Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_18-cv-04230/USCOURTS-azd-2_18-cv-04230-0/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 (DIWW)

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WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Tanya Thomas,

Plaintiff,

v. 

Commissioner of Social Security 

Administration,

Defendant.

No. CV-18-04230-PHX-JZB

ORDER 

Plaintiff Tanya Thomas seeks review under 42 U.S.C. § 405(g) of the final decision 

of the Commissioner of Social Security (“the Commissioner”), which denied her disability 

insurance benefits and supplemental security income under sections 216(i), 223(d), 

and 1614(a)(3)(A) of the Social Security Act. Because the decision of the Administrative 

Law Judge (“ALJ”) is not supported by substantial evidence and is based on legal error, 

the Commissioner’s decision will be vacated, and the matter remanded for an award of 

benefits.

I. Background.

On October 31, 2014, Plaintiff applied for disability insurance benefits and 

supplemental security income, alleging disability beginning July 1, 2014, which was later 

amended to an onset date of August 26, 2016. On September 12, 2017, she appeared with 

her attorney and testified at a hearing before the ALJ. A vocational expert also testified.

On March 13, 2018, the ALJ issued a decision that Plaintiff was not disabled within the 

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meaning of the Social Security Act. The Appeals Council denied Plaintiff’s request for 

review of the hearing decision, making the ALJ’s decision the Commissioner’s final 

decision.

II. Legal Standard.

The district court reviews only those issues raised by the party challenging the ALJ’s 

decision. See Lewis v. Apfel, 236 F.3d 503, 517 n.13 (9th Cir. 2001). The court may set 

aside the Commissioner’s disability determination only if the determination is not 

supported by substantial evidence or is based on legal error. Orn v. Astrue, 495 

F.3d 625, 630 (9th Cir. 2007). Substantial evidence is more than a scintilla, less than a 

preponderance, and relevant evidence that a reasonable person might accept as adequate to 

support a conclusion considering the record as a whole. Id. In determining whether 

substantial evidence supports a decision, the court must consider the record as a whole and 

may not affirm simply by isolating a “specific quantum of supporting evidence.” Id. As a 

general rule, “[w]here the evidence is susceptible to more than one rational interpretation, 

one of which supports the ALJ’s decision, the ALJ’s conclusion must be upheld.” Thomas 

v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002) (citations omitted). 

Harmless error principles apply in the Social Security Act context. Molina v. 

Astrue, 674 F.3d 1104, 1115 (9th Cir. 2012). An error is harmless if there remains 

substantial evidence supporting the ALJ’s decision and the error does not affect the 

ultimate non-disability determination. Id. The claimant usually bears the burden of showing 

that an error is harmful. Id. at 1111.

Here, Plaintiff raises two issues: (1) whether ALJ improperly found Ms. Tanya 

Thomas to be only partially credible, and, (2) whether the ALJ improperly weighed the 

assessment from the treating physician. The record indicates that Plaintiff’s argument 

succeeds and the ruling of the ALJ will be vacated. 

The ALJ is responsible for resolving conflicts in medical testimony, determining 

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

Cir. 1995). In reviewing the ALJ’s reasoning, the court is “not deprived of [its] faculties 

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for drawing specific and legitimate inferences from the ALJ’s opinion.” Magallanes v. 

Bowen, 881 F.2d 747, 755 (9th Cir. 1989).

III. The ALJ’s Five-Step Evaluation Process.

To determine whether a claimant is disabled for purposes of the Social Security Act, 

the ALJ follows a five-step process. 20 C.F.R. § 404.1520(a). The claimant bears the 

burden of proof on the first four steps, but at step five, the burden shifts to the 

Commissioner. Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999).

At the first step, the ALJ determines whether the claimant is engaging in substantial 

gainful activity. 20 C.F.R. § 404.1520(a)(4)(i). If so, the claimant is not disabled and the 

inquiry ends. Id. At step two, the ALJ determines whether the claimant has a “severe” 

medically determinable physical or mental impairment. § 404.1520(a)(4)(ii). If not, the 

claimant is not disabled and the inquiry ends. Id. At step three, the ALJ considers whether 

the claimant’s impairment or combination of impairments meets or medically equals an 

impairment listed in Appendix 1 to Subpart P of 20 C.F.R. Pt. 404. § 404.1520(a)(4)(iii).

If so, the claimant is automatically found to be disabled. Id. If not, the ALJ proceeds to step 

four. At step four, the ALJ assesses the claimant’s residual functional capacity (“RFC”) 

and determines whether the claimant is still capable of performing past relevant 

work. § 404.1520(a)(4)(iv). If so, the claimant is not disabled and the inquiry ends. Id. If 

not, the ALJ proceeds to the fifth and final step, where he determines whether the claimant 

can perform any other work based on the claimant’s RFC, age, education, and work 

experience. § 404.1520(a)(4)(v). If so, the claimant is not disabled. Id. If not, the claimant 

is disabled. Id.

At step one, the ALJ found that Plaintiff meets the insured status requirements of 

the Social Security Act through December 31, 2019, and that she has not engaged in 

substantial gainful activity since August 26, 2016, the amended onset date. (AR at 20.) At 

step two, the ALJ found that Plaintiff has the following severe impairments: “obesity, 

diabetes mellitus, hypertension, gastroesophageal reflux disease (GERD), plantar fasciitis, 

fibromyalgia, obstructive sleep apnea, degenerative joint disease, osteoarthritis, 

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rheumatoid arthritis, history of [C]rohn’s disease, and irritable bowel syndrome.” (Id.) At 

step three, the ALJ determined that Plaintiff does not have an impairment or combination 

of impairments that meets or medically equals an impairment listed in Appendix 1 to 

Subpart P of 20 C.F.R. Pt. 404. At step four, the ALJ found that Plaintiff has the RFC to 

perform:

sedentary work as defined in 20 CFR 404.1567(a) and 416.967(a) except she 

can frequently stoop, kneel, crouch and occasionally crawl and climb ramps 

and stairs but never ladders, ropes, or scaffolds. She can frequently reach, 

handle, and finger bilaterally. The claimant should avoid working around 

hazards such as moving machinery and unprotected heights.

(Id. at 23.)

The ALJ further found that Plaintiff is unable to perform any of his past relevant 

work. At step five, the ALJ concluded that, considering Plaintiff’s age, education, work 

experience, and residual functional capacity, there are jobs that exist in significant numbers 

in the national economy that Plaintiff could perform. (Id. at 28.)

IV. Analysis.

Plaintiff argues the ALJ’s decision is defective for two reasons: (1) the ALJ 

improperly discounted Plaintiff’s symptom testimony without clear and convincing 

reasons supported by the record as a whole; and (2) the ALJ errored in discounting 

Plaintiff’s treating physician’s medical opinion without clear and convincing evidence, 

when there are no other medical opinions rendered during the relevant time period.

(Doc. 13.) The Court will address each argument below.

A. The ALJ Did Err in Evaluating Plaintiff’s Credibility. 

In evaluating the credibility of a claimant’s testimony regarding subjective pain or 

other symptoms, the ALJ is required to engage in a two-step analysis: (1) determine 

whether the claimant presented objective medical evidence of an impairment that could 

reasonably be expected to produce some degree of the pain or other symptoms alleged; 

and, if so with no evidence of malingering, (2) reject the claimant’s testimony about the 

severity of the symptoms only by giving specific, clear, and convincing reasons for the 

rejection. Vasquez v. Astrue, 572 F.3d 586, 591 (9th Cir. 2009). 

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First, the ALJ found that Plaintiff’s medically determinable impairments could 

reasonably be expected to cause the alleged symptoms. Second, the ALJ found Plaintiff’s 

statements regarding the intensity, persistence, and limiting effects of the symptoms not 

credible to the extent they are inconsistent with the ALJ’s residual functional capacity 

assessment. In other words, the ALJ found Plaintiff’s testimony not credible to the extent 

she claims she is unable to perform in a competitive work environment. 

At the hearing, Plaintiff testified that she left her job at the sheriff’s office because 

she never knew if she would be able to get herself to work. (AR 59.) Plaintiff also alleged 

that she suffers from frequent bowel movements, which she struggles to control. 

(AR 58-59.) Plaintiff claimed to require an hour of bed rest three times per day. (AR 58.) 

She also testified that she struggles with walking one block, shopping for groceries, sitting 

for more than a half hour, lifting more than five pounds on certain days, and using her 

hands. (AR 57.) Plaintiff further claimed that she is in pain “all the time,” and that the pain 

interferes with her sleep. (AR 56.) 

The ALJ rejected Plaintiff’s symptom testimony as not credible. In support of her 

decision, the ALJ provides the following reasons: (1) “[Plaintiff’s] allegations regarding 

the severity of her physical symptoms and limitations are not supported by the objective 

findings of record or her treatment history” (AR 24); (2) Plaintiff has not pursued 

aggressive treatment of her conditions (AR 25); and (3) Plaintiff admits that “she had not 

been compliant” with recommended treatments (AR 25).

1. Not Supported by Evidence in the Record.

The ALJ’s first reason for discounting Plaintiff’s testimony is that portions of that 

testimony are not supported by evidence in the record. Specifically, the ALJ states

The claimant’s allegations regarding the severity of her physical 

symptoms and limitations are not supported by the objective findings of 

record or her treatment history. She has testified to frequent bowel 

movements but the record does not corroborate. In fact, treatment records 

show the claimant denied change in bowel habits. On February 24, 2015, 

intake notes from Estrella Gastroenterology revealed the claimant reported 

she was doing well, but having ongoing diarrhea. She denied pain. The 

claimant indicated she was taking omeprazole for GERD and Azathioprine 

for more than 2 years for rheumatoid arthritis. She stated she had been on 

Humira until about a year ago, when she lost her insurance. The claimant 

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explained she had been diagnosed with Crohn’s in 2004 based on a 

colonoscopy. In 2008, she had another colonoscopy, which was normal 

without evidence of irritable bowel disease. She denied vomiting, change in 

bowel habits, rectal pain, constipation, abdominal distension, blood in stool, 

and incontinence of stool. . . . On October 6, 2015, the claimant reported 

chronic diarrhea secondary to Crohn’s but also indicated her last 

gastroenterologist told her she did not have Crohn’s. She explained she was 

on Cymbalta for fibromyalgia and Prozac for depression (Exhibit 15F/p. 20). 

In November 2015, during a follow-up visit with her primary care physician, 

the claimant reported lower abdominal pain that had started the day prior. 

She reported having some diarrhea, but denied nausea, vomiting, blood in 

stool, and fevers. On exam, the claimant was in no distress. Her abdominal 

sounds were normal. There was generalized tenderness in the right upper 

quadrant but no CVA tenderness. She was diagnosed with acute cystitis 

without hematuria and prescribed nitrofurantoin. . . .

She had emergent care in January 2016. The claimant reported 

worsening abdominal pain for the past 3 days. However, she reported no 

abnormal bowel movements. She was treated with promethazine and 

prednisone. The claimant was released in stable condition (Exhibit 16F/pp. 

125-128). On March 25, 2017, the claimant had emergent care secondary to 

suffering from diarrhea for two days, extremity pain, and emesis. On exam, 

her abdomen was soft with normal bowel sounds. She exhibited no distention 

or mass. There was tenderness but no rebound or guarding. Her abdomen 

ultrasound was unremarkable. She reported that she felt better after bentyl. 

She was discharged in stable condition (Exhibit 19F/pp. 18-23). 

(AR 24-25.) 

“[A]n ALJ does not provide specific, clear, and convincing reasons for rejecting a 

claimant’s testimony by simply reciting the medical evidence in support of his or her 

residual functional capacity determination.” Brown-Hunter, 806 F.3d at 489. “[W]e require 

the ALJ to specify which testimony she finds not credible, and then provide clear and 

convincing reasons, supported by evidence in the record, to support that credibility 

determination.” Id.

Here, The ALJ’s comprehensive summary of Plaintiff’s medical record, without 

more, is insufficient to constitute a clear and convincing reason for discounting Plaintiff’s 

testimony. See Guerrero v. Berryhill, No. CV-17-04258-PHX-HRH, 2018 WL 5276418, 

at *4 (D. Ariz. Oct. 24, 2018) (rejecting ALJ credibility determination because “the ALJ 

did not link this medical evidence to her credibility findings. Instead, the ALJ simply 

recited the medical evidence, which is not sufficient.”). To be sure, the ALJ attempts to 

discuss one point of Plaintiff’s testimony the ALJ deemed inconsistent – stating that 

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Plaintiff “testified to frequent bowel movements but the record does not corroborate.” (AR 

24.) But, in that same paragraph, the ALJ contradicts her own position, identifying no fewer 

than four instances of Plaintiff reporting “ongoing diarrhea,” or “chronic diarrhea,” or 

requesting referral to a specialist due to her symptoms. (See id.)

1

The ALJ also summarized some treatment records regarding Plaintiff’s diabetes, 

hypertension, episodes of chest pain, sleep apnea, and plantar fasciitis, but fails to connect 

any of the cited information to anything in Plaintiff’s symptom testimony. (See AR 25-26.) 

Because the ALJ fails to provide any other link between the medical evidence and the 

ALJ’s credibility finding, the ALJ’s first reason for discounting Plaintiff’s symptom 

testimony is not clear and convincing. See Brown-Hunter, 806 F.3d at 489.

2. Conservative Treatment

The ALJ’s second reason for discounting Plaintiff’s symptom testimony is that 

Plaintiff failed to pursue “more aggressive treatment.” (AR 24.) Specifically, the ALJ states 

that “[t]he lack of more aggressive treatment, or treatment from a specialist suggests the 

claimant’s symptoms and limitations were not as severe as she alleged.” (Id.) In some 

circumstances, “evidence of ‘conservative treatment’ is sufficient to discount a claimant’s 

testimony regarding severity of an impairment.” Parra v. Astrue, 481 F.3d 742, 751 (9th 

Cir. 2007). Here, however, “no medical opinion in this record characterizes the treatment 

of Plaintiff’s [impairments] as ‘conservative,’ nor does substantial evidence support that 

conclusion.” Schultz v. Colvin, 32 F. Supp. 3d 1047, 1061 (N.D. Cal. 2014). 

To the extent the ALJ suggests that Plaintiff failed to see a specialist regarding her 

GI symptoms (AR 25), the ALJ is mistaken. The record shows that Plaintiff both sought 

referral to specialist by her treating physician (AR 797), and was seen by a 

gastroenterologist for her GI impairments (AR 567). Accordingly, the ALJ’s second reason 

for discounting Plaintiff’s symptom testimony is not clear and convincing. 

1 The ALJ appears to be attempting to show that the etiology of Plaintiff’s symptom may 

not be Chron’s disease, but it is the symptoms, not the underlying diagnosis that determines 

whether a claimant is disabled. See 20 C.F.R. § 404.1529. To that end, the ALJ’s discussion 

of Plaintiff’s medical record clearly supports the existence of symptoms identified in 

Plaintiff’s testimony. (See AR 24-25.) 

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3. Noncompliance with Recommended Treatment.

The ALJ’s third reason for discounting Plaintiff’s symptom testimony is that 

Plaintiff failed to fully comply with recommended treatment of her diabetes mellitus and 

hypertension. Specifically, the ALJ states “[a]lthough, there is no question that the medical 

evidence shows some basis for the claimant’s alleged symptoms secondary to diabetes 

mellitus and hypertension, the undersigned does not find these limitations precluded the 

claimant from work because of her noncompliance with diet/checking her sugars and 

failure to pursue specialized treatment through an endocrinologist or other specialist.”

(AR 25.) 

Although an ALJ may consider “whether the claimant fails to follow, without 

adequate explanation, a prescribed course of treatment,” Lingenfelter, 504 F.3d at 1040 

(emphasis added), there is no evidence of such a failure in this case. Here, the sole act of

“noncompliance” upon which the ALJ relies to discount Plaintiff’s symptom testimony is 

an August 2015 treatment note, where Plaintiff self-reports that she had not been testing 

her blood sugar or following her diet well. (AR 760.) The Commissioner does not cite, and 

the Court could not find, a single case in which a Plaintiff’s symptom testimony was 

discredited for an isolated incident of failing to strictly comply with a diet recommendation. 

Moreover, both the ALJ and the Commissioner ignore that Plaintiff’s diabetes is not 

the sole source of her pain and other disabling symptoms; indeed, by the ALJ’s own 

assessment, Plaintiff also suffers from: “obesity, . . . hypertension, gastroesophageal reflux 

disease (GERD), plantar fasciitis, fibromyalgia, obstructive sleep apnea, degenerative joint 

disease, osteoarthritis, rheumatoid arthritis, . . . and irritable bowel syndrome.” Thus, the 

fact she failed to flawlessly follow a recommended diet is not inconsistent with her

testimony of disabling symptoms, which could be caused by her other impairments. See 

Morris v. Astrue, 323 F. App’x 584, 586 (9th Cir. 2009) (finding a Plaintiff’s failure to 

seek treatment for sleep apnea was not inconsistent with his symptom testimony, because 

those symptoms could be caused by other impairments). 

Accordingly, the Court finds that the ALJ’s third reason does not constitute a 

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specific clear and convincing reason for discounting Plaintiff’s symptom testimony. 

B. Weighing of Medical Source Evidence.

Plaintiff argues that the ALJ improperly weighed the medical opinion of his treating 

physician/rheumatologist, Dr. Ravi Bhalla, M.D. (Doc. 13 at 17-24.)

1. Legal Standard.

The Ninth Circuit distinguishes between the opinions of treating physicians, 

examining physicians, and non-examining physicians. See Lester v. Chater, 81 

F.3d 821, 830 (9th Cir. 1995). Generally, an ALJ should give greatest weight to a treating 

physician’s opinion and more weight to the opinion of an examining physician than to one 

of a non-examining physician. See Andrews v. Shalala, 53 F.3d 1035, 1040-41 (9th 

Cir. 1995); see also 20 C.F.R. § 404.1527(c)(2)-(6) (listing factors to be considered when 

evaluating opinion evidence, including length of examining or treating relationship, 

frequency of examination, consistency with the record, and support from objective 

evidence). If it is not contradicted by another doctor’s opinion, the opinion of a treating or 

examining physician can be rejected only for “clear and convincing” reasons. Lester, 81 

F.3d at 830 (citing Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir. 1988)). A contradicted 

opinion of a treating or examining physician “can only be rejected for specific and 

legitimate reasons that are supported by substantial evidence in the record.” Lester, 81 F.3d 

at 830-31 (citing Andrews, 53 F.3d at 1043).

An ALJ can meet the “specific and legitimate reasons” standard “by setting out a 

detailed and thorough summary of the facts and conflicting clinical evidence, stating his 

interpretation thereof, and making findings.” Trevizo v. Berryhill, 871 F.3d 664, 675 (9th 

Cir. 2017) (quotations omitted). But “[t]he ALJ must do more than offer [his] conclusions.

[He] must set forth [his] own interpretations and explain why they, rather than the doctors’, 

are correct.” Embrey, 849 F.2d at 421-22. The Commissioner is responsible for 

determining whether a claimant meets the statutory definition of disability and does not 

give significance to a statement by a medical source that the claimant is “disabled” or 

“unable to work.” 20 C.F.R. § 416.927(d).

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2. Dr. Ravi Bhalla, M.D.

On June 24, 2014, Dr. Ravi Bhalla, M.D. of Valley Arthritis Care, LLC, began 

treating Plaintiff. (AR 544.) Between June 2014 and April 2017, Plaintiff was consistently 

treated at Valley Arthritis Care by either Dr. Bhalla or his physician’s assistant, Brady 

Nelson P.A.-C. (See AR at 544 (June 2014), 548 (October 2014), 552 (February 2015), 

1193 (November 2015), 1189 (January 2016), 1183 (April 2016), 1177 (August 2016), 

1171 (November 2016), 1165 (January 2017), 1158 (Janaury 2017).) On March 22, 2017, 

Dr. Bhalla and PA Nelson signed an assessment that indicated their findings concerning 

Plaintiff.2(AR 1129.) Therein, Dr. Bhalla opines that Plaintiff’s “disability is based on 

joint pains and stiffness, joint inflammation, fatigue, [and] muscle pain and weakness” and 

that Plaintiff’s “limitation does involve but is not limited to simple grasping with hands,

lifting and carrying weights, [and] reaching.” (AR 1129.) Dr. Bhalla also states that “[t]he 

exact number of hours for sitting, standing and the amount of weight the patient can lift is 

not the scope of this practice” and notes that he did not conduct a “functional capacities 

evaluation.” (AR 1129.) Ultimately, Dr. Bhalla concludes that Plaintiff “is disabled for all 

competitive work requirements.” (AR 1129.) 

Dr. Bhalla’s assessment is not contradicted by another medical source. As such, the 

ALJ can reject Dr. Bhalla’s medical assessment only for “clear and convincing” reasons. 

Lester, 81 F.3d at 830 (citing Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir. 1988.)) Here, 

the ALJ discounts Dr. Bhalla’s medical opinion for three reasons: (1) Dr. Bhalla’s 

statements “indicated they based their findings on the claimant’s subjective reports”; (2) 

Dr. Bhalla’s opinion fails to explain Dr. Bhalla’s findings; and (3) Dr. Bhalla’s opinion 

fails to detail Plaintiff’s specific limitations. (AR 27.) For the reasons discussed below, the 

Court finds that the ALJ failed to provide specific, clear and convincing reasons to discount 

the medical opinion of Dr. Bhalla. 

a. Opinion Based on Plaintiff’s Subjective Reports.

2 On Dec. 1, 2014, Dr. Bhalla completed a disability assessment concerning Plaintiff. 

(AR 387.) This assessment took place before Plaintiff amended her date of initial disability. 

This initial assessment was given minimal weight along with opinions from several state 

reviewing physicians from the same general time.

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The ALJ’s first reason for discounting Dr. Bhalla’s medical opinion is that Dr. 

Bhalla “indicated they based their findings on claimant’s subjective reports.” (AR 27.) A 

physician’s reliance on a claimant’s “subjective complaints hardly undermines his opinion 

as to her functional limitations, as a patient’s report of complaints, or history, is an essential 

diagnostic tool.” Valdez-Canez v. Colvin, No. CV-16-02780-PHX-DGC, 2017 WL 

2351664, at *5 (D. Ariz. May 31, 2017) (citing Green-Younger v. Barnhart, 335 F.3d 99, 

107 (2d Cir. 2003) (internal citations and quotations omitted)). But “[i]f a treating 

provider’s opinions are based ‘to a large extent’ on an applicant’s self-reports and not on 

clinical evidence,” and “the ALJ finds the applicant not credible, the ALJ may discount the 

treating provider’s opinion.” Ghanim, 763 F.3d at 1162 (quoting Tommasetti v. Astrue, 533 

F.3d 1035, 1041 (9th Cir. 2008)).

As discussed above, the Court has found that the ALJ improperly discounted 

Plaintiff’s credibility. Accordingly, the ALJ may not discount Dr. Bhalla’s medical opinion 

solely because it is based on Plaintiff’s subjective complaints. Accordingly, the ALJ’s first 

reason for discounting Dr. Bhalla’s medical opinion does not constitute clear and 

convincing evidence. 

b. Failed to Explain Findings.

The ALJ’s second reason for discounting Dr. Bhalla’s medical opinion is that it fails 

to explain Dr. Bhalla’s findings. “An ALJ may discredit treating physicians’ opinions that 

are conclusory, brief, and unsupported by the record as a whole or by objective medical 

findings.” Burrell v. Colvin, 775 F.3d 1133, 1140 (9th Cir. 2014). 

However, a physician’s check-box opinion need not explain each finding if those 

findings are supported by the record as a whole. See id. (finding that an ALJ’s rejection of 

a physician’s conclusory check-box opinion was improper because the physicians findings 

were consistent with the claimant’s testimony and the physician’s other treatment notes in 

the record). See also Trevizo v. Berryhill, 871 F.3d 664, 677 n.4 (9th Cir. 2017) (ALJs may 

not “reject the responses of a treating physician without specific and legitimate reasons for 

doing so, even where those responses were provided on a ‘check-the-box’ form, were not 

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accompanied by comments, and did not indicate to the ALJ the basis for the physician’s 

answers.”). But here, the record plainly supports Dr. Bhalla’s findings.3 Accordingly, the 

Court finds the ALJ’s second reason for discounting Dr. Bhalla’s medical opinion is not 

clear and convincing. 

c. Failed to Provide Specific Limitations. 

The ALJ’s third reason for discounting Dr. Bhalla’s medical opinion is it fails to 

provide specific limitations. (AR 27.) Specifically, the ALJ states that a number of medical 

records “showed mostly normal gait, strength, tone, and range of motion without 

tenderness, swelling, or deformity.” (AR 27.) But these findings are not mutually exclusive 

with debilitating pain; in fact, fibromyalgia, which the ALJ cites as one of Plaintiff’s severe 

impairments, is a disease that causes severe pain without symptoms such as muscle 

weakness, unusual sensory functions, or abnormal reflexes. Revels v. Berryhill, 874 F.3d 

648, 656 (9th Cir. 2017). See also Benecke v. Barnhart, 379 F.3d 587, 590 (9th Cir. 2004)

(finding that fibromyalgia is diagnosed “entirely on the basis of the patients’ reports of pain 

and other symptoms”). Moreover, the ALJ’s finding that Plaintiff experienced no 

tenderness is directly refuted by Dr. Bhalla and PA Nelson’s findings when checking 

fibromyalgia trigger points. (AR at 1161, 1168, 1174, 1180, 1191, 1195.)

The Commissioner implies that Dr. Bhalla relied only on Thomas’ self-reported 

symptoms. (Doc. 15 at 13.) But the record shows that Dr. Bhalla relied on his own findings 

and treatments in conjunction with Plaintiff’s self-reports to make his medical 

determination. (See, e.g., AR 1129; supra at n.3.) And while the ALJ notes that Dr. Bhalla 

did not offer any explanation for his findings in his assessment and failed to offer any 

specific functional capacity determination (AR 27), Dr. Bhalla’s failure to provide a 

specific RFC determination does not inherently render his opinion of little or no weight. 

See Simser v. Comm’r of Soc. Sec. Admin., 2018 WL 3416995, at *6 (D. Ariz. July 13, 

3 See, e.g., AR 550 (summary of Plaintiff’s pain); 552-55 (report of ongoing fibromyalgia 

symptoms and record of medical treatment); 669-72 (same); 673-76 (start of narcotic pain 

treatment); 1193-96 (reports of failed medications and new treatments tried); 1183-88 

(multiple fibromyalgia trigger points found on exam); 1177-81 (same); 1147-53 (March 

2017 emergency room visit with diarrhea and generalized pain).

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2018).4 As a treating physician, Dr. Bhalla and his office have provided several treatment 

records to corroborate his assessment. (AR 550-55, 669-76, 1158-96.) In his opinion, 

Dr. Bhalla even instructs the reader to refer to his treatment notes. (AR 1129.) Furthermore, 

even if Dr. Bhalla’s check-the-box opinion were devoid of explanation, it would be 

improper for the ALJ to reject those responses without specific and legitimate reasons for 

doing so. See Trevizo, 871 F.3d at 677 n.4 (ALJs may not “reject the responses of a treating 

physician without specific and legitimate reasons for doing so, even where those responses 

were provided on a ‘check-the-box’ form, were not accompanied by comments, and did 

not indicate to the ALJ the basis for the physician’s answers.”). See also Pontzious v. 

Berryhill, 2017 WL 6276371, at *4 (D. Ariz. Dec. 11, 2017) (“the Ninth Circuit has noted 

that “there is no authority that a ‘check-the-box’ form is any less reliable than any other 

type of form.”).

Accordingly, the Court finds that the ALJ failed to provide specific, clear, and 

convincing evidence that Dr. Bhalla’s opinion should be given minimal weight.

C. Remand.

Where an ALJ fails to provide adequate reasons for rejecting the opinion of a 

physician, the Court must credit that opinion as true. Lester, 81 F.3d at 834. An action 

should be remanded for an immediate award of benefits when the following three factors 

are satisfied: (1) the record has been fully developed and further administrative proceedings 

4 The Court in Simsir was also required to review an opinion by Dr. Bhalla. And while 

the case at hand requires a “clear and convincing” standard, the Court in Simsir found that 

the ALJ could not discount Dr. Bhalla’s opinion under the lower standard of “specific and 

legitimate” reasons for failing to give a specific functional assessment. 

The Court finds that the lack of specific limitations is a specific and 

legitimate reason to discredit Dr. Bhalla’s functional assessments. But the 

Court cannot conclude that this reason alone is sufficient to justify a blanket 

rejection of Dr. Bhalla’s opinions, which corroborate Plaintiff’s testimony 

and are based on 15 years of treating Plaintiff in Dr. Bhalla’s field of 

specialty. . . . The ALJ stated that Dr. Bhalla’s opinions were inconsistent 

with certain treatment records, but as explained above, the ALJ failed to 

support this statement with substantial evidence in the record. The ALJ erred 

in rejecting Dr. Bhalla’s opinions on the sole basis that his assessments did 

not provide specific functional limitations.

Simser, 2018 WL 3416995, at *6 (D. Ariz. July 13, 2018) (internal citations omitted).

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would serve no useful purpose; (2) the ALJ has failed to provide legally sufficient reasons 

for rejecting evidence, whether claimant testimony or medical opinion; and (3) if the 

improperly discredited evidence were credited as true, the ALJ would be required to find 

the claimant disabled on remand. Garrison v. Colvin, 759 F.3d 995, 1020 (9th Cir. 2014)

(citing Ryan v. Comm’r of Soc. Sec., 528 F.3d 1194, 1202 (9th Cir. 2008), Lingenfelter v. 

Astrue, 504 F.3d 1028, 1041 (9th Cir. 2007), Orn, 495 F.3d at 640, Benecke v. 

Barnhart, 379 F.3d 587, 595 (9th Cir. 2004), and Smolen v. Chater, 80 F.3d 1273, 1292 

(9th Cir. 1996)). There is “flexibility” which allows “courts to remand for further 

proceedings when, even though all conditions of the credit-as-true rule are satisfied, an 

evaluation of the record as a whole creates serious doubt that a claimant is, in fact, 

disabled.” Garrison, 759 F.3d at 1020.

Here, the record is fully developed and the ALJ has already made a ruling based on 

all available facts. The ALJ failed to provide a legally sufficient reason for rejecting the 

opinion of Dr. Bhalla. This medical opinion will be credited as true, and Plaintiff’s severe 

physical limitations detailed by Dr. Bhalla will be accepted as fact. Relying on Dr. Bhalla’s

assessment, the ALJ would be required to find that Plaintiff is disabled. Moreover, the ALJ 

also committed error by discounting Plaintiff’s testimony concerning the extent of her 

disabilities without sufficient reason. Relying on Plaintiff’s testimony, the Court notes that 

Plaintiff’s symptoms preclude her from competitive work assignments. Lastly, when 

viewed in its entirety, this case does not raise serious doubt that Plaintiff is actually 

disabled.

IT IS ORDERED that the final decision of the Commissioner of Social Security is 

vacated and this case is remanded for an award of benefits. The Clerk shall enter judgment 

accordingly and terminate this case.

Dated this 2nd day of March, 2020.

Honorable John Z. Boyle

United States Magistrate Judge

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