 

interruptions from psychologically based symptoms and to perform at a consistent pace 

without an unreasonable number and length of rest periods, and ability to respond 

appropriately to changes in the work setting. (AR 83–84). Dr. Kerns opined that Salinas 

was “able to maintain adequate attention and concentration for simple routines and to 

sustain a workday/workweek schedule” (AR 83) and that Salinas could “adapt to simple 

changes, avoid obvious hazards, and travel” (AR 84). Dr. Kerns also stated that Salinas 

could: 

meet the basic mental and emotional demands of competitive, renumerative, unskilled work including the abilities (on a 

sustained basis) to: 

A) Understand, carry out, and remember simple instructions. 

B) Make simple work-related decisions. 

C) Respond appropriately to supervision, co-workers, and 

work situations. 

D) Deal with routine changes in a work setting. 

(AR 84). 

Regarding Salinas’ physical impairments, Dr. Woodard found that Salinas was 

only partially credible because his allegations of total and permanent disability exceeded 

the limitations that would reasonably be expected based on the totality of the evidence. 

(AR 80). Dr. Woodard made the same RFC assessment as Dr. Fina. (AR 81–82). Dr. 

Woodard noted that Dr. Hassman’s opinion was more restrictive but that that opinion 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 18 of 47
- 19 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

relied heavily on Salinas’ subjective report of symptoms and limitations that were not 

supported by the evidence, and that Dr. Hassman’s opinion had inconsistencies. (AR 84). 

Dr. Woodard also stated that Dr. Hassman’s “opinion is an overstatement of the severity 

of the individual’s restrictions/limitations based only on a snapshot of the individual’s 

functioning,” whereas Dr. Woodard’s RFC finding was based on the totality of the 

evidence. (AR 85). 

The reconsideration report also found that Salinas could not perform his past 

relevant work as a prep cook because that work exceeded his RFC for light work, and 

could not perform his past relevant work as a quality control technician because of his 

mental RFC. (AR 85). However, the report noted that Salinas retained the capacity to 

perform other light, unskilled work, and thus was not disabled. (AR 86). 

E. Plaintiff’s Testimony

On a Disability Report dated February 22, 2012 Salinas reported that he injured 

his back and spine in a fall at work, that his condition caused him pain, and that he had 

stopped working because of his condition. (AR 179). 

On an Exertional Daily Activities Questionnaire dated May 16, 2012 Salinas 

reported that he “can’t do much like stand, walk,” that he had sleepless nights, and that 

his girlfriend helped out a lot. (AR 189). He reported dizziness and drowsiness were side 

effects of his medication. Salinas stated he could walk 20 yards and then had to stop 

because his ankles would swell up, his back would hurt, and his back and waist would 

want to lock up. He stated he could not lift and carry, did not do the grocery shopping, 

did not clean, cook, do laundry, yardwork, or other chores, drove very little, and had no 

activities. (AR 190). Salinas reported that he sleeps for 3 hours off and on, and that he 

also naps for several hours a day. He uses a cane to help walk. (AR 191). He described a 

burning sensation up and down his waist and reported his lower back was in constant 

pain, and that his feet swell up. (AR 191). 

On a Disability Report—Appeal dated July 6, 2012 Salinas reported his condition 

had gotten worse as of March 1, 2012, and that he had swelling of the joints, ankles, and 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 19 of 47
- 20 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

knees, was unable to walk, stand, or sit for any long period of time without being in 

severe pain, had trouble sleeping, and had trouble performing his everyday functions. 

(AR 200). Salinas also reported that he needed a cane to walk, and that he was physically 

and mentally stressed and exhausted due to pain and lack of sleep. He noted that he could 

not work so he was unable to obtain medical insurance, and that his pain was getting 

worse but he could not obtain medical treatment or pain medication. (AR 201). Salinas 

stated his girlfriend “needs to care for me with driving walking and keeping up our 

home” and that he “struggle[s] with driving and doing any household up keep.” (AR 

203). Salinas also stated that “[t]he lack of sleep due to pain and financial distress have 

put me in a depression. I can not [sic] think clearly.” Id. 

On a Function Report dated October 25, 2012 Salinas reported he was in severe 

pain and had no insurance to go to the doctor. (AR 208). He described his typical day as 

eating meals, watching TV, getting ready for bed, and not doing any heavy lifting. (AR 

209). Salinas stated he did not take care of any other people or animals, and that before 

his illness he could work 50 hours a week, take care of animals, and play sports. He 

reported that his pain was unbearable and his medications made him nauseous and 

restless and caused weight gain. Regarding his personal care, Salinas stated he could not 

tie his shoes, put on clothes, or button, had less desire to bathe because he was not very 

stable, washing his hair was difficult, and shaving, feeding himself, and using the toilet 

were ok. (AR 210). He reported that he never prepared his own meals (AR 210), did no 

chores or yardwork, went out four times a week with his fiancé or brother-in-law, drove 

very little (“only if necessary”), and did no shopping (AR 211). Salinas stated his fiancé 

handles all the finances and that he had no desire and a lack of concentration to handle 

money since his illness. (AR 212). The “only thing he can do is watch tv,” which he does 

every day, but Salinas noted watching TV used to be enjoyable and “now it is to [sic] 

painful and depressing.” Salinas reported he was “homebound” and that needed someone 

to accompany him places, and that he had no social activities. (AR 212–13). Salinas 

indicated that his illness affects his ability to: lift, squat, bend, stand, reach, walk, sit, 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 20 of 47
- 21 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

kneel, climb stairs, remember, complete tasks, concentrate, and use his hands. (AR 213). 

He stated he had very limited mobility due to chronic severe pain all over, could walk 20 

yards and then needed to rest, and indicated the amount of time he could pay attention 

varied. Salinas also stated he did not finish what he started, and had limited concentration 

but could follow written and spoken instructions ok. 

On a Disability Report—Appeal dated December 11, 2012, Salinas stated that his 

illness was worse since last completing a disability report and that he had more 

limitations and fewer activities. (AR 223, 226). Salinas stated that he was having more 

trouble using his arms and hands, and had numbness and pain in his feet. He reported that 

he needed help with bathing and dressing and that he needed to sit down to put on his 

shoes and only wore slip on shoes. (AR 226). 

Salinas testified at his hearing before the ALJ on June 6, 2013. Salinas stated that 

he lived with his fiancé, brother-in-law, and four dogs, and that he did not do anything to 

care for the dogs. (AR 36). He testified that he was injured on the job on March 20, 2011, 

that worker’s compensation sent him for an independent medical exam and the doctor 

told him to go back to work the next day, and that he did not return to work because he 

was unable to work. (AR 38). He tried to take action to appeal the closing of his worker’s 

compensation case but was not able to obtain counsel in time for the hearing. (AR 38–

39). Salinas stated that since he stopped working, he supports himself financially by 

borrowing money from his mom, sister, and fiancé, and receives food stamps. (AR 39). 

He also received worker’s compensation money until his case was closed and lived on 

that for one year. (AR 42). 

Salinas testified that that he was currently seeing Dr. Milazzo for treatment of his 

pain, and was not receiving PT. (AR 41). When questioned by the ALJ as to whether 

there was some explanation as to why Dr. Hassman’s “findings were sort of dramatic in 

nature about the problems you were having,” Salinas stated that at that time he had run 

out of medication and was not seeing a doctor, so it was a tough time for him. (AR 42–

43). The ALJ questioned whether Salinas was “actually better than what that report 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 21 of 47
- 22 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

would suggest? That was just a particular bad day for you?” and Salinas said “yeah” and 

agreed that his medications helped. (AR 43). 

Salinas testified that he had pain every day and stated “It’s 24/7, right now.” (AR 

43). He described his pain as “centralized on the back of my lower back, waist, on the left 

side,” a burning sensation up and down his spine, and if he walks a certain distance there 

is burning pain down the back of his legs to the bottom of his feet and it feels like he is 

walking on nails. (AR 47). His feet and ankles also swell. Without medication, he rated 

his pain at a 7 or 8/10, and a 10/10 when he had a spasm attack. (AR 43). With 

medication, Salinas said his pain was a 6 and was “constantly burning.” There are no 

days when he is not in pain. (AR 44). He can stay on his right side but has problems 

sleeping, and has to be careful with his movements because “[m]ovements is what causes 

my pain.” Salinas stated that he does not move at all if possible, and that if he raises his 

arms up for 5 to 10 minutes to read a newspaper, his back goes into spasm and severe 

pain. All day he tries to prevent his back from going into spasm, so he avoids movement 

and spends his time in a recliner or lying on his side in bed. (AR 47). Salinas testified that 

he was currently taking Ibuprofen 400 for pain (AR 43), and while the transcript is 

somewhat unclear, it seems that Salinas was also taking a second pain medication (AR 

44). 

Regarding his emotional health, Salinas stated that he was definitely suffering 

from depression because his life had completely changed since the day of his accident. 

(AR 48). He was not getting any treatment or taking medication for his depression, and 

stated that “there’s other medications Milazzo has prescribed for me but due to the fact I 

have no income, or any type of insurance, I can’t afford those medications.” 

Salinas testified that he could stand longer than sit (AR 44), and that he can stand 

still for about a half hour and sit for about 15 minutes (AR 45). When questioned how he 

got to the hearing and whether he could sit for the whole drive, Salinas testified that his 

brother-in-law was his driver and that the car had reclining seats so that Salinas could 

recline back and relieve the stress on his back. (AR 45–46). When questioned about 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 22 of 47
- 23 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

chores, Salinas stated that he did not do laundry, cook, or go grocery shopping, and that 

“washing dishes because of the arm movements or anything like that, puts the back into 

spasms.” (AR 46). 

F. Vocational Evidence 

At the hearing before the ALJ, Lynda Berkley testified as a vocational expert. She 

stated that Salinas’ past work with Baxter Health Care as a warehouse worker was 

classified as medium, and that his work as a quality control technician was classified as 

light work but Salinas performed it at the medium level. (AR 51). The ALJ noted she was 

not going to count Salinas’ past work as a kitchen helper because it “was a pretty short 

job.” 

Based on the first hypothetical provided by the ALJ,4 Berkley testified that Salinas 

could not perform his past relevant work as a quality control inspector as he actually 

performed it, but that he could perform the work as it is described in the DOT. (AR 53). 

Based on the second hypothetical provided by the ALJ, which included some moderate 

mental limitations,5 Berkley testified that Salinas could not perform the job of quality 

control inspector. (AR 54). When the ALJ questioned what jobs the person could do, 

Berkley stated “I don’t believe any, and primarily because of the -- if there’s a moderate 

impairment in maintaining regular attention -- attendance, being punctual, working within 

a consistent pace, I think that’s going to preclude all work.” Based on the third 

hypothetical provided by the ALJ, which did not include limitations on concentration, 

 

4 This hypothetical included the following: lift and carry 20 pounds occasionally and 10 pounds frequently, stand or walk for 6 hours, sit for 6 hours, occasionally climb 

ladders, ropes, scaffolds, stoop, crouch, and crawl, frequently climb ramps and stairs, 

balance, and kneel. (AR 53). 

5 The ALJ added to the first hypothetical the following: moderate limitations in ability to maintain concentration and attention for extended periods, perform activities 

within a schedule, maintain regular attendance and be punctual, complete a normal 

workday and workweek without interruptions from psychologically based symptoms, 

perform at a consistent pace, and respond appropriately to changes in the work setting. 

(AR 53–54). The ALJ defined “moderate” as “more than a slight limitation in this area but the individual is still able to function satisfactorily.” (AR 53). 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 23 of 47
- 24 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

attention, attendance or pace,

6 Berkley testified that Salinas could not perform his past 

relevant work but could do other light work, specifically the jobs of a housekeeper 

cleaner or a fast food worker. (AR 55). 

When questioned by Salinas’ attorney, Berkley stated that her understanding of 

simple work is that it is unskilled work (AR 56), and that someone with mild limitations 

could still sustain unskilled work (AR 57). Berkley further stated that someone with 

moderate to marked limitations in concentration, persistence, and pace would be 

precluded from all work. (AR 57). 

G. ALJ’s Findings 

The ALJ found that Salinas had the following severe impairments: back pain and 

depression. (AR 15). The ALJ noted that these impairments were more than slight 

abnormalities and had more than a minimal effect on Salinas’ ability to do basic physical 

or mental work activities and were therefore severe. The ALJ also considered the 

Paragraph B criteria set out in the social security disability regulations for evaluating 

mental disorders.7

 The ALJ found Salinas had mild limitations in activities of daily living 

and maintaining social functioning, moderate difficulties in maintaining concentration, 

persistence, or pace, and had no episodes of decompensation of an extended duration.

(AR 16). 

The ALJ found Salinas’ testimony regarding the intensity, persistence, and 

limiting effects of his symptoms was not fully credible based on his ability to participate 

in activities and because the medical evidence did not support the severity of the alleged 

 

6 The ALJ added to the first hypothetical the following: mild limitations in understanding and remembering simple instructions, carrying out simple instructions, and 

ability to make judgments on simple work related decisions. Moderate limitations in 

ability to understand, remember, and carry out complex instructions, ability to make judgments on complex work related decisions, and ability to respond appropriately to 

usual work situations and change in a routine work setting. (AR 55). 

7 The criteria are: (1) activities of daily living; (2) social functioning; (3) 

concentration, persistence, or pace; and (4) periods of decompensation. As to the first 

three of these, the court determines whether their severity is none, mild, moderate, 

marked, or extreme. As to the fourth criteria, it is the number of times these “periods of 

decompensation” occur. See 20 CFR 404.1520a(d)(1) and 20 CFR 404, Subpart P, App. 1, § 12.00 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 24 of 47
- 25 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

allegations. (AR 18–19). The ALJ noted that while Salinas stated he could not do much 

and his girlfriend helped out a lot, Salinas also said he could drive very little, and 

acknowledged his daily activities included eating, watching television, and getting ready 

for bed. (AR 18). The ALJ also noted that while Salinas said he did not do any heavy 

lifting, he provided no limitations for light lifting, which the ALJ found “inconsistent 

with his previous allegations of not being able to lift and/or carry.” The ALJ further noted 

that while Salinas alleged he could not tie his shoes or put on clothes with buttons, 

“[o]therwise he acknowledged the ability to perform all other personal care activities with 

some difficulty bathing and caring for hair.” The ALJ also pointed to Salinas’ statements 

that he went outside four times a week, could go out alone, could drive very little only if 

necessary, spent time with his family, could walk 20 yards and then required varying 

minutes of rest, his ability to concentrate varied, and he could follow spoken instructions. 

The ALJ also noted that Salinas testified that he was not receiving PT at the time 

of the hearing, that he admitted he felt better with pain medication, that he was not taking 

any pain or depression medication at the time of the CEs in November 2012 and that he 

was not as bad now as he was in November 2012 because he was now on pain 

medication, and that at the time of the hearing he was not taking mental health 

medications or receiving psychiatric treatment. (AR 18). 

The ALJ also considered the medical evidence and found that it did not support 

Salinas’ allegations because Salinas “was documented as receiving routine and 

conservative treatment for back pain, numbness, and spasms.” (AR 19). The ALJ further 

noted that Salinas was prescribed medications, received PT and facet block, and stated 

his medications were helpful. The ALJ also found that Salinas’ diagnostic images did not 

support the severity of his allegations, and that the EMG and nerve conduction velocity 

findings were normal. (AR 19–20). She summarized the abnormal MRI and CT findings 

but noted that “the remainder of the images were unremarkable.” (AR 19). 

The ALJ further found that Salinas failed to follow treatment recommendations, 

noting that Salinas was discharged from PT for failing to return/complete the program 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 25 of 47
- 26 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

and did not comply with the attendance policy by failing to show or cancelling three or 

more consecutive appointments. (AR 20). The ALJ also stated that Salinas was 

documented as refusing to go to PT in a treatment note dated April 24, 2013, and noted 

that while “it is not the primary basis for the decision in this case, the claimant’s failure to 

follow prescribed treatment without a good reason is a basis for finding the claimant is 

not disabled.” 

Regarding Salinas’ credibility as to his mental impairments, the ALJ found that 

while Salinas alleged he could not afford treatment, “[t]his is inconsistent with the fact 

that he did receive some treatment, including prescriptions for medication, after the 

alleged onset date.” (AR 22). The ALJ also noted “there is no evidence the claimant 

sought low cost or no cost mental health care.” The ALJ concluded that Salinas’ “failure 

to seek consistent mental health treatment and take mental health medications as 

prescribed demonstrates a possible unwillingness to do what is necessary to improve his 

condition” and “may also be an indication that his symptoms were not as severe as he 

purported.” 

The ALJ gave little weight to the opinion of Karen Lunda because the limitations 

noted by Lunda were inconsistent with Salinas’ statement that he drove 2 hours and 10 

minutes to the exam, stopping once for gas, and because Salinas’ examination was 

“generally unremarkable.” (AR 20). The ALJ also gave little weight to Dr. Bamford’s 

opinion, and noted that Dr. Bamford opined that Lunda’s limitations were cautious and 

generous, but that Salinas could return to work with the limitations noted by Lunda. The 

ALJ further noted that Lunda was a PT and thus not an acceptable medical source 

opinion, and Dr. Bamford’s opinion was related to Salinas returning to work. (AR 21). 

The ALJ gave great weight to the state agency physical medical consultants, 

noting that the physicians opined that Salinas could perform a range of light work. (AR 

21). The ALJ stated that she had assessed a similar RFC, taking into consideration 

Salinas’ subjective complaints and the entire objective record. 

The ALJ first stated that she gave great weight to the opinion of Dr. Ostrowski 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 26 of 47
- 27 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

(AR 21), but then stated that she gave his opinion some weight (AR 22). The ALJ noted 

that “Dr. Ostrowski stated there were no objective abnormal findings on physical 

examination that were consistent with a definable myofascial pain, orthopedic spinal 

problems, or neurologic spine disorder” and that Dr. Ostrowski opined that Salinas could 

return to work full-time with no temporary or permanent work restrictions. (AR 21). The 

ALJ noted that Dr. Ostrowski’s opinion was provided in the context of a workers 

compensation claim, but stated that he “was an independent medical examiner and 

subsequently did not have the same type of bias associated with medical opinions on 

either side of the workers compensation claim.” (AR 22). 

The ALJ gave little weight to Dr. Hassman’s opinion because her opinion “does 

not adequately take into consideration all of the claimant’s subjective and objective 

symptoms, signs, limitations, and severity of condition” and because Dr. Hassman did not 

“have access to the claimant’s entire medical record and testimony.” (AR 22). The ALJ 

also noted that Salinas testified that he was not taking any pain medication at the time of 

his appointment with Dr. Hassman and that his condition was improved with medication. 

The ALJ gave little weight to Dr. King’s opinion that Salinas had moderate to 

marked limitations, and noted that the ALJ found Salinas had different mental limitations 

based on the entire evidence of record. (AR 22–23). The ALJ also noted that Dr. King did 

not have access to the entire medical record and testimony, and that Salinas testified that 

he was not receiving mental health treatment or taking medications. (AR 23). 

The ALJ also gave little weight to the state agency psychological consultants who 

assessed some mild and moderate limitations on reconsideration. (AR 23). The ALJ noted 

that she had “provided for different attendance and punctuality limitations given the 

record” (AR 23), and that the state agency consultants “did not have the benefit of 

considering the additional evidence that was available only after the reconsideration 

determination including subsequent medical evidence and the hearing testimony” (AR 

24). 

 The ALJ concluded Salinas could perform light work with the following 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 27 of 47
- 28 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

restrictions: 

lifting and/or carrying 20 pounds occasionally and 10 pounds frequently; sitting, standing, and/or walking about six hours 

in an eight-hour workday; occasionally climbing ladders, ropes, or scaffolds; occasionally stooping, crouching, and/or 

crawling; frequently climbing ramps and stairs, balancing, 

and kneeling; mildly limited with understanding and 

remembering simple instructions, carrying out simple 

instructions, and making judgments on simple work-related 

decisions; moderately limited with understanding and 

remembering complex instructions, carrying out complex 

instructions, and making judgments on complex work-related 

decisions; no limitations with interacting appropriately with 

the public, supervisors, and/or coworkers; moderately limited with responding appropriately to usual work situations and to 

changes in a routine work setting; and moderately is defined 

as more than a slight limitation in this area but the individual 

is still able to function satisfactorily. 

(AR 17). At Step Five of the SSI/DIB evaluation process, the ALJ found Salinas was able 

to perform other work in the national economy including the jobs of housekeeper cleaner 

and fast food worker. (AR 24–25). The ALJ therefore concluded Salinas was not 

disabled. (AR 25). 

III. Standard of Review 

The Commissioner employs a five-step sequential process to evaluate SSI and 

DIB claims. 20 C.F.R. §§ 404.920, 416.1520; see also Heckler v. Campbell, 461 U.S. 

458, 460-462 (1983). To establish disability the claimant bears the burden of showing she 

(1) is not working; (2) has a severe physical or mental impairment; (3) the impairment 

meets or equals the requirements of a listed impairment; and (4) claimant’s residual 

functional capacity (“RFC”) precludes her from performing her past work. 20 C.F.R. §§ 

404.920(a)(4), 416.1520(a)(4). At Step Five, the burden shifts to the Commissioner to 

show that the claimant has the RFC to perform other work that exists in substantial 

numbers in the national economy. Hoopai v. Astrue, 499 F.3d 1071, 1074 (9th Cir. 2007). 

If the Commissioner conclusively finds the claimant “disabled” or “not disabled” at any 

point in the five-step process, she does not proceed to the next step. 20 C.F.R. §§ 

404.920(a)(4), 416.1520(a)(4). 

Here, Salinas was denied at Step Five of the evaluation process. Step Five requires 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 28 of 47
- 29 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

the ALJ to consider whether, based on the claimant’s RFC, the claimant can make an 

adjustment to a new kind of work. 20 C.F.R. § 416.920(a)(4)(v). If the ALJ determines 

the claimant can make an adjustment to other work, the disability claim is denied. Id. 

“While the claimant has the burden of proof at steps one through four, ‘the burden of 

proof shifts to the [Commissioner]’ at step five ‘to show that the claimant can do other 

kinds of work.’” Valentine v. Comm’r Soc. Sec. Admin., 574 F.3d 685, 689 (9th Cir. 

2009) (quoting Embrey v. Brown, 849 F.2d 418, 422 (9th Cir. 1988)). 

The findings of the Commissioner are meant to be conclusive. 42 U.S.C. §§ 

405(g), 1383(c)(3). The court may overturn the decision to deny benefits only “when the 

ALJ’s findings are based on legal error or are not supported by substantial evidence in the 

record as a whole.” Aukland v. Massanari, 257 F.3d 1033, 1035 (9th Cir. 2001). As set 

forth in 42 U.S.C. § 405(g), “[t]he findings of the Secretary as to any fact, if supported by 

substantial evidence, shall be conclusive.” Substantial evidence “means such relevant 

evidence as a reasonable mind might accept as adequate to support a conclusion,” 

Valentine, 574 F.3d at 690 (internal quotation marks and citations omitted), and is “more 

than a mere scintilla, but less than a preponderance.” Aukland, 257 F.3d at 1035. The 

Commissioner’s decision, however, “cannot be affirmed simply by isolating a specific 

quantum of supporting evidence.” Sousa v. Callahan, 143 F.3d 1240, 1243 (9th Cir. 

1998) (internal citations omitted). “Rather, a court must consider the record as a whole, 

weighing both evidence that supports and evidence that detracts from the Secretary’s 

conclusion.” Aukland, 257 F.3d at 1035 (internal quotation marks and citations omitted). 

The ALJ is responsible for resolving conflicts in testimony, determining 

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

1995). “When the evidence before the ALJ is subject to more than one rational 

interpretation, [the court] must defer to the ALJ’s conclusion.” Batson v. Comm’r Soc. 

Sec. Admin., 359 F.3d 1190, 1198 (9th Cir. 2004). This is so because “[t]he [ALJ] and not 

the reviewing court must resolve conflicts in evidence, and if the evidence can support 

either outcome, the court may not substitute its judgment for that of the ALJ.” Matney v. 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 29 of 47
- 30 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

Sullivan, 981 F.2d 1016, 1019 (9th Cir. 1992) (internal citations omitted). 

Additionally, “[a] decision of the ALJ will not be reversed for errors that are 

harmless.” Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005). The claimant bears the 

burden to prove any error is harmful. McLeod v. Astrue, 640 F.3d 881, 888 (9th Cir. 

2011) (citing Shinseki v. Sanders, 556 U.S. 396, 129 S.Ct. 1696, 1706 (2009)). An error 

is harmless where it is “inconsequential to the ultimate nondisability determination.” 

Molina v. Astrue, 674 F.3d 1104, 1115 (9th Cir. 2012) (internal citations omitted); see 

also Stout v. Comm’r Soc. Sec. Admin., 454 F.3d 1050, 1055 (9th Cir. 2006). “[I]n each 

case [the court] look[s] at the record as a whole to determine whether the error alters the 

outcome of the case.” Molina, 674 F.3d at 1115. In other words, “an error is harmless so 

long as there remains substantial evidence supporting the ALJ’s decision and the error 

does not negate the validity of the ALJ’s ultimate conclusion. Id. (internal quotation 

marks and citations omitted). Finally, “[a] claimant is not entitled to benefits under the 

statute unless the claimant is, in fact, disabled, no matter how egregious the ALJ’s errors 

may be.” Strauss v. Comm’r Soc. Sec., 635 F.3d 1135, 1138 (9th Cir. 2011). 

IV. Analysis 

Salinas argues that the ALJ erred in weighing the medical opinions and in 

negatively assessing Salinas’ credibility, and contends that these errors resulted in a RFC 

assessment that is not supported by substantial evidence. (Doc. 23 at 1–2). Salinas also 

argues that the ALJ erred in making her Step Five determination that Salinas could 

perform other working existing in the national economy because the ALJ relied on the 

VE’s responses to the third hypothetical, which Salinas contends is inaccurate and not 

supported by the medical record. Id. at 24–25. Salinas argues that in light of Dr. King’s 

opinion and the VE’s responses to the second hypothetical, this matter should be 

remanded for an award of benefits. Id. at 26. Alternatively, Salinas requests that this 

matter be remanded for further administrative proceedings to give proper context to Dr. 

Ostrowski’s opinion and to provide the VE “a hypothetical that includes all the material 

and relevant mental and physical impairments that Salinas suffers from.” Id. 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 30 of 47
- 31 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

The Commissioner argues that the ALJ reasonably discredited Salinas’ subjective 

complaints and properly evaluated the medical opinions to include all credible limitations 

in the RFC finding. (Doc. 25 at 6, 11). The Commissioner further contends that the ALJ’s 

Step Five determination that Salinas could perform other work was supported by 

substantial evidence and that the ALJ properly relied on the VE’s testimony. Id. at 20–21. 

The Commissioner states that Salinas has failed to demonstrate harmful error requiring 

remand for an award of benefits, and requests that if the Court does find error, that this 

matter be remanded for further administrative proceedings. Id. at 22–23. 

The Court concludes that the ALJ erred in negatively assessing Salinas’ credibility 

based on his activities of daily living, and that she gave improper consideration to 

Salinas’ lack of treatment. These errors impacted the ALJ’s RFC assessment and the 

hypotheticals posed to the VE. Consequently, these errors were not harmless because 

they ultimately impacted the Step Five nondisability finding, and the Court finds remand 

is appropriate. 

A. RFC Assessment 

Residual functional capacity is “the most [a claimant] can still do despite [his] 

limitations,” and includes assessment of the claimant’s “impairment(s), and any related 

symptoms, such as pain, [which] may cause physical and mental limitations that affect 

what [he] can do in a work setting.” 20 C.F.R. § 404.1545(a)(1). In determining the RFC, 

if the ALJ finds a claimant cannot do his past work, the ALJ may still find that a claimant 

can adjust to other work if he can do any jobs that “exist in significant numbers in the 

national economy.” 20 C.F.R. § 404.1560(c)(1). 

The Commissioner retains the ultimate responsibility for assessing a claimant’s 

RFC. 20 C.F.R. §§ 404.1527(e)(2), 416.927(e)(2). The ALJ was required to assess 

Salinas’ RFC based on all the record evidence, including medical sources, examinations, 

and information provided by Salinas. 20 C.F.R. §§ 404.1545(a)(1)-(3), 416.945(a)(1)-(3). 

However, the ALJ need not include all possible limitations in her assessment of what a 

claimant can do, but rather is only required to ensure that the residual functional capacity 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 31 of 47
- 32 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

“contain[s] all the limitations that the ALJ found credible and supported by the 

substantial evidence in the record.” Bayliss v. Barnhart, 427 F.3d 1211, 1217 (9th Cir. 

2005). 

Here, Salinas challenges the ALJ’s RFC assessment based on the weighing of the 

medical opinions and the finding that Salinas was not fully credible. 

i. Credibility Finding 

The ALJ found that Salinas’ testimony regarding the intensity, persistence, and 

limiting effects of his symptoms was not fully credible based on his ability to participate 

in activities and because the medical evidence did not support the severity of the alleged 

allegations. (AR 18–19). Salinas argues that the ALJ failed to provide clear and 

convincing reasons for negatively assessing his credibility and that she gave improper 

weight to his activities of daily living and lack of medical treatment. (Doc. 23 at 18–23). 

“An ALJ’s assessment of symptom severity and claimant credibility is entitled to 

great weight.” Honaker v. Colvin, 2015 WL 262972, *3 (C.D. Cal. Jan. 21, 2015) 

(internal quotations and citations omitted). This is because “an ALJ cannot be required to 

believe every allegation of disabling pain, or else disability benefits would be available 

for the asking, a result plainly contrary to 42 U.S.C. § 423(d)(5)(A).” Treicherler v. 

Comm’r. Soc. Sec. Admin., 775 F.3d 1090, 1106 (9th Cir. 2014) (citation omitted). “If the 

ALJ’s credibility finding is supported by substantial evidence in the record, the reviewing 

court may not engage in second-guessing.” Honaker, 2015 WL 262972 at * 3 (internal 

quotations and citation omitted). 

While questions of credibility are functions solely for the ALJ, this Court “cannot 

affirm such a determination unless it is supported by specific findings and reasoning.” 

Robbins v. Comm’r Soc. Sec. Admin. 466 F.3d 880, 885 (9th Cir. 2006). “To determine 

whether a claimant’s testimony regarding subjective pain or symptoms is credible, an 

ALJ must engage in a two-step analysis.” Ligenfelter v. Astrue, 504 F.3d 1028, 1035–36 

(9th Cir. 2007). “First, the ALJ must determine whether the claimant has presented 

objective medical evidence of an underlying impairment ‘which could reasonably be 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 32 of 47
- 33 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

expected to produce the pain or other symptoms alleged.’” Id. at 1036 (quoting Bunnell v. 

Sullivan, 947 F. 2d 341, 344 (9th Cir. 1991)). “Second, if the claimant meets this first test 

and there is no evidence of malingering, ‘the ALJ can reject the claimant’s testimony 

about the severity of the symptoms only by offering specific, clear and convincing 

reasons for doing so.’” Lingenfelter, 504 F.3d at 1036 (quoting Smolen v. Chater, 80 F.3d 

1273, 1282 (9th Cir. 1996)). Further, “[t]he ALJ must specifically identify what 

testimony is credible and what testimony undermines the claimant’s complaints.” 

Morgan v. Comm'r of Soc. Sec. Admin., 169 F.3d 595, 599 (9th Cir. 1999). 

While it is permissible for an ALJ to look to the objective medical evidence as one 

factor in determining credibility, the ALJ’s adverse credibility finding must be supported 

by other permissible evidence in the record. Bunnell, 947 F.2d at 346-47 (“adjudicator 

may not discredit a claimant’s testimony of pain and deny disability benefits solely 

because the degree of pain alleged by the claimant is not supported by objective medical 

evidence”). However, “an ALJ may reject a claimant’s statements about the severity of 

his symptoms and how they affect him if those statements are inconsistent with or 

contradicted by the objective medical evidence.” Robbins, 466 F.3d at 887 (emphasis in 

original). 

“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). 

 Here, the ALJ did not make a finding that Salinas was malingering; therefore, to 

support her discounting of Salinas’ assertions regarding the severity of his symptoms, the 

ALJ had to provide clear and convincing, specific reasons. 

a. Activities of Daily Living

The ALJ’s credibility finding was based in part on her determination that 

“[d]espite his alleged limitations, the claimant has engaged in a somewhat normal level of 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 33 of 47
- 34 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

daily activity and social interaction.” (AR 18). The ALJ stated that Salinas’ 

activities of daily living included eating, watching television, 

and getting ready for bed. He stated he did not do any heavy 

lifting, but provided no limitations with regard to light lifting. 

This is inconsistent with his previous allegations of not being 

able to lift and/or carry. He alleged he could not tie his shoes 

or put on clothing with buttons. Otherwise, he acknowledged 

the ability to perform all other personal care activities with 

some difficulty bathing and caring for hair. He stated he went 

outside four times a week, he could go out alone, and he 

could drive very little only if necessary. He acknowledged he 

occasionally spent time with family, fiancé, brother-in-law, 

and visitors. 

Id. The ALJ further noted that “some of the physical and mental abilities and social 

interactions required in order to perform these activities are the same as those necessary 

for obtaining and maintaining employment.” Id. 

However, the ALJ’s summation of Salinas’ activities of daily living ignores 

Salinas’ own testimony regarding these activities. In contrast to the ALJ’s finding that 

Salinas could perform all personal care activities, Salinas stated that he had trouble 

performing his everyday functions (AR 200), and that he could not tie his shoes, put on 

clothes, or button, had less desire to bathe because he was not very stable, and that 

washing his hair was difficult (AR 210). Salinas also reported that he needed help with 

bathing and dressing and that he needed to sit down to put on his shoes and only wore 

slip on shoes. (AR 226). Similarly, while the ALJ found Salinas could watch TV, go out 

alone, and spend time with family and visitors, Salinas testified that he had no activities 

(AR 190, 213), that he watched TV every day and that it used to be enjoyable but was 

now painful and depressing (AR 212), and that he was homebound and that needed 

someone to accompany him places (AR 212). The ALJ also noted that one of Salinas’

daily activities was eating, but Salinas testified that he could not cook, do the grocery 

shopping, or do the dishes (AR 46, 190), and that he never prepared his own meals (210).

Salinas also consistently testified that he could not do any household chores or yardwork 

(AR 46, 190, 211), that he relied on his fiancé to care for him and their home (AR 189, 

203), and that he had difficulty sleeping due to pain (AR 44, 189, 191, 200). 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 34 of 47
- 35 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

“[D]aily activities may be grounds for an adverse credibility finding ‘if a claimant 

is able to spend a substantial part of his day engaged in pursuits involving the 

performance of physical functions that are transferrable to a work setting.’” Orn v. 

Astrue, 495 F.3d 625, 639 (9th Cir. 2007) (quoting Fair v. Bowen, 885 F.2d 597, 603 (9th 

Cir. 1989)). “The ALJ must make ‘specific findings relating to [the daily] activities’ and 

their transferability to conclude that a claimant’s daily activities warrant an adverse 

credibility determination.” Id. (quoting Burch v. Barnhart, 400 F.3d 676, 681 (9th Cir. 

2005). “ALJs must be especially cautious in concluding that daily activities are 

inconsistent with testimony about pain and other symptoms because impairments that 

would unquestionably preclude work will often be consistent with doing more than 

merely resting in bed all day.” Garrison v. Colvin, 759 F.3d 995, 1016 (9th Cir. 2014). 

“‘[M]any home activities may not be easily transferable to a work environment where it 

might be impossible to rest periodically or take medication.’” Id. (quoting Fair, 885 F.2d

at 603). 

“The critical differences between activities of daily living and 

activities in a full-time job are that a person has more flexibility in scheduling the former than the latter, can get 

help from other persons . . . , and is not held to a minimum 

standard of performance, as she would be by an employer. 

The failure to recognize these differences is a recurrent, and 

deplorable, feature of opinions by administrative law judges 

in social security disability cases.” 

Id. (quoting Bjornson v. Astrue, 671 F.3d 640, 647 (7th Cir. 2012)). 

“Here, there is neither evidence to support that [Salinas’] activities were 

‘transferrable’ to a work setting nor proof that [Salinas] spent a ‘substantial’ part of his 

day engaged in transferrable skills.” Orn, 495 F.3d at 639. Salinas’ daily activities of 

eating meals, watching TV, and getting ready for bed “are so undemanding that they 

cannot be said to bear a meaningful relationship to the activities of the workplace,” 

especially when taking into consideration Salinas’ statements that he is unable to walk, 

stand, or sit for any long period of time without being in severe pain (AR 200) and that he 

is always in pain (AR 43, 44, 47, 191, 208, 213). Id.; see also Garrison, 759 F.3d at 1016 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 35 of 47
- 36 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

(claimant’s “daily activities, as she described them in her testimony, were consistent with 

her statements about the impairments caused by her pain ... [and are] also consistent with 

an inability to function in a workplace environment.”). Further, “[t]he record does not 

suggest that Plaintiff at any time reported that [he] performed activities which would 

translate to sustained activity in a work setting on a regular and continuing basis for eight 

hours a day, five days a week.” Benjamin v. Colvin, 2014 WL 4437288, at *4 (C.D. Cal. 

Sept. 9, 2014). 

 A claimant “does not need to be ‘utterly incapacitated’ in order to be disabled.” 

Vertigan v. Halter, 260 F.3d 1044, 1050 (9th Cir. 2001) (quoting Fair, 885 F.2d at 603). 

Here, it is clear from Salinas’ testimony that his daily activities were extremely limited 

due to his pain, and the ALJ’s own notation that Salinas’ activities included “eating, 

watching television, and getting ready for bed” does not support her conclusion that 

Salinas had a “somewhat normal level of daily activity and social interaction” or that “the 

abilities and social interactions required in order to perform these activities are the same 

as those necessary for obtaining and maintaining employment.” (AR 18); see Garrison, 

759 F.3d at 1016 (quoting Reddick v. Chater, 157 F.3d at 722) (“Recognizing that 

‘disability claimants should not be penalized for attempting to lead normal lives in the 

face of their limitations,’ we have held that ‘[o]nly if [her] level of activity were 

inconsistent with [a claimant’s] claimed limitations would these activities have any 

bearing on [her] credibility.’”). 

Accordingly, the Court finds that the ALJ erred in finding that Salinas’ activities 

of daily living were inconsistent with his testimony regarding his pain-related 

impairments. Further, this error was not harmless. Had the ALJ credited Salinas’ 

testimony regarding his pain and limited daily activities, including Salinas’s testimony 

that he has pain “24/7,” can perform no household or yardwork tasks, and must 

frequently change positions from sitting to standing to take pressure off his back, it would 

have likely impacted the ALJ’s assessment of the medical evidence, the RFC finding, and 

the hypothetical posed to the VE. Thus, this error was harmful because it affected the 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 36 of 47
- 37 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

ultimate nondisability determination. See Molina, 674 F.3d at 1115. 

b. Lack of Treatment 

The ALJ’s finding that Salinas was not entirely credible regarding his pain and 

limitations was also based in part on her determination that the medical record did not 

support Salinas’ allegations. (AR 18). The ALJ noted that Salinas “was documented as 

receiving routine and conservative treatment for back pain, numbness, and spasms” and 

that Salinas’ diagnostic images did not support the severity of his allegations. (AR 19). 

However, the CT and MRI scans did reveal some abnormalities (AR 402, 405), and 

“[t]he amount of pain caused by a given physical impairment can vary greatly from 

individual to individual.” Fair, 885. F.2d at 601. 

The ALJ also noted that Salinas testified that he was not receiving PT at the time 

of the hearing, that he admitted he was feeling better with pain medication, that he was 

not taking any pain or depression medication at the time of the CEs in November 2012 

and that he was not as bad now as he was in November 2012 because he was now on pain 

medication, and that he was not taking mental health medications or receiving psychiatric 

treatment. (AR 18). The ALJ further found that Salinas failed to follow treatment 

recommendations, noting that Salinas was discharged from PT for failing to 

return/complete the program and did not comply with the attendance policy by failing to 

show or cancelling three or more consecutive appointments, and that Salinas was 

documented as refusing to go to PT in a treatment note dated April 24, 2013. (AR 20).

Regarding Salinas’ mental impairments, the ALJ found that Salinas’ allegation that he 

could not afford treatment was “inconsistent with the fact that he did receive some 

treatment, including prescriptions for medication, after the alleged onset date.” (AR 22). 

The ALJ also noted that “there is no evidence the claimant sought low cost or no cost 

mental health care.” The ALJ concluded that Salinas’ “failure to seek consistent mental 

health treatment and take mental health medications as prescribed” and his refusal to

attend PT “demonstrates a possible unwillingness to do what is necessary to improve his 

condition” and “may also be an indication that his symptoms were not as severe as he 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 37 of 47
- 38 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

purported.” (AR 20, 22). 

“[I]f a claimant complains about disabling pain but fails to seek treatment, or fails 

to follow prescribed treatment, for the pain, an ALJ may use such failure as a basis for 

finding the complaint unjustified or exaggerated.” Orn v. Astrue, 495 F.3d 625, 638 (9th 

Cir. 2007). However, “[d]isability benefits may not be denied because of the claimant’s 

failure to obtain treatment he cannot obtain for lack of funds.” Id. (quoting Gamble v. 

Chater, 68 F.3d 319, 321 (9th Cir. 1995)). While Social Security regulations require 

claimants to follow “treatment prescribed by [a] physician” to receive benefits, the same 

regulations make clear that if the claimant has “a good reason” for not following the 

prescribed treatment, rejection of treatment will not be held against the claimant. 20 

C.F.R. § 416.930(a) & (b); SSR 96–7p. The ALJ “‘must not draw any inferences about an 

individual’s symptoms and their functional effects from a failure to seek or pursue 

regular medical treatment without first considering any explanations that the individual 

may provide, or other information in the case record, that may explain infrequent or 

irregular medical visits or failure to seek medical treatment’ including inability to pay . . 

.” Orn, 495 F.3d at 638 (quoting SSR 96–7p at 7–8). 

Here, the ALJ’s decision seems to ignore the fact that Salinas has been without 

medical insurance for a number of years. Salinas repeatedly noted that he could not 

afford medical treatment or medications due to his lack of insurance and limited funds. 

(AR 48, 201, 208). Dr. Milazzo prescribed several medications for Salinas that he could 

not fill because he was unable to afford them, and while Dr. Bamford recommended facet 

block injections, there is no record of Salinas being seen at the pain clinic. As to Salinas’ 

alleged refusal to attend PT, the discharge summary notes that Salinas was seen for 8 

visits for back pain, and that Salinas was to call after his last doctor’s appointment if 

further PT was needed. (AR 495). Salinas did not call and was administratively 

discharged from PT. The discharge occurred shortly after Salinas saw Dr. Ostrowski, 

who stated that he would not recommend any further treatment with PT and opined that 

Salinas did not need additional treatment and could return to work full time. (AR 574–

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 38 of 47
- 39 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

75). Thus, Salinas explained his failure to pursue regular treatment based on lack of 

funds, and the fact that he was not regularly going to the doctor, attending PT, or taking 

mental health medications is not a clear and convincing reason for discrediting his 

symptom testimony. The ALJ did not suggest Salinas’ proffered reason for not seeking 

treatment was “not believable,” and the Court finds that “[Salinas’] failure to receive 

medical treatment during the period that he had no medical insurance cannot support an 

adverse credibility finding.” Orn, 495 F.3d at 638; see also Smolen, 80 F.3d at 1284 

(“Where a claimant provides evidence of a good reason for not taking medication for her 

symptoms, her symptom testimony cannot be rejected for not doing so.”). 

Accordingly, the Court finds the ALJ erred in improperly relying on Salinas’ lack 

of medical treatment as a reason to discount his credibility. Further, this error was not 

harmless. Had the ALJ properly considered Salinas’ lack of medical insurance as a reason 

for his “routine and conservative treatment,” the ALJ could not have relied on this lack of 

treatment to justify her adverse credibility finding, which in turn affected the ALJ’s RFC 

assessment and the hypotheticals posed to the VE. Thus, this error was harmful because it 

affected the ultimate nondisability determination. See Molina, 674 F.3d at 1115. 

ii. Medical Testimony 

Salinas alleges that the ALJ’s medical opinion weight findings are not supported 

by clear and convincing reasons and are inconsistent with the law and evidence. Salinas 

specifically objects to the ALJ’s assessment of the opinions of Dr. Ostrowski, Dr. 

Hassman, and Dr. King. 

The Ninth Circuit distinguishes between treating, examining, and nonexamining 

physicians, and as a general rule, more weight is usually accorded to the treating 

physician’s opinion. Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1996). The ALJ may 

reject a treating or examining physician’s uncontradicted opinion only if he gives clear 

and convincing reasons for doing so. Id. at 830-31; see also Weetman v. Sullivan, 877 

F.2d 20, 22 (9th Cir. 1989). If the treating or examining physician’s opinion is 

contradicted by another doctor, the ALJ may reject that opinion only if he provides 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 39 of 47
- 40 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

specific and legitimate reasons supported by substantial evidence in the record. Lester, 81 

F.3d at 830-31. Further, “when evaluating conflicting medical opinions, an ALJ need not 

accept the opinion of a doctor if that opinion is brief, conclusory, and inadequately 

supported by clinical findings.” Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th Cir. 2005). 

Finally, if the ALJ determines that the plaintiff’s subjective complaints are not credible, 

this is a sufficient reason for discounting a physician’s opinion that is based on those 

subjective complaints. Bray v. Comm’r Soc. Sec. Admin., 554 F.3d 1219, 1228 (9th Cir. 

2009). 

a. Dr. Ostrowski 

 Dr. Ostrowski performed an independent medical examination of Salinas for his 

worker’s compensation claim, and concluded that Salinas could return to work at regular 

duty with no temporary or permanent work restrictions. In her decision, the ALJ first 

stated that she gave Dr. Ostrowski’s opinion “significant weight,” and then later stated 

that she gave the opinion “some weight.” While it is thus unclear how much weight the 

ALJ actually assigned to Dr. Ostrowski’s opinion, the Court finds that Salinas has failed 

to show how any alleged error by the ALJ in evaluating Dr. Ostrowski’s opinion was 

harmful because the ALJ actually assessed more limitations in her RFC finding than what 

Dr. Ostrowski recommended. For example, while Dr. Ostrowski found that Salinas had 

no limitations and could return to his previous work as a prep cook full-time at regular 

duty, the ALJ found that Salinas was limited to light work, which precluded his past work 

as both a prep cook and a quality control technician. 

Salinas also contends that the ALJ erred in misconstruing the meaning of 

“independent medical examiner” because Dr. Ostrowski was hired by the insurance 

company to conduct an examination for Salinas’ worker’s compensation claim, and thus 

was not actually independent. However, as noted above, even if Dr. Ostrowski’s opinion 

cannot be considered to be truly independent, Salinas has failed to show harmful error on 

this issue because the ALJ actually assessed more limitations than Dr. Ostrowski 

recommended in his opinion. 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 40 of 47
- 41 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

Accordingly, the Court finds that the ALJ did not err in her assessment of Dr. 

Ostrowski’s opinion, and that if any error did occur, the error was harmless because it did 

not affect the ultimate nondisability determination. See Molina, 674 F.3d at 1115. 

b. Dr. Hassman 

 Dr. Hassman performed a physical medicine CE of Salinas. The ALJ gave little 

weight to Dr. Hassman’s opinion because it did “not adequately take into consideration 

all of the claimant’s subjective and objective symptoms, signs, limitations, and severity 

of condition” and because Dr. Hassman did not “have access to the claimant’s entire 

medical record and testimony.” (AR 22). The ALJ also noted that Salinas testified that he 

was not taking any pain medication at the time of his appointment with Dr. Hassman and 

that his condition was improved with medication. 

During the examination, Dr. Hassman noted that Salinas had a very abnormal gait, 

took tiny steps, and was very stiff. (AR 527). Salinas said he could not stand or walk on 

his toes or heels, could not hop, could not bend, could not kneel, and could not sit down 

because of pain. Dr. Hassman observed that Salinas “seemed to have an unusual response 

to anything I asked him to do. He sort of smiled to himself and looked around, as if he 

were confused and distracted, and just could not perform anything” and that when she 

asked him to perform cervical flexion, “[h]e obviously heard me but he did not move his 

head. Instead, he moved his eyes in all directions.” (AR 527). Dr. Hassman opined that 

Salinas could occasionally and frequently lift and carry less than 10 pounds, stand and 

walk at least 2 hours but less than 6 hours in an 8 hour workday, and sit for 3 hours. (AR 

528–29). She further opined that Salinas could occasionally stoop and reach, and that he 

could never kneel, crouch, crawl, or climb ramps, stairs, scaffolds, or ladders. (AR 530). 

Dr. Hassman’s opinion was contradicted by Dr. Ostrowski’s opinion, thus the ALJ 

was required to give specific and legitimate reasons for assigning Dr. Hassman’s opinion 

little weight. The Court finds that the ALJ has met this burden. First, the ALJ noted that 

Dr. Hassman’s opinion did not adequately take into consideration all of Salinas’ 

subjective and objective symptoms and the severity of his condition. As noted above, 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 41 of 47
- 42 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

during the exam Salinas refused to perform many of the tests, and had an “unusual 

response” to anything that Dr. Hassman asked him to do. The ALJ is not required to 

accept an opinion that is inadequately supported by clinical findings, thus the ALJ could 

properly discount Dr. Hassman’s opinion where the limitations Dr. Hassman assessed 

were not based on objective findings because Salinas refused to perform the tests. See 

Bayliss, 427 F.3d at 1216; see also Bullene v. Astrue, 2012 WL 6917774, *7 (W.D. 

Wash. 2012) (“[T]he ALJ was entitled to discount a medical opinion where the provider 

noted that the claimant did not put forth full effort on testing, because the opinion is 

based on invalid test results.”). Second, the ALJ noted that Dr. Hassman did not have 

access to Salinas’ entire medical record and testimony. At the hearing before the ALJ, 

Salinas testified that at that time of his appointment with Dr. Hassman, he had run out of 

medication and was not seeing a doctor, so it was a tough time for him. (AR 42–43). 

Salinas also agreed with the ALJ that he was “actually better than what [Dr. Hassman’s] 

report would suggest” and that the examination was performed on a particularly bad day 

for him. (AR 43). This was a specific and legitimate reason for the ALJ to assign little 

weight to Dr. Hassman’s opinion because the opinion was based on an incomplete and 

inaccurate understanding of Salinas’ condition. See Conlee v. Colvin, 31 F. Supp. 3d 

1165, 1172 (E.D. Wash. 2014); Chaudhry v. Astrue, 688 F.3d 661, 671 (9th Cir. 2012). 

Salinas also argues that the ALJ erred in failing to include Dr. Hassman’s 

lift/carry, sit/stand/walk, and stooping limitations in the hypothetical to the VE.8

However, the ALJ is only required to include restrictions in a hypothetical that are 

supported by substantial evidence. See Greger v. Barnhart, 464 F.3d 968, 973 (9th Cir. 

2006). Here, the ALJ assigned little weight to Dr. Hassman’s opinion, and gave specific 

and legitimate reasons for the weight finding. Because the ALJ properly assigned little 

weight to the opinion, the ALJ was not required to include all of Dr. Hassman’s 

limitations in the hypothetical to the VE, particularly where those limitations were not 

 

8 The ALJ did include Dr. Hassman’s restriction of occasional stooping, but did not assess the same lifting/carrying and sitting/standing/walking limitations as Dr. 

Hassman recommended. 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 42 of 47
- 43 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

supported by objective findings on examination. 

Accordingly, the Court finds that the ALJ did not err in assigning little weight to 

Dr. Hassman’s opinion, and in not including all of the limitations assessed by Dr. 

Hassman in the hypothetical to the VE. 

c. Dr. King 

Dr. King performed a psychological CE of Salinas and opined that Salinas had 

moderate to marked limitations in sustained concentration and persistence “based on his 

reported level of chronic and persistent pain.” (AR 538). Dr. King also found that 

“[b]ased on his reported presentation, he would have difficulty performing tasks within a 

normal work day due to significant interruptions and frequent rest periods.” Id. 

Dr. King’s opinion was contradicted by Dr. Kerns’ opinion, thus the ALJ was 

required to give specific and legitimate reasons for assigning Dr. King’s opinion little 

weight. The ALJ noted that Dr. King documented Salinas as being able to cook simple 

meals9

 and described Salinas as demonstrating overall ability to maintain a household, 

and observed that Salinas presented with good interpersonal skills, reported no symptoms 

of psychosis, and demonstrated no significant problems with cognitive functioning. (AR 

22–23). Thus, the ALJ pointed to specific findings in Dr. King’s report that undermined

Dr. King’s opinion that Salinas had moderate to marked limitations, and this

contradiction was a specific and legitimate reason to assign Dr. King’s opinion little 

weight. 

The ALJ also noted that “Dr. King stated that the claimant’s reports contradicted 

information from Dr. Ostrowski . . . that the claimant was able to return to employment in 

February 2012.” (AR 23). However, what Dr. King actually stated was that “Mr. Salinas 

reports contradictory information from an independent medical examiner that apparently 

alleged the claimant was about to return to employment.” (AR 538). Dr. King did not 

make her own independent finding that Salinas’ reports contradicted Dr. Ostrowksi’s 

 

9 Salinas objects to this wording, but Dr. King did specifically note that Salinas could cook things in the microwave. (AR 535). 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 43 of 47
- 44 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

opinion. Thus, this is not a specific and legitimate reason to reject Dr. King’s opinion. 

However, the Court must consider not just whether the ALJ erred, but whether the error 

was harmful. In this case, any error from the ALJ implying that Dr. King found a conflict 

between Salinas’ subjective complaints and Dr. Ostrowski’s opinion was harmless

because the ALJ provided additional legitimate reasons for assigning Dr. King’s opinion 

little weight. See Burch, 400 F.3d at 679. Because the ALJ gave at least one valid reason 

for assigning little weight to Dr. King’s opinion, the ALJ’s weight finding must be 

upheld. See Batson, 359 F.3d at 1198 (court must defer to ALJ’s conclusion when 

evidence is subject to more than one rational interpretation). 

B. Step Five Finding

 Salinas objects to the ALJ’s Step Five finding as “inconsistent with the evidence 

and the law.” (Doc. 23 at 23). At “step five of the five-step sequential inquiry, the burden 

shifts to the Commissioner to prove that, based on the claimant’s residual functional 

capacity, age, education, and past work experience, [he] can do other work.” Smolen v. 

Chater, 80 F.3d 1273, 1291 (9th Cir. 1996). “If [he] can, [he] is not disabled; if [he] 

cannot, [he] is disabled.” Id. “The Commissioner may carry this burden by ‘eliciting the 

testimony of a vocational expert in response to a hypothetical that sets out all the 

limitations and restrictions of the claimant.’” Conlee, 31 F. Supp. 3d at 1173 (quoting 

Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995)). “The ALJ’s depiction of the 

claimant’s disability must be accurate, detailed, and supported by the medical record.” Id. 

(citing Gamer v. Secretary of Health and Human Servs., 815 F.2d 1275, 1279 (9th 

Cir.1987) (hypothetical questions must “set out all of the claimant’s impairments”)). “‘If 

the assumptions in the hypothetical are not supported by the record, the opinion of the 

vocational expert that claimant has a residual working capacity has no evidentiary 

value.’” Id. (quoting Gallant v. Heckler, 753 F.2d 1450, 1456 (9th Cir. 1984)). “The ALJ, 

though, ‘is free to accept or reject restrictions in a hypothetical question that are not 

supported by substantial evidence.’” Greger v. Barnhart, 464 F.3d 968, 973 (9th Cir. 

2006) (quoting Osenbrock v. Apfel, 240 F.3d 1157, 1164-65 (9th Cir. 2001)). 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 44 of 47
- 45 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

Here, Salinas argues that the ALJ erred by relying on the VE’s response to the 

third hypothetical and concluding that Salinas could work as a housekeeper cleaner or a 

fast food worker. The third hypothetical included mild limitations in understanding and 

remembering simple instructions, carrying out simple instructions, and ability to make 

judgments on simple work related decisions, and moderate limitations in ability to 

understand, remember, and carry out complex instructions, ability to make judgments on 

complex work related decisions, and ability to respond appropriately to usual work 

situations and change in a routine work setting. (AR 55). Salinas argues that the third 

hypothetical is inaccurate and unsupported by the medical record because no 

psychologist opined that Salinas had mild impairments in the areas noted in the 

hypothetical. Rather, Salinas contends that Dr. King found that he had moderate to 

marked limitations in the areas of sustaining concentration, persistence, and pace, which 

the VE testified would preclude all work (AR 57). 

As discussed above, the Court finds that the ALJ did not err in assessing the 

medical opinions of Drs. Ostrowski, Hassman, and King; however, the Court does find 

that the ALJ erred in negatively assessing Salinas’ credibility based on his activities of 

daily living and lack of medical treatment. This credibility finding impacted the ALJ’s 

RFC determination, which in turn also impacted the ALJ’s hypotheticals to the VE. 

While the ALJ was only required to include limitations in the hypothetical that the ALJ 

found to be credible and supported by substantial evidence in the record, in this case the 

ALJ’s error in assessing Salinas’ credibility casts doubt on the reliability of the VE’s 

testimony at Step Five. Accordingly, the Court finds that remand is appropriate. 

V. Remedy

 A federal court may affirm, modify, reverse, or remand a social security case. 42 

U.S.C. § 405(g). Absent legal error or a lack of substantial evidence supporting the ALJ’s 

findings, this Court is required to affirm the ALJ’s decision. After considering the record 

as a whole, this Court simply determines whether there is substantial evidence for a 

reasonable trier of fact to accept as adequate to support the ALJ’s decision. Valentine, 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 45 of 47
- 46 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

574 F.3d at 690. 

“‘[T]he decision whether to remand the case for additional evidence or simply to 

award benefits is within the discretion of the court.’” Rodriguez v. Bowen, 876 F.2d 759, 

763 (9th Cir. 1989) (quoting Stone v. Heckler, 761 F.2d 530, 533 (9th Cir.1985)). 

“Remand for further administrative proceedings is appropriate if enhancement of the 

record would be useful.” Benecke v. Barnhart, 379 F.3d 587, 593 (9th Cir. 2004). 

Conversely, remand for an award of benefits is appropriate where: 

(1) the ALJ failed to provide legally sufficient reasons for 

rejecting the evidence; (2) there are no outstanding issues that 

must be resolved before a determination of disability can be 

made; and (3) it is clear from the record that the ALJ would 

be required to find the claimant disabled were such evidence 

credited. 

Benecke, 379 F.3d at 593 (citations omitted). Where the test is met, “we will not remand 

solely to allow the ALJ to make specific findings.... Rather, we take the relevant 

testimony to be established as true and remand for an award of benefits.” Id. (citations 

omitted); see also Lester v. Chater, 81 F.3d 821, 834 (9th Cir.1995). 

Here, the Court finds “[r]emand for further administrative proceedings is 

appropriate [because] enhancement of the record would be useful.” Benecke, 379 F.3d at 

593. The ALJ erred in finding that Salinas’ activities of daily living were inconsistent 

with his testimony regarding his pain-related impairments and in negatively assessing his 

credibility, as well as by giving improper consideration to Salinas’ lack of treatment. 

Because of these errors, issues remain regarding Salinas’ RFC and his ability to perform 

work existing in significant numbers in the national economy. This Court offers no 

opinion as to whether Salinas is disabled within the meaning of the Act. However, the 

ALJ is required to consider all of Salinas’ alleged impairments, whether severe or not, in 

her assessment on remand, and “[t]he RFC assessment must be based on all the relevant 

evidence in the case record.” SSR 96–8p, 1996 WL 374184, at *5 (emphasis in original) 

(“The adjudicator must consider all allegations of physical and mental limitations or 

restrictions and make every reasonable effort to ensure that the file contains sufficient 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 46 of 47
- 47 - 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

evidence to assess RFC. Careful consideration must be given to any available information 

about symptoms because subjective descriptions may indicate more severe limitations or 

restrictions than can be shown by objective medical evidence alone.”); C.F.R. § 

416.920(e) (ALJ must consider claimant’s subjective experiences of pain).

VI. Conclusion 

 In light of the foregoing, the Court REVERSES the ALJ’s decision and the case is 

REMANDED for further proceedings consistent with this decision, including additional 

hearing testimony, if necessary. 

 Accordingly, IT IS HEREBY ORDERED that the Commissioner’s decision is 

remanded back to an ALJ with instructions to issue a new decision regarding Salinas’ 

eligibility for disability insurance benefits. The ALJ will: (1) reassess Salinas’ credibility 

and activities of daily living; (2) give further consideration to all of the previously 

submitted medical records, (3) further develop the record to fully and fairly assess 

Salinas’ conditions and limitations, as warranted, (4) further consider Salinas’ residual 

functional capacity, citing specific evidence in support of the assessed limitations, and (5) 

continue the sequential evaluation process to assess whether in fact Salinas is disabled 

within the meaning of the SSA and whether he is able to perform any work existing in the 

national economy. 

IT IS FURTHER ORDERED the Clerk of the Court shall enter judgment, and 

close its file in this matter. 

 Dated this 8th day of March, 2016. 

Case 4:15-cv-00009-EJM Document 26 Filed 03/09/16 Page 47 of 47