Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_18-cv-02633/USCOURTS-casd-3_18-cv-02633-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:0402 Social Security Benefits

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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

KIMBERLY C.,

Plaintiff, 

v.

ANDREW M. SAUL, Acting

Commissioner of Social Security,

1

Defendant. 

Case No.: 18-cv-2633-LAB-MDD

REPORT AND 

RECOMMENDATION OF UNITED 

STATES MAGISTRATE JUDGE 

RE: MOTION AND CROSS 

MOTION FOR SUMMARY 

JUDGMENT

[ECF Nos. 13 and 15]

This Report and Recommendation is submitted to United States 

District Judge Larry A. Burns pursuant to 28 U.S.C. § 636(b)(1) and Local 

Civil Rule 72.1(c) of the United States District Court for the Southern 

District of California. 

Plaintiff Kimberly C. (“Plaintiff”) filed this action pursuant to 42 U.S.C. 

§ 405(g) for judicial review of the final administrative decision of the 

 

1 Andrew M. Saul became Commissioner of Social Security on June 17, 2019 and is 

therefore substituted for Nancy A. Berryhill as the Defendant in this action. See 42 U.S.C. 

§ 405(g); Fed. R. Civ. P. 25(d).

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Commissioner of the Social Security Administration (“Commissioner”). (ECF 

No. 13-1 at 2).2 The final administrative decision of the Commissioner denied 

Plaintiff’s application for Disability Insurance Benefits under Title II of the 

Social Security Act (“Title II”) and for Supplemental Security Income under 

Title XVI of the Social Security Act (“Title XVI”). (AR 15).3

For the reasons set forth herein, the Court RECOMMENDS Plaintiff’s 

Motion for Summary Judgment be GRANTED IN PART, Defendant’s Cross 

Motion for Summary Judgment be DENIED, and that the case be 

REMANDED for further proceedings.

I. BACKGROUND

Plaintiff was born on May 26, 1962. (AR 570). At the time the instant 

application was filed on August 21, 2014, Plaintiff was 52 years-old which 

categorized her as a person closely approaching advanced age. 20 C.F.R. §§ 

404.1563, 416.963. 

A. Procedural History

On August 21, 2014, Plaintiff protectively filed an application for a 

period of Disability Insurance Benefits under Title II. (AR 15). On August 1, 

2014, Plaintiff protectively filed an application for a period of Supplemental

Security Income under Title XVI. (Id.). The application alleged a disability 

beginning February 11, 2013. (Id.). After her application was denied 

initially and upon reconsideration, Plaintiff requested an administrative 

hearing before an administrative law judge (“ALJ”). (Id.). An administrative 

 

2 All pincite page references refer to the automatically generated ECF page 

number, not the page number in the original document.

3 “AR” refers to the Certified Administrative Record filed on August 26, 2019. 

(ECF No. 12).

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hearing was held on May 23, 2017. (Id.). Plaintiff appeared and was 

represented by attorney Yong Young. (AR 34). Testimony was taken from 

Plaintiff, impartial medical expert Arnold Ostrov, and from impartial 

vocational expert Connie Hillary. (AR 32-67). On July 6, 2017, the ALJ 

issued a decision finding Plaintiff was not disabled from February 11, 2013

through the date of the decision and therefore denied Plaintiff’s claim for 

benefits. (AR 25-26). 

On July 6, 2017, Plaintiff sought review with the Appeals Council. (AR 

1). On September 12, 2018, the Appeals Council denied Plaintiff’s request for 

review and declared the ALJ’s decision to be the Commissioner’s final 

decision in Plaintiff’s case. (Id.). This timely civil action followed. 

II. DISCUSSION

A. Legal Standard

Sections 405(g) and 1383(c)(3) of the Social Security Act allow 

unsuccessful applicants to seek judicial review of a final agency decision of 

the Commissioner. 42 U.S.C. §§ 405(g), 1383(c)(3). The scope of judicial 

review is limited in that a denial of benefits will not be disturbed if it is 

supported by substantial evidence and contains no legal error. Id.; see also 

Batson v. Comm’r of the SSA, 359 F.3d 1190, 1193 (9th Cir. 2004). 

Substantial evidence means “more than a mere scintilla but less than a 

preponderance. . . .” Sandgathe v. Chater, 108 F.3d 978, 980 (9th Cir. 1997)

(internal quotation marks and citation omitted). “[I]t is such relevant 

evidence as a reasonable mind might accept as adequate to support a 

conclusion.” Id. (quoting Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 

1995)). The court must consider the record as a whole, weighing both the 

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

Desrosiers v. Sec’y of Health & Human Servs., 846 F.2d 573, 576 (9th Cir. 

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1988). If the evidence supports more than one rational interpretation, the 

court must uphold the ALJ’s decision. Batson, 359 F.3d at 1193. When the 

evidence is inconclusive, “‘questions of credibility and resolution of conflicts in 

the testimony are functions solely of the Secretary.’” Sample v. Schweiker, 

694 F.2d 639, 642 (9th Cir. 1982) (quoting Waters v. Gardner, 452 F.2d 855, 

858 n.7 (9th Cir. 1971)). 

Even if a reviewing court finds that substantial evidence supports the 

ALJ’s conclusion, the court must set aside the decision if the ALJ failed to 

apply the proper legal standards in weighing the evidence and reaching his or 

her decision. Batson, 359 F.3d at 1193. Section 405(g) permits a court to 

enter a judgment affirming, modifying, or reversing the Commissioner’s 

decision. 42 U.S.C. § 405(g). The reviewing court may also remand the 

matter to the Social Security Administration for further proceedings. Id. 

B. Summary of the ALJ’s Findings

In rendering his decision, the ALJ followed the Commissioner’s five step 

sequential evaluation process. See 20 C.F.R. § 404.1520. At step one, the 

ALJ found that Plaintiff had not engaged in substantial gainful employment 

since February 11, 2013. (AR 18).

At step two, the ALJ found that Plaintiff had the following severe 

impairments: gastrointestinal system disorder including chronic rectal pain 

and migraine headaches (20 C.F.R. 404.1520(c) and 416.920(c)). (Id.). 

At step three, the ALJ found that Plaintiff did not have an impairment 

or combination of impairments that met or medically equaled one of the 

impairments listed in the Commissioner’s Listing of Impairments. (AR 19)

(citing 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. 404.1520(d), 

404.1525, 404.1526, 416.920(d), 416.925 and 416.926)).

Next, after considering the entire record, the ALJ determined that 

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Plaintiff had the “residual functional capacity [(RFC)] to perform light work 

as defined in 20 C.F.R. 404.1567(b) and 416.967(b),” with the following 

limitations:

sit for 6 hours in an 8-hour workday with normal breaks; the 

claimant can stand and/or walk for 6 hours in an 8-hour workday 

with normal breaks; the claimant can occasionally climb stairs 

and ramps; the claimant can never climb ladders, ropes and 

scaffolds; the claimant can frequently stoop, kneel, crouch, and 

crawl; the claimant must avoid even concentrated exposure to 

temperature extremes and vibrations; the claimant must avoid all 

exposure to hazards such as moving machinery and unprotected 

heights; and the claimant should have access to a bathroom within 

100 yards from the work station. 

(AR 19). The ALJ stated he considered the opinion evidence in 

accordance with the requirements of 20 C.F.R. 404.1527 and 416.927. 

(AR 20). 

The ALJ then proceeded to step four of the sequential evaluation

process. He found Plaintiff was able to perform her past relevant work. (AR

25). For the purposes of his step four evaluation, the ALJ relied upon the

testimony of the vocational expert (“VE”), and the ability of someone with the 

claimant’s RFC, both as actually done and as generally done in the national 

economy. (Id.). The VE testified that Plaintiff’s past relevant work included 

the following job: accounting clerk. (AR 61). 

C. Whether the ALJ Erred by Failing to Provide Specific and 

Legitimate Reasons for Rejecting Opinion of the Treating Physician 

Plaintiff contends the ALJ failed to articulate specific and legitimate 

reasons for rejecting the opinion of Plaintiff’s treating physician, Dr. Steven 

Horowitz, that her chronic rectal pain prevents her from sitting for more than 

fifteen minutes at a time and standing for long periods of time. (ECF No. 13-

1 at 4; AR 568-75). Specifically, Plaintiff argues the ALJ’s articulated 

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reasons for discounting Dr. Horowitz’s opinion “are based on two isolated 

moments” with little relevance to Plaintiff’s chronic rectal pain. (See id. at 

10).

“‘Although a treating physician’s opinion is generally afforded the 

greatest weight in disability cases, it is not binding on an ALJ with respect to 

the existence of an impairment or the ultimate determination of disability.’” 

Batson, 359 F.3d at 1195 (quoting Tonapetyan v. Halter, 242 F.3d 1144, 1149 

(9th Cir. 2001)). Where a treating physician’s opinion is not contradicted by

another doctor, it may be rejected only for “clear and convincing” reasons. 

Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995). Where a treating 

physician’s opinion is contradicted by another doctor, an ALJ may not reject 

the treating physician’s opinion without providing specific, legitimate 

reasons, supported by substantial evidence in the record. Id.

Here, Dr. Horowitz’s opinion is contradicted by other doctors. (AR 24). 

For example, Dr. Arnold Ostrow opined that Plaintiff could sit for eight hours 

with normal breaks and could stand and or walk for eight hours with normal 

breaks and Drs. P. Ombres, H. Amado, and M. Gleason opined that Plaintiff 

could work at a sedentary level. (AR 24-25). Accordingly, the ALJ must 

provide specific and legitimate reasons supported by substantial evidence to 

reject Dr. Horowitz’s opinion. See Lester, 81 F.3d at 830. 

The ALJ gave “less weight” to Dr. Horowitz’s opinion because “the 

objective treatment records are not fully consistent with the less than 

sedentary functional capacity asserted by Dr. Horowitz.” (AR 24). In 

particular, the ALJ cited Dr. Horowitz’s progress notes from October 29, 

2014, which indicated that “Norco helped,” that Plaintiff was in “no acute 

distress,” was well-nourished, and was fully oriented with good insight. (AR 

24). The ALJ also cited notes from a February 9, 2016 physical examination 

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at a hospital, which showed that Plaintiff “had normal pupils; no evidence of 

hemorrhage on fundoscopic exam; intact exocular [sic] muscles in all four 

directions; normal and supple neck without rigidity; a non-tender 

gastrointestinal exam without rebound, guarding, or masses; normal 

movement in all four extremities; fully oriented in all spheres; and no 

apparent distress[.]” (Id.).

Many of the reasons cited by the ALJ are irrelevant or unrelated to 

Plaintiff’s gastrointestinal system disorder including chronic rectal pain. (See

AR 18). The fact that Plaintiff was well-nourished, fully oriented with good 

insight, had a normal and supple neck without rigidity, and normal 

movements in all four extremities are irrelevant to her chronic rectal pain. 

Even more irrelevant to her condition are notes regarding Plaintiff’s eyes—

i.e., that Plaintiff had normal pupils, no hemorrhaging on her fundoscopic 

exam and intact ocular muscles. Finally, the fact that Plaintiff had a nontender gastrointestinal exam without rebound, guarding, or masses, on 

February 9, 2016, is not particularly relevant. On that date, Plaintiff went to 

the hospital complaining of a headache and visual disturbance and the focus 

was not on Plaintiff’s chronic rectal pain. (AR 764-71). Accordingly, these 

are not specific and legitimate reasons to discount Dr. Horowitz’s opinion. 

See Elliott v. Comm’r of SSA, No. CV-18-8201-PCT-JFM, 2019 U.S. Dist. 

LEXIS 111464, at *52-57 (D. Ariz. July 2, 2019) (finding the ALJ erred by 

affording little weight to a treating physician based on evidence in the 

medical evidence that was irrelevant).

The fact that Norco was helpful is also not a specific and legitimate 

reason to discount Dr. Horowitz’s opinion. Effective control of an impairment 

with medication is a specific and legitimate reason to discount a treating 

physician’s opinion. See Warre v. Comm’r of Soc. Sec. Admin., 439 F.3d 1001, 

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1006 (9th Cir. 2006). However, Dr. Horowitz specifically indicated that while 

Norco helps, “the effect is quite limited and [Plaintiff] continues to have 

pain.” (AR 520). The limited effect of Plaintiff’s medication is consistently 

noted throughout the objective medical record. (See AR 298, 310, 343-56, 359, 

378, 436, 448). As such, this reason is not supported by substantial evidence

in the record. See Lester, 81 F.3d at 830.

Finally, the ALJ notes that Plaintiff was not in apparent or acute 

distress and that the “longitudinal objective treatment records” are 

inconsistent with Dr. Horowitz’s opinion. (AR 24). The objective medical 

record shows that Plaintiff had a colonoscopy in 2011 that showed 

“significant internal/external hemorrhoids.” (See AR 298). As a result, 

Plaintiff had a hemorrhoidectomy in March 2011. (AR 298, 301). “She had a 

very painful postoperative vent and things seemed to get worse at times. She 

was unable to have normal bowel movements [and] developed a rectocele.” 

(AR 357). Three months later, in January 2012, the same surgeon performed 

a rectocele repair, which showed “poor relaxation and only small increase in 

the rectal pressure” with push attempts,” indicating a “subtle type of pelvic 

floor discoordination.” (AR 301, 357). Plaintiff “did not do well and things 

seemed to get worse” after the repair. (AR 357). “She began to develop some 

looseness of her bowels and difficulties with a uterine prolapse.” (Id.). 

Accordingly, in March of 2012, Plaintiff had a hysterectomy, bilateral 

salpingo oophorectomy, and a prolapse repair. (AR 310, 357). Following this 

surgery, Plaintiff “had fairly profound postoperative pain and was unable to 

have normal bowel movements.” (AR 357). 

Since these surgeries, Plaintiff’s major symptoms have been “pain and 

difficulty with evacuation.” (AR 315). Specifically, “[s]he has difficulty 

sitting and is unable to sit and function on her job,” has “some pain in the 

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lower quadrant of the abdomen . . . as well as the midline.” (Id.). Plaintiff 

explains she has difficulty with evacuation and takes laxatives, uses enemas, 

and evacuates with her fingers daily. (Id.). 

Plaintiff’s primary care physician initially prescribed Vicodin, but later 

prescribed Norco which was more helpful. (AR 357). By December 6, 2012, 

Plaintiff was referred to Dr. Horowitz for further pain management issues 

because her pain was still “moderate to severe” even with Norco. (AR 356).

Plaintiff was also referred to a UCSD bowel program because she “had 

functional bowel movements but had some significant problems.” (AR 357). 

UCSD performed a defecography “and found that although her sphincter 

opened and closed normally it simply did not open enough as it was surgically 

repaired too tightly.” (Id.). Additionally, Biofeedback demonstrated that her 

“sphincter was moving but simply did not open enough to do the job.” (Id.). 

 On September 17, 2012, a defogram demonstrated a mild degree of 

internal prolapse of the rectal mucosa, persistent narrowing of the anal canal 

that could represent spasm stricture, and possible internal hemorrhoids. (AR 

309). On October 23, 2012, Plaintiff followed up with Dr. Mittal regarding 

the defogram. (See AR 312). Dr. Mittal stated that Plaintiff likely has pelvic 

floor discoordination or some narrowing as a result of hemorrhoidectomy and 

scarring. (Id.). He recommended “biofeedback therapy,” “balloon dilation in 

case there was some scarring” and possibly “Botox injection[s].” (AR 312-13). 

On January 17, 2013, Dr. Mittal suspected that Plaintiff has “anal stenosis,” 

although “there is no way to be 100% sure.” (AR 314). He noted that 

Plaintiff had a “significant rectocele in spite of rectocele repair” and that she 

has narrowing of the anal canal.” (Id.) This time, Dr. Mittal recommended 

“anal dilation.” (Id.). However, on March 21, 2013, Dr. Mittal reported that 

the “dilation did not make any difference” and that Plaintiff “continues to be 

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quite distressed.” (AR 315, 325-27). At the time, Plaintiff reported spending 

“2 to 3 hours in the toilet in the morning to have a bowel movement.” (AR 

315). Dr. Mittal referred Plaintiff to see Dr. Ramamoorthy. (AR 316).

On May 21, 2013, Dr. Johnathan Takei Unkart and attending physician 

Dr. Ramamoorthy noted that while “[a]natomically, [Plaintiff’s] anus should 

pass stool,” she “likely has a functional dysfunction that may lead to a 

mechanical obstruction.” (AR 301). Drs. Unkart and Ramamoorthy noted 

that surgery would “likely not improve her symptoms” and “possibly worsen 

and pose significant complications,” but suggested that a “trial of Botox 

injections” may be beneficial. (Id.). On August 13, 2013, Dr. Mittal 

questioned whether Plaintiff’s Norco tablets were causing a narcotic bowel. 

(AR 322). To deal with Plaintiff’s complaints of constant pain and being in 

the bathroom half the day, Dr. Mittal decided to give Plaintiff “a trial of 

Relistor” injections every other day for two months. (Id.).

By May of 2014, Plaintiff reported she has constantly been in the same 

amount of pain, even though it is “moderately controlled” with medication. 

(AR 468). In June of 2014, Plaintiff reported somewhat worsening rectal pain 

with cramping due to her “inability to relax her rectal sphincter muscle.” (AR 

466). She reported having to “liquify” her stool to have bowel movements. 

(Id.). By October 2014, Plaintiff was still experiencing pain. (AR 440). She 

reported spending the first six hours of her day in the bathroom “trying to get 

things going” and feels she is “slowly getting worse” even though “Norco 

helps” somewhat. (Id.). On February 23, 2015, Plaintiff reported that her 

rectal pain remains the same, although it is under “some control” with 

medication. (AR 448). On March 6, 2015, Dr. Horowitz opined that Plaintiff’ 

is “unlikely to improve” because her “neurological system for the bowel has 

been deranged by multiple surgeries.” (AR 575). 

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On August 26, 2016, Plaintiff reported severe symptoms of chronic 

rectal pain that “occur constantly.” (AR 813). As of February 2017, Plaintiff 

was still complaining of chronic rectal pain. (AR 799). Based on the record, 

Plaintiff has consistently complained of chronic rectal pain that limits her 

daily activities and causes her to “live[] in the bathroom daily.” (AR 298).

After years of treating Plaintiff, Dr. Horowitz opined that Plaintiff “does 

not have the physical wherewithal to tolerate activities at work as a result of 

her ongoing continuing fairly profound gastrointestinal issues and chronic 

pain in this regard.” (AR 569-75). Pain is an inherently subjective symptom. 

See Smolen v. Chater, 80 F.3d 1273, 1282 (9th Cir. 1996). Neither the 

existence, nor severity of pain can be objectively measured or verified. Fair v. 

Bowen, 885 F.2d 597, 601 (9th Cir. 1989). By discounting Dr. Horowitz’s 

opinion as inconsistent with Plaintiff’s longitudinal objective treatment 

records and failure to present in notable pain, the ALJ improperly required 

objective evidence of pain—a symptom which is not susceptible to objective 

measurement. See Benecke v. Barnhart, 379 F.3d 587, 594 (9th Cir. 2004). 

Based on the foregoing, the ALJ did not articulate specific and 

legitimate reasons to discount Dr. Horowitz’s opinion regarding sitting for

more than fifteen minutes at a time and standing for long periods of time. 

(See AR 24).

D. Remand for Further Administrative Proceedings

The law is well established that the decision whether to remand for 

further proceedings or simply to award benefits is within the discretion of the 

Court. See, e.g., Salvador v. Sullivan, 917 F.2d 13, 15 (9th Cir. 1990); 

McAllister v. Sullivan, 888 F.2d 599, 603 (9th Cir. 1989); Lewin v. Schweiker, 

654 F.2d 631, 635 (9th Cir. 1981). Remand pursuant to sentence four of §

405(g) for further proceedings is warranted where additional administrative 

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proceedings could remedy defects in the decision. See, e.g., Kail v. Heckler, 

722 F.2d 1496, 1497 (9th Cir. 1984); Lewin, 654 F.2d at 635. Remand

pursuant to sentence six for the payment of benefits is appropriate where no 

useful purpose would be served by further administrative proceedings, 

Kornock v. Harris, 648 F.2d 525, 527 (9th Cir. 1980); where the record has 

been fully developed, Hoffman v. Heckler, 785 F.2d 1423, 1425 (9th Cir. 

1986); or where remand would unnecessarily delay the receipt of benefits to 

which the disabled plaintiff is entitled, Bilby v. Schweiker, 762 F.2d 716, 719 

(9th Cir. 1985). 

As noted above, the ALJ erred in discounting the opinion of Plaintiff’s 

treating physician, relying on unrelated or irrelevant reasons, reasons 

unsupported by substantial evidence, or reasons based on a 

misunderstanding of Plaintiff’s condition. “The ALJ erred by effectively 

requiring objective evidence for a disease that eludes such measurement.” 

Benecke, 379 F.3d at 594 (internal quotation marks and citation omitted). On 

remand, should the ALJ determine that Dr. Horowitz’s opinion is entitled to 

greater weight, there is a reasonable possibility that the residual functional 

capacity assessment may change. Accordingly, the matter must be remanded 

for further proceedings in accordance with these findings.

III. CONCLUSION AND RECOMMENDATION

For the foregoing reasons, this Court RECOMMENDS that Plaintiff’s 

Motion for Summary Judgment be GRANTED IN PART, Defendant’s Cross 

Motion for Summary Judgment be DENIED, and that the case be 

REMANDED pursuant to sentence four of 42 U.S.C. § 405(g) for further 

proceedings in accordance with this Report and Recommendation. This 

Report and Recommendation of the undersigned Magistrate Judge is 

submitted to the United States District Judge assigned to this case, pursuant 

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to the provisions of 28 U.S.C. § 636(b)(1) and Local Civil Rule 72.1(c) of the 

United States District Court for the Southern District of California. 

IT IS HEREBY ORDERED that any written objection to this report 

must be filed with the Court and served on all parties no later than 

December 27, 2019. The document should be captioned “Objections to

Report and Recommendations.”

IT IS FURTHER ORDERED that any reply to the objections shall be 

filed with the Court and served on all parties no later than January 3, 2020. 

The parties are advised that failure to file objections within the specified time 

may waive the right to raise those objections on appeal of the Court’s order. 

Martinez v. Ylst, 951 F.2d 1153 (9th Cir. 1991). 

IT IS SO ORDERED.

Dated: December 12, 2019 /1, t cYM);l ~- ~ L 

Hon. Mitchell D. Dembin 

United States Magistrate Judge 

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