Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_15-cv-01965/USCOURTS-casd-3_15-cv-01965-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:0405id Review of HHS Decision (SSID)

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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

CHARLES VINCENT SHORTS,

Plaintiff,

CASE NO. 15cv1965-BEN

(KSC)

ORDER GRANTING

PLAINTIFF’S MOTION FOR

SUMMARY JUDGMENT and

DENYING DEFENDANT’S

CROSS-MOTION FOR

SUMMARY JUDGMENT

vs.

CAROLYN W. COLVIN, Acting

Commissioner of Social Security,

Defendant.

An applicant may seek judicial review of a final agency decision pursuant to

42 U.S.C. §§ 405(g), 1383(c)(3). Plaintiff Charles Vincent Shorts filed this action

seeking judicial review of the Social Security Commissioner’s denial of his

application for disability insurance benefits. The Honorable Magistrate Judge

Karen S. Crawford issued a thoughtful and thorough Report and Recommendation

recommending the decision be affirmed. Plaintiff filed timely objections. Where a

timely objection to a report and recommendation has been filed, the district court

reviews de novo the report or recommendations to which an objection was filed. 28

U.S.C. § 636(b)(1). Having conducted a de novo review, the Court declines to

adopt the Report and Recommendation, grants Plaintiff’s motion for summary

judgment, and denies Defendant’s cross motion for summary judgment.

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BACKGROUND

The procedural history and a summary of the administrative record (“AR”) is

carefully and methodically laid out in the thorough Report and Recommendation.

Plaintiff applied for disability and supplemental security benefits claiming he was

unable to work as of January 30, 2012. He was diagnosed with a malignant,

inoperable, lethal brain stem tumor (or “glioma”) in 2010. He suffers from

recurring headaches and dizziness. The Administrative Law Judge (“ALJ”)

recognized as much: “The claimant has the following severe impairment:

inoperable brain stem glioma (malignant neoplasm of the brain stem) with chronic

headaches. . . .” (AR 24) (emphasis added). Indeed, Dr. Thomas Schweller, M.D.,

the board-certified consulting neurologist hired by the Commissioner to assess Mr.

Shorts, agreed. Dr. Schweller opined, 

He has chronic headache pain that periodically requires

emergency room treatment. There is no obvious evidence

of papilledema or increased intracranial pressure, but it is

certainly likely that there are some issues with circulation

due to brainstem glioma. This is a lethal condition that

will progress within a short period of time. It is uncertain

what the length of time this progression might be. At the

present time, he is not significantly symptomatic on his

physical examination. (AR 234).

Nevertheless, the ALJ concluded that Plaintiff was not disabled. The Appeals

Council denied review of the ALJ’s decision, and the ALJ’s decision became final. 

So, why did the ALJ find the Plaintiff not disabled? Because he found Plaintiff’s

pain testimony “not entirely credible.” Plaintiff would be found disabled if his

headache pain testimony is credited, because the vocational expert testified there

would be no jobs Plaintiff could do. (AR 44). Instead, the ALJ concluded:

The claimant has alleged disability due to chronic

headaches due to brain stem glioma. After careful

consideration of the evidence, the undersigned finds that

the claimant’s medically determinable impairments could

reasonably be expected to cause the alleged symptoms;

however, the claimant’s statements concerning the

intensity, persistence and limiting effects of these

symptoms are not entirely credible for the reasons

explained in this decision. (Emphasis added).

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Plaintiff asserts that the ALJ failed to articulate clear and convincing reasons

for rejecting Charles Shorts’ pain testimony. 

DISCUSSION

In a recent decision, the Ninth Circuit evaluated a rejection of a claimant’s

pain testimony where an ALJ used similar phraseology. In Brown-Hunter v. Colvin,

806 F.3d 487, 491 (9 Cir. 2015), the ALJ wrote that “the claimant’s statements th

concerning the intensity, persistence and limiting effects of these symptoms are not

credible. . . .” (emphasis added) (reversing finding of non-disability). The Court of

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Appeals articulated the standard for review. Before a claimant’s testimony can be

rejected, where (as here) there is objective medical evidence of an underlying

impairment and there is no evidence of malingering, the ALJ must provide specific,

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clear, and convincing reasons. Id. at 488–89 (“When an Administrative Law Judge

(ALJ) determines that a claimant for Social Security benefits is not malingering and

has provided objective medical evidence of an underlying impairment which might

reasonably produce the pain or other symptoms she alleges, the ALJ may reject the

claimant's testimony about the severity of those symptoms only by providing

specific, clear, and convincing reasons for doing so.”). This standard applies to

Plaintiff’s appeal.

In denying benefits, the ALJ here provided five reasons for disbelieving the

Plaintiff’s pain testimony, but the reasons are not convincing. As another physician

1 This phraseology for discounting pain testimony as incredible has

been used before. See, e.g., Burrell v. Colvin, 775 F.3d 1133, 1137 (9 Cir.

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2014) (emphasis added) (“the claimant’s statements concerning the intensity,

persistence and limiting effects of these symptoms [migraine headaches] are

not credible . . . .”) (reversing finding of non-disability). 

2 Despite the numerous emergency room visits documented in the

administrative record, not one of the physicians has suggested that Mr. Shorts

might be malingering or that his complaints of headache pain were false or

exaggerated. 

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opined about brain stem gliomas,

It’s really difficult to have a brain stem glioma and not to

have symptoms. The brain stem is a really small, little

area about yea big, and in that are all of the functions that

keep us alive. It keeps our heart beating, our blood

flowing. Our respiratory center is there. That’s not higher

levels of functioning. That’s not where you think. That’s

not where you’re smart. That’s where you live. And it’s

real difficult to have a brain stem glioma for very long that

does not begin causing very, very significant problems. 

Peeks v. Apfel, Case No. 99-cv-1083, 2000 WL 1458812 *6 (S.D. Ohio Sept.

22, 2000). 

First Reason: Objective Medical Evidence of Headaches

The first reason of the decision is not convincing. The ALJ found that the “weight

of the objective evidence does not support the claims of claimant’s disabling

limitations to the degree alleged.” (AR 25-26). In support, he explained that

consulting neurologist Dr. Schweller’s examination found that Plaintiff was “not

significantly symptomatic” and had mostly normal physical and mental health. He

explained that findings of mostly normal physical and mental health were consistent

with the results of other examinations conducted by his treating oncologists, Dr.

Kesari and Dr. Piccioni, and by the physicians who examined Plaintiff in emergency

rooms. (R&R at 24). 

There are records from twenty emergency room visits. Physicians reported

that Plaintiff would arrive with intense headache pain that was beyond what could

be controlled at home. For example, Clayton B. Whiting, M.D., notes on a

December 11, 2013 emergency room visit, 

A 26-year-old gentleman, well known to the Scripps system. This

patient unfortunately suffers from chronic headache. He has a known

brainstem glioma. He has had radiation in the past. I last cared for this

patient on my own, back in November 2012, which is over a year ago. 

The patient states that he has headaches five days a week. 

Unfortunately there are some days that are worse and he has to come to

the emergency department for treatment. (AR 259).

Similarly, one year earlier, on a December 3, 2012 emergency room visit, Marcus

Wang, M.S., noted, 

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This is a 25-year-old male with a history of glioblastoma of the brain

stem status post radiation therapy. . . . He says occasionally he does get

headaches. He gets it almost daily, but sometimes worse than others

and today he has a headache again, it is generalized and it is worse with

movement, worse with coughing and laughing and the pain is about

7/10 to 8/10, and because of the headache, he decided to come to the

emergency room for evaluation and treatment. (AR 288).

The emergency room treating physicians determined that Plaintiff’s

headaches were likely caused by his brainstem glioma and did not doubt that

Plaintiff’s headaches were chronic or severe. Plaintiff points out that the medical

findings of his treating oncologists at UCSD, Dr. Kesari and Dr. Piccioni, do not

negate Mr. Shorts’ testimony regarding his disabling headaches. (Objections at 4). 

With respect to Dr. Kesari, during his January 2013 exam, Plaintiff denied

exhibiting chest pain, shortness of breath, abdominal pain, memory loss, neck pain,

rashes, or weight loss. (AR 240). Headaches were his only symptoms at the time. 

Dr. Kesari performed a thorough examination, which revealed normal physical and

neurological results except for some abnormal eye movement and a mild issue with

muscle coordination in his left arm. (AR 241-242). In May 2013, Plaintiff reported

dizziness and headaches but denied other symptoms. (AR 243). An MRI of

Plaintiff’s brain showed a “slight interval decrease in the size of the expansile mass”

and “no abnormal enhancement.” (AR 244, 247).

Dr. Piccioni evaluated Plaintiff in October 2014. Plaintiff reported

headaches, nausea, vomiting, and difficulty falling asleep due to the headaches. 

(AR 343). Dr. Piccioni recommended that Plaintiff take Midrin for his headaches

and Phenergan for his nausea. (AR 345). He noted that Plaintiff had a “stable

MRI” from 18 months ago that showed a “mild decrease in size,” but he ordered a

new MRI. (Id.) 

That other physical conditions were found to be mostly normal hardly

undercuts the findings of chronic headache pain, as headache pain is the primary

symptom caused by brain stem gliomas. Consequently, to say that other physical

conditions are normal does not diminish the existence or severity of Plaintiff’s

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headache pain. On the contrary, that a person is driven by headache pain to seek

emergency department treatment on some twenty different occasions suggests that

the weight of the objective evidence does support the claims of disabling limitations

to the degree alleged. See Burch v. Barnhart, 400 F.3d 676, 680 (9 Cir. 2005) (“In th

evaluating the credibility of pain testimony after a claimant produces objective

medical evidence of an underlying impairment, an ALJ may not reject a claimant’s

subjective complaints based solely on a lack of medical evidence to fully

corroborate the alleged severity of pain.”). In this case, the ALJ made the same

mistake as that described in Brown-Hunter. 806 F.3d at 490-91. In both cases the

ALJ found a lack of credibility but made the mistake of summarizing the medical

record without tying a particular statement found to be not credible to particular

medical evidence. Id. at 493 (“The ALJ here made the identical conclusory

statement and likewise failed to identify specifically which of Brown-Hunter’s

statements she found not credible and why.”). That is insufficient. Id.

Second Reason: Conservative Course of Treatment

The ALJ also discredited Plaintiff’s testimony because he had “not generally

received the type of medical treatment one would expect for a totally disabled

individual. [His] course of treatment since his alleged disability onset date has

generally reflected a conservative course of treatment.” (AR 26). The ALJ does

not, however, point to any evidence to say that more aggressive treatment was

recommended. Indeed, the glioma is inoperable. One physician remarked that

Plaintiff is receiving palliative care at this point because the glioma is inoperable. 

(AR 274) (Emergency Department notes of Valerie Norton, M.D., dated June 7,

2013) (“He does not wish to be admitted. He just wants symptomatic control, and

since he is a palliative care patient, I feel this is appropriate.”). Consequently, the

ALJ’s observation that the course of treatment has generally reflected a

conservative approach does not “clearly and convincingly” support the ALJ’s

rejection of Plaintiff’s pain testimony. 

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Third Reason: Physical Limitations and Special Accommodations

The ALJ’s third reason given for rejecting Plaintiff’s testimony is that,

according to the ALJ, the record did not show that he required any special

accommodations to relieve his pain or symptoms. (AR 26). The ALJ then recites

the medical evidence about atrophy, loss of strength, and difficulty moving that are

indicative of severe and disabling pain. For example, the ALJ says, “[i]t is

noteworthy that while he has alleged loss of balance, he has a normal gait and does

not require any assistive devices to ambulate.” Id.

Plaintiff objects because “this is not a case where a disability applicant suffers

a near continuous degree of symptoms.” (Objections at 5). The ALJ’s reason is not

convincing. In essence, the reason can be restated as: when not experiencing severe

headaches, Plaintiff can walk fine without muscle atrophy. In other words, a

finding that Plaintiff is fine when not suffering headaches is not a clear and

convincing reason to find that his credibility is lacking when describing gliomainduced headaches that Plaintiff is experiencing. This is not an inconsistency. 

Moreover, it is not entirely accurate. Plaintiff’s many visits to emergency rooms

demonstrate that, in spite of home care, medical expertise and emergent treatment is

sometimes the only “accommodation” that can relieve his disabling pain. 

Fourth Reason: Effectiveness of Medications

The ALJ’s fourth reason given for rejecting Plaintiff’s claims about the

intensity of his symptoms is that “the medications have been relatively effective in

controlling the claimant’s symptoms.” (AR 26). Obviously, over twenty visits to

hospital emergency rooms suggests the opposite is true – that the medications were

not particularly effective in controlling Plaintiff’s headache pain. The ALJ does not

address this. The only explanation offered is one example of improvement with

Decadron in March 2011. Perhaps that medication helped in 2011. But by May

2013, Decadron was not working. Treating oncologist David E. Piccioni, M.D.,

noted: “dizziness x 2 wks, headaches still and has been going to ER regularly for

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pain meds. Headaches are bifrontal, sharp and lying down makes them worse. No

seizures. Decadron did not help back in Jan.” (AR 342-43) (emphasis added). In

August of 2013, Plaintiff presented to the emergency room for headache pain. Mark

C. Cannus, M.D. reports, “he says, he has been taking Percocet at home which is not

helping enough.” (AR 269). Dr. Cannus treated Plaintiff with Zofran, Dilaudid,

and Benadryl intravenously, observing “[t]his is the 3 combo medications that he

receives IV when he has this type of symptom that he says helps immensely.” (AR

270). By November 2014, Dr. Piccioni was prescribing Midrin for headaches and

Phenergan for nausea. (AR 344). In view of the record, this fourth reason for

discounting Plaintiff’s pain testimony is not supported by the record and is not

convincing. A reviewing court is “constrained to review the reasons the ALJ

asserts.” Brown-Hunter, 806 F.3d at 492 (quoting Connett v. Barnhart, 340 F.3d

871, 874 (9 Cir. 2003)). th

Fifth Reason: Lack of Medical Opinion Testimony

The ALJ’s final reason given for rejecting Plaintiff’s testimony is that the

“none of the claimant’s physicians have opined that he is totally and permanently

disabled from any kind of work.” (AR 26). This reason is not convincing because

Plaintiff’s treating physicians have simply not offered an opinion about whether his

condition is disabling. The only physician which has offered an opinion is the

Commissioner’s consulting physician, Dr. Schweller. The only conclusion Dr.

Schweller reaches about Plaintiff’s chronic headache pain is that, “[a]t the present

time, his is not significantly symptomatic.” (AR 234). 

The record is replete with other times, however, where plaintiff was

significantly symptomatic. (Jan. 10, 2012) (AR 303-05); (Mar. 14, 2012) (AR 300-

02); (July 19, 2012) (AR 298-99); (Oct. 20, 2012) (AR 294-97); (Nov. 8, 2012) (AR

291-92); (Dec. 3, 2012) (AR 288-90); (Dec. 11, 2012) (AR 286-87); (Dec. 16, 2012)

(AR 283-85); (Dec. 25, 2012) (AR 281-83); (Jan. 26, 2013) (AR 279-80); (Apr. 24,

2013) (AR 275-78); (June 7, 2013) (AR 273-74); (July 20, 2013) (AR 271-72);

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(Aug. 26, 2013) (AR 269-70); (Sept. 9, 2013) (AR 265-67); (Oct. 8, 2013) (AR 261-

64); (Dec. 11, 2013) (AR 259-60); and (Feb. 1, 2014) (AR 316-25). One may be

disabled from a severe impairment while symptoms wax and wane. Taylor v.

Commissioner, 659 F.3d 1228, 1234 (9 Cir. 2011) (quoting Vertigan v. Halter, 260

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F.3d 1044, 1050 (9 Cir. 2001) (error to find ability to work where attacks of

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muscle weakness come and go because “one does not need to be utterly

incapacitated in order to be disabled.”). In fact, it is error to reject a claimant’s

testimony merely because symptoms wax and wane. Garrison v. Colvin, 759 F.3d

995, 1017 (9 Cir. 2014) (“[I]t is error to reject a claimant’s testimony merely

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because symptoms wax and wane in the course of treatment.”).

To sum up, Dr. Schweller’s opinion was based on an examination when

Plaintiff’s symptoms were not significant. There were numerous other days when

physicians treated Plaintiff for symptoms that were significant using significant

intravenous medications. Neither these treating physicians, nor the Commissioner’s

consulting physician, suggest that Plaintiff’s recurring headache pain is fabricated

or exaggerated. That makes sense. One would expect headaches with a glioma. 

See Casteel v. Astrue, No. 12cv136-S, 2012 WL 5398537 *n.5 (W.D. Ky. Sept. 21,

2012) (“The term ‘glioma’ includes a broad range of brain and spinal cord tumors

that originate in the glial cells of the brain. . . . The symptoms of a glioma depend

on the area of the brain affected, with the most common symptom being a headache. 

Approximately half of all individuals diagnosed with a brain tumor will exhibit

headaches with other possible symptoms to include seizure, memory loss, physical

weakness, loss of muscle control, visual or language symptoms, cognitive decline

and personality changes. See http:// www.webmed.com / cancer / brain-cancer /

malignant-gliomas (last visited Sept. 12, 2012).”). Therefore, the fact that “none of

the claimant’s physicians have opined that he is totally and permanently disabled” is

not a convincing reason to discredit Plaintiff’s credibility concerning his headache

pain limitations. 

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The ALJ has not provided legally sufficient, convincing reasons for rejecting

Charles Shorts’ pain testimony. Brown-Hunter, 806 F.3d at 493. That is not to say

that the ALJ’s decision was careless. His decision demonstrates a thorough

understanding of the medical record, a reasoned consideration of the case and a fair

judgment on a difficult question. The above reasons convinced the ALJ to discount

the claimant’s complaints of pain. The reasons given are not far-fetched, absurd, or

capricious. Nevertheless, the reasons must be also convincing to this Court in order

to withstand review. As explained above, they are not convincing to this Court.

Alternate grounds

The ALJ rejected Plaintiff’s pain testimony at step five of the well-known

disability evaluation process without substantial evidence in the record to support

the decision. But there is also not substantial evidence supporting the ALJ’s

conclusion at step four. At step four, the ALJ determined that Plaintiff’s malignant

brain stem glioma did not meet or equal any of the “listings.” The ALJ was required

to evaluate Petitioner’s tumor under the listing criteria in Appendix 1, section 13.13.

20 C.F.R. Pt. 404, Subpt. P., App. 1. See e.g., Wiggins v. Astrue, No. CV07-491-SCWD, 2009 WL 205230 *5 (D. Idaho Jan. 28, 2009) (evaluating brain tumor

impairment under then-existing listings).

The listings are medical conditions that the Social Security Administration

accepts as disabling without any additional evidence of symptoms or functional

deficits. Relevant to this disability claim, 20 C.F.R. § 404, Subpt. P, App. 1.,

instructs on primary central nervous system (CNS) tumors. “We use the criteria in

13.13 to evaluate cancers that originate within the CNS (that is, brain and spinal

cord cancers). The CNS cancers listed in 13.13A1 are highly malignant and

respond poorly to treatment, and therefore we do not require additional criteria to

evaluate them.” Id. at listing13.00K6a. The listing for a brain stem glioma is

covered by listing13.13A and it includes cancers described in 1, 2, or 3: 

1. Glioblastoma multiforme, ependymoblastoma, and diffuse intrinsic brain

stem gliomas (see 13.00K6a).

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2. Any Grade III or Grade IV CNS cancer (see 13.00K6b), including

astrocytomas, sarcomas, and medulloblastoma and other primitive

neuroectodermal tumors (PNETs).

3. Any primary CNS cancer, as described in a or b:

a. Metastatic.

b. Progressive or recurrent following initial anticancer therapy.

Title 20 C.F.R. § Pt. 404, Subpt. P, App. 1 (emphasis added); see also Watson v.

Colvin, No. EDCV 13-1091-OP, 2014 WL 585293 *4 (C.D. Cal. Feb. 13, 2014). 

While nowhere in the administrative record is Plaintiff’s glioma categorized as a

Grade III or IV, it is described as a malignant glioma. The grading of a glioma has 3

been described this way: “A glioma is defined as ‘a tumor composed of tissue which

represents neuroglia (i.e., the supporting structure of nervous tissue) in any one of

its stages of development.’ [A] ‘low-grade glioma is a 1 or a 2, meaning benign.’ A

‘high-grade glioma, a 3 or a 4 . . . would be a malignancy.’” Peeks ex rel. Decanter

v. Apfel, No. 99cv1083, 2000 WL 1458812, at *5 (S.D. Ohio Sept. 22, 2000)

(citations omitted). 

In other words, Mr. Shorts’ malignant glioma may be a Grade III or IV. If so,

he would automatically be considered disabled without regard to any other

symptoms or impairments. See Social Security Program Operations Manual System

(POMS) DI 23022.735 Glioma - Grade III and IV (“Grade III and IV gliomas meet

listings 13.13A1 and 113.13 upon confirmed diagnosis, regardless of effectiveness

of treatment.”). 

The ALJ noted correctly that no physician stated that Plaintiff’s impairment

meets any listing. (AR 25). But the ALJ incorrectly noted that “the state agency

program physicians opined that it does not.” Id. The decision does not indicate

where the notation finds support in the record and this Court’s review of the record

finds none. Whether Plaintiff meets listing 13.13A(1), (2), or (3) is simply not

3 Listing 13.00K6b explains, “[w]e consider a CNS tumor to be

malignant if it is classified as Grade II, Grade III, or Grade IV under the

World Health Organization (WHO) classification of tumors of the CNS.” 

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addressed by physicians or the ALJ and it appears likely that Plaintiff does meet the

listing.

Remedy

In light of the reversible error, the question is one of remedy. Plaintiff

correctly argues that in instances such as this, the credit-as-true test applies. 

Garrison v. Colvin, 759 F.3d 995, 1019-21 (9 Cir. 2014). Under that test, a court

th

credits the claimant’s pain testimony and the associated limitations and remands for

calculation and award of benefits. Id. at 1020 (remand for award appropriate where:

(1) the record is fully developed and further administrative proceedings would serve

no useful purpose; (2) the reasons for rejecting the claimant’s testimony are not

sufficient; and (3) if the discredited testimony were credited as true, the ALJ would

be required to find the claimant disabled). 

Here, all three parts of the test are met and the administrative record as a

whole convinces the Court that Plaintiff is, in fact, disabled. Remanding for an

award of benefits will have the salutary effect of “ensuring that deserving claimants

will receive benefits as soon as possible.” Id. at 1019 (test recognizes that

“applicants for disability benefits often suffer from painful and debilitating

conditions, as well as severe economic hardship [for which] delaying the payment

of benefits by requiring multiple administrative proceedings that are duplicative and

unnecessary only serves to cause the applicant further damage – financial, medical,

and emotional.”). 

CONCLUSION

For the reasons discussed above, having reviewed the decision de novo, the

Report and Recommendation is declined. Plaintiff’s motion for summary judgment

is granted. Defendant’s cross-motion for summary judgment is denied. 

IT IS THEREFORE ORDERED that the final decision of the

Commissioner of Social Security is reversed and the case is remanded for the

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calculation and award of benefits.

DATED: February 6, 2017

Hon. Roger T. Benitez

United States District Judge

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