Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_12-cv-00730/USCOURTS-azd-4_12-cv-00730-0/pdf.json

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

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UNITED STATES DISTRICT COURT 

DISTRICT OF ARIZONA 

Robert Moreno Garcia, 

 Plaintiff, 

vs. 

Carolyn W. Colvin, Commissioner of the

Social Security Administration, 

 Defendant. 

CV 12-0730-TUC-DCB (JR) 

REPORT AND 

RECOMMENDATION 

 

 Plaintiff Robert Moreno Garcia brought this action pursuant to 42 U.S.C. § 

405(g) seeking judicial review of a final decision by the Commissioner of Social 

Security denying his claim for disability insurance benefits (“DIB”) under Title II of 

the Social Security Act, 42 U.S.C. §§ 401-433. Plaintiff presents three issues on 

appeal: (1) whether the Administrative Law Judge (“ALJ”) properly evaluated the 

medical opinions; (2) whether the ALJ properly evaluated Plaintiff’s credibility; (3) 

and whether this case should be remanded for benefits or further proceedings. 

Pending before the court is an Opening Brief filed by Plaintiff (Doc. 20), the 

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Commissioner’s Opposition (Doc. 23), and Plaintiff’s Reply Brief (Doc. 24). Based 

on the pleadings and the administrative record submitted to the Court, the Magistrate 

Judge recommends that the District Court, after its independent review, affirm the 

decision of the ALJ. 

I. PROCEDURAL HISTORY 

 Plaintiff filed an application for disability insurance benefits on February 1, 

2010, alleging disability since September 1, 2009. (Administrative Record (AR) 11.) 

The Social Security Administration denied Plaintiff’s application for DIB initially 

and upon reconsideration. (Id.) Plaintiff requested a hearing before an ALJ. (AR 

89.) A hearing was held on July 5, 2011. (AR 23-39.) In a decision issued on July 

22, 2011, the ALJ concluded that Plaintiff was not disabled within the meaning of the 

SSA. (AR 11-21.) The Appeals Council denied Plaintiff’s request for review of the 

ALJ’s decision. (AR 1-5.) This appeal followed. 

II. FACTUAL HISTORY 

 A. Plaintiff’s Background 

Plaintiff claimed to be disabled beginning September 1, 2009. (AR 11.) He 

was 56 years old on the date of his application and 58 years old on the date of the 

decision. (AR 17.) Plaintiff reported he previously worked as a bookkeeper at two 

different companies and as a counter clerk at a convenience store. (AR 112-16.) He 

alleged he was disabled due to epilepsy. 

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B. Medical Records 

 On October 23, 2009, Plaintiff was enrolled in a clinical trial for refractory 

partial seizures. (AR 179.) In an office record dated that same day, David J. Teeple, 

M.D., the doctor in charge of the trial, reported Plaintiff’s subjective medical 

background and noted that Plaintiff reported having seizures from the age of 13 or 

14. The seizures were described as three different types. The first was characterized 

by speech arrest and occured once a week for 2-3 minutes. The second was 

characterized by “lost time,” and although he was not certain, Plaintiff suspected 

these seizures last from 2-5 minutes. Plaintiff reported the last seizure of this type 

happened about two weeks prior. The third type of seizure was described as general 

tonic-clonic seizures that had not happened in many years. His current medications 

were reported as Carbamazepine and Phenytoin. (AR 157.) In his assessment, Dr. 

Teeple suspected “localization-related epilepsy, although there are some features of 

his seizures that are suggestive of a primary generalized epilepsy (lack of postictal 

manifestations, age of onset).” (AR 158.) The doctor recommended further 

screening and an MRI. (AR 159.) 

 The findings in an MRI head scan report dated November 25, 2009, were 

reported as follows: 

There is no evidence of an intracranial mass or hydrocephalus. No 

definite seizure foci are seen. There are a few scatter foci of increased 

T2 signal intensity in the white matter of both cerebral hemispheres 

most likely angiopathic given the patient’s age. No abnormal contrast 

enhancement seen. 

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(AR 161.) An electroencephalographic examination (“EEG”) the same day was 

reported as abnormal due to focal slowing in the left temporal region, which was 

reported as “likely secondary to observed epileptiform discharges, but would 

correlate with imaging to exclude structural abnormality.” The EEG also showed 

frequent left temporal epileptiform discharges consistent with a focal epilepsy. (AR 

162.) 

 On April 24, 2010, at the request of the ALJ, Plaintiff was seen by James Rau, 

Ph.D. (AR 163-170.) Plaintiff reported to having weekly seizures for the past year. 

He described the seizures as typically “rather light” and causing him to “pause 

momentarily.” (AR 164.) Plaintiff reported that he had difficulty remembering 

names “at times,” but that he remembered day-to-day events and conversations, his 

concentration was “fine,” and he slurred his speech less when he was on 

anticonvulsant medication. (AR 164.) Plaintiff reported that he socialized with his 

brothers and sisters weekly and described managing his activities of daily living 

without any difficulty. (AR 165.) 

 Dr. Rau’s intellectual functioning tests showed that Plaintiff functioned 

overall in the “average” range, but indicated a “left hemisphere inefficiency.” (AR 

166.) Dr. Rau noted that Plaintiff did well in his job at Circle K and “doing 

reasonably well neurocognitively.” (AR 167.) Dr. Rau diagnosed a cognitive 

disorder, but stated: 

 that overall his deficits are quite mild and he is not showing any 

uniform impairment nor any uniform borderline deficit functioning 

either, so he is quite fortunate. 

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(AR 167-168.) Dr. Rau indicated that he did not feel the cognitive disorder would 

impose any limitations for 12 months. (AR 169.) 

 On May 4, 2010, Dr. Teeple reported in a study record that Plaintiff reported 

that he was having approximately 2-3 simple partial seizures per month which were 

characterized by an arrest of speech. Dr. Teeple reported that throughout the clinical 

trial, labs and ECGs, Plaintiff was within normal limits. He also reported some 

short-term memory impairment and non-fluent aphasia, which caused difficulty in 

word-finding and naming and caused Plaintiff’s speech to be “choppy, interrupted, 

and awkwardly articulated.” During the course of the study, Plaintiff was removed 

from Dilantin and Carbamazepine and placed on “a stable dose of lacosamide.” (AR 

179.) 

 In another record from June 8, 2011, Dr. Teeple noted that Plaintiff’s “simple 

partial seizures have increased in frequency” from 2-3 times per month to 9-10 per 

month. Plaintiff also reported an increase in complex partial seizures, which 

involved grimacing, right arm posturing, head movements, and eye deviation. The 

seizures were accompanied by a loss of awareness and frequently followed by several 

hours of lethargy. (AR 178.) 

 Later in June 2011, Dr. Teeple completed a Seizure Questionnaire for Treating 

Physicians, wherein he noted that Plaintiff’s seizures occurred on average twice 

weekly, but recently had increased to 9-10 times per month. He indicated that 

Plaintiff had one to four hours of lethargy after a seizure, which included fatigue, 

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weakness, sleepiness, depression, anxiety, and anger. Dr. Teeple stated that Plaintiff 

could not drive at all and that he would be absent from work for six to eight days per 

month due to seizures. 

C. Hearing Testimony 

 1. Plaintiff’s Testimony

 At the July 5, 2011, hearing, Plaintiff was represented by counsel and testified 

that he was unmarried and had no children and had a bachelor’s degree in forestry 

and political science. (AR 26-27.) He lives with his sister and her son at his sister’s 

house. His sister drove him to the hearing and although he has a driver’s license, he 

uses it only for identification. (AR 27.) His only income is $200 month in food 

stamps. (AR 28.) 

 He last worked in June or July 2009 as a clerk at Circle K. He left that job 

after suffering a seizure. A customer called 911 and although he had recuperated by 

the time paramedics arrived, his manager began watching him closely and eventually 

fired him because “in their interpretation because of my minor seizures or heavy 

seizures I had been violating safety rules.” (AR 28.) He subsequently sought other 

employment, but could not find anything. Before working at Circle K, Plaintiff 

worked as a bookkeeper for two companies, one of which he partly owned. (AR 29-

30.) That worked required him to work on a computer. (AR 30.) 

 When asked why he could no longer work as a bookkeeper, Plaintiff explained 

that he had a problem with seizures that can occur four or five times per week and 

leave him feeling “almost like coming out of a coma . . . .” (AR 31.) The seizures 

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began when he was in high school. (AR 35.) He explains that he is unable to 

determine precisely how many seizures he has because he has no idea when it is 

happening. (AR 32.) He indicated that he had lost several teeth in seizure-related 

falls (id.), and that the seizures caused muscle cramps and fatigue. (AR 37.) 

 When asked why there were no treatment notes, the Plaintiff and his counsel 

explained that the Plaintiff was participating in a study program through the 

neuroscience center. The study involved a proprietary drug (Lacosamide) and 

treatment notes were unavailable because it was a testing program. (AR 34.) 

Plaintiff stated that he had previously been on Dilantin and Carbamazepine. (AR 34-

35.) 

 D. ALJ’s Decision 

 The ALJ found that Plaintiff had severe impairment of epilepsy. (AR 13.) 

The ALJ found that the Plaintiff had the RFC to perform a full range of work at all 

exertional levels, but was limited to simple and unskilled jobs. (AR 13.) The ALJ 

then found that “considering the [Plaintiff’s] age, education, work experience, and 

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

national economy that the [Plaintiff] can perform.” (AR 17.) The ALJ therefore 

concluded that the Plaintiff was not disabled. (AR 18.) 

III. STANDARD OF REVIEW 

 For purposes of Social Security benefits determinations, a disability is defined 

as: 

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The inability to do any substantial gainful activity by reason of any 

medically determinable physical or mental impairment which can be 

expected to result in death or which has lasted or can be expected to 

last for a continuous period of not less than 12 months. 

20 C.F.R. § 404.1505. 

 Whether a claimant is disabled is determined using a five-step evaluation 

process. It is claimant’s burden to show (1) he has not worked since the alleged 

disability onset date, (2) he has a severe physical or mental impairment, and (3) the 

impairment meets or equals a listed impairment or (4) his residual functional capacity 

(“RFC”) precludes him from doing his past work. If at any step the Commission 

determines that a claimant is or is not disabled, the inquiry ends. If the claimant 

satisfies his burden though step four, the burden shifts to the Commissioner to show 

at step five that the claimant has the RFC to perform other work that exists in 

substantial numbers in the national economy. See 20 C.F.R. § 404.1520(a)(4)(i)-(v). 

 In this case, Plaintiff was denied at step five of the evaluation process. The 

step five determination is made on the basis of four factors: the claimant’s RFC, age, 

education, and work experience. Hoopai v. Astrue, 499 F.3d 1071, 1074 (9th

Cir.2007). The Commissioner can meet his burden at Step Five “through the 

testimony of a vocational expert or by reference to the Medical Vocation 

Guidelines.” Thomas v. Barnhart, 278 F.3d 947, 955 (9th Cir.2002); 20 C.F.R. pt. 

404, subpt. P, app.2 (the “grids”). 

 The ALJ’s decision to deny disability benefits will be vacated “only if it is not 

supported by substantial evidence or is based on legal error.” Robbins v. Soc. Sec. 

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Admin., 466 F.3d 880, 882 (9th Cir.2006). “’Substantial evidence’ means more than a 

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

reasonable mind might accept as adequate to support a conclusion.” Id. Substantial 

evidence is “such relevant evidence as a reasonable mind might accept as adequate to 

support a conclusion.” Sandgathe v. Chater, 108 F.3d 978, 980 (9th Cir.1997). In 

evaluating whether the decision is supported by substantial evidence, the Court must 

consider the record as a whole, weighing both the evidence that supports the decision 

and the evidence that detracts from it. Reddick v. Chater, 157 F.3d 715, 720 (9th

Cir.1998); see 42 U.S.C. § 405(g) (“findings of the Commissioner of Social Security 

as to any fact, if supported by substantial evidence, shall be conclusive”). If there is 

sufficient evidence to support the Commissioner’s determination, the Court cannot 

substitute its own determination. See Young v. Sullivan, 911 F.2d 180, 184 (9th

Cir.1990). 

IV. DISCUSSION 

A. Evaluation of Dr. Teeple’s Opinions 

 “The ALJ must consider all medical opinion evidence.” Tommasetti v. Astrue, 

533 F.3d 1035, 1041 (9th Cri.2008); see 20 C.F.R. § 404.1527(d); SSR 96-5p, 1996 

WL 374183, at *2 (July 2, 1996). “[T]he ALJ may only reject a treating or 

examining physician’s uncontradicted medical opinion based on ‘clear and 

convincing’ reasons.” Carmickle v. Comm’r Soc. Sec. Admin., 533 F.3d 1155, 1164 

(9th Cir.2008) (citing Lester v. Chater, 81 F.3d 821, 830-31 (9th Cir.1995)). Where a 

treating physician’s opinion is contradicted, it may be rejected for specific and 

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legitimate reasons that are supported by substantial evidence in the record. 

Carmickle, 533 F.3d at 1164 (citing Murray v. Heckler, 722 F.2d 499, 502 (9th

Cir.1983)). “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.” Thomas v. Barnhart, 278 F.3d 947, 957 (9th

Cir.2002). “The opinions of non-treating or non-examining physicians may also 

serve as substantial evidence when the opinions are consistent with independent 

clinical findings or other evidence in the record.” Id. 

 In his decision, the ALJ provided legitimate reasons supported by the record 

for refusing to give Dr. Teeples’ opinion controlling weight. The ALJ first 

thoroughly summarized Dr. Teeples’ brief records and Dr. Rau’s examination report. 

(AR 14-15.) The ALJ then proceeded to note that Dr. Teeple furnished little 

documentation of the medication administered to the study group and no treatment 

records that would support a finding of disability. Plaintiff does not dispute that 

there were no medical records, but blames that fact on the inability of Dr. Teeples to 

provide the records because they are “proprietary.” This lack of records is a 

sufficient basis for the ALJ to reject Dr. Teeples’ medical opinion because it is 

“unsupported by the record as a whole.” Batson v. Comm'r of the Soc. Sec. Admin., 

359 F.3d 1190, 1195 (9th Cir. 2003). 

 Additionally, no medical provider has indicated seeing Plaintiff have a seizure 

and the clinical studies performed show either no evidence of seizure (MRI) or only 

contain limited indications (EEG). Thus, the ALJ properly discounted Dr. Teeples’ 

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records because they were largely premised on Plaintiff’s self-reports of seizures and 

were not supported by objective evidence. Meanel v. Apfel ̧172 F.3d 1111, 1113-14 

(9th Cir. 1999); Lester, 81 F.3d at 831; see also Morgan v. Comm'r of Soc. Sec. 

Admin., 169 F.3d 595, 602 (9th Cir. 1999) (when physician's opinion of disability 

premised “to a large extent” upon claimant's own accounts of symptoms, limitations 

may be disregarded if complaints have been “properly discounted”). 

 The ALJ also properly discounted Dr. Teeples’ opinions by relying on the 

examination records of Dr. Rau. Dr. Rau concluded that “overall [Plaintiff’s] deficits 

are quite mild and he is not showing any uniform impairment nor any uniform 

borderline deficit functioning either, so he is quite fortunate.” (AR 167-168.) This 

statement constitutes the sort of specific and legitimate reason supported by 

substantial evidence that would allow the ALJ to reject the opinion of a treating 

physician. Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th Cir. 2005); Tonapetyan v. 

Halter, 242 F.3d 1144, 1149 (9th Cir. 2001) (ALJ can favor opinion conflicting with 

that of a treating physician where treating physician’s opinion is conclusory, brief, 

and unsupported by clinical findings). 

B. Plaintiff’s Credibility 

 The Plaintiff criticizes the ALJ for discrediting his testimony by relying on 

“the numerous activities he performs on a regular basis.” Opening Brief, p. 5. In the 

Decision, the ALJ noted that the Plaintiff reported walking daily for forty or fortyfive minutes, sitting in a public park, doing household chores, and actively 

volunteering. The ALJ found these activities inconsistent with total disability. (AR 

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16.) Contrary to Plaintiff’s assertion, this was entirely appropriate. See Morgan v. 

Commissioner, 169 F.3d 595, 600 (9th Cir. 1999) (ability “to spend a substantial part 

of his day engaged in pursuits involving the performance of physical functions that 

are transferable to a work setting” can be used to discredit a plaintiff). 

 The adverse credibility finding is also supported by the ALJ’s evaluation of 

the medical record. Assessing a plaintiff's testimony regarding the severity of his 

impairments depends on the medical evidence. See Chaudhry v. Astrue, 688 F.3d 

661, 670 (9th Cir.2012) (“Because the RFC determination must take into account the 

claimant's testimony regarding his capability, the ALJ must assess that testimony in 

conjunction with the medical evidence.”). As discussed above, the medical evidence 

supported the ALJ’s refusal to find Plaintiff disabled based on Dr. Teeple’s records. 

That same evaluation applies to the evaluation of Plaintiff’s testimony. Considered 

in tandem, the ALJ’s findings that Plaintiff’s activities of daily living and the lack of 

objective medical evidence of disability undermined his credibility are clear and 

convincing because they were supported by “findings sufficiently specific to permit 

the court to conclude that the ALJ did not arbitrarily discredit [the Plaintiff’s] 

testimony.” Thomas v. Barnhart, 278 F.3d 947, 958 (9th Cir. 2002) (citations 

omitted). As such, the ALJ properly discounted Plaintiff’s subjective complaints. 

V. RECOMMENDATION

 For the foregoing reasons, the Magistrate Judge recommends the District 

Court, after its independent review, enter an order affirming the decision of the 

Commissioner and denying benefits. 

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 This Recommendation is not an order that is immediately appealable to the 

Ninth Circuit Court of Appeals. Any notice of appeal pursuant to Rule 4(a)(1), 

Federal Rules of Appellate Procedure, should not be filed until entry of the District 

Court’s judgment. 

 However, the parties shall have fourteen (14) days from the date of service of 

a copy of this recommendation within which to file specific written objections with 

the District Court. See 28 U.S.C. § 636(b)(1) and Rules 72(b), 6(a) and 6(e) of the 

Federal Rules of Civil Procedure. Thereafter, the parties have fourteen (14) days 

within which to file a response to the objections. If any objections are filed, this 

action should be designated case number: CV 12-730-TUC-DCB. Failure to timely 

file objections to any factual or legal determination of the Magistrate Judge may be 

considered a waiver of a party’s right to de novo consideration of the issues. See 

United States v. Reyna-Tapia, 328 F.3d 1114, 1121 (9th Cir.2003)(en banc). 

 Dated this 25th day of July, 2013. 

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