Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_09-cv-01358/USCOURTS-azd-2_09-cv-01358-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:405 Review of HHS Decision (SSID)

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WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

SHAWN E. NORTON, 

Plaintiff, 

v.

MICHAEL J. ASTRUE,

Commissioner of Social Security,

Defendant. 

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No. CV 09-01358-PHX-MHM

ORDER

Plaintiff Shawn Norton ("Plaintiff") seeks judicial review of the decision of the

Commissioner of Social Security pursuant to Section 205(g) of the Social Security Act, as

amended, 42 U.S.C. Section 405(g). Upon judicial review by the Court, Plaintiff seeks for

the Court to reverse the decision of the Commissioner of Social Security denying Plaintiff’s

claim for disability insurance benefits and to remand solely for calculation and award of

benefits. (Doc. 20). Currently before the Court is Defendant Michael J. Astrue’s

(“Defendant”) motion to remand for further proceedings pursuant to sentence four of Section

205(g) of the Social Security Act, 42 U.S.C. § 405(g). (Doc. 23). After considering the

arguments set forth in the Parties’ briefs, the record as a whole, and the applicable law, the

Court issues the following order.

/ / / 

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I. PROCEDURAL HISTORY

On December 17, 2003, Plaintiff filed applications for Disability Insurance Benefits

under Title II of the Social Security Act (“the Act”), 42 U.S.C. §§ 401-433 and Supplemental

Security Income under Title XVI of the Act, 42 U.S.C. §§ 1381-1383c. (Administrative

Record (“AR”) 181-83). He alleged that his disability onset date was May 1, 2000. (AR

181). Plaintiff’s applications were denied initially (AR 148-51) and after reconsideration.

(AR 143-45). On November 3, 2004, he requested an administrative hearing. (AR 141). A

hearing was held before Administrative Law Judge ("ALJ") Edward T. Morris on April 26,

2005. (AR 1420-55). On March 7, 2006, the ALJ denied Plaintiff's application for Social

Security Disability Insurance and Supplemental Security Income, finding that Plaintiff was

not disabled. (AR 97-106). The Appeals Council granted Plaintiff’s request for review of

the ALJ’s decision and remanded the claim for a new hearing and decision on August 10,

2007. (AR 92-94). A second hearing was held on May 19, 2008, before ALJ Morris. (AR

1462-83). In a decision dated June 26, 2008, the ALJ again found Plaintiff not disabled.

(AR 12-28). The decision became the final decision of the Commissioner of Social Security

when the Appeals Council denied Plaintiff’s subsequent request for review on May 21, 2009,

and again on July 14, 2009. (AR 3-6). On June 25, 2009, Plaintiff initiated the instant action

for judicial review of the decision of the Commissioner of Social Security. (Doc. 1). 

II. BACKGROUND

A. Plaintiff's Background

Plaintiff was born in 1967 and was 32 years of age at the time of the alleged onset of

disability. (AR 1424). Plaintiff served in the Navy from July 1989 to July 1993 and in the

Army from January 1996 to May 2000. (AR 170). He worked as a radio mechanic and

aircraft mechanic for the military prior to his onset date of disability. (AR 1451-1452). 

Plaintiff’s physical health and mental health are summarized below. 

/ / / 

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1. Physical Health

In 1993, while serving in the military, Plaintiff fell approximately 20 feet from a

helicopter. (AR 178). In 1998, Plaintiff was injured in the line of duty in Korea when he

was dropped on his head while doing an exercise. (Id.). These two events and the

demanding physical requirements of military service are alleged to have contributed to

Plaintiff’s current condition. (AR 178, 821). 

Plaintiff has a long history of medical treatment for back and neck pain, headaches,

migraines, and post-traumatic stress disorder. (AR 190-204, 207-210). He first obtained

medical treatment for neck and shoulder pain in 1996 and for chronic low-back pain in 1998.

(AR 190-204). In late 1999, Plaintiff was treated by an orthopaedic resident for neck and

low-back pain. (AR 834). The doctor assessed him as having isolated chronic neck and back

pain, likely to be derivative to degenerative changes in his cervical spine and dehydrated disc

at L4-L5. (AR 836). 

In February 2000, Dr. Wilkie evaluated Plaintiff for moderate/frequent headaches,

back pain, and neck pain. (AR 821). Plaintiff reported constant 8 out of 10 back and neck

pain, and stated that he had to stop working several days per week because of headaches,

back pain, or neck pain. (AR 819-20). Dr. Wilkie recommended treatment of the headaches

with prophylactic therapy and medication management, stating that there was not likely to

be significant improvement. (AR 818). Plaintiff received repeat radiofrequency blocks at

the Pain Management Center of the Medical College of Georgia on March 8, 2000, June 16,

2000, and October 20, 2000. (AR 1295, 1294, 1289). 

On December 5, 2000, Plaintiff began treatment at the Veterans Affairs Medical

Center (“VAMC”) in Augusta, Georgia. (AR 1275). He reported constant sharp burning

pain in the low-back that had grown progressively worse and was present 24 hours a day.

(AR 1275). He reported treatment with numerous medications that did not provide relief.

(AR 1278). He indicated that pain increased with bending, squatting, and prolonged sitting

and standing. (Id.). He described associated symptoms of migraines, hand weakness,

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occasionally dropping things, and pain radiating to his legs with numbness. (AR 1278). The

VAMC doctor diagnosed Plaintiff with neck and back pain. 

In July 2001, Dr. Kumud Smith of the VAMC noted multiple areas of paraspinal

muscle spasm and tenderness. (AR 1238). Dr. Kumud Smith diagnosed chronic pain

secondary to herniated discs, performed trigger point injections of the lower back and right

upper cervical paraspinal region, and prescribed OxyContin, Darvocet, Valium, and Bentyl.

(AR 1238-39). 

On August 27, 2001, Plaintiff underwent cervical spine surgery at the VAMC related

to a herniated disk at C5-6. (AR 1144). The surgery entailed a C5-6 anterior cervical

discectomy and fusion with allograft and anterior cervical plate. (Id.). Plaintiff returned to

the VAMC again in September 2001 and October 2001 for treatment associated with

headaches, neck symptoms, and back pain. (AR 1125-33). An examination of the Plaintiff

revealed he walked with a slight limp, used a cane, and suffered spasms of the neck. The

VAMC doctor diagnosed Plaintiff with chronic low back pain with exacerbation and

prescribed Oxycodone and Valium. (AR 1128).

On December 19, 2001, John Downey at Augusta Pain Management began treatment

of Plaintiff. (AR 796). Up to that date, Plaintiff’s treatment had included cervical surgery,

pelvic traction, physical therapy, trigger-point injections, osteopathic manipulation,

radiofrequency treatment, facet blocks, and a TENS unit. (Id.). His medications were

OxyContin, Percocet, Valium, Imitrex, Neurontin, Flexeril, Amitriptyline, and Phenergan

(Id.). During the visit, Dr. Downey treated Plaintiff with trigger-point injections and

osteopathic manipulation. (AR 795). Plaintiff continued to be seen for unchanged

complaints of neck and back pain and was given trigger-point injections and/or manipulation

of the spine during regular visits to Dr. Downey from December 2001 through July 2004. 

In February 2003, a magnetic resonance imaging (“MRI”) of Plaintiff’s lumbar spine

showed a lumbosacral transitional element, disc degeneration at L2-3, L4-5, and L5-S1 with

bilateral facet hypertrophy at L5-S1 and central broad-based disc protrusions at L4-5 and L5-

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1

Even if a veteran’s service-connected disability rating is not 100%, VA benefits are

available to compensate veterans at the 100% level in the event that they are not able to work

because of their service-connected disability/disabilities. This benefit is called a total

(“100%”) rating on the basis of individual unemployability due to service-connected

disability and revolves around the inability to engage in “substantially gainful employment.”

According to VA regulations, “all veterans who are unable to secure and follow a

substantially gainful occupation by reason of service-connected disabilities shall be rated

totally disabled.” 38 C.F.R. 416(a), (b).

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S1, as well as bulges at L2-3 and L3-4 with mild central canal stenosis at L4-5 and L5-S1.

(AR 1946). 

On November 5, 2003, Luis Cedeño, a vocational rehabilitation counselor for the

Department of Veterans Affairs (“VA”), evaluated Plaintiff. (AR 178-179). Mr. Cedeño

noted in his report that Plaintiff applied for vocational rehabilitation in March 2000 but had

not been able to complete a single semester of schooling due to disability exacerbations,

which had been manifested in school attendance, periods of absences due to chronic pain and

side effects of medications. (AR 179). Mr. Cedeño found that Plaintiff “will not benefit

from vocational rehabilitation services in which competitive employment is the goal” and

that “by virtue of his numerous service-connected disabilities incurred in the line of duty, he

is found to [be] infeasible” for participation in competitive employment activities. (AR 179).

In April 2004, the VA evaluated Plaintiff’s service-connected disabilities as 80%

disabling and determined that Plaintiff was unable to remain employed due to his serviceconnected disabilities. (AR 171). As a result, the VA granted Plaintiff individual

unemployability compensation at the 100% rate effective April 2, 2004.1

 (AR 168). The VA

based its decision on a finding that “[m]edical evidence shows you have severe complications

from your physical / mental disabilities.” (AR 171). The medical evidence evaluated by the

VA included treatment reports from Eisenhower Medical Center, Augusta Pain Center,

Southern Neurology Institute, an infeasibility statement from Vocational Rehabilitation and

Employment, and Plaintiff’s VA Form 21-8940. (Id.) 

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That month, Dr. Wilson, a Disability Adjudication Services Medical Consultant,

found, on the other hand, that Plaintiff had no significant motor, sensory, or reflex deficits

and that Plaintiff had no significant atrophy or motor loss in the spine. (AR 989). Dr.

Wilson noted that although Plaintiff’s activities would be restricted, all activities would not

be precluded. (Id.) Finally, he noted that although Plaintiff had occasional postural

limitations, Plaintiff could stand and sit (with normal breaks) for about 6 hours in an 8-hour

workday, could occasionally lift 20 pounds, and could frequently lift 10 pounds. (AR 990,

993).

In October 2004, Dr. Lindaberry of Carolina Forest Family Medicine began treating

Plaintiff and diagnosed depression, migraines, back pain, and muscle spasms. (AR 712). Dr.

Linadberry performed trigger point injections in October 2004. These injections continued

to be performed every week through March 2005. 

On referral from Dr. Lindaberry, Dr. Bangco began treating Plaintiff in February 2005

and diagnosed chronic pain syndrome. In April 2005, Dr. Bangco and Dr. Downey both

completed medical statements for Plaintiff’s social security disability claim regarding

headaches, chronic pain syndrome, low-back pain, and cervical spine disorders. (AR 665-72,

680-85, 688-89). Both doctors noted the presence of neuron-anatomic distribution of pain,

limitation of motion of the spine, motor loss, sensory or reflex loss, severe burning or painful

dysesthesia, need to change position more than once every two hours, chronic pain, and

weakness and inability to ambulate effectively. (AR 669, 680). They also found that

Plaintiff suffered from severe pain and was limited to stand or sit no more than fifteen

minutes at one time, and could not work even one hour a day. (AR 669, 680). They found

that Plaintiff could not lift any weight and could never stoop and only occasionally bend.

(AR 669, 680). The doctors assessed that Plaintiff was markedly limited in activities of daily

living and social functioning, and had deficiencies in concentration, persistence, or pace due

to pain. (AR 667, 688). Dr. Downey commented that Plaintiff has “severe pain that

interferes with all aspects of his life.” (AR 688).

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In October 2005, Plaintiff underwent a MRI of the lumbar spine and it showed

multilevel spondylosis. (AR 308-309). Then, in December 2005, Plaintiff underwent

another MRI of the cervical spine which showed left disc osteophyte complex and uncal

vertebral joint hypertrophy at C3-4 resulting in left neural foraminal stenosis with potential

irritation of existing left C4 nerve root. (AR 438). 

On March 14, 2006, Dr. Lindaberry noted that Plaintiff required twenty-four hour

home care when his wife was not present and difficulty with ambulation and frequent falls.

(AR 618). On April 4, 2006, Dr. Lindaberry found that Plaintiff was unable to be employed

for the foreseeable future. (Id.). Dr. Lindaberry resumed Plaintiff’s weekly trigger point

injections in April 2006. On July 27, 2007, Dr. Lindaberry completed a “Multiple

Impairment Questionnaire” and diagnosed neuromuscular dyskinesis, severe headaches, and

severe back pain. (AR 534). Clinical findings included an inability to stand, transfer to and

from his wheelchair without assistance, to tolerate light, and continued muscle spasms. (Id.).

The doctor rated Plaintiff’s pain as moderate to severe. (AR 536). Dr. Lindaberry found that

Plaintiff could only sit less than one hour total and stand/walk less than one hour total in an

eight-hour workday. (Id.). It was noted that Plaintiff could never lift or carry any weight.

(AR 537). The doctor assessed significant limitations in doing repetitive reaching, handling,

fingering, or lifting due to neuromuscular dyskinesis, and marked limitations from grasping,

turning, and twisting objects, performing fine manipulation and reaching. (AR 537-36). It

was noted that Plaintiff’s post-traumatic stress disorder (“PTSD”) contributed to the severity

of his symptoms and functional limitations, and he was incapable of even low work stress.

(AR 539). Dr. Lindaberry stated that these symptoms and limitations detailed in the

questionnaire were present since June 2004. (AR 540). 

Plaintiff continued receiving regular trigger-point injections from Dr. Lindaberry

through April 2008. An MRI of the cervical spine dated April 28, 2008 revealed multiple disc

level neural foraminal stenosis with disc osteophyte contacting the anterior surface of the

cord at C4-5 and C7-T1, annular tear at C7-T1 with increased degree of disc osteophytes, and

compression of the spinal cord since March 2005. (AR 430). An MRI of the lumbar spine

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dated May 2008 showed multilevel spondylosis. (AR 375-76). Plaintiff continued seeking

medical treatment at the VAMC in Phoenix, Arizona in July 2008 after moving to the area.

(AR 1374-91). 

2. Mental Health

On January 19, 2001, Dr. Arena conducted a psychological intake of Plaintiff at the

VAMC and noted that it was “clear” that Plaintiff was very depressed and anxious. (AR

1263). Dr. Arena completed a detailed report following a second evaluation on July 2, 2001.

(AR 1231-35). In the report, Plaintiff noted a history of psychiatric breakdowns and reported

nightmares from his combat experience in the Gulf War. He reported being physically and

sexually abused. (AR 1232-33). A mental status examination revealed depression, memory

and concentration problems, moderate to severe signs of anxiety, mild stuttering, and severe

behavioral signs of pain. (AR 1233-34). Dr. Arena diagnosed chronic pain disorder

associated with psychological factors and a general medical condition, generalized anxiety

disorder, major depressive episode (recurrent, moderate), and personality disorder. (AR

1235). 

Dr. Sperr, a clinical psychologist, evaluated Plaintiff at the request of the

Administration on February 23, 2004. (AR 998). Plaintiff’s mental status examination

revealed a lack of orientation to day of the month, depressed mood, variable effect from tense

to tears, and somewhat limited insight. (AR 1000). Plaintiff scored a verbal IQ of 79, but

was unable to complete the remainder of the testing due to problems with migraines and

vision during the assessment. (Id.). Dr. Sperr stated that Plaintiff’s testing revealed he

operated in the borderline range of intellectual functioning, but was likely impaired due in

part to pain and emotional distress. (AR 1002). Dr. Sperr found that Plaintiffs symptoms

would significantly impair his ability to attend and concentrate on job tasks, maintain

consistency, and communicate and cooperate with job peers and supervisors, and could

likely preclude an ability to sustain a 40 hour work week. Plaintiff was diagnosed with

PTSD, major depression (severe, recurrent), pain disorder associated with both psychological

factors and general medical condition, chronic neck and back pain, and migraines. (Id.). 

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2

A GAF is a numeric scale (0 through 100) used by mental health clinicians and

doctors to rate the social, occupational, and psychological functioning of adults. American

Psychiatric Association, Diagnostic and Statistical Manual of Mental Impairments, 4th text

rev., 2000, p.32 (DSM-IV-TR). A GAF score of 51-60 is indicative of moderate symptoms,

such as flat affect or occasional panic attacks, or any moderate difficulty in social,

occupational, or school functioning. (Id.). A GAF score of 41-50 is indicative of serious

symptoms, and a GAF score of 61-70 is indicative of mild symptoms. (Id.).

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In April 2004, Dr. Susan Haverstock at the VAMC evaluated Plaintiff in a mental

health consultation. (AR 918). Plaintiff stated he suffered from depression because pain has

ruined his life and he cannot function. (Id.). He admitted to PTSD related to seeing Kurds

get shot. (AR 919). Dr. Haverstock diagnosed pain disorder with physical and psychiatric

components, depression secondary to general medical condition, personality disorder, and

chronic back pain. (AR 919). 

On month later, in May 2004, Dr. Coyle, a psychological consultant, conducted a

Functional Capacity Assessment. (AR 981). Dr. Coyle found that Plaintiff had mild

limitations of activities of daily living, moderate limitations in concentration and social

functioning, and no episodes of decompensation. (Id.). 

Dr. Fahy began seeing Plaintiff in February 2005 and diagnosed post traumatic stress

disorder. (AR 719). In April 2005, Dr. Fahy completed a “Medical Statement Concerning

Depression for Social Security Disability Claim.” (AR 677-79). Dr. Fahy diagnosed chronic

PTSD with a Global Assessment of Functioning (“GAF”)2

 of 45. (AR 677). Dr. Fahy found

that Plaintiff had extreme restriction when engaging in activities of daily living and difficulty

in maintaining social functioning. (Id.). Specifically, Dr. Fahy found that Plaintiff was

extremely impaired in his ability to perform activities, including the ability to maintain

attention and concentration for extended periods, complete a normal workday without

interruptions from psychologically based symptoms, and perform at a consistent pace without

an unreasonable number and length of rest periods. (AR 678-79) (emphasis added). The

doctor also found him markedly impaired in his social interactions, including his ability to

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maintain socially appropriate behavior and to understand, remember, and carry out detailed

instructions. (AR 678) (emphasis added).

At Plaintiff’s request, in a letter dated February 2006, Dr. Fahy noted that Plaintiff

was confined to a wheelchair, unable to walk, suffered from PTSD as a result of his service

in the Gulf War, and endured intractable migraine headaches. (AR 357). He indicated that

Plaintiff required full time care. (Id.). In June 2006, Dr. Fahy reported Plaintiff was very

depressed, having high levels of anxiety, nightmares every night, and flashbacks every day.

Dr. Fahy gave Plaintiff a GAF score of 50 in June 2007. Five months later, in November

2007, Dr. Fahy completed a Psychiatric/Psychological Impairment Questionnaire. (AR 606-

13). The doctor assessed a GAF score of 44. (AR 606). Dr. Fahy found that Plaintiff was

markedly limited in all his daily mental activities. (AR 607). Dr. Fahy assessed that

Plaintiff was incapable of even low stress work. (AR 612). He concluded that “[t]he

combination of his physical and mental debility make for a severely disabled person.” (AR

613). 

In April 2008, Dr. Cusack evaluated Plaintiff and assessed PTSD by history,

depression secondary to physical illness, anxiety disorder secondary to physical illness,

cervicalgia, and migraines. (AR 384-85). Later that year, in October 2008, Plaintiff was

seen at the VAMC’s mental health clinic in Phoenix, Arizona. (AR 1374). The VAMC

diagnosed Plaintiff with mood disorder, likely major depressive disorder (“MDD”), PTSD

by history, and assessed a GAF score of 49. (AR 1376). 

B. Hearing Testimony

At the April 26, 2005 hearing, Plaintiff testified that he spends most of the his day

sleeping, tilted up watching TV, or taking a phone call, as he can not do anything except go

to doctor appointments, which he attends roughly three times a week. (AR 1426). He stated

that during his weekly doctor appointments he receives approximately 25 trigger points in

his back and that he also attends a program for Persian Gulf PTSD on Thursday mornings.

(AR 1426-27). He testified that he had started using a cane but “my legs were still falling

out from underneath . . . so then they moved me up for crutches,” which he attested to have

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been using for roughly three to four years. (AR 1430-31). He highlighted that he had sold

his two story-house and moved to a condominium because he did not have the strength or

energy to get up and down the stairs of his house. (AR 1435). He stated further that he was

medically discharged from the military and that following the military he tried to go to

school, but his grants for school were pulled because “I was missing too many days . . .

because I was getting sick all the time.” (AR 1436-37). He testified that his wife helps him

get dressed, bathes him, and helps him with his medications. Plaintiff’s wife corroborated

this testimony by testifying that she has assisted with her husband’s care for about four or

five years and that on a good day she spends six hours caring for her husband. (AR 1444-45).

Dixon Pearsall, a vocational expert (“VE”), testified, in response to a hypothetical

posed by the ALJ, that a hypothetical person who can perform light work and who has mild

to moderate limitations in concentration and attention due to pain and the side effects of

medication could perform the job of radio mechanic, but not the work of an aircraft

mechanic. (AR 1452). The VE testified further that assuming the same elements of the first

hypothetical, with the additional limitation of unscheduled work breaks totaling two hours

for each eight-hour day, that the hypothetical person could not perform the job of radio

mechanic. (AR 1453). 

At the second hearing on May 19, 2008, Plaintiff testified that since his alleged onset

date of disability in May 2000, he has worked only three weeks in 2003 as a headhunter, but

did so from home, handling all of his work over the phone. (AR 1467-68). Plaintiff testified

further that he has never had full relief of his neck and back pain, despite the fact that: 

I’ve tried everything. I’ve tried physical therapy. I’ve tried TENS units. I’ve

tried heat pads. I’ve tried ice. I’ve tried trigger point injections I get now from

Dr. Lindenberry . . . [he] does about 24 to 32 injections into my back. This is

about three times a month if I can handle it . . . [i]t’s the only thing that gives

me, takes me from a level 9 or a level 10 down to about a level 7 pain where

I live with everyday. 

(AR 1472- 73). 

He indicated that since May 2000, he has not been able to walk without an assistive

device because “it’s just . . . too painful.” (AR 1477). He testified further that he is unable

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to walk by himself and that “I always use my wife as something to lean upon or a crutch or

something to hold me up.” (AR 1477). 

C . ALJ’s Conclusion

On June 26, 2008, in his second decision on the matter, the ALJ denied Plaintiff’s

claim for disability insurance benefits by following the requisite five-step sequential

evaluation process for determining whether an applicant is disabled under the Social Security

Act. See 20 CFR §§ 404.1520 and 416.920. (AR 15-23). 

At step one, the ALJ found that the Plaintiff had not engaged in substantial gainful

activity since the alleged disability onset date of May 1, 2000. (AR 18). At step two, the

ALJ concluded that Plaintiff had the following severe impairments: degenerative disc disease

of the lumbar and cervical spine, depression, and PTSD. (AR 17). However, at step three,

the ALJ concluded that Plaintiff’s impairments did not meet or equal one of the listed

impairments set forth in Appendix 1 of the Regulations, 20 CFR Part 404, Subpart P,

Appendix 1. (AR 18). As the ALJ’s analysis did not determine that Plaintiff’s impairments

meet or medically equal the criteria of a listing, the ALJ proceeded to step four to determine

whether Plaintiff has the residual functional capacity to perform the requirements of his past

relevant work. At step four, the ALJ found that Plaintiff has the residual functional capacity

to perform the full range of light work, but that Plaintiff’s depression and Post Traumatic

Stress Disorder “would limit him to unskilled work.” (AR 19). Yet the ALJ found Plaintiff

unable to perform any of his past relevant work. (AR 22). As Plaintiff was found unable to

do any past relevant work, the ALJ proceeded to the fifth and last step to determine if

Plaintiff is able to do any other type of work. Upon consideration of Plaintiff’s residual

functional capacity, age, education, and work experience, in conjunction with the MedicalVocational Guidelines, the ALJ concluded that there are jobs that exist in significant numbers

in the national economy that Plaintiff can perform. (AR 23). Accordingly, the ALJ

concluded that Plaintiff is not disabled under the Act. (Id.). 

III. STANDARD OF REVIEW

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To qualify for disability insurance benefits, an applicant must establish that he is

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

mental impairment that has lasted or can be expected to last for a continuous period of not

less than 12 months. See 42 U.S.C. § 1382c (a)(3)(A). The applicant must also show that

he has a physical or mental impairment of such severity that the applicant is not only unable

to do her previous work, but cannot, considering her age, education, and work experience,

engage in any other kind of substantial gainful work which exists in the national economy.

Quang Van Han v. Bowen, 882 F.2d 1453, 1456 (9th Cir. 1989). To determine whether an

applicant is eligible for disability insurance benefits, the ALJ must conduct the following

five-step sequential analysis:

(1) determine whether the applicant is currently employed in

substantial gainful activity;

(2) determine whether the applicant has a medically severe

impairment or combination of impairments;

(3) determine whether the applicant’s impairment equals one of a

number of listed impairments that the Commissioner

acknowledges as so severe as to preclude the applicant from

engaging in substantial gainful activity;

(4) if the applicant’s impairment does not equal one of the listed

impairments, determine whether the applicant is capable of

performing his or her past relevant work;

(5) if not, determine whether the applicant is able to perform other

work that exists in substantial numbers in the national economy.

20 CFR §§ 404.1520, 416.920; see also Bowen v. Yuckert, 482 U.S. 137, 140-41 (1987). 

The Court must affirm an ALJ’s findings of fact if they are supported by substantial

evidence and free from reversible legal error. See 42 U.S.C. 405(g); see also Ukolov v.

Barnhart, 420 F.3d 1002, 1004 (9th Cir. 2005). Substantial evidence means “more than a

mere scintilla,” but less than a preponderance, i.e., “such relevant evidence as a reasonable

mind might accept as adequate to support a conclusion.” See, e.g., Sandgathe v. Chater, 108

F.3d 978, 980 (9th Cir. 1997); Clem v. Sullivan, 894 F.2d 328, 330 (9th Cir. 1990).

In determining whether substantial evidence supports a decision, the record as a whole

must be considered, weighing both the evidence that supports and the evidence that detracts

from the ALJ’s conclusion. See Richardson v. Perales, 402 U.S. 389, 401 (1971); see also

Tylitzki v. Shalala, 999 F.2d 1411, 1413 (9th Cir. 1993). Nonetheless, “[i]t is for the ALJ,

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not the courts, to resolve ambiguities and conflicts in the medical testimony and evidence.”

Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995) (citations and internal quotation

marks omitted). The ALJ may draw inferences logically flowing from the evidence, and

“[w]here evidence is susceptible to more than one rational interpretation, it is the ALJ’s

conclusion which must be upheld.” Id. (citation omitted). Regardless, “[i]f the evidence can

support either affirming or reversing the ALJ's conclusion, [then the Court] may not

substitute [its] judgment for that of the ALJ.” Robbins v. Social Sec. Admin., 466 F.3d 880,

882 (9th Cir. 2006).

IV. DISCUSSION

Plaintiff contends that the ALJ erred by (1) failing to properly consider that Plaintiff

was per se disabled under the Medical Listings at 20 C.F.R. Part 404, Subpart P, Appendix

1; (2) failing to follow the treating physician rule, including failing to evaluate the

Department of Veterans Affairs’ (“VA”) April 2004 disability rating; (3) failing to properly

evaluate Mr. Norton’s credibility; and (4) failing to properly apply the Medical-Vocational

Guidelines. (Doc. 20). Defendant concedes that the ALJ erred, but only with respect to the

failure to evaluate the VA’s disability rating. (Doc. 23). As the ALJ’s failure to evaluate the

VA’s disability rating constitutes legal error, the Court reverses the ALJ’s decision on this

ground and does not reach the other grounds of error asserted by Plaintiff. 

A. The ALJ erred in evaluating the Veterans Affairs April 2004 Disability Rating

In April 2004, the VA evaluated Plaintiff’s service-connected disabilities as 80%

disabling and determined that Plaintiff was unable to remain employed due to his serviceconnected disabilities. (AR 171). As a result, the VA granted Plaintiff individual

unemployability compensation at the 100% rate. (AR 168–172). 

In McCartey v. Massanari, the Ninth Circuit held that “although a VA rating of

disability does not necessarily compel the SSA to reach an identical result, the ALJ must

consider the VA’s finding in reaching his decision.” 298 F.3d 1072, 1076 (9th Cir. 2002)

(reversing a denial of benefits because the ALJ “failed to consider the VA finding and did

not mention it in his opinion”). The Ninth Circuit held further that “an ALJ must ordinarily

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give great weight to a VA determination of disability.” Id. However, because the VA and

Social Security Administration criteria for determining disability are not identical, the ALJ

may give less weight to a VA disability rating if he gives persuasive, specific, valid reasons

for doing so that are supported by the record. Id.

Here, the ALJ failed to properly evaluate the Plaintiff’s VA’s disability rating in his

decision, a fact that Defendant concedes. (Doc. 23) (“Commissioner concedes only that the

ALJ erred in evaluating the VA rating.”). Although the ALJ was cognizant of the fact that

“there is evidence in the record that the claimant has a 100% service-connected disability due

to his cervical injuries,” (AR 36-37), the ALJ did not state any “persuasive, specific, valid

reasons” for what weight, if any, he gave to the VA disability rating. Instead, the ALJ merely

stated that “I am not bound by any disability determination of another agency.” (AR 36).

Accordingly, the Court holds that the ALJ’s failure to consider Plaintiff’s VA disability

rating in reaching his decision constitutes legal error. The Commissioner’s decision,

therefore, must be reversed and remanded.

The question of whether to remand a case for additional evidence and findings, or

simply to award benefits, is a matter for the Court’s discretion. McCartey, 298 F.3d at 1076

(citing Smolen v. Chater, 80 F.3d 1273, 1292 (9th Cir. 1996) (“We have discretion to remand

a case either for additional evidence and findings or for an award of benefits.”)). The Ninth

Circuit has held that evidence should be credited and an immediate award of benefits

directed, where “(1) the ALJ has failed to provide legally sufficient reasons for rejecting such

evidence, (2) there are no outstanding issues that must be resolved before a determination of

disability can be made, and (3) it is clear from the record that the ALJ would be required to

find the claimant disabled were such evidence credited.” Harman v. Apfel, 211 F.3d 1172,

1178 (9th Cir. 2000) (quoting Smolen v. Chater, 80 F.3d 1273, 1292 (9th Cir. 1996)). This

test recognizes the “importance of expediting disability claims.” Holohan v. Massanari, 246

F.3d 1195, 1210 (9th Cir. 2001). It also furthers “the primary purpose of the Social Security

Act, ‘to give financial assistance to disabled persons because they are without the ability to

sustain themselves.’” Id. A Court may direct an award of benefits where remand would

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unnecessarily delay the receipt of benefits. Such a remand for benefits is particularly

appropriate where a claimant has already experienced lengthy, burdensome litigation. Terry

v. Sullivan, 903 F.2d 1273, 1280 (9th Cir. 1990).

Here, the parties do not contest that the ALJ failed to provide legally sufficient

reasons for rejecting the VA’s disability rating. Therefore, the first prong of the test is

satisfied. Next, there are no outstanding issues that must be resolved before a determination

of disability can be made because the VA disability rating speaks directly to whether Plaintiff

is disabled. Finally, under the third prong of the test, the Court finds that the evidence in the

record does not outweigh the “great weight” that must be afforded to the VA’s disability

rating that Plaintiff is disabled and unable to work due to his service-connected disabilities.

As such, it is clear that the ALJ would be required to find Plaintiff disabled. 

In arriving at this conclusion, the Court notes that it disagrees with the ALJ’s

interpretation of Plaintiff’s credibility. The ALJ determined that Plaintiff’s statements

concerning the intensity, persistence and limiting effects of his symptoms were not credible

and inconsistent with the residual functional capacity assessment. When making a credibility

determination, it is true that “[a]n ALJ is not required to believe every allegation of disabling

pain or other non-exertional impairment.” Orn, 495 F.3d at 635. However, if the medical

evidence establishes an objective basis for some degree of pain and related symptoms, and

there is no evidence affirmatively suggesting that the claimant was malingering, then the

ALJ’s reason for rejecting Plaintiff’s testimony must be clear and convincing and supported

by specific findings. See Social Security Ruling 96-7 (stating that adverse credibility

determinations must be sufficiently specific to make clear to any subsequent reviewers the

weight the adjudicator gave to the individual’s statements and the reasons for that weight).

Dodrill v. Shalala, 12 F.3d 915, 917 (9th Cir. 1993). 

Here, the ALJ pointed out inconsistencies in Plaintiff’s statements and testimony by

noting that “the only significant treatment that [Plaintiff] has received has been

radiofrequency ablation of the lumbar spine and an anterior cervical discectomy in August

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2001.” (AR 20). However, in reviewing the record as a whole, the Court finds substantial

evidence that detracts from the ALJ’s conclusion with respect to Plaintiff’s credibility. The

Court notes for example that Plaintiff also treated his symptoms with pelvic traction,

physical therapy, frequent and regular trigger-point injections, osteopathic manipulation,

facet blocks, a TENS unit, a Fentanyl patch, and a morphine pump. (AR 796, 1445, 1473).

In addition, Plaintiff testified in April 2005 that, 

“they call me a high risk candidate for doing anything else . . . that you would

have to cut me so many times [in] the same areas to fix the different joints or

the facet area and all that, that it causes even more pain and more inability to

do anything.” 

(AR 1430). He also testified to being on “very significant medications” for his various

conditions, (AR 1432), and the record indicates that Plaintiffs has been prescribed numerous

prescription medications to treat pain, migraines, and muscle spasms, including OxyContin,

Hydrocodone, Percocet, Valium, Morphine, Imitrex, Duragesic, Neurontin, Flexeril,

Marcaine and Lidocaine. (AR 178, 796, 1427). 

The ALJ further discredited Plaintiff’s credibility by noting that the surgery that

Plaintiff underwent in August 2001 was “generally successful in relieving the claimant’s

symptoms.” (AR 20). To support his finding, the ALJ cited x-rays taken in October 2001

and November 2006, which document a “solid appearing cervical fusion with intact

hardware.” (Id.). These findings appear contrary to the record, as Plaintiff testified that the

surgery did not work and did not solve his underlying problems: 

Q: Are many of the symptoms you’re describing attributable to the surgery

not solving the underlying problems? You had surgery. Evidently it didn’t

work.

A: Yes, sir.

Q: Is that correct?

A: Yes, sir. 

(AR 1429). There is also substantial evidence in the record that demonstrates that despite

the surgery, Plaintiff continues to suffer from spinal problems and associated symptoms.

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 An exaggerated physiologic tremor is a mechanical reflex tremor. See Mark Hallett,

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See e.g., (AR 308-309) (indicating that a October 2005 MRI showed multilevel spondylosis

of the lumbar spine); (AR 438) (noting that a December 2005 MRI showed disc osteophyte

complex and uncal veterbral joint hypertrophy of the cervical spine resulting in neural

foraminal stenosis); and (AR 375-76) (indicating that a May 2008 MRI showed multilevel

spondylosis of the lumbar spine). 

Next, the ALJ discredited Plaintiff’s credibility by indicating that “claimant probably

exaggerated a physiological tremor in August 2005.” (AR 21). However, upon a review

of the medical record, the Court finds that the ALJ’s finding appears to be taken out of

context. The record indicates that “No tremor seen on exam. By history, this is a fine

postural tremor, brought out by stress, pain and anxiety. probably exaggerated physiological

tremor; no need to intervene.” (AR 336). Taken in context, the medical record does not

explicitly indicate that the Plaintiff himself exaggerated about his tremor, but rather appears

to speak to Plaintiff’s type of physiological tremor.3

In addition, the ALJ found that “[i]n May 2008, records note that the claimant did not

identify a traumatic event connected to his alleged post traumatic stress disorder condition.”

(AR 21). While the record supports this finding as to this particular doctor visit (AR 363),

in considering the record as a whole, the Court notes that in April 2004 Plaintiff attributed

his PTSD to “seeing Kurds get shot” (AR 919) and that during a medical examination in

July 2001, he stated he “saw combat [during] the Gulf War and states that he still has

nightmares from these experiences.” (AR 1232). The record also indicates that Plaintiff

was diagnosed with PTSD by multiple doctors. (AR 1002, 719, 364, 1376). 

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The ALJ also questioned Plaintiff’s credibility by highlighting that Plaintiff was

injured while stepping out of a small boat in March 2004, “which is something a severely

impaired person would not be likely to do,” (AR 20), and noting that Plaintiff has reported

“working on a computer for several hours, working on a lawn mower, traveling to Brazil for

two months, eating out, which are not limited to the extent one would expect, given his

complaints of disabling symptoms and limitations.” (AR 21). The record shows that

Plaintiff engaged in these activities. It also demonstrates that Plaintiff attended school for

at least one year, held a job for three weeks, went to the store with his wife at least once a

week, attended church, fished, and worked around the house. 

This Circuit has made clear, however, that the mere fact that a claimant engages in

daily activities such as grocery shopping and driving a car “does not in any way detract from

[his] credibility as to [his] overall disability.” Vertigan v. Halter, 260 F.3d 1044, 1050 (9th

Cir. 2001). “The Social Security Act does not require that claimants be utterly

incapacitated to be eligible for benefits, and many home activities are not easily

transferrable to what might be the more grueling environment of the workplace[.]” Fair v.

Bowen, 885 F.2d 597, 603 (9th Cir. 1989). Several courts, including [this Circuit], have

recognized that disability claimants should not be penalized for attempting to lead normal

lives in the face of their limitations. Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998)

(citations omitted). An ALJ may reject testimony based on daily activities where the ALJ

makes specific findings that those activities are transferable to the work setting. See Fair,

885 F.2d at 603; Orn v. Astrue, 495 F.3d 625, 639 (9th Cir. 2007). 

Here, the ALJ failed to explain in his decision how Plaintiff’s daily activities

translate into an ability to perform in a work setting. In addition, the ALJ lists Plaintiff’s

activities but fails to account for the limitations encountered by Plaintiff when engaging in

these activities. The record, considered as a whole and in the proper context, demonstrates

that Plaintiff experienced significant limitations when engaging in his daily activities. In

a Social Security Administration Function Report, Plaintiff indicated that he attends church

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once a month, yet “leaves early because I can’t sit to[o] long[,] my back goes into spasms.”

(AR 803). While Plaintiff disclosed in a medical report that he worked in front of the

computer for four hours, (AR 1039), he also stated he developed a right-sided headache

after engaging in this activity. (Id.). Plaintiff testified that he held a part-time job as a

headhunter for three weeks in 2003, yet medical records indicate that he was not able to

continue work because of pain. (AR 791). Plaintiff disclosed that mowing the lawn made

his low back pain worse. (AR 1027). The record also shows that he attended school, but

“had to stop due to his pain and physical problems.” (AR 1001, 1233). Finally, Plaintiff

testified that he does not do any household chores because he can’t bend down and “if I

make a mistake . . . I pay for it with my life, three to four days in the bedroom.” (AR 1438).

The Court, therefore, does not agree with the ALJ’s findings concerning Plaintiff’s

credibility as to the intensity, persistence, and limiting effects of Plaintiff’s symptoms,

finding instead that the record supports Plaintiff’s testimony. 

With respect to the opinions of the treating physicians, the ALJ gave little weight to

Dr. Speer’s opinion that Plaintiff’s symptoms of PTSD and depression would preclude work

on a full-time basis; to Dr. Fahy’s assessment regarding Plaintiff’s extensive limitations in

daily living and social functioning; to Dr. Lindaberry’s restrictive assessment; to Dr.

Bangco’s assessment of Plaintiff’s marked restrictions of activities of daily living and social

functioning; and to Dr. Downey’s assessment of severe pain. (AR 21-22, 35). On the other

hand, the ALJ afforded significant weight to the Disability Determination Services (“DDS”)

medical consultants. (AR 22). Nonetheless, in light of the “great weight” that must be

afforded to the VA disability rating that Plaintiff is disabled and unable to work due to

service-connected disabilities and the Court’s determination that the record supports that the

Plaintiff is credible, the weight afforded to the DDS medical consultants fails to overcome

the “great weight” of the VA’s disability rating. 

In light of the foregoing, the Court finds that the evidence presented by the ALJ with

respect to Plaintiff’s credibility and the opinion evidence does not dispel the “great weight”

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of the VA’s disability rating that Plaintiff is disabled and unable to work due to a serviceconnected disability. Consequently, the Court finds the ALJ would be required to find the

claimant disabled and must, under the three-part test, remand for an award of benefits. In

so doing, the Court notes that further administrative proceedings would unnecessarily extend

Plaintiff’s long wait for benefits. Remanding a disability claim for further proceedings can

delay much needed income for claimants who are unable to work and are entitled to

benefits, often subjecting them to “tremendous financial difficulties while awaiting the

outcome of their appeals and proceedings on remand.” Varney, 859 F.2d at 1398. Plaintiff

has waited over six years for his disability determination, a period that has previously been

delayed as a result of a remand by the Appeals Council due to errors committed by the ALJ

in his first decision. (AR 92-94). Additional proceedings would only delay Plaintiff’s

entitlement to benefits. In light of these considerations, the Court reverses the

Commissioner’s decision to deny Plaintiff disability benefits and remands for a calculation

of benefits. 

V. SUMMARY

The Court finds that the ALJ improperly disregarded the VA’s disability rating that

Plaintiff is unable to work due to a service-connected disability. As such, the ALJ’s

decision constitutes legal error and must be reversed. The Court, credits the evidence and

remands for an award of benefits as the ALJ has failed to provide legally sufficient reasons

for rejecting the evidence, no outstanding issues remain that must be resolved before a

determination of disability can be made, and it is clear from the record that the ALJ would

be required to find Plaintiff disabled were the rejected evidence credited. 

Accordingly,

IT IS HEREBY ORDERED reversing the Commissioner of Social Security’s

decision to deny Plaintiff disability benefits. 

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IT IS FURTHER ORDERED that Defendant’s motion to remand for further

proceedings is DENIED. (Doc. 23).

IT IS FURTHER ORDERED remanding the case to the ALJ for a finding of

disability and a calculation of benefits from May 1, 2000, the onset date of disability.

IT IS FURTHER ORDERED directing the Clerk of the Court to enter judgment

accordingly.

DATED this 27th day of September, 2010.

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