Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_15-cv-00270/USCOURTS-casd-3_15-cv-00270-0/pdf.json

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

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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

ROBIN P. STIVERS,

Plaintiff,

v.

CAROLYN W. COLVIN 

Acting Commissioner of Social Security,

Defendant.

3:15-cv-00270-BAS-NLS

REPORT AND 

RECOMMENDATION FOR ORDER

GRANTING PLAINTIFF’S MOTION 

FOR SUMMARY JUDGMENT AND 

DENYING DEFENDANT’S CROSSMOTION FOR SUMMARY 

JUDGMENT

(Dkt. Nos.12, 19)

I. INTRODUCTION

Plaintiff Robin P. Stivers (“Plaintiff”) brings this action under the Social Security 

Act, 42 U.S.C. § 405(g), seeking judicial review of the decision of the Social Security 

Administration (“Defendant”) to deny her claims for disability insurance benefits and for 

supplemental security income benefits. This case was referred for a report and 

recommendation on the parties’ cross motions for summary judgment. See 28 U.S.C. § 

636(b)(1)(B). After carefully considering the papers submitted, the administrative record, 

and the applicable law, the Court RECOMMENDS that Plaintiff’s motion for summary 

judgment and for reversal and/or remand be GRANTED and REMANDED for additional 

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proceedings, and that Defendant’s cross motion for summary judgment be DENIED.

II. BACKGROUND

a. Procedural History

On July 4, 2011, Plaintiff filed a Title II application for disability insurance benefits 

and a Title XVI application for supplemental security income benefits.1 Administrative 

Record (“AR”) 72, 175-80, 181-89, 190-91. She alleged her disability began on June 1, 

2009. AR 177, 181, 190. 

The Social Security Administration initially denied Plaintiff’s applications on March 

22, 2012, and denied them again upon reconsideration on May 29, 2012. AR 121-25, 130-

35. Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”). AR 136-

37. 

On October 24, 2013, the ALJ held a hearing. AR 29. The ALJ issued a decision 

on November 15, 2013, denying Plaintiff’s applications on grounds she was not disabled. 

AR 104-15. The Appeals Council denied Plaintiff’s request for review of the ALJ’s 

decision, and the decision became final. AR 1-6, 12-14. 

Plaintiff filed this Complaint for judicial review. (Dkt. No. 1.) She asks the Court 

to reverse the ALJ’s decision and award benefits or alternatively to remand for further 

proceedings. (Dkt. No. 12 at 2.)

b. Documentary Medical Evidence

i. State Agency Physician Opinions

State Agency physician Pamela Ombres, M.D., reviewed Plaintiff’s medical records 

at the initial level. AR 48-71. On February 27, 2012 and on March 8, 2012, Dr. Ombres 

opined Plaintiff is capable of a duration to light Residual Functional Capacity (“RFC”) as 

written, which was to occasionally lift and/or carry 20 pounds and frequently lift and/or 

carry 10 pounds; to stand or walk for 6 hours in an 8-hour workday; and sit for 6 hours in 

 

1 Because the disability insurance benefits (“DIB”) Code of Federal Regulations are virtually identical to 

the supplemental security income Regulations, the parties cite to the DIB citations only throughout their 

briefs. See Dkt. Nos. 12, 19-1 at 5, fn.1. The Court does so here as well. 

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an 8-hour workday. AR 55. Dr. Ombres opined Plaintiff could occasionally climb ramps 

or stairs, balance, stoop, kneel, crouch and crawl, but should never climb ladders, ropes or 

scaffolds. Id. She opined Plaintiff would have limited reaching, handling, fingering and 

feeling. AR 56. Dr. Ombres also opined Plaintiff could perform frequent handling and 

occasional fingering. Id. On May 25, 2012, State Agency physician G. Taylor-Holmes, 

M.D. affirmed Dr. Ombres’ findings. AR 80. 

ii. Treating Physician George C. Fareed, M.D.

On June 22, 2009, treating physician Dr. Fareed examined Plaintiff and reported that 

Plaintiff was “generally active and in satisfactory or normal health.” AR 274-75. Plaintiff 

complained of abdominal pain, body aches, and fever symptoms. AR 274. Dr. Fareed 

noted that Plaintiff had no recent hospitalizations for major illnesses, accidents, surgeries, 

or injuries. Id. Upon examination, Plaintiff’s neck was supple; her abdomen was nontender with no organomegaly; her musculoskeletal system was essentially unchanged or

stable; her back had no CVA (costovertebral angle) or spot tenderness; and her neurological 

examination was non-focal with motor and sensory systems intact or unchanged. AR 274-

75. Dr. Fareed also reported that Plaintiff’s gait and balance were normal. AR 275.

On February 22, 2011, Dr. Fareed again examined Plaintiff. His examination 

findings were largely the same as before, but he also noted a few additional diagnoses of

leg pain and neuropathy. AR 279-80. Dr. Fareed’s April, August, and September 2011 

examination findings were essentially the same. AR 282-83; 284-86; 287-88; 290-92. His 

December 2011 findings were also essentially the same, though he added a diagnosis of

paresthesia (tingling) in the left arm and fingers. AR 565-67.

On February 22, 2012, Dr. Fareed again saw Plaintiff. His findings were essentially 

the same as before, though he added impressions and diagnoses of cervical spondylosis 

with myelopathy (compressional of the spinal cord), and disc displacement. AR 569-70. 

Dr. Fareed’s October 25, 2012 examination notes indicate Plaintiff was evaluated for the 

same diagnoses listed in the February 2012 notes. He also again noted no recent 

hospitalizations for major illnesses, accidents, surgeries or injuries, noted as being 

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“generally active and in satisfactory or normal health.” AR 574. Her musculo-skeletal 

system was noted as “unremarkable and essentially unchanged/stable.” AR 575. Her 

neurological exam showed it was “non-focal with motor and sensory systems intact or 

unchanged from before. Gait and balance are normal.” AR 575.

On January 7, 2013, Plaintiff saw Dr. Fareed for complaints pertaining to bronchitis. 

AR 577-78. On May 16, 2013, Plaintiff again saw Fareed for complaints pertaining to 

gastrointestinal hemorrhage and blood clots in the stool. AR 580-81. Dr. Fareed noted 

that her neck was supple, that her musculo-skeletal system is unremarkable and essentially 

unchanged/stable. Her back was without CVA or spot tenderness. He also noted her 

motor and sensory systems were intact or unchanged from before, and her gait and balance 

were normal. AR 581.

iii. Neurologist Sayed Monis

On July 6, 2010, Neurologist Sayed Monis, M.D. evaluated Plaintiff for her 

complaints of low back pain and neck pain. Summary notes from Dr. Monis’ consultation 

report stated low back radiation to B/L lower extremities with some sensory loss and 

diminished reflexes of knees and ankles; tenderness in the lower back area; a positive facet 

loading test; neck pain radiation to B/L; consistent exam findings with diminished pin prick 

and temperature sensation and B/L upper extremities; B/L intrinsic hand muscle weakness, 

tenderness in the upper back and diminished reflexes in the UE; as well as B/L diffuse hand 

and feet diminished sensation and diminished sensation on the right side of the face and 

right upgoing plantar. Dr. Monis diagnosed Plaintiff with differential diagnoses of lumbar 

degenerative disc disease with radiculopathy; cervical degenerative disc disease with 

radiculopathy; R/O intracranial lesion or metastasis, and facet joint disease or arthritis. AR 

383. She recommended a nerve conduction study and electromyogram (“EMG”) of the 

lower extremities. Id.

iv. Oncologist Hasnat Ahmed

On June 7, 2011, Plaintiff was seen by oncologist Hasnat Ahmed, M.D. The doctor 

noted she had neuropathy that primarily affected her feet but ambulated normally. Plaintiff 

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was alert and comfortable and had a supple neck. He noted that her carpal tunnel surgery 

resulted in improved strength in her hand and grip, and that she had a 5/5 wrist strength. 

AR 327. On December 6, 2011, Dr. Ahmed again examined Plaintiff. Plaintiff complained 

of peripheral neuropathy in the feet, and pain in her feet. Upon physical examination, he 

noted she was ambulating normally, her neck was supple, her grip strength was good and 

power was 5/5 in all four limbs, and there was no tenderness on percussion of the vertebral 

column. AR 539-40.

Approximately one year later on January 9, 2013, Dr. Ahmed again saw Plaintiff. 

Upon physical examination, he noted her neck as supple, and power was 5/5 in all four 

limbs. AR 545. He also assessed that she had sensory neuropathy in the feet. Id.

v. Dr. Charles Stevens

Dr. Fareed referred Plaintiff to see Charles Stevens, M.D. of Advanced Pain 

Associates. See AR 506, 609. Plaintiff saw Dr. Stevens on May 17, 2012; she complained 

of pain located in her neck and both arms, and the pain was constant and aching and 

sharpshooting, numbing and tingling. Upon physical examination, the doctor noted 

Plaintiff ambulated with a slowed gait but had a normal heel and toe walk; she had a full 

normal forward flexion and left and right lateral flexion. He also noted a negative straight 

leg-raise bilaterally and 5/5 strength in the upper extremities with a full range of motion of 

her bilateral upper extremities. From her upper extremities she also had a positive 

Spurling’s sign (pain assessment in the neck) bilaterally. He also noted a normal range of 

motion and intact sensation reflexation in her lower extremities. Dr. Stevens diagnosed 

Plaintiff with malignant neoplasm of the breast; unspecified essential hypertension; 

unspecified idiopathic peripheral neuropathy; brachia-neuritis or radiculitis not otherwise 

specified; and spinal stenosis in the cervical region. AR 506-09.

On October 5, 2012, Plaintiff again saw Dr. Charles Stevens. Plaintiff complained 

of cervical and lumbar spine pain; hip, knee and ankle/foot pain in the joints; and of pain

in both upper extremities and her lower right extremity. AR 601. Physical examination 

notes indicated no muscle tenderness in the spine, though a limited range of motion in all 

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directions and a positive Spurling’s bilaterally; for the lumbosacral spine there were trigger 

points at mid-quadrant of the buttocks, nontender musculature, moderate pain with 

extension/axial loading and minimal discomfort with lateral bending, a limited range of 

motion in all directions, normal muscle strength and tone, and a straight leg raise test was 

positive on the right. Upper and lower extremities were noted as having a range of motion 

appropriate with age and/or no limitation on the range of motion, no pain with the range of 

motion, and no tenderness. Her gait and station were noted as ataxic gait–right, and she 

was able to stand without difficulty and ambulate without the assistance of orthosis. The 

assessment findings were myalgia and myositis, unspecified; muscle spasm; lumbago; 

spondylosis without myelopathy; chronic pain syndrome; lumbar radiculitis; lumbar 

degenerative disc disease; and lumbar spinal stenosis. Dr. Stevens noted Plaintiff had low 

back pain on the right that was greater than on the left, along with right leg radicular pain 

in an LS/S1 distribution along with associated paresthesias (abnormal tingling). Dr. 

Stevens ordered an MRI of the lumbar spine and physical therapy. AR 606-07. In 

November 2012, Dr. Stevens reviewed Plaintiff’s MRI and referred her to a neurology 

consult for an EMG/NCV. AR 609. A progress note from Dr. Charles Stevens dated 

December 20, 2012, indicates largely the same physical examination findings, though 

myofascial pain was added to the assessment. AR 617-622.

On January 28, 2013, Plaintiff again saw Dr. Stevens. The physical examination 

findings were largely the same, though Dr. Stevens noted pain with range of motion in the 

right ankle/foot. He also reviewed Plaintiff’s EMG/NCV and noted it showed right L4/L5 

and LS/SI radiculopathy with an MRI that showed minimal pathology. AR 624-629. A 

few weeks later on February 8, 2013, Plaintiff again saw Dr. Stevens. Plaintiff complained 

that her medication gave her headaches as she was dizzy and unable to “function.” Physical 

examination was largely the same, though she was noted to have a trigger point at the 

anterior aspect of the interspaces between the transverse processes of C5-C7 (bilateral) and 

paraspinal muscle tenderness in the lumbosacral spine. Dr. Stevens decreased her 

medication. AR 631-37. In April, May, and June of 2013, Plaintiff continued to visit Dr. 

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Stevens. Her physical examination findings were largely the same, though in May of 2013

Plaintiff complained of pain in her right hip and that she was experiencing a functional 

decrease because her pain symptoms were increasing within the past month. AR 638-44; 

645-51; 652-57. On August 14, 2013, Plaintiff again saw Dr. Stevens. Plaintiff complained 

of pain in her right hip. The examination notes were largely the same as before, and 

summarized as follows: that Plaintiff has a chronic pain syndrome, with cervical spinal 

stenosis and cervical radiculopathy, she has low back pain on the right greater than the left 

along with right leg raiduclar pain in an L5/S1 distribution along with associated 

parasthesias. He also restated her MRI findings of mild facet anthropathy but no stenosis 

to explain her right leg radicular pain and parathesias. He also restated her EMG/NCV 

findings that showed right L4-L5, L5-S1 radiculopathy. AR 659-65.

vi. Diagnostic Studies 

On July 16, 2010, an MRI of Plaintiff’s lumbar spine was taken, which showed

anatomic vertebral body alignment, no congenital or acquired spinal stenosis, no abnormal 

bone marrow signal, a benign focus of increased signal intensity involving the S1 segment 

of the sacrum, normal signal intensity of the conus, and normal appearance of the nerve 

rootlets below the conus. AR 362-63.

On July 22, 2010, an MRI of Plaintiff’s cervical spine was taken. Impressions 

indicated no enhancement of any of the vertebrae to suggest any primary or metastatic bone 

lesions, the vertebral body heights are maintained showing small anterior osteophytes at 

C4-5 through C6-7, no enhancing lesions in the cervical cord or any syrinx, mild 

degenerative disc thinning of C4-5 and age-appropriate disc desiccation of the remaining 

cervical discs, mild right foraminal stenosis secondary to a lateral disc osteophyte complex 

at C4-5, small central and lateral disc bulge without stenosis at C5-6, and a right lateral 

disc bulge plus uncinated spurring, resulting in mild to moderate right foraminal stenosis 

without nerve root compromise at C6-7. AR 360-61.

On February 1, 2012, an MRI was taken of Plaintiff’s cervical spine. The impression 

notes from the MRI report states there was normal signal and overall appearance of the

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cervical vertebrae, stable small anterior osteophytes opposing C4-5 through C6-7, stable 

mild degenerative disc thinning at C4-5 and C6-7, and moderate to moderately severe right 

foraminal stenosis at C6-7 that showed mild interval worsening since July 22, 2010. AR 

470.

A lumbar spine MRI was taken on October 26, 2012. Impressions indicated a 

symmetric disc bulge with bilateral facet anthropathy, resulting in mild bilateral lateral 

recess stenosis and minimal bilateral inferior neural foraminal narrowing. The spinal canal 

and neural foramina were found to be otherwise adequate throughout. AR 599-600.

On January 28, 2013, Plaintiff underwent a full body bone scan. Impressions 

showed an increase in radiopharmaceutical concentration in the cervical spine, right 

shoulder, sacroiliac joints and right knee, commensurate with degenerative arthrosis (joint 

disease). No scintigraphic abnormalities were found with the right hip, and there was also 

no scintigraphic evidence of osseous metastatic disease. AR 549.

On May 31, 2013, electromyography and nerve conduction velocity testing 

(EMG/NCV) was performed of Plaintiff’s right lower extremity. The findings showed that 

all nerve conduction studies were within the normal limits. Impressions from the testing 

showed mild chronic right L4-L5-S1 radiculopathy, and that there was no evidence of any 

other focal nerve entrapment, peripheral neuropathy, myopathy in the right lower limb. 

AR 594. Dr. Jacobo wrote a summary of the EMG and nerve conduction study. He stated 

the study shows mild chronic right L4-L5, L5-S1 radiculopathy without an acute 

component. He found no evidence of a peroneal neuropathy. AR 597.

vii. Dr. Fareed’s RFC Questionnaire

On October 14, 2013, Dr. Fareed completed an RFC questionnaire. He reported 

Plaintiff’s diagnoses as cervical spondylosis (changes in the area of the spine at the back 

of the neck), disc displacement, neuropathy (disorder affecting the nervous system), and 

sciatica (pain or discomfort associated with the sciatic nerve, which runs from the lower 

part of the spinal cord down the back of the leg to the foot). AR 666. Dr. Fareed opined 

that Plaintiff could rarely lift and carry less than 10 pounds and no weight greater than 10 

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pounds; sit for 15 minutes at a time and for about one hour in an eight-hour day; stand or 

walk for 15 minutes at a time and for about one hour in an eight-hour day; needed six to 

seven unscheduled breaks during an eight-hour day; could not use either hand for gross 

handling, grasping, turning, or twisting objects; could finger and reach for half an hour 

during an eight-hour day; and could rarely bend or stoop. AR 666-67. He opined that 

Plaintiff would have difficulty sustaining full time work due to chronic sciatica and a neck 

disc disorder. AR 667. 

c. Plaintiff’s Testimony From The Hearing

The hearing was held via videoconference. Plaintiff appeared at the hearing in El 

Centro, California and the ALJ presided over the hearing from Tucson, Arizona. AR 104. 

An impartial vocational expert, Joy Yoshioka, M.S., also appeared at the hearing. Id.

At the hearing before the ALJ, Plaintiff testified about her work history, which 

included positions as a restaurant owner, a construction supervisor, a cook supervisor, a 

cook, and as a cashier. AR 34-35. She testified she could no longer work as of June 1, 

2009 because she was diagnosed with neuropathy in her feet, legs and hands, and because 

she has sciatic nerves on her right side. AR 33. Upon questioning by her counsel, Plaintiff 

testified she lays down about six to seven times per day due to her medications, cannot 

bend, and can only sometimes grip objects. AR 38-39.

An impartial vocational expert, Joy Yoshioka, also testified at the hearing. The ALJ 

posed a hypothetical as to whether a person could work the jobs Plaintiff previously

performed with the following restrictions: sit six hours of an eight-hour day, stand six hours 

out of an eight-hour day, walk six hours out of an eight-hour day, can occasionally lift and 

carry 20 pounds, frequently lift and carry ten pounds and can occasionally climb stairs, 

never climb ladders, occasionally balance, stoop kneel, crouch and crawl and has limits on 

reach, gross handling and fine fingering and fine feeling. AR 42. Yoshioka opined that 

such a person could perform positions as a bartender, cashier and business owner positions. 

AR 42-43. On cross-examination by Plaintiff’s attorney, Yoshioka opined that if the 

hypothetical individual cannot sit or stand more than 15 minutes in an eight-hour day, 

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cannot lift more than ten pounds frequently or 20 pounds occasionally and needs to lie 

down for 20 minutes every two hours, then that individual could not perform any of the 

past relevant work Plaintiff did. AR 44. She also opined that an individual who cannot 

use fine manipulation more than 15 minutes an hour, who cannot stand more than 20

minutes in an hour and needs to lie down for half an hour every four hours could not

perform any of the past relevant work that Plaintiff did. AR 44-45.

d. The Sequential Evaluation Process

To qualify for disability benefits under the Social Security Act, an applicant must 

show that he or she cannot engage in any substantial gainful activity because of a medically 

determinable physical or mental impairment that has lasted or can be expected to last at 

least 12 months. The Social Security regulations establish a five-step sequential evaluation 

for determining whether an applicant is disabled under this standard. 20 C.F.R. § 

404.1520(a). The Ninth Circuit summarized the five-step sequential process for evaluating 

disability determinations as follows: 

The five-step process for disability determinations begins, at the first and 

second steps, by asking whether a claimant is engaged in ‘substantial gainful 

activity’ and considering the severity of the claimant’s impairments. [] If the 

inquiry continues beyond the second step, the third step asks whether the 

claimant’s impairment or combination of impairments meets or equals a 

listing ... and meets the duration requirement. [] If so, the claimant is 

considered disabled and benefits are awarded, ending the inquiry. See id. If 

the process continues beyond the third step, the fourth and fifth steps consider 

the claimant’s ‘residual functional capacity’ in determining whether the 

claimant can still do past relevant work or make an adjustment to other work.

Kennedy v. Colvin, 738 F.3d 1172, 1175 (9th Cir. 2013) (citations omitted); see also 

Garrison v. Colvin, 759 F.3d 995, 1010-1011 (9th Cir. 2014) (discussing the sequential 

process in greater length); see also Dominguez v. Colvin, 808 F.3d 403 (9th Cir. 2015)

(discussing sequential process under Title XVI). 

e. The ALJ’s Decision

On November 15, 2013, the ALJ issued a written decision. AR 104-15. The ALJ 

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found Plaintiff would need to establish disability by or before June 30, 2014, to be entitled 

to a period of disability and disability insurance benefits. AR 104. The ALJ concluded 

that Plaintiff was not under a disability as defined in the Social Security Act from June 1, 

2009 through the date of the decision. AR 105. 

At step one, the ALJ found Plaintiff has not engaged in substantial gainful activity 

since the alleged onset date of June 1, 2009. AR 106. At step 2, the ALJ found Plaintiff 

has impairments of degenerative disc disease and neuropathy in the hands, which are 

“severe” impairments as defined in the regulations. AR 107. At step 3, the ALJ determined 

Plaintiff’s impairments were not of a severity to meet or medically equal the criteria of 

listed impairments. Id. The ALJ also found Plaintiff has the residual functional capacity 

to “perform light work as defined in 20 C.F.R. 404.1567b and 416.967(b); except, she 

could sit or stand and/or walk for six hours in an eight-hour workday.” The ALJ also found 

that “she could lift and carry twenty pounds occasionally and ten pounds frequently,” and 

that “she could occasionally climb, balance, bend, stoop, kneel, crouch or crawl and 

frequently perform fine and gross manipulations.” Id.

In making these findings, the ALJ did not give treating physician Dr. Fareed’s 

opinion controlling weight. AR 111-12, citing 20 C.F.R. § 404.1527(d), 416.927(d) and 

SSR 96-2p. The ALJ based this decision on a number of reasons. Those reasons included 

that although Dr. Fareed assessed significant limitations in the physical RFC questionnaire, 

his treatment notes did not support such limitations; that Plaintiff’s MRI scan showed her 

mild abnormalities were not worsening over time; that the pain management specialist’s 

examination findings were not consistent with the extensive limitations assessed by Dr. 

Fareed; that in Plaintiff’s follow-up examination with Dr. Fareed she did not complain of 

neck or back pain and her only complaints were gastrointestinal hemorrhage and blood 

clots in her stool; and that Dr. Fareed is a general practice physician who does not specialize 

in any orthopedics, neurology or pain management and thus would not be in the best 

position to assess Plaintiff’s functional limitations. AR 111-12. Thus, the ALJ accorded 

less weight to Dr. Fareed’s opinion. Id.

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The ALJ further noted that in determining Plaintiff’s RFC she considered Plaintiff’s 

allegations of her symptoms and functional limitations. To the extent Plaintiff alleged she 

could not perform work at the RFC capacity stated by the ALJ, the ALJ found Plaintiff’s 

allegations not totally credible as to the intensity, persistence and limiting effects for a 

number of reasons. AR 112-13. The ALJ noted a number of Plaintiff’s activities of daily 

living which do not indicate a disabling level of impairment; that her treatment notes found 

her to be generally active and in satisfactory or normal health and her physical examination 

findings, MRI scans and EMG/NCV studies demonstrated it was not consistent with 

someone experiencing a disabling level of impairment; that no physician ever opined her 

impairments ever met or equaled a listing level limitation; and that her medical record does 

not establish impairments likely to produce disabling pain or other limitations for 12 or 

more continuous months. AR 113.

At step 4, the ALJ found that Plaintiff is capable of performing her past relevant 

work as a bartender, business owner or as a cashier. AR 113. She noted this work does 

not require performing work-related activities precluded by her residual functional 

capacity. Id. The ALJ alternatively found Plaintiff could perform other jobs, which existed 

in significant numbers in the national economy. AR 114-15. The ALJ thus found Plaintiff 

was not under a disability as defined in the Social Security Act from January 1, 2009, 

through the date of her decision on November 15, 2013. AR 115.

III. DISCUSSION

a. Assertion of Error

Plaintiff asserts the ALJ erred because she failed to articulate specific and legitimate 

reasons supported by substantial evidence for rejecting the treating physician’s opinion. 

Dkt. No. 12 at 4. She argues the goal of a treating physician is to treat their patient, and 

not take notes in preparation for litigation, and so the ALJ’s justification for rejecting Dr. 

Fareed’s opinion – which was based in part on grounds that his notes did not show all of 

Plaintiff’s continued complaints – lacks specificity and legitimacy. (Dkt. No. 12 at 7.) She 

also argues the ALJ mischaracterized the 2012 MRI findings as mild. (Id.) She also argues 

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that contrary to the ALJ’s reasoning, the May 17, 2012 examination was abnormal, and 

progress notes from that physician show Plaintiff continues to deteriorate. (Id.) Plaintiff 

also contendsthe ALJ’s argument that Dr. Fareed is not a specialist and thus is not accorded 

to more weight lacks merit as a specific and legitimate reason because there is no other 

functional opinion evidence from other specialists. (Id. at 8.) She also argues the ALJ 

should have requested supplemental testing and examination to the extent the ALJ found 

Dr. Fareed’s treatment notes inconsistent with his opinions. (Id.) Finally, Plaintiff asserts 

that because the ALJ rejected the treating physician’s opinion, all that was left was the nonexamining physician’s opinion, which “cannot by itself” constitute substantial evidence to 

justify rejecting an examining or treating physician’s opinion. (Id. at 9.) Defendant 

disagrees with Plaintiff and contends the ALJ properly evaluated Dr. Fareed’s opinion and 

accorded it little weight because it was inconsistent with his own progress notes, other 

medical evidence of record, and Plaintiff’s own reports. (Dkt. No. 19-1 at 7, 8-12, 15.) 

b. Legal Standard of Review

The Social Security Act provides for judicial review of a final agency decision 

denying a claim for disability benefits. 42 U.S.C. § 405(g). A reviewing court must affirm 

the denial of benefits if the agency’s decision is supported by substantial evidence and 

applies the correct legal standards. Batson v. Comm’r of the Social Security Admin., 359 

F.3d 1190, 1193 (9th Cir. 2004). Substantial evidence means “such relevant evidence as a 

reasonable mind might accept as adequate to support a conclusion.” Osenbrock v. Apfel, 

240 F.3d 1157, 1162 (9th Cir. 2001) (citation omitted). If the evidence is susceptible to 

more than one reasonable interpretation, the agency’s decision must be upheld. Id.; Batson, 

359 F.3d at 1193. Further, when medical reports are inconclusive, questions of credibility 

and resolution of conflicts in the testimony are the exclusive functions of the agency. 

Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989). The reviewing court cannot 

reinterpret or re-evaluate the evidence however much a re-evaluation may reasonably result 

in a favorable outcome for the plaintiff. See Batson, 359 F.3d at 1193.

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c. Whether The ALJ Provided Specific and Legitimate Reasons Supported 

by Substantial Evidence For Rejecting The Treating Physician’s Opinion

A treating physician’s opinion is generally afforded “substantial weight.” Bray v. 

Comm’r of SSA, 554 F.3d 1219, 1228 (9th Cir. 2009). However, “an ALJ need not give 

controlling weight to the opinion of a treating physician. ‘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 1194-95 (citation omitted). “The ALJ may disregard the 

treating physician’s opinion whether or not that opinion is contradicted.” Id., quoting 

Magallanes, 881 F.2d at 751.

If an ALJ rejects a treating physician’s opinion that is contradicted by another doctor, 

he must provide specific, legitimate reasons based on substantial evidence in the record for 

doing so. See Valentine v. Comm’r of Soc. Sec. Admin., 574 F.3d 685, 692 (9th Cir. 2009); 

see also Andrews v. Shalala, 53 F.3d 1035, 1043 (9th Cir. 1995) (an ALJ must give specific, 

legitimate reasons based on substantial evidence for rejecting the opinion of a treating 

physician based in part on the testimony of a non-examining medical advisor); Magallanes, 

881 F.2d at 752-53. The ALJ can meet this burden “by setting out a detailed and thorough 

summary of the facts and conflicting clinical evidence, stating his interpretation thereof, 

and making findings.” Id. at 751-55. Additionally, when confronted with conflicting 

medical opinions, an “ALJ need not accept the opinion of any physician, including a 

treating physician, if that opinion is brief, conclusory, and inadequately supported by 

clinical findings.” Bray, 554 F.3d at 1228 (internal quotation marks and citation omitted)). 

Finally, the “ALJ is the final arbiter with respect to resolving ambiguities in the medical 

evidence.” Tommasetti v. Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008). 

i. Dr. Fareed’s Treatment Notes

First, Plaintiff argues the goal of a treating physician is to treat their patient, and not 

take notes in preparation for litigation. She argues the ALJ’s justification for rejecting Dr. 

Fareed’s opinion, which was based in part on grounds that his notes did not show all of 

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Plaintiff’s continued complaints, therefore lacks specificity and legitimacy. (Dkt. No. 12 

at 7.) Defendant contends that if Plaintiff had continuing severe problems, these should 

have been included in Dr. Fareed’s progress notes and his treatment records should reflect 

her alleged problems and what was done to treat them. (Dkt. No. 19-1 at 12.) In support, 

Defendant argues Dr. Fareed’s January 2013 and May 2013 notes do not contain any 

mention of complaints of neck or back pain or neuropathy, which formed the basis for his 

opinion that Plaintiff had severe limitations. (Id., citing AR 577, 580, 666-67.)

Here, the ALJ’s basis for rejecting Dr. Fareed’s opinion on this ground is not a 

specific and legitimate reason. The Ninth Circuit has explained that “[t]he primary 

function of medical records is to promote communication and record-keeping for health 

care personnel—not to provide evidence for disability determinations.” Orn v. Astrue, 495 

F.3d 625, 634 (9th Cir. 2007). The Ninth Circuit concluded they “therefore do not require 

that a medical condition be mentioned in every report to conclude that a physician’s 

opinion is supported by the record.” Id. Indeed, one of the benefits of having “a stable 

treating relationship is to alleviate the need for the patient to repeat his full litany of 

complaints on each visit to the doctor.” Nelson v. Astrue, 2012 U.S. Dist. LEXIS 48877, 

*26 (D. Or. 2012). 

Additionally, the ALJ’s reasoning failed to consider the January 2013 and May 2013 

treatment notes within the context of the medical record as a whole. Tommasetti, 533 F.3d 

at 1041 (“The ALJ must consider all medical opinion evidence. 20 C.F.R. § 404.1527(b)”); 

see also 20 C.F.R. § 404.1527(c)(4) (in determining how much weight to afford the treating 

physician’s medical opinion, factors include the consistency of the physician’s opinion 

with the record as a whole). Although Dr. Fareed’s January and May 2013 notes do not 

contain indications of Plaintiff’s relevant complaints, the record indicates that it was Dr. 

Fareed who referred Plaintiff to pain management specialist Dr. Stevens for treatment of 

these complaints (AR 506, 609), and that Dr. Stevens’ examination notes throughout 2013

indicate continued complaints and diagnoses pertaining to neck pain, back pain and 

neuropathy, as well as what was done to try to treat them. See e.g., supra, § II.b.v. It is 

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not surprising, then, that Plaintiff would describe these complaints in detail to the pain 

management specialist as opposed to Dr. Fareed. Cf. Ryan v. Comm'r of Soc. Sec., 528 

F.3d 1194, 1200 (9th Cir. 2008) (medical records are not inconsistent when claimant 

described symptoms with more detail to specialist than to general practitioner). 

Accordingly, the ALJ’s reason for discounting Dr. Fareed’s opinion on this basis is not a 

specific and legitimate reason supported by substantial evidence. 

ii. Characterization Of Diagnostic Study Findings

Next, Plaintiff argues the ALJ mischaracterized the 2012 MRI findings as mild. 

(Dkt. No. 12 at 7.) The MRI report states there is “mild right foraminal stenosis” at C4-5, 

and “moderate to moderately severe right foraminal stenosis” at C6-7 that shows “mild 

interval worsening since 7/22/2010.” AR 470. 

Although Plaintiff is correct that the MRI report states there was moderate to 

moderately severe formainal stenosis, the report also states it shows mild interval 

worsening. AR 470. The ALJ acknowledged both these findings of mild and moderate to 

moderately severe stenosis in the opinion (see AR 109), and also noted that the findings 

showed only mild interval worsening since July 22, 2010, which is consistent with the MRI 

report. AR 111. Accordingly, the Court disagrees with Plaintiff’s assertion that the ALJ 

mischaracterized the evidence.

iii. Progress Notes From Pain Management Specialist Dr. Stevens

Next, Plaintiff contends that contrary to the ALJ’s reasoning, the May 17, 2012 

examination by Dr. Stevens was abnormal, and more importantly, that Dr. Stevens’ 

progress notes show Plaintiff continues to deteriorate. Dkt. No. 12 at 7. Defendant 

responds that the ALJ properly characterized Dr. Stevens’ May 17, 2012 findings, and 

states that while Dr. Stevens’ notes do show some reports of limited range of motion and 

positive Spurling’s tests, it does not support the severe limitations Dr. Fareed assessed. 

(Dkt. No. 19-1 at 13.) As explained below, the Court concludes the ALJ appropriately 

recounted Dr. Stevens’ May 17, 2012 findings, but the ALJ’s reasoning for rejecting Dr. 

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Fareed’s opinion based on Dr. Stevens’ findings did not account for the entire diagnostic 

picture presented by the rest of Dr. Stevens’ findings from late 2012 through 2013. 

As to the May 17, 2012 examination notes, Plaintiff contends they contain positive

indications for joint pain, joint swelling, and neck pain. (Dkt. No. 12 at 7, citing AR 506.) 

These issues, however, are listed the Review of Systems section of the notes, which 

inventories the patient’s subjective complaints and not the physician’s findings. (See AR 

506.) The ALJ properly described Dr. Steven’s May 17, 2012 physical examination 

findings as having a normal heel and toe walk; normal and full forward flexion and left and 

right lateral flexion; a negative straight raise bilaterally; 5/5 strength in the bilateral upper 

extremities and a full range of motion of her bilateral upper extremities. (See AR 111-12; 

506-07.) The ALJ’s recounting of the May 17, 2012 examination findings was therefore

not in error.

However, the ALJ’s reasoning in relying on Dr. Stevens’ findings as being 

inconsistent with Dr. Fareed’s functional opinion does not reconcile with the entire 

diagnostic picture presented by Dr. Stevens’ notes. See Tommasetti, 533 F.3d at 1041 

(“The ALJ must consider all medical opinion evidence. 20 C.F.R. § 404.1527(b)”); see 

also 20 C.F.R. § 404.1527(c)(4). Indeed, although the ALJ justified her reasoning on the 

ground that Dr. Fareed’s functional opinion was not consistent with Dr. Stevens’ findings, 

the ALJ did not mention any of Dr. Stevens’ extensive examination findings from 

November 2012, December 2012, January 2013, February 2013, April 2013, May 2013, 

June 2013 and August 2013. See supra, § II.b.v. Dr. Stevens’ notes from October 2012 

through August of 2013 contain complaints by Plaintiff of pain in her neck and back, as 

well as her upper and lower extremities. Those documents also contain examination 

findings that include spondylosis, chronic pain syndrome, radiculitis, degenerative disc 

disease, and stenosis. See id. Thus, the ALJ’s reason for discounting Dr. Fareed’s opinion 

on this basis is not supported by substantial evidence. 

iv. The Factor That Treating Physician Dr. Fareed Is Not A Specialist

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Plaintiff next contends the ALJ’s reasoning that Dr. Fareed is not a specialist and 

therefore his opinion is not accorded to more weight lacks merit because there is no other 

functional opinion evidence in the record from other specialists. (Dkt. No. 12 at 8.) 

Defendant contends the ALJ properly considered Dr. Fareed’s lack of specialization in 

conjunction with the lack of consistency in his progress notes and other evidence, to 

conclude that it weighed against affording his opinion greater weight. (Dkt. No. 19-1.)

By regulation, the Commissioner “generally give[s] more weight to the opinion of a 

specialist about medical issues related to his or her area of specialty than to the opinion of 

a source who is not a specialist.” 20 C.F.R. § 404.1527(c)(5). The Court interprets this

regulation as evaluating the factor of whether or not the physician is a specialist in the area 

upon which the opinion is rendered. The Court does not read into the regulation a 

requirement that other opinions from specialists must be in evidence to compare and afford 

lesser weight to the source who is not a specialist. See e.g., Garcia v. Colvin, 2014 U.S. 

Dist. LEXIS 607, *16 (E.D. Wash. Jan. 3, 2014) (where ALJ factored into evaluation that 

the treating physician was not a specialist, the court concluded that “[w]hile this fact alone 

is not a reason to reject his assessment, it is true that more weight generally is given to the 

opinion of a specialist about issues within that specialist's area of expertise than to the 

opinion of a source who is not a specialist,” and that “is certainly a factor that the ALJ 

could properly consider in affording less weight to that portion of his opinion.”) (citing 20 

C.F.R. § 404.1527(c)(5)). As such, the ALJ properly considered this factor in her analysis 

of what weight to assign to Dr. Fareed’s opinion.

v. Failure To Order A Consultive Examination

Plaintiff also argues the ALJ should have requested supplemental testing and 

examination to the extent the ALJ found Dr. Fareed’s treatment notes inconsistent with his 

opinions. (Dkt. No. 12 at 8.) Defendant contends the ALJ was not under a duty to order a 

consultive examination under the circumstances presented by this case. (Dkt. No. 19-1.)

The Commissioner has broad latitude in whether to order a consultive examination. 

Reed v. Massanari, 270 F.3d 838, 842 (9th Cir. 2001). “Ambiguous evidence, or the ALJ’s 

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own finding that the record is inadequate to allow for proper evaluation of the evidence, 

triggers the ALJ’s duty to ‘conduct an appropriate inquiry.’” Tonapetyan v. Halter, 242 

F.3d 1144, 1150 (9th Cir. 2001) quoting Smolen, 80 F.3d at 1288. 

The Court agrees with Defendant that the ALJ’s disagreement with Dr. Fareed’s 

opinion does not require ordering a consultive examination. In this case, the ALJ found 

inconsistencies between Dr. Fareed’s opinion in his questionnaire and his progress notes 

and other treatment notes. AR 111. Contrary to Plaintiff’s contention, inconsistency does 

not equate to ambiguity. Thus, although the ALJ found inconsistencies between Dr. 

Fareed’s treatment notes and his opinion, this does not mean that the evidence in the record 

was ambiguous or that the record was inadequate to allow for proper evaluation. 

Furthermore, the record itself was neither ambiguous nor inadequate, and thus no duty was 

triggered to order a further consultive examination. Accordingly, the ALJ did not err by 

failing to order a consultive examination. 

vi. Non-Examining Physician’s Opinion

Lastly, Plaintiff asserts that because the ALJ rejected the treating physician’s 

opinion, all that was left was the non-examining physician’s opinion, which “cannot by 

itself” constitute substantial evidence to justify rejecting an examining or treating 

physician’s opinion. (Id. at 9.) Defendant contends that the opinion of a non-examining 

physician may serve as substantial evidence where it is consistent with and supported by 

other evidence in the record. (Dkt. No. 19-1 at 14.)

“The opinion of a nonexamining physician cannot by itself constitute substantial 

evidence that justifies the rejection of the opinion of either an examining physician or a 

treating physician.” Lester v. Chater, 81 F.3d 821, 831 (9th Cir. 1995). A Commissioner’s 

decision to reject the opinion of a treating or examining physician, however, may be upheld 

where it is based in part on the testimony of a nonexamining medical advisor. Id. (citing 

e.g. Magallanes, 881 F.2d at 751-55; Andrews, 53 F.3d at 1043; Roberts v. Shalala, 66 

F.3d 179 (9th Cir. 1995)). Where the ALJ does not rely on a nonexamining physician’s 

testimony alone to reject the treating physician’s opinions, but rather also relies on an 

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abundance of other evidence in the record to also support the ALJ’s decision, the rejection 

of the treating physician’s opinion is adequately supported. See id.

Here, the ALJ’s decision to not assign controlling weight to Dr. Fareed’s opinion 

was based only in part on the non-examining medical advisor’s opinion. The ALJ did not 

rely on the non-examining advisor’s opinion alone as to Plaintiff’s RFC; rather, the ALJ 

also cited numerous other evidence in the record, such as diagnostic studies and the 

conflicting testimony from Plaintiff, to support the decision. As such, this argument by 

itself does not justify reversal. 

However, as stated in the earlier portions of the Court’s discussion regarding the 

ALJ’s decision, some of the reasons the ALJ gave for discounting Dr. Fareed’s testimony 

based on other evidence is not adequately supported by the record. Accordingly, this Court 

concludes that the ALJ’s denial of benefits is not supported by substantial evidence. 

IV. REMEDY

“When an ALJ’s denial of benefits is not supported by the record, ‘the proper course, 

except in rare circumstances, is to remand to the agency for additional investigation or 

explanation.’” Hill v. Astrue, 698 F.3d 1153, 1162 (9th Cir. 2012) (citation omitted). The 

court may exercise its discretion and direct an award of benefits “where no useful purpose 

would be served by further administrative proceedings and the record has been thoroughly 

developed.” Id. (citation omitted). “Remand for further proceedings is appropriate where 

there are outstanding issues that must be resolved before a determination can be made, and 

it is not clear from the record that the ALJ would be required to find the claimant disabled 

if all the evidence were properly evaluated.” Id. (citations omitted). 

In this case, the Court finds that remand is appropriate because outstanding issues 

must be resolved before a determination can be made. In particular, on remand, the ALJ 

should provide due consideration to Dr. Fareed’s findings and opinions in light of the 

evidence from Dr. Stevens’ examination notes and findings that span from October 2012 

and forward. See AR 601-665.

/

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V. CONCLUSION

Accordingly, the Court RECOMMENDS that Plaintiff’s motion for summary 

judgment be GRANTED and the case REMANDED for further administrative 

proceedings, and that Defendant’s cross motion for summary judgment be DENIED. 

This Report and Recommendation is submitted to the United States district judge 

assigned to this case pursuant to 28 U.S.C. § 636(b)(1). Any party may file written 

objections with the court and serve a copy on all parties on or before February 1, 2016. 

The document should be captioned “Objections to Report and Recommendation.” Any 

response to the objections shall be filed and served on or before February 8, 2016. The 

parties are advised that any failure to file objections within the specified time may waive 

the right to raise those objections on appeal of the Court’s order. Baxter v. Sullivan, 923 

F.2d 1391, 1394 (9th Cir. 1991).

IT IS SO ORDERED.

Dated: January 15, 2016

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