Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_18-cv-07117/USCOURTS-cand-3_18-cv-07117-0/pdf.json

Nature of Suit Code: 865
Nature of Suit: Social Security - RSI (405(g))
Cause of Action: 42:416 Denial of Social Security Benefits

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United States District Court

Northern District of California

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

P.E.,

Plaintiff,

v.

ANDREW SAUL,

Defendant.

Case No. 18-cv-07117-JCS 

ORDER GRANTING PLAINTIFF’S 

MOTION FOR SUMMARY 

JUDGMENT, DENYING 

DEFENDANT’S MOTION FOR 

SUMMARY JUDGMENT AND 

REMANDING FOR FURTHER 

PROCEEDINGS

Re: Dkt. Nos. 21, 28

I. INTRODUCTION 

Plaintiff P.E.

1

brings this action challenging the final decision of Defendant Andrew Saul, 2

Commissioner of Social Security (the “Commissioner”) denying P.E.’s application for disability 

benefits under Title II of the Social Security Act, 42 U.S.C. §1381, et seq. The parties have filed 

cross motions for summary judgment pursuant to Civil Local Rule 16-5. For the reasons set forth

below, P.E.’s motion is GRANTED, the Commissioner’s motion is DENIED, and the matter is 

REMANDED for further administrative proceedings consistent with this order.3

II. BACKGROUND 

P.E. is a 58-year-old former janitor with a fourth-grade education. Administrative Record 

(“AR”) at 44, 67, 76. He alleges disability based on trigeminal neuralgia, hyperlipidemia, seizure 

disorder, and depression and anxiety. Id. P.E. alleges an onset day of June 28, 2013. Id. P.E. 

1 Because opinions by the Court are more widely available than other filings and this Order 

contains potentially sensitive medical information, this Order refers to Plaintiff only by his initials. 

2 Andrew Saul was confirmed as Commissioner while this action was pending and is therefore 

substituted as the defendant as a matter of law. See 42 U.S.C. § 405(g); Fed. R. Civ. P. 25(d).

3 The parties have consented to the jurisdiction of the undersigned magistrate judge for all 

purposes pursuant to 28 U.S.C. § 636(c).

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speaks only Spanish. Id. at 71. 

A. Education and Employment

P.E. was born in Mezcala, Jalisco, Mexico. AR at 200. He left school in the fourth grade 

because of a learning disability. Id. at 530. He came to the United States in 1975 and moved back 

and forth between the United States and Mexico until 1999, when he and his family permanently 

settled in California. Id. P.E. and his wife M.E. have two children and two grandchildren. Id. He 

is pursuing citizenship through naturalization. Id. at 599. 

P.E. worked as a janitor from 2004 until 2013, when his contract expired. Id. at 45, 240. 

According to P.E., he worked at that job for six to seven years. Id. He testified that after that, he 

was “unable to perform at other jobs he was offered.” Id. at 528; see also id. at 534 (“unable to 

learn new jobs”). In 2000, he also worked in construction. Id. at 45. 

B. Medical Background

1. Trigeminal Neuralgia 

P.E. developed trigeminal neuralgia around 1998 and was treated with Tegretol 

(carbamazapine). AR at 528. P.E. was seen by Dr. Jelalian, a neurologist, for his trigeminal 

neuralgia in 2007. Id. at 402. Dr. Jelalian prescribed carbamazepine, ordered lab tests after a 

week on that medication to establish a baseline, and referred P.E. for an MRI to determine whether 

there was any “structural lesion on the trigeminal nerve.” Id. at 403. 

In 2010, P.E. saw Dr. Efron to treat his right-side trigeminal neuralgia. Id. at 403. Dr. 

Efron described P.E.’s condition as “medically refractory.” Id. 

P.E. saw Dr. Carlos Enrique Meza, a primary care physician, for a routine physical on 

March 3, 2013. Id. at 323. Dr. Meza listed P.E.’s “active problem[s]” as trigeminal neuralgia and 

hyperlipidemia. Id. at 324. He recorded that P.E. complained of “R trigeminal pain” and opined 

that he “[c]ould use a tranquilizer.” Id. Dr. Meza noted that P.E. had had trigeminal neuralgia for 

thirteen years. Id. at 337. Dr. Meza listed P.E.’s diagnoses as trigeminal neuralgia, depression, 

and anxiety. Id. at 322. Dr. Meza had several lab tests performed, all of which came back 

“normal” on March 4, 2013. Id. at 331. 

At an appointment on March 24, 2013, Dr. Meza noted that P.E. was having “breakthrough 

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pain” despite being on carbamazepine and that he was unable to go to work. Id. at 337. Dr. Meza 

started P.E. on nortriptyline for pain and continued P.E. on carbamazepine. Id. at 337-338. He 

also prescribed lorazepam for anxiety. Id. at 338. Dr. Meza ordered a lab test to determine P.E.’s 

carbamazepine level, which came back within normal range. Id. at 342. 

On April 4, 2014, Dr. Meza’s assistant called P.E. to inform him of the lab results and to 

ask whether the carbamazepine was controlling his pain; she spoke with P.E.’s wife, who told her 

that P.E.’s pain was “being well controlled.” Id. at 343. 

On April 26, 2013, P.E. began a series of acupuncture treatments to help manage his pain. 

Id. at 422–26. P.E. told the acupuncturist, Josef Inderkum, that his pain was “triggered at times 

with talking.” Id. at 426. At his first visit, P.E. told Inderkum that he had struggled with 

trigeminal neuralgia for twelve years. Id. at 426. P.E. also told the acupuncturist that the pain did 

not disrupt his sleep but that it did impact his family. Id. P.E. underwent a total of six sessions of 

acupuncture. Id. at 422. 

On April 28, 2014 2014, Dr. Meza put P.E. on state disability. Id. at 352. In May 2014, 

Dr. Meza extended P.E.’s state disability to December 28, 2014. Id. at 352-353.

On May 22, 2014, Dr. Meza noted that P.E. was having good results with medication. Id. 

at 347. Throughout 2014, Dr. Meza consistently noted that P.E. was “alert, well appearing, and in 

no distress.” Id. at 414, 416, 417. On January 7, 2015, Dr. Meza wrote that P.E. was “wellappearing,” “in no distress,” and “[r]esponds to present therapy.” Id. at 386. 

At an office visit on May 22, 2015, Dr. Meza noted that P.E. was “[f]rustrated about his 

trigeminal neuralgia – states that it affects him psychologically, it makes him depressed[.] Upset 

and unable to carry on his ADL’s.” Id. at 411. He was oriented but “anxious.” Id. Dr. Meza 

added “Recommend personal disability” to P.E.’s problem list. Id. at 412. 

On May 28, 2015, M.E. called Deborah Williams at Kaiser. Id. at 410. She told Williams 

that P.E.’s pain was getting worse and that “she can’t see him going back to work in his 

condition.” Id. M.E. told Williams that P.E. was “trying to see if he could be deem[ed] 

permanently disabled.” Id. Williams asked Dr. Jelalian for next steps; Dr. Jelalian replied that 

P.E. had already seen the neurosurgeon and that “he needs to talk with his PCP about disability.” 

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Id. Medical Assistant Gita Swaminathan called M.E., who told Swaminathan that the PCP was 

“not helping” and was “not writing enough to address disability.” Id. Dr. Jelalian reiterated that 

she did not “do disability papers.” Id. P.E.’s daughter called Williams back and clarified that P.E. 

was asking to be seen by Dr. Jelalian to determine if there were additional options for his pain, 

including the possibility of an MRI to see what was going on, as P.E.’s pain was getting worse. 

Id. Dr. Jelalian then ordered an MRI. Id. 

On June 5, 2015, P.E. underwent an MRI of his brain. Id. at 403-404. The MRI revealed a 

stable lesion on his brain, which the radiologist thought was benign. Id.; see also id. at 434–35 

(“As this lesion appears closely associated with the tip of the basilar artery, a chronic . . . 

aneurysm or other vascular lesion may be considered.”), 465-467 (full results). P.E. underwent a 

CT test of his brain on June 11, 2015. Id. at 402–03. The test revealed a lesion, but the 

interpreting physician agreed that it was benign. Id. at 403. 

Dr. Jelalian opined on June 12, 2015 that “CT scan results do not show a reason for his 

facial pain.” Id. at 406; see also 434 (summary of results). Dr. Jelalian called P.E. and spoke to

P.E. and his wife on June 12, 2015. Id. at 403. M.E. reported that P.E. was having trouble with 

his memory and was depressed. Id. P.E. told Dr. Jelalian that he was feeling a sharp, persistent, 

worsening pain which “[o]ccurs more when he is under stress.” Id. Dr. Jelalian recommended 

that P.E. consider having surgery, but, according to M.E., he was not interested. Id. 

Dr. Sharon Ghandi, a neurologist, saw P.E. on June 17, 2015. AR at 402. She referred 

P.E. to the Kaiser pain clinic. Id. She also found that P.E. would be a “[g]ood candidate for 

microvascular decompression or radiosurgery.” Id. However, P.E. again declined surgery. Id. at 

528]

P.E. met with Timothy Moore, M.F.T., on July 9, 2015. Id. at 518. Using his wife as a 

translator, P.E. told Moore that he “does not want to increase medication, does not want surgical 

options.” Id. 

P.E. saw Dr. Lanny Hsu, a physician with Kaiser’s Chronic Pain Management Program, on 

July 14, 2015. Id. at 461. Dr. Hsu’s notes describe P.E.’s pain as “sharp, shooting, [and like an] 

ice pick,” occurring “intermittent[ly]” and exacerbated by “stress, anxiety, eating, talking.” Id. at 

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512 (emphasis in original). Dr. Hsu told P.E. to stop taking Nortriptyline for a few nights to see 

how his pain level was affected, and also prescribed a ketamine pain relief gel to be used two to 

three times a day, as needed, for facial pain. Id. at 518. 

In a telephone appointment on July 16, 2015, P.E. reported that he didn’t feel much 

different when he was off Nortriptyline and Dr. Hsu told him to stay off it. Id. at 511. Dr. Hsu 

also instructed P.E. to reduce his morning dose of Tegretol (carbamazepine) to see if this reduced

its side effects. Id. at 511. 

At a phone appointment on July 20, 2015, P.E. told Dr. Hsu that his pain was exacerbated 

by his mood, stress, and “sleep disruption.” Id. at 510. Dr. Hsu noted that P.E. had an “[u]nclear 

response to dose reduction in Tegretol aside from possibly mildly worsened pain when he has 

flares.” Id. P.E. had another telephone appointment with Dr. Hsu on July 23, 2015, this time with 

a telephonic translator instead of his wife. Id. at 508. He reported worsening pain along with 

additional side effects: “feels floppy, loose, does later confirm he feels less tired and less difficulty 

concentrating.” Id. Dr. Hsu prescribed gabapentin to rotate with, and eventually replace, Tegretol 

and referred P.E. for opioid titration “if necessary.” Id. at 508–509. 

On August 4, 2015, Dr. Hsu noted that P.E. was still experiencing “fatigue, body aches, 

drowsiness,” which P.E. attributed to his medication. Id. P.E. also mentioned that his pain 

worsened when he was brushing his teeth. Id. He told Dr. Hsu that the ketamine gel was not 

helpful because it was difficult to predict when his pain would flare. Id. at 505-506. Dr. Hsu 

advised P.E. and his wife “to work on distraction techniques and stress reduction as stress, anxiety, 

poor sleep, can increase pain.” Id. at 506 (emphasis in original). 

On August 11, 2015, Dr. Hsu had P.E. start taking baclofen for pain on a trial basis. Id. at 

504-505. On August 17, 2015, P.E. told Dr. Hsu he was “doing great” with baclofen. Id. at 502. 

Dr. Hsu remarked that P.E.’s “mood sounds better over the phone.” Id. At their appointment on 

August 24, 2015, Dr. Hsu increased P.E.’s dose of baclofen and noted that P.E. was “[t]olerating it 

very well compared to prior meds. However, not sure if much difference in pain although last 

time he thought maybe he had less severe pain attacks.” Id. at 501. On August 31, 2015, Dr. Hsu 

noted that P.E. reported he could “do more activities as a result” of being on baclofen. Id. at 500. 

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At their telephone appointment on August 31, 2015, Dr. Hsu wrote that P.E. had been 

taking a higher dose of baclofen than prescribed and reported that this resulted in decreased 

frequency of his attacks but had no effect on their intensity. Id. at 497–98. Dr. Hsu noted that 

P.E. was “able to do more activities as a result” but likely could not tolerate a further increase 

because of the side effects, particularly “sedation.” Id. at 500. 

On October 2, 2015, Dr. Hsu noted that P.E. was experiencing “some benefits” from his 

“self-adjusted” baclofen dose but that P.E. wanted to reduce further the frequency of his pain 

“attacks.” Id. at 498. Dr. Hsu raised P.E.’s dose slightly. Id. He noted that P.E. “[s]eem[ed] 

emotionally and functionally stable and still better than before.” Id. at 498. 

P.E. saw M.F.T. Moore on October 19, 2015, when he reported “no change or 

improvement since starting program. Still very frustrated. Hurts worse when talking or eating.” 

Id. at 492. 

On November 3, 2015, P.E. told Dr. Hsu that he had mixed up his medication and was 

experiencing dizziness, sweating, and fatigue. Id. at 491. P.E. told Dr. Hsu on December 9, 2015 

that the medication regime was helping with his pain but that he “continue[d] to occasionally have

poor energy and cognitive issues.” Id. at 490. He reported that he had a cough, which made his 

trigeminal neuralgia pain worse. Id. at 485. 

On May 9, 2016, Dr. Meza noted that P.H. had had a “poor memory for the last few 

years,” which P.E. attributed to his medications, but that his memory did not improve when P.E. 

discontinued some of his medications. Id. at 577. Id. at 577. P.E. told Dr. Meza that tramadol 

was no longer effective at a visit on June 23, 2016. Id. at 569. Dr. Meza prescribed hydrocodone–

acetaminophen (Norco) to treat P.E.’s pain. Id. at 570. 

P.E. was seen by Shruti Datta, M.D., on November 9, 2016, “for evaluation of cognitive 

concerns.” Id. at 551. His wife accompanied him to the appointment. Id. P.E. answered “yes” 

when asked whether he was “anxious most of the time and [felt] that is impacting your life.” Id. at 

554. Dr. Datta diagnosed P.E. with mild cognitive impairment “likely . . . related to pain, 

medications, and . . . anxiety [and] severe depression.” Id. at 558. She referred P.E. to the 

“psychiatry department for medication management.” Id. She ordered blood tests, a sleep test 

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and further neuropsychological testing to address how P.E.’s medications were affecting his 

cognitive functioning and whether his memory deficits were normal for his age. Id. at 558, 528.

She also discussed with P.E. and M.E. techniques for improving his memory and concentration. 

Id. at 563-564. 

On November 9, 2016, another CT scan of P.E.’s brain was done. Id. at 553. Like the 

2007 CT scan, it showed a lesion but it appeared to be stable, which “favor[ed] benignity.” Id. 

On December 8, 2016, P.E. underwent another MRI of his brain. Id. at 547-549. The MRI, like 

the CT scan, showed a lesion (which radiologist Eamon Kenichi Kato described as “nonspecific 

heterogeneous ill-defined area of soft tissue”) that appeared to be stable and revealed no new 

abnormalities since the June 2015 MRI. Id. at 549. The aneurysm was also unchanged. Id. 

Dr. Shelly Peery, a psychologist, completed a Spanish-language neuropsychological 

evaluation of P.E. based on examinations conducted on January 3, 2017 and January 17, 2017, 

upon the referral of Dr. Datta. Id. at 528-535. P.E. was accompanied to the appointment by his 

wife, who provided historical information. Id. at 528. Summarizing his past treatment, Dr. Peery 

wrote that P.E. completed a pain management program in September of 2016 and that he declined 

surgery for his trigeminal neuralgia in 2010. Id. at 528. She also wrote “[a]fter he was laid off 

from his job as a janitor at Shell in 2014, he was unable to perform at other jobs he was offered, 

even those offered by family and friends.” Id. Dr. Peery noted that while P.E. was “independent” 

with regard to his basic activities of daily living and could drive himself, he usually had someone 

drive with him because his family was concerned he would get lost. Id.

M.E. told Dr. Peery that P.E. had problems with his memory: 

[T]he patient frequently forgets what she has told him, he forgets to 

do important tasks, he forgets his medications, and he is unable to 

complete errands or fill out paperwork. He accidentally left the 

electric stove on the day before the present examination. Medical 

records also show that he has forgotten some of his appointments. 

Id. She found that “[o]n a memory screener, [P.E.’s] performance fell in the range of mild 

cognitive impairment.” Id.

Dr. Peery noted that P.E. experienced disrupted sleep and weight loss, and that because 

eating triggered his trigeminal neuralgia pain, he ate alone and took small bites. Id. at 529. She 

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observed this his “[s]enses of smell and taste have also declined since 2000.” Id. According to 

Dr. Peery, P.E. reported pain “as great as 10/10 for 3 or more attacks per day; each attack lasts 5-

15 minutes before subsiding.” Id. He also reported walking for between half an hour and an hour 

“most days.” Id. Neither of P.E.’s parents and none of his siblings had memory issues. Id. When 

recounting his educational history, P.E. explained that he had a “reading learning disability” as a 

child and left school after repeating the third and fourth grades because of his learning disability. 

Id. at 530. 

When explaining her testing methodology, Dr. Peery noted that P.E. “may not have been 

able to put forth his best effort. Therefore, the present result must be interpreted with caution; 

while [P.E.’s] true ability is likely greater than his performance during the present evaluation, it is 

not likely lower.” Id. at 531. However, Dr. Peery also found that malingering was “unlikely 

given the multitude of alternative explanations for reduced effort,” such as P.E.’s fatigue, pain, 

“mood disorders,” and a “‘cry for help’ and/or frustration with the evaluation process.” Id.

In Dr. Peery’s opinion, P.E.’s general intellectual functioning was “[l]ow average 

compared to individuals with 4 years of education; moderately impaired compared to high school 

educated individuals.” Id. at 532. Specifically, his attention and concentration were average to 

low average; his verbal functioning was “[m]ostly average”; his perceptual-motor functioning and 

processing speed was average; and his memory and learning ability was average to high average. 

Id. at 533-534. Dr. Peery again asserted that she did not believe P.E. was putting forth his full 

effort, particularly with regard to recognition and visual recall tasks. Id. Dr. Peery found that 

P.E.’s executive functioning skills were “[l]ow average or above, except for multitasking and 

judgment (impaired).” Id. at 533. 

Overall, Dr. Peery concluded:

This pattern of performance is not suggestive of a primary 

neurological disorder that results from neuropathology. However, 

[P.E.’s] functioning is significantly impaired by his depression and 

anxiety, which are very real physiological conditions with known 

depressive effects on the functioning on the brain. Given his low level 

of functioning, [P.E.] meets criteria for Minor Neurocognitive 

Disorder due to his depression, anxiety, insomnia, obstructive sleep 

apnea, and chronic pain due to his trigeminal neuralgia. 

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Id. at 534–35. Dr. Peery opined that P.E. was at a “moderate risk for suicide” and recommended 

that he be “monitored regularly.” Id. at 535. She also noted that, after being treated for his mood 

disorder, P.E. should reconsider his opposition to neurosurgery for his trigeminal neuralgia. Id. 

Nurse Practitioner Mary Cochran Abraham reviewed Dr. Peery’s report with P.E. and his wife 

with the help of a video interpreter. Id. at 541. 

2. Anxiety, Depression and Cognitive Impairment

In his notes from a March 3, 2013 routine check-up exam, Dr. Meza included anxiety in 

P.E.’s diagnosis and prescribed Lorazepam to treat it. Id. at 322-324. On June 12, 2015, P.E.’s 

wife told Dr. Jelalian that P.E. was depressed. Id. at 403. She also told a social worker who 

followed up on June 18, 2015 that P.E. was depressed but that he would not be open to seeing 

someone for his depression. Id. at 402. Nonetheless, P.E. was evaluated by a psychologist, Dr. 

Alberto Matias, Ph.D., on June 2, 2015. Id. at 408. P.E. reported to Dr. Matias that he had been 

suffering from anxiety “for a long time.” Id. Dr. Matias wrote that P.E. was experiencing 

“excessive worry, restlessness, muscle tension, insomnia, restless sleep, and somatic complaints.” 

Id. P.E. reported that carbamazepine and Nortiptyline were “not helping.” Id. Dr. Matias 

performed a mental status examination. Id. at 408–09. He found that while P.E.’s mood was 

“anxious,” his affect was appropriate and all other categories were within normal limits. Id. 

According to Dr. Matias, P.E. was not currently experiencing suicidal or homicidal ideation but he 

had experienced suicidal ideation about a month before, “triggered by strong pain.” Id. at 409. 

Dr. Matias assigned P.E. a Global Assess of Functioning (“GAF”) score of “41-50 serious 

symptoms.” P.E.’s PHQ-9 score was 22, but Dr. Matias noted that P.E. “appeared less depressed 

than score may suggest.” Id. Dr. Matias diagnosed P.E. with Adjustment Disorder. Id. 

On June 6, 2015, P.E. returned to Dr. Matias complaining of stress, depression, and pain. 

Id. at 405. Dr. Matias found that P.E.’s treatment compliance was within normal limits and noted 

that P.E. wanted to start working again, but was “afraid he will get fired.” Id. Dr. Matias updated 

P.E.’s mental status exam to reflect that his mood was “depressed.” Id. at 406. He assigned P.E. a 

GAF of “51-60 moderate symptoms.” Id. 

P.E. was seen by M.F.T. Moore for a Pain Clinic Psychological Evaluation on July 9, 

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2015. Id. at 518. His wife participated in the session at P.E.’s request. Id. P.E. said that his pain 

medications (carbamazepine and Nortiptyline) helped “a little.” Id. at 519. However, his wife 

reported that the Nortriptyline “really changed” P.E.’s personality and that he had developed 

“significant problems” with his short-term memory. Id. Moore noted that P.E.’s main stressor 

“other than pain and disability” was his financial situation, namely, that he had not worked for two 

years and “disability and unemployment have run out.” Id. Moore listed P.E.’s diagnosis as 

adjustment disorder with anxiety and depressed mood. Id. He noted that P.E.’s PHQ-9 score was 

23, indicating “severe depressive symptoms,” his mood was depressed, and his affect was 

“blunted but showed some range.” Id. at 520. He listed P.E.’s GAF Score as 51-60, indicating 

“moderate symptoms.” Id. at 521. 

P.E. was referred by the Department of Social Services for a disability evaluation by 

psychologist April Young, who examined P.E. on August 15, 2015. Id. at 473–76. The exam 

was conducted in English and P.E. participated with the help of an interpreter. Id. at 473. Dr. 

Young’s report was based on her own examination as well as review of Dr. Matias’s June 2, 2015 

evaluation (see id. at 408-409) and the Adult Function report completed by P.E. (see id. at 249-

256, discussed below). In summarizing P.E.’s employment history, Dr. Young noted that P.E. 

“quit as the new company took over and no longer provided employee benefits.” Id. at 474. She 

noted that P.E. had been diagnosed with an adjustment disorder. Id. Dr. Young observed that P.E. 

was “pleasant and cooperative,” and that his mood presented as “euthymic.” Id. at 475. 

Dr. Young conducted a mental status examination and found: 

[P.E.] was alert and oriented. He displayed adequate attention and 

concentration for conversation. His memory for immediate, recent 

and remote events appeared to be grossly intact in terms of related his 

personal history. He was able to recall 3/3 items immediately and 1/3 

items after delay. . . . [P.E.] reported that his mood is “nervous.” His 

affect was full in range and was appropriate to the setting. [P.E.’s] 

thought process was linear. No impairment with regard to thought 

content was noted. There was no evidence of hallucinations, 

delusions or other symptoms suggestive of a thought disorder present 

during this evaluation. He denied experiencing suicidal or homicidal 

ideation. However, he stated he has the desire to hit his head against 

the wall to dislodge whatever is causing his pain. 

Id. at 475. She also conducted a test of P.E.’s intellectual functioning, the TONI-3. Id. at 474. 

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P.E. “earned a deviation quotient of 60 which falls within the < 1 percentile,” suggesting 

“impaired cognitive functioning.” Id. at 575. She noted that P.E. described himself as 

“forgetful.” Id. Dr. Young reported that P.E. “denied a history of anxiety prior to experiencing 

his symptoms.” Id. She noted that although P.E. did not have a history of suicide attempts, he

reported experiencing “suicidal ideation related to strong pain.” Id. Dr. Young’s diagnostic 

impression was “Adjustment Disorder with Mixed Anxiety and Depressed Mood.” Id. at 476. 

She added “[Rule Out] Mood Disorder due to Pain” and “[Rule Out] Cognitive Disorder NOS.” 

Id. 

Based on her observations, Dr. Young offered the following assessment of P.E.’s abilities: 

[T]he claimant would be able to deal with the public, supervisors, and 

coworkers in an appropriate manner. 

[P.E.’s] ability to understand instructions is adequate. When 

confronted with straightforward one- and two-step tasks, the results 

of the current examination indicate that the claimant’s abilities would 

be moderately impaired. [P.E.] is unable to perform work activities 

without special or additional supervision. The claimant has fair 

ability to adapt to the usual stress encountered in the work setting. 

The claimant is able to be aware of normal hazards in the workplace 

and react appropriately. 

Based on the current evaluation, [P.E.] has adequate ability to manage 

his supplementary funds independently. 

Id. at 476. 

On October 2, 2015, medical assistant Ileana Del Carmen Alas called P.E. to schedule a 

follow-up with M.F.T. Moore and left a message on P.E.’s voicemail. Id. at 499. She called back 

on October 7, 2015 and spoke with M.E. Id. at 499. M.E. reported as follows: 

[P.E.] hasn’t been doing so well with medication and has been down 

and depressed. Wife states she’s never seen husband so depressed . . 

. . Wife states her brother had to take him out of the house just to 

distract him. Wife explained that every time appointment is booked 

with Tim [Moore, M.F.T.] husband decides to cancel the day before. 

He has expressed to her that no one understands how he feels due to 

the language barrier. . . . She feels that his depression is getting worse 

with his pain. She doesn’t know if it’s the medication side effects. 

Id. at 497. 

At his October 19, 2015 appointment, P.E. reported to M.F.T. Moore that he had 

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experienced “no change or improvement” since starting the pain management program and was 

“still very frustrated.” Id. at 493. Moore noted that P.E. seemed “somewhat less uncomfortable 

and less down than the initial visit.” Id. He found that P.E.’s mental status was overall “normal” 

but that P.E. presented as “mildly withdrawn and irritated.” Id. 

In her January 2017 neuropsychological examination of P.E. (discussed above), Dr. Peery 

noted that P.E. did not want to see mental health providers who did not speak Spanish. Id. at 530. 

Dr. Peery described P.E. as “a pleasant man who appeared fatigued and depressed. Affect was flat 

. . . . He was alert and fully oriented. . . . Thought processes were logical and coherent.” Id. at 

531. Dr. Peery noted that P.E.’s questionnaire responses indicated that he had mild anxiety and 

severe depression. Id. at 532. She noted that P.E. also expressed passive suicidal ideation. Id. 

Dr. Peery opined that “he meets the diagnostic criteria for Major Depressive Disorder, and he is at 

moderate risk for suicide,” id., and that “[P.E.]’s depression and anxiety have worsened despite 

ongoing psychotherapy.” Id. Dr. Peery also found that “[P.E.] is significantly impaired by his 

depression and anxiety.” Id. at 534. 

On March 2, 2017, P.E. and M.E. met with Gwendolyn Moody-Tzannes, M.F.T., to 

discuss medication management. Id. at 679–80. Between December of 2015 and June of 2017,

P.E. continued to see Dr. Matias, who consistently described P.E.’s mood as “depressed.” Id. at 

635, 641, 655, 661, 665, 669, 674, 683, 688, 700, 708, 723; but see id. at 692, 713, 718, 727, 732, 

737 (recording P.E.’s mood as “expansive”), 742 (recording P.E.’s mood as “anxious”). 

On May 4, 2017, Dr. Matias completed Form N-648 (Medical Certification for Disability 

Exceptions) (the “USCIS Form”) in support of P.E.’s request to be excused from the English 

language and United States civics and history requirements in connection with his application for 

United States citizenship. Id. at 599-606. In the form, Dr. Matias listed P.E.’s diagnoses as “Mild 

Neurocognitive Disorder;” “Major Depressive Disorder;” and “Chronic Pain . . . due to medically 

Refractory Trigeminal Neuralgia.” Id. at 602. He noted that the information in the form “has 

been collected in the process of providing [P.E.] Mental Health Services for Depression/Anxiety 

symptoms only.” Id. 

The form asked for a “basic description” of the disability or impairment, “for example, 

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Intellectual Disability (severe) is a genetic disorder that causes lifelong intellectual disability, 

developmental delays, and other problems.” Id. In response, Dr. Matias provided descriptions of 

“Mild Neurocognitive Disorder” and “Major Depressive Disorder.” Id. He described the 

diagnosis of Mild Neurocognitive Disorder as:

. . . a marked decline in cognitive functioning and significant 

impairment in cognitive performance. Patients may report symptoms 

of memory impairment, decline in the ability to perform everyday 

activities, though still able to perform these activities without 

assistance, and difficulties with language, perceptual-motor and 

social skills.

Id. He described Major Depressive Order as:

. . .depressed mood, diminished interest or pleasure in activities, 

decrease or increase in appetite, insomnia or hypersomnia, 

psychomotor retardation, fatigue, tiredness, loss of energy, feelings of 

worthlessness, inappropriate guilt, inability to think or concentrate, 

memory problems, indecisiveness and recurrent thoughts of death.

Id. 

Dr. Matias stated in the form that he had been treating P.E. for one year and eleven 

months, first seeing P.E. on June 2, 2015 and seeing him most recently May 4, 2017, the date 

when he completed the form. Id. Dr. Matias stated that he expected P.E.’s impairments to last 12 

months or more. Id. at 603. 

The USCIS Form asked for the “cause of the applicant’s medical disability,” to which Dr. 

Matias responded, “[l]ikely chonic pain (Refractory Trigeminal Neuralgia) triggered 

mood/cognitive dysfunction. Medications’ side effects used to treat condition may also exacerbate 

reported mood/cognitive symptoms.” Id. at 603. Dr. Matias stated that “[m]ood and cognitive 

impairments are in the way of applicant acquiring new knowledge (like English as second 

language and US history/civics.)” Id. at 604.

C. Opinions of State Agency Consultants

State agency consultant C. Eskander, M.D., reviewed P.E.’s medical records on August 6, 

2015, in connection with P.E.’s initial application for disability benefits. Id. at 74–75. Dr. 

Eskander opined that P.E. had no exertional, postural, manipulative, visual, or communicative 

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limitations. Id. at 74. However, he found that P.E. had environmental limitations and should 

avoid concentrated exposure to extreme cold, extreme heat, noise, vibrations, and hazards. Id. at 

74–75. Dr. Eskander found that P.E. could actively perform his past relevant work as a janitor. 

Id. at 46. 

On September 11, 2015, state agency reviewer Mack Stephenson, PhD, reviewed P.E.’s 

records and found that P.E.’s mental impairment was non-severe and that there was “insufficient 

evidence to substantiate the presence of a disorder.” Id. at 73. On February 5, 2016, Pamela 

Hawkins, PhD, reached the same conclusion based on her review of the record. Id. at 85. 

However, state agency consultant M. Acinas, M.D., agreed with the findings of Dr. Eskander 

based on review of the record on February 1, 2016. Id. at 87.

D. Adult Function Report

On July 23, 2015, P.E. filled out a function report with the help of his non-attorney

representative. Id. at 249–57. P.E. reported that he lived in a house with his family. Id. at 249. 

He wrote that his memory problems, concentration problems, right jaw pain, anxiety, and 

depression limited his ability to work. Id. He wrote that he isolated himself, experienced loss of 

interest in doing things, that “too many questions confuse[d] [him],” that he was “unable to 

maintain any type of schedule” and lost his temper easily. Id. He described his daily routine as 

follows:

Wake up at 8am. Have breakfast, take care of personal hygiene. Go 

out for walks per my doctor’s orders. If I am having a good [day] I 

get on exercise bike, watch T.V., go tend yard, go out for walk again, 

watch T.V., have dinner. go to bed @ 10[pm]. 

Id. at 250. He did not take care of any children or pets. Id. He also wrote that his illness affected 

his sleep because he would wake up either from the pain or from a racing mind. Id. 

P.E. checked boxes indicating that, while he did not need special reminders to tend to his 

personal care, he did need to be reminded to take his medication, and his wife ordered his 

medications for him. Id. at 251. He wrote that his wife also prepared his meals and did all of the 

house cleaning, as she had since they’d married. Id. He stated that he tended to his small yard for 

twenty minutes per day when he felt “up to it.” Id. at 252. P.E. reported that he went outside 

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“daily” and got around by walking, driving or riding in a car, or riding his bicycle. Id. He stated 

he could go out alone but needed someone with him to help with directions on long drives because 

otherwise he got confused. Id. His wife did “all the shopping,” though P.E. accompanied her. He 

wrote that he went to the grocery store and the hardware store but that he “end[ed] up buying the 

wrong things.” Id. 

According to P.E., his only hobby was walking, which he undertook “daily – all day a 

couple of times.” Id. at 253. He did not think his activities had changed since the onset of his 

allegedly disabling conditions, although he did state that he walked when he was anxious. Id. 

Socially, he visited a neighbor “almost daily” and went to church on Sunday. Id. He indicated 

that he needed to be reminded to go places, such as his doctor appointments. Id. His wife 

accompanied him everywhere except on his daily walks. Id. When asked whether he had 

problems getting along with others, P.E. answered that he did and added “sometimes people get on 

my nerves.” Id. at 254. He wrote that he used to be “the ‘joker’ of the parties,” but that “now 

[he] only attend[ed] family events.” Id. 

P.E. did not check any of the boxes denoting limitations in his abilities. Id. He reported 

having no problems with walking and that he could walk around the block several times if he was 

not in pain. Id. He wrote that the longest he could pay attention was one hour, which was how 

long it took him to complete the form. Id. He indicated that he had trouble finishing things,

especially conversations, reading, and watching sports. Id. In addition, P.E. wrote that he could 

not follow written instructions and needed verbal instructions to be repeated. Id. When asked 

about his ability to get along with authority figures, P.E. wrote that he “ha[d] no need to deal with 

them.” Id. at 255. He stated that he had not been fired or laid off from a job as a result of trouble 

getting along with others. Id. He stated that he “become[s] anxious” in response to stress and that 

he does not handle changes in his routine well because he “gets nervous.” Id. Finally, P.E. listed 

Tegretol as his only medication, which he reported caused him to suffer side effects of fatigue and 

memory problems. Id. at 256. 

E. Seizure Questionnaire

While P.E. included a seizure disorder as one of his disabling conditions, he wrote on July 

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23, 2015 that he had not had a seizure in fifteen years. Id. at 245–47.

F. Third Party Function Report

P.E.’s wife, M.E., completed a third-party function report with the help of P.E.’s nonattorney representative. Id. at 259–66. She wrote that she spent “usually all day [with P.E.]” 

because he sometimes gets confused. Id. at 259. M.E. stated that P.E. “loses his temper – has no 

patience – [e]specially when the pain hits him,” and that he “isolates in the house” and gets 

anxious and depressed. Id. She stated that P.E. has good days “[o]nce in a while” but “you never 

know when therefore no guarantee he would make it to work.” Id. M.E. wrote that P.E. used to 

be social and independent but now needs her to be with her at all times, including during doctor 

appointments. Id. at 260. She wrote that his sleep was disturbed and the couple was no longer 

physically intimate. Id. M.E. had to remind her husband to take his medication and go to his 

appointments. Id. at 261. She reported that he only performed about twenty minutes’ worth of 

chores “if he feels up to it,” and he did not complete those tasks. Id. 

According to M.E., while she and P.E. sometimes went shopping together, she could not 

send P.E. grocery shopping alone because he often purchased the wrong items. Id. at 262. She

reported that she handled the family finances. Id. at 262–63. Since the onset of his illness, M.E. 

noted, P.E. had begun to take long walks around the neighborhood. Id. at 263. While P.E. still 

attended church on Sundays, he needed M.E. to accompany him. Id. He no longer enjoyed social 

gatherings and was irritated by others when he was in pain. Id. at 264. 

M.E. checked boxes indicating that P.E.’s illness limited his ability to lift, his memory and 

concentration, and his ability to complete tasks and follow instructions. Id. She added: “No heavy 

lifting. Gets frustrated following directions.” Id. She did not think her husband could follow 

written instructions and would need spoken instructions to be repeated and to be “simple.” Id. 

M.E. opined that P.E.’s ability to pay attention depended on how much pain he was in. Id. 

G. Summary of Administrative Proceedings

P.E. filed his initial application for benefits on May 3, 2015. AR at 78. The application

was denied on September 14, 2015. Id. at 93. He requested reconsideration on November 23, 

2015. Id. at 99. Upon reconsideration, the application was denied again on February 5, 2016. Id. 

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at 100. On April 18, 2016, P.E. requested a hearing. Id. at 107. Although the request was not 

filed timely, id. at 109, the untimeliness was excused based on a showing of good cause and the 

request was granted on June 1, 2016. Id. at 112–113, 118. 

H. The Administrative Hearing 

A hearing was held on June 30, 2017, in Oakland, California. AR at 39. The 

Administrative Law Judge (“ALJ”), Kevin Gill, heard testimony from P.E, his wife M.E., and 

Vocational Expert (“VE”) Susan Allison. Id. P.E. was represented by a non-attorney and was 

assisted by an interpreter. Id. 

In response to the ALJ’s questions, P.E. testified that he had a driver’s license and drove 

“[a]s necessary.” Id. at 44. He testified that he had attended school through the fourth grade and 

did not have any other education or vocational training. Id. P.E. told the ALJ that the last time he 

was employed, he worked as a janitor at the Shell refinery in Martinez, California, a position he 

held for six or seven years. Id. He testified that he also worked briefly in construction. Id. at 45–

46. When asked why he stopped working, P.E. pointed to the right side of his face and replied: 

“Because of the sickness that I have, you know, that it won’t let me, and sometimes I get 

depressed.” Id. The ALJ asked what sickness P.E. was referring to; he replied: “It’s a jabbing 

pain that I get here, right side of my face and it’s very strong.” He testified that he experienced the 

pain “many times a day,” that he was in pain “most of the day,” and that the flares were more 

frequent when he was “stressed out.” Id. at 46–47. He testified that he worked with the pain for a 

while but stopped working when the pain got worse. Id. P.E. testified that he helped his wife with 

household chores only when he did not have “the jabbing pain.” Id. at 47- 48. The ALJ also 

asked P.E. how his depression affected him. Id. at 47. P.E. testified that it “lower[ed] all of [his] 

energy.” Id. at 47. 

P.E. was then questioned by his representative, who asked about his depression. Id. at 49. 

P.E. testified that his depression was bad enough that he thought about suicide when his pain was 

“really strong.” Id. He testified that he was seeing a psychologist, Dr. Matias, but could not 

remember when he started seeing Dr. Matias. Id. at 49–50. When his representative asked 

whether he thought he could perform “a simple job,” P.E. replied that he did not think he could 

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because of his struggles with his memory. Id. at 50. He also testified that he had trouble 

concentrating and that when he was in pain, he could not “think of anything else.” Id. at 50-51. 

He testified that he needed to be reminded by his wife to take his medication and also needed her 

help handling his medical appointments. Id. at 51. P.E. also reported that he suffered from 

anxiety. Id. 

P.E. testified that on an ordinary day, he woke up at seven or eight in the morning 

depending on what time he went to sleep, which was usually ten p.m. Id. at 52. He went for 

walks and did some yard work. Id. He did not read in either English or Spanish because of the 

pain and because reading made his eyes tired. Id. He testified that because of his problems with 

reading and with his memory, P.E. had his doctor write a letter to help him become a U.S. citizen. 

Id. at 52. He testified that medication helped with the pain and that he increased his dosage as the 

pain increased. Id. at 53. 

The representative next questioned P.E. about his daily activities. Id. P.E. testified that he 

mowed the lawn twice a month, tended the roses and pulled weeds in his yard. Id. He said he was 

able to go out by himself to go to the store or complete chores. Id. He testified that he had tried to 

look for work but had to stop as his symptoms worsened. Id.

Next, P.E.’s wife, M.E., testified. Id. She told the ALJ that she was around her husband 

“24/7” to keep an “eagle eye” on him. Id. In response to questions from P.E.’s representative, 

M.E. told the ALJ about the changes she’d seen in her husband in recent years:

He has changed so much . . . . Now it’s like he’ll be at the house, or 

just walk around the block. People know him. They might think he’s 

homeless if they don’t know him because he doesn’t like being around 

people . . . . We don’t have dinner together . . . . And if we go places 

that it’s crowded, I have to keep an eye on him. 

Id at 55–56. She estimated that P.E. had lost thirty pounds, testifying that eating was difficult 

because it triggered P.E.’s face pain. Id. at 56–57. When asked whether P.E. had trouble getting 

along with others, M.E. testified that P.E. was “friendly” but that he “trie[d] to avoid people” 

because “once he ha[d] the pain he ha[d] to leave because he [could not] talk.” Id. at 57. She 

testified that he would “sit . . . for hours by himself in the yard.” Id. M.E. further testified about 

P.E.’s problems with his memory. Id. at 57-59. She testified that when she told P.E. things he 

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forgot them and that when he went places he later forgot he had been there. Id. at 57-58. M.E. 

testified that she had to watch him at almost all times and go to all of his doctor appointments. Id. 

at 59. She said that while doctors had told them that P.E.’s memory problems were related to his 

medications, numerous changes in his medications had had no impact on P.E.’s memory. Id.

Next, the ALJ questioned the VE. Id. at 60. She testified that P.E.’s past work as a janitor 

constituted “heavy exertional work, performed at medium, unskilled, SVP of 2.” Id. at 61. The 

ALJ offered the following hypothetical: 

[A]ssume a hypothetical of the claimant’s age and education and with 

the past job that you described. Further assume this individual is 

limited to lifting and carrying 50 pounds occasionally, 25 pounds 

frequently. 

Sit, stand, walk six hours in an eight hour day. This individual is 

limited to reading nothing finer than ordinary newsprint or book print. 

This individual is limited to occasional exposure to unprotected 

heights. 

Only occasional exposure to extreme cold or extreme heat. This 

individual is limited to only occasional vibration. This individual is 

limited to no more than loud noise. This individual should also avoid 

concentrated exposure to hazards including dangerous, heavy 

machinery and open heat sources. 

This individual is further limited to performing simple, routine tasks, 

and limited to simple work related decisions. 

Id. The VE testified that such a person could perform P.E.’s past work as well as work as a 

cleaner, a light unskilled job with an SVP of 2 and 387,000 jobs in the national economy, a 

hospital cleaner, a medium unskilled job with an SVP of 2 and 387,000 jobs in the national 

economy, a hand packager, a medium unskilled job with an SVP of 2 and approximately 170,00 

positions nationally, and a kitchen helper, a medium unskilled job with an SVP of 2 and 

approximately 200,00 positions nationally. Id. at 62. 

The ALJ offered a second hypothetical: 

[C]onsider the same person from hypothetical number one but this 

person is further limited to understanding simple oral instructions, and 

to communicating simple information. Can this hypothetical 

individual perform any of the jobs you just described, or any other 

work? 

Id. The VE replied that such a person could perform all of the jobs she described in response to 

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the first hypothetical and that such an individual could also perform P.E.’s past work as he 

performed it but “not as the DOT.” Id. at 63. 

Finally, the ALJ gave the VE a third hypothetical: “[c]onsider the same person from 

hypothetical number two, but in addition to normal breaks, this person’s going to be off task 15 

percent of the time in an eight hour day. Can this hypothetical individual perform any work?” Id. 

The VE testified that such a person “would not be able to sustain employment in the open labor 

market.” Id. 

I. Framework for Determining Disability 

1. Five-Step Analysis

When a claimant alleges a disability and applies to receive Social Security benefits, the 

ALJ evaluates the claim using a sequential five step process. 20 C.F.R. § 404.1520(a)(4). At step 

one, the ALJ determines whether the applicant is engaged in “substantial gainful activity.” 20 

C.F.R. § 404.1520(a)(4)(i). Substantial gainful activity is “work activity that involves doing 

significant physical or mental activities . . . that the claimant does for pay or profit.” 20 C.F.R. 

§ 220.141(a)–(b). If the claimant is engaging in such activities, the claimant is not disabled; if not, 

the evaluation continues at step two. 

At step two, the ALJ considers whether the claimant has a severe and medically 

determinable impairment or combination of impairments. An impairment or combination of 

impairments is severe when it “significantly limits [the claimant’s] physical or mental ability to do 

basic work activities.” 20 C.F.R. § 404.1520(c). If the claimant does not suffer from a severe 

impairment, the claimant is not disabled; if the claimant does have a severe impairment, the ALJ 

proceeds to step three. 

At step three, the ALJ turns to the Social Security Administration’s listing of severe 

impairments (the “Listing”). 20 C.F.R. § 404.1520(d); see also 20 C.F.R. § 404, Subpt. P, App. 1. 

If the claimant’s alleged impairment meets one of the entries in the Listing, the claimant is 

disabled. If not, the ALJ moves to step four. 

At step four, the ALJ assesses the claimant’s residual functional capacity, or RFC, to 

assess whether the claimant can perform past relevant work. 20 C.F.R. § 404.1520(e). The RCF 

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is a determination of “the most [the claimant] can do despite [the claimant’s] limitations.” 20 

C.F.R. § 404.1545(a)(1). The ALJ considers past relevant work to be “work that [the claimant] 

has done within the past fifteen years, that was substantial gainful activity, and that lasted long 

enough for [the claimant] to learn how do to it.” 20 C.F.R. § 404.1560(b)(1). If the claimant is 

able to perform past relevant work, the claimant is not disabled; if the claimant is not able to 

perform such past relevant work, the ALJ continues to step five. 

At the fifth and final step, the burden shifts from the claimant to the Commissioner to 

“identify specific jobs existing in substantial numbers in the national economy that the claimant 

can perform despite her identified limitations.” Meanel v. Apfel, 172 F.3d 1111, 1114 (9th Cir. 

1999) (citing Johnson v. Shalala, 60 F.3d 1428, 1432 (9th Cir. 1995)). If the Commissioner is 

able to identify such work, then the claimant is not disabled; if not, the claimant is disabled and 

entitled to benefits. 20 C.F.R. § 404.1520(g)(1). 

2. Supplemental Regulations for Determining Mental Disability

The Social Security Administration has supplemented the five-step general disability 

evaluation process with regulations governing the evaluation of mental impairments at steps two 

and three of the five-step process. See generally 20 C.F.R. § 404.1520a. First, the Commissioner 

must determine whether the claimant has a medically determinable mental impairment. 20 C.F.R. 

§ 404.1520a(b)(1). Next, the Commissioner must assess the degree of functional limitation 

resulting from the claimant’s mental impairment with respect to the following functional areas: 1) 

understand, remember, or apply information; 2) interact with others; 3) concentrate, persist, or 

maintain pace; and 4) adapt or manage oneself. 20 C.F.R. § 404.1520a(b)(2), (c)(3). Finally, the 

Commissioner must determine the severity of the claimant’s mental impairment and whether that 

severity meets or equals the severity of a mental impairment listed in Appendix 1. 20 C.F.R. § 

404.1520a(d). If the Commissioner determines that the severity of the claimant’s mental 

impairment meets or equals the severity of a listed mental impairment, the claimant is disabled. 

See 20 C.F.R. § 404.1520(a)(4)(iii). Otherwise, the evaluation proceeds to step four of the general 

disability inquiry. See 20 C.F.R. § 404.1520a(d)(3).

Appendix 1 provides impairment-specific “Paragraph A” criteria for determining the 

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presence of various listed mental impairments, but all listed mental impairments share certain 

“Paragraph B” severity criteria in common (and some have alternative “Paragraph C” severity 

criteria). See generally 20 C.F.R. § 404, Subpt. P, App. 1 at 12.00. Therefore, any medically 

determinable mental impairment—i.e., one that satisfies the Paragraph A criteria of one or more 

listed mental impairments—is sufficiently severe to render a claimant disabled if it also satisfies 

the general Paragraph B criteria, which requires that a claimant’s mental disorder “result in 

‘extreme’ limitation of one, or ‘marked’ limitation of two, of the four areas of mental 

functioning.” Id. at 12.00(A)(2)(b). A claimant has a “marked” limitation if the claimant’s 

“functioning in this area independently, appropriately, effectively, and on a sustained basis is 

seriously limited.” 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(F)(2)(d).

This evaluation process is to be used at the second and third steps of the sequential 

evaluation discussed above. Social Security Ruling 96-8p, 1996 WL 374184, at *4 (“The 

adjudicator must remember that the limitations identified in the ‘paragraph B’ and ‘paragraph C’ 

criteria are not an RFC assessment but are used to rate the severity of mental impairment(s) at 

steps 2 and 3 of the sequential evaluation process.”). If the Commissioner determines that the 

claimant has one or more severe mental impairments that neither meet nor are equal to any listing, 

the Commissioner must assess the claimant’s residual functional capacity. 20 C.F.R. §§ 

404.1520a(d)(3). This is a “mental RFC assessment [that is] used at steps 4 and 5 of the 

sequential process [and] requires a more detailed assessment by itemizing various functions 

contained in the broad categories found in paragraphs B and C of the adult mental disorders 

listings in 12.00 of the Listing of Impairments . . . . ” Social Security Ruling 96-8p, 1996 WL 

374184, at *4.

J. The ALJ’s Decision 

In a written decision dated October 6, 2017, the ALJ found P.E. not disabled. AR at 21. 

First, the ALJ found that P.E. met the insured requirements through December 31, 2018 and 

therefore could receive benefits so long as he demonstrated that he was disabled on or before that 

date. Id. at 23. At step one, the ALJ found that P.E. had not engaged in substantial gainful 

employment since his alleged onset date, June 28, 2013. Id. At step two, the ALJ found that 

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P.E.’s depression and trigeminal neuralgia were severe medically determinable impairments. Id.

He found that P.E.’s hyperlipidemia and seizure disorder were not severe. Id. 

At step three, the ALJ addressed whether P.E.’s impairments met a listing. Id. at 24. In 

evaluating P.E.’s impairments under the “paragraph B” criteria, the ALJ found that P.E. had 

moderate impairments in three of the four functional categories: understanding, remembering, or 

applying information; concentrating, persisting, or maintaining pace; and adapting and managing 

himself. Id. He found that P.E. had no limitations in interacting with others. Id. In support of his 

finding that P.E. had moderate limitations in understanding, remembering, or applying 

information, the ALJ pointed generally to “the weight of the record.” Id. The ALJ did not credit 

M.E.’s testimony about the severity of P.E.’s memory problems, finding that P.E. “appeared to 

have good recent and distant memory as he testified at the hearing.” Id. The AJL also found that 

none of P.E.’s treating physicians “has had any concerns “ about whether P.E. “can understand 

medical advice or treatment options,” and that “Dr. Peery’s opinion regarding the claimant’s 

memory supports this finding.” Id. 

In finding that P.E. had no limitations in interacting with others, the ALJ noted that “[t]he 

evidence, discussed in more detail elsewhere in this decision, shows that the claimant has 

interacted with health care providers, that he lives with other people, [and] that he regularly 

attends church.” Id. Overall, he opined that there was not enough evidence in the record to 

support limitations in this area. Id.

In finding that P.E. had moderate limitations in concentrating, persisting, or maintaining 

pace, the ALJ stated that he took into account P.E.’s testimony while noting that “his treating 

medical providers have found his thought processes to be within normal limits.” Id. Likewise, in 

finding that P.E. had moderate limitations in adapting or managing himself, the ALJ stated that he 

took into account P.E.’s testimony while again noting that P.E.’s medical providers had found his 

thought processes to be within normal limits. Id. 

The ALJ further found that P.E. did not meet the “paragraph C” criteria, “which require, 

among other things, a mental disorder that is ‘serious and persistent’ and evidence of marginal 

adjustment.” Id. 

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At step four, the ALJ found that P.E. had the following RFC: 

[T]he claimant has the residual functional capacity to perform 

medium work as defined in 20 CFR 404.1567(c) except he can lift 

and/or carry fifty pounds occasionally and twenty-five pounds 

frequently; he can sit for six hours, stand for six hours, and walk for 

six hours; he can push and/or pull as much as he can lift and/or carry; 

he is limited to reading ordinary newspaper or book print; he can work 

at unprotected heights occasionally; he can work in extreme cold or 

heat occasionally; he can work in vibration occasionally; he can work 

in loud noise occasionally; he must avoid concentrated exposure to 

hazards including dangerous heavy machinery and open heat sources. 

He is limited to performing simple, routine tasks, and to making 

simple work-related decisions. 

Id. at 25. 

In forming this RFC, the ALJ found that P.E.’s medically determinable impairments could 

reasonably cause his alleged symptoms but that P.E.’s “statements concerning the intensity, 

persistence, and limiting effects of these symptoms[were] not entirely consistent with the medical 

evidence and other evidence in the record.” Id. at 27. In particular, the ALJ noted that P.E. had a 

long history of anxiety that predated his alleged onset date and but that he did not seek mental 

health care until mid-2015 and further finding that “all mental health care ha[d] been 

conservative.” Id. at 27. In support of his conclusion that treatment of P.E.’s anxiety and 

depression was conservative, the ALJ noted that P.E.’s record did not reflect any “imminent 

suicidal ideation” or psychiatric confinement. Id. He also found that P.E.’s “thought process, 

thought content, attention, concentration, memory, fund of knowledge, impulse control, insight 

and judgment, were noted to be within normal limits when he sought mental health care in 2015.” 

Id. 

Similarly, the ALJ found that P.E.’s trigeminal neuralgia was longstanding but was only 

intermittent and had been “conservatively treated.” Id. The ALJ rejected P.E.’s testimony that 

his pain lasted most of the day, finding instead that the medical record showed it was intermittent; 

he found that P.E.’s acupuncture treatment “seemed effective” and noted that P.E. took medication 

for his condition “with good results,” according to physicians’ notes from May 2014 and January 

2015. Id. at 27-28. The ALJ acknowledged that P.E.’s complaints of pain increased in 2015 but 

noted that the findings of the MRI performed in 2015 were unchanged as compared to his 2007 

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MRI, and that a head CT scan in 2015 showed “consistent findings.” Id. at 28. He also pointed to 

a follow-up CT scan in November 2016 and MRI in December 2016 that showed no significant 

change. Id. The ALJ also pointed out that although P.E.’s doctors suggested surgery P.E. 

declined to undergo surgery. Id. In addition, he described M.E.’s communications with treatment 

providers during this period related to her belief that P.E. was unable to work and seeking 

assistance with P.E.’s application for disability. Id. The ALJ specifically found that P.E.’s 

testimony that his pain lasted “most of the day” was not credible, finding that the medical record 

showed that his pain was, instead, “intermittent.” Id. at 27.

The ALJ gave “limited weight” to M.E.’s opinions as expressed in her third-party function 

report “because she is not a medical doctor and is not familiar with the rules applicable to the 

Social Security Administration’s disability programs,” and because her opinions are in large part 

duplicative of the claimant’s own allegations, which are not entirely consistent with the medical 

evidence of record.” Id. at 29. 

In explaining how he weighed the medical opinion evidence, the ALJ wrote that he gave 

“limited weight” to the opinions of P.E.’s treating psychiatrist, Dr. Matias, expressed in the USCIS 

Form “because they are not supported with an explanation and are not supported by or consistent 

with relevant evidence.” Id. (citing AR 604). The ALJ further noted that Dr. Matias’s opinions 

in the USCIS Form “appear to have been prepared for submission to immigration authorities, with 

different metrics applicable for determining whether a cognitive impairment exists.” Id. 

The ALJ gave “significant weight” to the opinion of Dr. Peery, who examined P.E. on 

January 31, 2017 and conducted testing in Spanish, because the opinion was “supported by 

explanations and with relevant evidence, and [is] consistent with and supported by the record as a 

whole.” Id. He also gave “great weight” the opinions of state agency medical reviewers Dr. 

Eskander and Dr. Acinas “because [their opinions] are consisted with and supported by the record 

as a whole” and because the two physicians had experience with Social Security disability 

determinations. Id. at 30. On the other hand, the ALJ gave “little weight” to the opinions of state 

reviewing psychiatrists Dr. Stephenson and Dr. Hawkins, finding that their opinions were not 

consistent with the entire record and noting that they did not have the opportunity to review the 

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evidence submitted at the hearing level, having conducted their review in connection with the 

initial denial of P.E.’s application for disability benefits. Id. 

Finally, the ALJ explained how he weighed the opinions of Dr. Young, who examined P.E.

on August 15, 2015. Id. He gave “great weight” to most of her opinion, but “little weight” to her 

opinion that P.E. was unable to work without special supervision because “this part of the opinion 

is not explained and does not tie back to any of the findings of the mental status exam.” Id. 

The ALJ also found support for his RFC determination based on P.E.’s testimony that he 

continued to work after his conditions were diagnosed and that he left his job as a janitor for 

reasons unrelated to his impairments, and based on evidence that P.E.’s conditions “have been 

treated conservatively.” Id. at 30. 

At step five, the ALJ found that P.E. was capable of returning to his past work as a janitor. 

Id. at 31. In addition to his past relevant work, the ALJ found that P.E. could work at one of the 

jobs that the VE identified at the hearing, all of which were unskilled and did not require fluency 

in spoken or written English: a cleaner, a hospital cleaner, a hand packager, or a kitchen helper. 

Id. at 31–32. Accordingly, the ALJ found that P.E. was not disabled. Id. at 32. 

K. Plaintiff’s Contentions 

P.E. contends the ALJ erred in numerous respects. First, P.E. argues the ALJ improperly 

weighed the medical opinion evidence, failing to provide sufficient reasons supported by 

substantial evidence for giving little weight to the opinions of Dr. Matias, who treated P.E., while 

giving “great weight” to the opinions of state agency doctors who only reviewed the record; and 

by failing to take into account findings by Dr. Peery about the severity of his limitations even as 

the ALJ purported to give her opinion “significant weight.” 

Second, P.E. argues that the ALJ erred in assessing P.E.’s credibility because he failed to 

provide “specific, clear and convincing reasons” for the rejecting P.E. testimony about his 

symptoms. In particular, P.E. contends the ALJ selectively relied on information in the record that 

suggests his condition is controlled while ignoring medical evidence that pointed to the opposite 

conclusion. 

Third, P.E. argues that the ALJ erred by giving “limited weight” to the statements of M.E.

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in the Third Party Function Report. To the extent the ALJ relied on the fact that M.E. is not a 

“medical doctor,” P.E. argues that this is not relevant because M.E. was offering lay testimony. 

He further contends the ALJ was incorrect in concluding that M.E.’s statements about P.E.’s 

symptoms was duplicative of P.E.’s testimony and therefore could be rejected on the same 

grounds the ALJ rejected P.E.’s symptom testimony. Finally, P.E. argues that the ALJ erred by 

failing to address at all the testimony that M.E. offered at the administrative hearing.

Fourth, P.E. argues that the ALJ’s RFC is not supported substantial evidence because it 

does not reflect his limitations associated with anxiety and chronic pain, his limited ability to read, 

write and speak English and his need for additional supervision at work. According to P.E., this 

error is not harmless as it is unlikely that he would be able to perform his past work with an RFC 

that included additional supervision. Likewise, he argues that he probably would not be able to 

perform the other jobs listed by the VE with an RFC that accurately reflected his non-exertional 

limitations. 

Finally, P.E. argues that the ALJ erred by posing a hypothetical to the VE that did not 

reflect the opinions of Dr. Matias and Dr. Young with respect to his limitations. 

III. ANALYSIS 

A. Legal Standard Governing Review of the Commissioner’s Decisions

District courts have jurisdiction to review the final decisions of the Commissioner and may 

affirm, modify, or reverse the Commissioner’s decisions with or without remanding for further 

hearings. 42 U.S.C. § 405(g); see also 42 U.S.C. § 1383(c)(3). “This court may set aside a denial 

of Social Security disability insurance benefits when the [Commissioner’s] findings are based on 

legal error or are not supported by substantial evidence in the record as a whole.” Desrosiers v. 

Sec’y of Health & Human Servs., 846 F.2d 573, 575–76 (9th Cir. 1988). Substantial evidence is 

“such evidence as a reasonable mind might accept as adequate to support a conclusion” and that is 

based on the entire record. Richardson v. Perales, 402 U.S. 389, 401 (1971). “‘Substantial 

evidence’ means more than a mere scintilla,” id., but “less than preponderance.” Desrosiers, 846 

F.2d at 576. Even if the Commissioner’s findings are supported by substantial evidence, the 

decision should be set aside if proper legal standards were not applied when weighing the 

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evidence. Benitez v. Califano, 573 F.2d 653, 655 (9th Cir. 1978) (quoting Flake v. Gardner, 399 

F.2d 532, 540 (9th Cir. 1978)). In reviewing the record, the Court must consider both the 

evidence that supports and the evidence that detracts from the Commissioner’s conclusion. 

Smolen v. Chater, 80 F.3d 1273, 1279 (9th Cir. 1996) (citing Jones v. Heckler, 760 F.2d 993, 995 

(9th Cir. 1985)). 

B. Whether the ALJ Erred in Weighing the Medical Evidence

1. Legal Standards Governing Weight of Medical Opinions 

“Cases in this circuit distinguish among the opinions of three types of physicians: (1) those 

who treat the claimant (treating physicians); (2) those who examine but do not treat the claimant 

(examining physicians); and (3) those who neither examine nor treat the claimant (nonexamining 

physicians).” Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995), as amended (Apr. 9, 1996). The 

Ninth Circuit “afford[s] greater weight to a treating physician’s opinion because ‘he is employed 

to cure and has a greater opportunity to know and observe the patient as an 

individual.’” Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989) (quoting Sprague v. 

Bowen, 812 F.2d 1226, 1230 (9th Cir. 1987)). For claims filed before March 27, 2017, as is the 

case here, “[t]he medical opinion of a claimant’s treating physician is given ‘controlling weight’ 

so long as it ‘is well-supported by medically acceptable clinical and laboratory diagnostic 

techniques and is not inconsistent with the other substantial evidence in [the claimant’s] case 

record.’” Trevizo v. Berryhill, 871 F.3d 664, 675 (9th Cir. 2017) (quoting 20 C.F.R. § 

404.1527(c)(2)).4 The Commissioner must provide clear and convincing reasons for rejecting the 

uncontradicted opinion of a treating or examining physician. Lester v. Chater, 81 F.3d at 830-31. 

“[T]he opinion of an examining doctor, even if contradicted by another doctor, can only be 

rejected for specific and legitimate reasons that are supported by substantial evidence in the 

record.” Id. 

“Opinions of a nonexamining, testifying medical advisor may serve as substantial evidence 

4 The regulations regarding evaluation of medical evidence have been amended for claims filed 

after March 27, 2017. See Revisions to Rules Regarding the Evaluation of Medical Evidence 

(“Revisions to Rules”), 2017 WL 168819, 82 Fed. Reg. 5844, at 5867-68 (Jan. 18, 2017); see also

20 C.F.R. §§ 404.1520c (a), 416.920c(a). 

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when they are supported by other evidence in the record and are consistent with it.” Morgan, 169 

F.3d at 600 (citing Andrews v. Shalala, 53 F.3d 1035, 1041 (9th Cir. 1995)). “The ALJ can meet 

this burden by setting out a detailed and thorough summary of the facts and conflicting clinical 

evidence, stating his interpretation thereof, and making findings.” Id. at 600–01 (quoting 

Magallanes, 881 F.2d at 750 (9th Cir. 1989)). 

2. The ALJ Did Not Give Specific and Legitimate Reasons to Discount the 

Opinions of Dr. Matias Stated in the USCIS Form

As discussed above, Dr. Matias listed three diagnoses on the USCIS Form, “Mild 

Neurocognitive Disorder;” “Major Depressive Disorder;” and “Chronic Pain . . . due to medically 

Refractory Trigeminal Neuralgia,” and opined that they “are in the way of applicant acquiring new 

knowledge (like English as second language and U.S. history/civics.”). AR at 602. The ALJ gave 

“limited weight” to Dr. Matias’s opinions, finding that they were “not supported with an 

explanation and are not supported by or consistent with relevant evidence.” Id. at 29 (citing AR 

604). The ALJ further noted that Dr. Matias’s opinions in the USCIS Form “appear to have been 

prepared for submission to immigration authorities, with different metrics applicable for 

determining whether a cognitive impairment exists.” The Court finds that these are not specific 

and legitimate reasons supported by substantial evidence for discounting Dr. Matias’s opinions.

First, the ALJ’s finding that Dr. Matias’s opinion is not supported by an explanation is not 

a legitimate reason for discounting Dr. Matias’s opinions. The main opinion Dr. Matias offered in 

the USCIS Form was that P.E. is impaired with respect to his ability to acquire new knowledge, 

which is directly related to Dr. Matias’s diagnoses of Major Depressive Disorder and Mild 

Neurocognitive Order. As Dr. Matias stated on the USCIS Form, P.E.’s diagnoses are 

characterized by, inter alia, “memory impairment,” “decline in the ability to perform everyday 

activities,” “difficulties with language skills,” “inability to think or concentrate,” “and “memory 

problems.” Id. Further, Dr. Matias explained the source of P.E.’s mood disorder, namely, his 

chronic pain. Id. The USCIS Form also makes clear that Dr. Matias’s opinions are based on 

almost two years of treating P.E. and the results of neuropsychological testing conducted by Dr. 

Peery (to which the ALJ gave “great weight”). It is not clear what further “explanation” the ALJ 

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was seeking and the absence of “explanation” is not a sufficient reason to discount Dr. Matias’s 

opinion.

Second, the ALJ’s generic statement that Dr. Matias’s opinion was inconsistent with the 

medical record is insufficiently specific to meet the ALJ’s burden. When an ALJ rejects a treating 

provider’s opinion, he must “set[] out a detailed and thorough summary of the facts and 

conflicting clinical evidence, stating his interpretation thereof, and making findings.” Magallanes, 

881 F.2d at 751. The ALJ did not do this. 

Finally, in finding that Dr. Matias’s opinion was not supported by the record, the ALJ 

ignored significant medical evidence in the record that was consistent with Dr. Matias’s opinion. 

Among other things, the ALJ ignored Dr. Peery’s opinion that “reductions in [P.E.’s] functional 

memory likely related to his pain, depression, and insomnia.” Id. at 534. Dr. Peery, like Dr. 

Matias, diagnosed P.E. with chronic pain caused by Trigeminal Neuralgia, mild cognitive 

impairment and adjustment disorder with mixed anxiety and depressed mood. Id. at 529. The 

ALJ also overlooked Dr. Datta’s diagnosis of mild cognitive impairment, “likely . . . related to 

pain, medications, and . . . anxiety [and] severe depression.” Id. at 558. Dr. Young also 

concluded based on her testing that P.E. had impaired cognitive functioning. Id. at 575. The ALJ 

erred in ignoring this evidence to find that Dr. Matias’s opinion was inconsistent with the medical 

record. See Holohan v. Massanari, 246 F.3d 1195, 1207 (9th Cir. 2001)(holding that the ALJ’s 

“specific reason for rejecting [a treating physician’s medical opinion [was] not supported by 

substantial evidence” by “selectively rel[ying] on some entries in [the claimant’s] records ... and 

ignor[ing] the many others that indicated continued, severe impairment.”).

The fact that Dr. Matias’s opinion was offered in the context of P.E.’s application for 

citizenship also is not a sufficient reason for discounting Dr. Matias’s opinion. While it is true that 

the USCIS Form was submitted to a different agency in support of his application to be excused 

from the English language and U.S. history and civics requirements for U.S. citizenship – and not 

to establish that he was disabled under the Social Security Act – the ALJ does not explain why this 

has any bearing on the objective medical evidence offered by Dr. Matias in the USCIS Form. An 

ALJ may not simply ignore medical evidence, even if it is submitted to another agency for another 

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purpose, without providing some reasonable basis for concluding that it is entitled to less weight 

because of the context in which it was offered. See Gonzalez v. Commissioner of SSA, Case No. 

16-cv-5310 KAW, 2018 WL 1426655, at *7 (N.D. Cal. 2018) (“Simply because medical evidence 

was derived from a worker’s compensation proceeding does not mean the ALJ is not required to 

review that medical evidence and explain why such evidence should be afforded particular 

weight.”); Ray v. Saul, No. 2:18-CV-0561 DB, 2019 WL 3767454, at *3 (E.D. Cal. Aug. 9, 2019) 

(“‘the ALJ should evaluate the objective medical findings set forth in the medical reports for 

submission with the worker’s compensation claim by the same standards that s/he uses to evaluate 

medical findings in reports made in the first instance for the Social Security claim, unless there is 

some reasonable basis to believe a particular report or finding is not entitled to comparable 

weight.’”) (quoting Coria v. Heckler, 750 F.2d 245, 248 (3rd Cir. 1984)).

In sum, the ALJ erred by failing to provide specific and legitimate reasons based on 

substantial evidence for discounting Dr. Matias’s opinion. 

3. The ALJ Did Not Provide Specific and Legitimate Reasons to Reject Part of 

Dr. Young’s Opinion

The ALJ gave “great weight” to the majority of Dr. Young’s opinion but “little weight” to 

her opinion that P.E. would require special supervision at work, finding that “[t]his part of the 

opinion is not explained and does not tie back to any of the findings in the mental status exam.” 

AR at 30. This is not a specific and legitimate reason for rejecting Dr. Young’s opinion and it is 

not supported by substantial evidence. 

The ALJ may reject the opinion of any physician “if that opinion is brief, conclusory, and 

inadequately supported by clinical findings.” Thomas v. Barnhart, 278 F.3d 947, 957 (9th Cir. 

2002) (citing Matney v. Sullivan,, 981 F.2d 1015, 1019 (9th Cir. 1992)). Here, however, the ALJ 

looked only to the results of Dr. Young’s mental status exam and did not address the other 

grounds for her opinion, namely, the results of the test she conducted of P.E.’s intellectual 

functioning (which found him in the < 1 percentile range), P.E.’s report to her that he was 

“forgetful” and her review of P.E.’s Adult Function Report. P.E.’s Adult Function Report 

described the need for supervision in his daily life with respect to numerous activities, including 

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taking long drives (he needed to be accompanied because he got confused about directions), 

grocery shopping (he could accompany his wife but could not be entrusted to do the grocery 

shopping on his own because he bought the wrong things), going places (other than going on daily 

walks around the block, his wife was always with him), and following instructions (he needed 

verbal instructions and needed repetition of instructions because he forgot them.). See id. at 249-

257. As discussed below, the ALJ did not give adequate reasons for declining to credit P.E.’s 

report of his limitations and symptoms in his Adult Function Report. Likewise, he offered no 

explanation for why he looked only to Dr. Young’s mental status exam in finding that her 

conclusion with respect to the need for supervision was not supported by the record. As her 

conclusion that P.E. needed special supervision clearly tied back to the evidence discussed above 

of low intellectual functioning, poor memory, and inability to function independently with respect 

to many daily activities, the ALJ’s conclusion was not a specific and legitimate reason for 

rejecting this limitation and was not supported by substantial evidence. 

4. The ALJ Improperly Gave Great Weight to the Opinions of Nonexamining 

Physicians

The ALJ gave “great weight” the opinions of state agency medical reviewers Dr. Eskander 

and Dr. Acinas that P.E.’s trigeminal neuralgia was “controlled by medication” and P.E.’s only 

nonexertional limitations should be to avoid concentrated exposure to cold or heat, or to noise and 

vibration, finding that their opinions were “consistent with and supported by the record as a 

whole” and pointing to the fact that these doctors had experience with Social Security disability 

determinations. Id. at 30. P.E. contends that the two reasons the ALJ provided for relying 

heavily on the opinions of these non-examining physicians are not specific and legitimate or 

supported by substantial evidence in the record. The Court agrees.

First, the nonexamining physicians’ findings that P.E.’s trigeminal neuralgia was 

controlled by medication ignores the extensive evidence in the record, mostly from doctors who 

treated P.E., that although his pain ebbed and flowed, P.E. continued to experience significant pain 

as a result of his trigeminal neuralgia, despite participating in a pain management program at 

Kaiser, undergoing acupuncture, and numerous changes in his medications. See, e.g., AR at 403 

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(Dr. Efron describes trigeminal neuralgia as “medically refractory” in 2010); 461-511 (summary 

by Chronic Pain Management Physician Dr. Hsu of P.E.’s history of chronic pain and medication 

changes and treatment notes from July through December 2015 documenting numerous trials to 

adjust medications and P.E.’s ongoing chronic pain); 337 (Dr. Meza’s treatment note dated 

March 24, 2013 that P.E. was having “breakthrough pain” despite being on carbamazepine and 

that he was unable to go to work); 422-426 (records showing that P.E. underwent a series of 

acupuncture sessions aimed at alleviating his pain); 411 (Dr. Meza’s treatment note dated May 

22, 2015, noting that P.E. was “[f]rustrated about his trigeminal neuralgia – states that it affects 

him psychologically, it makes him depressed[.] Upset and unable to carry on his ADL’s.” ); 411 

(June 12, 2015 treatment note by Dr. Jelalian noting that P.E. reported he was feeling a sharp, 

persistent, worsening pain); 529 (note from Peery’s 2017 report that P.E. reported pain “as great 

as 10/10 for 3 or more attacks per day; each attack lasts 5-15 minutes before subsiding.”); 476 

(2015 report by Dr. Young noting that P.E. reported “suicidal ideation related to strong pain and 

diagnosing “Adjustment Disorder with Mixed Anxiety and Depressed Mood” and “[Rule Out] 

Mood Disorder due to Pain” and “[Rule Out] Cognitive Disorder NOS.”); 493 (October 19, 2015 

treatment note by M.F.T. Moore that P.E. had experienced “no change or improvement” since 

starting the pain management program and was “still very frustrated.”); 569-570 (June 23, 2016 

treatment note by Dr. Meza that tramadol was no longer effective and prescribing hydrocodone–

acetaminophen (Norco) to treat P.E.’s pain).

Moreover, doctors who examined or treated P.E. found that his pain contributed to his 

anxiety and depression, which caused additional symptoms related to P.E.’s ability to function

such as difficulty concentrating and remembering things. See, e.g., id. at 558 (November 9, 2016 

treatment note by Dr. Datta diagnosing P.E. with mild cognitive impairment “likely . . . related to 

pain, medications, and . . . anxiety [and] severe depression.” ); 409 (June 2, 2015 treatment note 

by Dr. Matias noting that P.E. had experienced suicidal ideation about a month before, “triggered 

by strong pain.”); 602 (USCIS Form by Dr. Matias listing P.E.’s diagnoses as “Mild 

Neurocognitive Disorder;” “Major Depressive Disorder;” and “Chronic Pain . . . due to medically 

Refractory Trigeminal Neuralgia.”). 

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The ALJ does not explain why the state agency physicians, who conducted only a review 

of P.E.’s medical records, were in a better position to evaluate P.E.’s non-exertional limitations or 

why their opinion that P.E.’s pain was controlled by medication was entitled to greater weight than 

the opinions and treatment records of P.E.’s medical providers pointing to the opposite conclusion. 

Further, the ALJ does not explain why the familiarity of these doctors with social security 

disability determinations justifies giving greater weight to their opinions than to the opinions of 

the doctors who treated and examined him. Therefore, the Court concludes that the ALJ erred in 

adopting the opinions of Drs. Eskander and Acinas by failing to provide specific and legitimate 

reasons supported by substantial evidence for doing so. 

C. Whether the ALJ Provided Clear and Convincing Reasons to Reject P.E.’s 

Testimony

1. Legal Standards Governing Claimant Credibility Determinations

“The ALJ is responsible for determining credibility and resolving conflicts in medical 

testimony.” Magallanes v. Bowen, 881 F.2d 747, 750 (9th Cir. 1989) (citing Allen v. Heckler, 749 

F.2d 577, 579 (9th Cir. 1984)). In assessing credibility, the ALJ must first determine “whether the 

claimant has presented objective medical evidence of an underlying impairment ‘which could 

reasonably be expected to produce the pain or other symptoms alleged.’” Treichler v. Comm’r of 

Soc. Sec. Admin., 775 F.3d 1090, 1102 (9th Cir. 2014) (quoting Lingenfelter v. Astrue, 504 F.3d 

1028, 1036 (9th Cir. 2007)). Then, if there is no evidence of malingering, “the ALJ can reject the 

claimant’s testimony about the severity of [his] symptoms only by offering specific, clear and 

convincing reasons for doing so.” Smolen v. Chater, 80 F.3d at 128. These reasons must be 

“sufficiently specific to permit the court to conclude that the ALJ did not arbitrarily discredit 

claimant’s testimony.” Thomas v. Barnhart, 278 F.3d 947, 958 (9th Cir. 2002). “General findings 

are insufficient.” Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998) (internal quotation marks 

omitted). “[T]he ALJ must identify what testimony is not credible and what evidence undermines 

the claimant's complaints.” Lester v. Chater, 81 F.3d 821, 834 (9th Cir. 1995), as amended (Apr. 

9, 1996) (citing Dodrill v. Shalala, 12 F.3d 915, 918 (9th Cir.1993); Varney v. Secretary of Health 

and Human Services, 846 F.2d 581, 584 (9th Cir.1988)). 

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2. Discussion

In his Adult Function Report and at the hearing, P.E. offered testimony about the severity 

and effects of his chronic pain, which included his depression and thoughts of suicide when 

experiencing pain flares, self-isolation, increased anxiety in response to stress, difficulty finishing 

things, inability to perform simple tasks, such as grocery shopping, problems understanding and 

remembering instructions, and a need to be accompanied to doctors’ appointments and when 

driving more than a short distance due to confusion. The ALJ found as a general matter that P.E.’s 

testimony as to the severity of his symptoms was not credible, but the only specific testimony he 

identified as not credible was P.E.’s testimony about having memory problems and that he was in 

pain “most of the day.” See id. at 24, 27. The ALJ’s credibility determination fell short in several 

respects.

First, the reason the ALJ gave for rejecting P.E.’s testimony that he was in pain most of the 

day was not clear and convincing. The ALJ stated that he rejected this testimony because the 

medical record reflected P.E.’s pain was “intermittent” but did not explain why evidence that 

P.E.’s pain was intermittent contradicted P.E.’s testimony. Having reviewed the hearing 

transcript, the Court finds that it is not. The exchange between the ALJ and P.E. regarding his 

daily pain reflects that P.E. (like his doctors) described it as a “jabbing pain” that occurs “many 

times a day,” that is, intermittently. See AR at 46-47. As the term “intermittently” sheds no light 

on the frequency of P.E.’s pain flares, the ALJ’s reason for rejecting P.E.’s testimony about the 

portion of his day in which he is in pain is not a clear and convincing reason for rejecting that 

testimony and it is not based on substantial evidence. 

Second, the only reason the ALJ gave for rejecting P.E.’s testimony about his memory 

problems was that P.E. “appeared to have good recent and distant memory as he testified at the 

hearing.” Id. at 24. The ALJ’s reliance on his own observations is the sort of “sit and squirm” 

jurisprudence that the Ninth Circuit has rejected, at least under circumstances where, as here, the 

claimant’s statements are supported by objective medical evidence. See Perminter v. Heckler, 765 

F.2d 870, 872 (9th Cir. 1985). Here, Dr. Datta, a medical doctor, examined P.E. and diagnosed 

him with mild cognitive impairment based on his memory problems, having conducted a memory 

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screening test. Id. at 558; see also id. at 528 (note by Dr. Peery that on a memory screener, 

P.E.’s “performance fell in the range of mild cognitive impairment.”). It was improper for the 

ALJ, who is not a medical doctor, to rely on his own opinion of P.E’s memory based on 

observation of P.E. at the hearing when it contradicted the opinion of these medical professionals. 

Third, to the extent that the ALJ implicitly rejected P.E.’s testimony that he did not 

specifically identify, he erred. As discussed above, an ALJ must provide reasons that are 

“sufficiently specific to permit the court to conclude that the ALJ did not arbitrarily discredit 

claimant’s testimony.” Thomas v. Barnhart, 278 F.3d at 958. Thus, for example, the ALJ should 

have explained why he declined to credit P.E.’s testimony that he needed a great deal of 

supervision in his daily life, including needing to be accompanied on long drives and to doctor 

appointments, among other things. This testimony mirrors that of his wife and is supported by Dr. 

Young’s opinion (which the ALJ also rejected improperly) yet the ALJ did not explain why he did 

not find it credible. 

Fourth, the reasons the ALJ did offer for finding generally that P.E.s testimony was not 

fully credible are inadequate. The ALJ relied heavily on the fact that P.E.’s diagnoses predate his 

alleged onset date of June 28, 2013, when P.E. stopped working, and that he stopped working 

because his job no longer offered benefits and not due to the severity of his symptoms. As the 

ALJ recognized, however, P.E. could qualify for disability so long as he demonstrated that he was 

disabled on or before his date last insured of December 31, 2018. Therefore, to the extent the ALJ 

relied on evidence and testimony showing that P.E. was able to work in 2013, this is not a clear 

and convincing reason for rejecting his symptom testimony in his July 2015 Adult Function 

Report and at the June 2017 hearing.

Nor does the ALJ’s reliance on P.E.’s “conservative” treatment, use of medication, and 

MRI and CT scan results meet this requirement. As to the MRI and CT scan results, it is wellestablished that “the Commissioner may not discredit the claimant’s testimony as to the severity of 

symptoms merely because they are unsupported by objective medical evidence.” Reddick v. 

Chater, 157 F.3d 715, 722 (9th Cir. 1998). Further, the ALJ’s apparent conclusion that P.E.’s pain 

was well-controlled by medication is based on a highly selective reading of the record. As 

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discussed above, the ALJ ignored the extensive evidence in the record that although P.E.’s pain 

ebbed and flowed, he continued to experience significant pain as a result of his trigeminal 

neuralgia, as well as related anxiety and depression, despite participating in a pain management 

program at Kaiser, undergoing acupuncture, and making numerous changes in his medications. 

There is also evidence in the record that P.E.’s pain worsened in 2015.

With respect to the ALJ’s reliance on P.E.’s conservative treatment, the ALJ also erred. In 

the Ninth Circuit, “an unexplained, or inadequately explained, failure to seek treatment may be the 

basis for an adverse credibility finding unless one of a number of good reasons for not doing so 

applies.” Orn v. Astrue, 495 F.3d 625, 638 (9th Cir. 2007) (internal quotation and citation 

omitted) (emphasis added). The record indicates that P.E. was reluctant to seek and continue 

treatment both for his pain management and his mental health because of the language barrier 

between him and his healthcare providers. See AR at 497 (“Wife explained that every time 

appointment is booked with booked with Tim [Moore, M.F.T.] husband decides to cancel the day 

before. He has expressed to her that no one understands how he feels due to the language 

barrier.”); 530 (“[P.E.] declined to participate in psychotherapy with anyone who does not speak 

Spanish, owing to frustration about not being understood.”). The record also indicates that P.E. 

had financial difficulties and lost his work-related benefits in 2013. Id. at 474 (noting that P.E.

“quit as the new company took over and no longer provided employee benefits.”); 519 (noting that 

P.E.’s main stressor was financial). “Disability benefits may not be denied because of the 

claimant’s failure to obtain treatment he cannot obtain for lack of funds.” Gamble v. Chater, 68 

F.3d 319, 321 (9th Cir.1995). 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 . . . failure to seek medical treatment.” S.S.R. 96–7p at 7–8. The 

ALJ did not ask P.E. why he delayed seeking treatment even though the record suggests that P.E. 

may have deferred treatment for reasons other than the nonseverity of his condition. The ALJ also 

did not ask P.E. at the hearing why he declined surgery for his trigeminal neuralgia. For this 

reason, the Court finds the ALJ’s reliance on P.E.’s “conservative” treatment is not convincing. 

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The Court also rejects the ALJ’s reliance on the fact that P.E. had not been hospitalized or 

exhibited “imminent” suicidal ideation to support his finding of conservative treatment. Courts in 

this circuit have found that psychiatric hospitalization is not a benchmark for conservative 

treatment. See Morales v. Berryhill, 239 F. Supp. 3d 1211, 1216 (E.D. Cal. 2017) (“A claimant 

may suffer from mental health impairments that prevent him from working but do not require 

psychiatric hospitalization.”). P.E.’s doctors unanimously agreed that his anxiety and depression 

were triggered by his chronic pain associated with his trigeminal neuralgia, and P.E. took 

numerous medications to address that condition, which persisted nonetheless. Consequently, the 

fact that P.E. was not hospitalized for his mental impairments and did not experience “imminent” 

suicidal ideation is not a clear and convincing reason for discrediting his symptom testimony

regarding his mental impairment. See Callahan v. Berryhill, No. EDCV 17-1247-KS, 2018 WL 

2446649, at *4 (C.D. Cal. May 29, 2018) (holding that the ALJ had erred in finding the claimant’s 

treatment was conservative because there was no evidence of counseling sessions or 

hospitalization where the record showed that the claimant had been prescribed several psychiatric 

medications and still experienced mood swings).

Finally, the ALJ’s finding that P.E.’s testimony was not credible because “[h]is thought 

process, thought content, attention, concentration, memory, fund of knowledge, impulse control, 

insight and judgment were noted to be within normal limits when he sought mental health care in 

2015,” AR at 27, is not a clear and convincing reason for rejecting his testimony. Again, the ALJ 

has cherry-picked the record, ignoring medical evidence that does not support his conclusion. Dr. 

Matias diagnosed P.E. with “Adjustment Disorder with mixed anxiety and depressed mood” on 

June 2, 2015, assigning a GAF score of 41-50, signifying “serious symptoms.” Id. at 404, 409. 

On July 9, 2015, M.F.T. Moore found that P.E. had “severe depressive symptoms” and that his 

affect was “blunted but showed some range.” Id. at 520. In 2017, Dr. Peery noted that P.E.

“meets the diagnostic criteria for Major Depressive Disorder, and he is at moderate risk for 

suicide,” and that therapy did not seem to improve his symptoms. Id. at 532. Finally, between 

December of 2015 and June of 2017, P.E.’s medical providers repeatedly described P.E.’s mood 

as “depressed” or “anxious.” Id. at 635, 641, 655, 661, 665, 669, 674, 683, 688, 700, 708, 723, 

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742. 

For these reasons the Court finds that the ALJ did not provide specific, clear and 

convincing reasons for declining to fully credit P.E.’s testimony about his symptoms.

D. Whether the ALJ Gave Germane Reasons for Rejecting M.E.’s Testimony 

The ALJ further erred when he failed to provide sufficient reasons for finding M.E.’s 

testimony not credible. “Lay testimony as to a claimant’s symptoms is competent evidence that an 

ALJ must take into account, unless he or she expressly determines to disregard such testimony and 

gives reasons germane to each witness for doing so.” Lewis v. Apfel, 236 F.3d 503, 511 (9th Cir. 

2001) (citing Nguyen v. Chater, 100 F.3d 1462, 1467 (9th Cir.1996) (internal citation omitted)). 

The ALJ gave two reasons for rejecting M.E.’s testimony: 1) M.E. is not a medical source familiar 

with the Social Security Administration’s disability determination process; and 2) M.E. repeated 

many of P.E.’s statements, which the ALJ found inconsistent with the record. AR at 29. Neither 

of these reasons is “germane.” 

First, to the extent the ALJ discounted M.E.’s statements because she was not an 

“acceptable medical source,” the ALJ misunderstood the role of lay testimony in the disability 

determination. While “medical diagnoses are beyond the competence of lay witnesses and 

therefore do not constitute competent evidence, . . . lay testimony as to a claimant’s symptoms or 

how an impairment affects ability to work is competent evidence.” Nguyen v. Chater, 100 F.3d at 

1467; see also Bruce v. Astrue, 557 F.3d 1113, 1116 (9th Cir. 2009) (holding that a “lay person . . 

. though not a vocational or medical expert, was not disqualified from rendering an opinion as to 

how [the claimant’s] condition affects [her] ability to perform basic work activities.”) (citing 20 

C.F.R. § 404.1513(d)(4)). M.E. offered her testimony not as a medical provider or an expert on 

social security disability determinations but rather based on her observations of her husband’s 

symptoms as they affect his ability to function in his daily life. These observations are competent 

evidence; the ALJ erred when he discounted M.E.’s testimony on this ground. 

The ALJ’s rejection of M.E.’s testimony on the ground that it was “largely duplicative” of 

P.E.’s testimony was also error. As discussed above, the ALJ’s credibility analysis with respect to 

P.E.’s testimony was flawed in numerous respects. To the extent that he offers those same reasons 

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for rejecting M.E.’s testimony, they are also inadequate. 

E. Whether the RFC and Resulting VE Hypothetical Adequately Captured P.E.’s 

Limitations

The only nonexertional limitations the ALJ included in P.E.’s RFC were limitations to: 1) 

“performing simple, routine tasks;” and 2) “making simple work-related decisions.” AR at 25. 

P.E. argues that the ALJ erred with respect to his RFC – and the hypothetical he posed to the VE 

based on that RFC – because it did not address the evidence in the record relating to the likely 

impact his chronic pain would have on his ability to work. The Court agrees.

Pain is a nonexertional impairment when it does not affect the claimant’s strength but 

affects him in other ways that limit a claimant’s ability to work, such as the ability to focus, 

understand instructions or function without supervision. See Desrosiers v. Secretary of Health 

and Human Services, 846 F.2d 573, 579 (9th Cir.1988). Further, “[t]he hypothetical an ALJ 

poses to a vocational expert, which derives from the RFC, ‘must set out all the limitations and 

restrictions of the particular claimant.’” Valentine v. Comm'r Soc. Sec. Admin., 574 F.3d 685, 690 

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

above, the ALJ failed to offer adequate reasons for rejecting P.E. and M.E.’s testimony regarding 

the limitations on his ability to function due to chronic pain and improperly weighed the opinions 

of P.E.’s medical providers with respect to the symptoms associated with his chronic pain. 

Therefore, the Court finds that the ALJ’s RFC was not supported by substantial evidence and that 

the hypothetical posed to the VE did not accurately reflect P.E.’s nonexertional limitations. See 

Robbins v. Soc. Sec. Admin., 466 F.3d 880, 886 (9th Cir. 2006) (An “ALJ’s failure to account for 

the testimony of [the claimant and lay witnesses] calls into question the validity of his [RFC 

determination] . . . . Because those determinations were flawed, the hypothetical posed to the 

vocational expert was legally inadequate.”) (citing Osenbrock v. Apfel, 240 F.3d 1157, 1163–65 

(9th Cir. 2001)).

F. Remedy

 “A district court may affirm, modify, or reverse a decision by the Commissioner ‘with or 

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without remanding the cause for a rehearing.’” Garrison v. Colvin, 759 F.3d 995, 1019 (9th Cir. 

2014) (quoting 42 U.S.C. § 405(g)) (emphasis omitted). “If additional proceedings can remedy 

defects in the original administrative proceeding, a social security case should be remanded.” 

Lewin v. Schweiker, 654 F.2d 631, 635 (9th Cir. 1981). Here, the Court finds that further 

proceedings are necessary to address the ALJ’s errors with respect to his weighing of the medical 

evidence and consideration of the testimony of P.E. and M.E. The Commissioner should 

reevaluate P.E.’s limitations to determine whether his impairments meet or equals a listing at step 

three; if they do not, the Commissioner should determine P.E.’s RFC under correct legal standards 

and whether there is work available in the national economy that P.E. can perform in light of that 

RFC. 

IV. CONCLUSION 

For the reasons stated above, P.E.’s motion is GRANTED, the Commissioner’s motion is 

DENIED and the matter is REMANDED to the Commissioner for further proceedings consistent 

with this Order. The Clerk is instructed to enter judgment accordingly and close the file.

IT IS SO ORDERED.

Dated: April 17, 2020

______________________________________

JOSEPH C. SPERO

Chief Magistrate Judge

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