Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_13-cv-01573/USCOURTS-azd-2_13-cv-01573-0/pdf.json

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

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WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Todd Gill, 

Plaintiff, 

v. 

Carolyn W. Colvin, 

Defendant.

No. CV-13-01573-PHX-BSB

ORDER 

 Todd Gill (Plaintiff) seeks judicial review of the final decision of the 

Commissioner of Social Security (the Commissioner) denying his application for 

disability insurance benefits under the Social Security Act (the Act). The parties have 

consented to proceed before a United States Magistrate Judge pursuant to 28 

U.S.C. § 636(b) and have filed briefs in accordance with Local Rule of Civil Procedure 

16.1. For the following reasons, the Court reverses the Commissioner’s decision and 

remands for further proceedings. 

I. Procedural Background 

 On March 23, 2010, Plaintiff applied for disability insurance benefits and 

supplemental security income under Titles II and XVI of the Act. (Tr. 12.)1

 Plaintiff 

alleged that he had been disabled since October 1, 2009. (Id.) Plaintiff later amended the 

alleged disability onset date to April 14, 2010. (Tr. 295.) After the Social Security 

 

1

 Citations to “Tr.” are to the certified administrative transcript of record. (Doc. 14.) 

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Administration (SSA) denied Plaintiff’s initial application and his request for 

reconsideration, he requested a hearing before an administrative law judge (ALJ). After 

conducting a hearing, the ALJ issued a decision finding Plaintiff not disabled under the 

Act. (Tr. 12-24.) This decision became the final decision of the Commissioner when the 

Social Security Administration Appeals Council denied Plaintiff’s request for review. 

(Tr. 1-4); see 20 C.F.R. § 404.981 (explaining the effect of a disposition by the Appeals 

Council.) Plaintiff now seeks judicial review of this decision pursuant to 

42 U.S.C. § 405(g). 

II. Medical Record 

 The record before the Court establishes the following history of diagnosis and 

treatment related to Plaintiff’s health. The record also includes opinions from State 

Agency Physicians who examined Plaintiff or reviewed the records related to his health, 

but who did not provide treatment. 

A. Medical Treatment 

 Before the April 2010 amended disability onset date, Plaintiff saw Afeworki 

Kidane, M.D., for diabetes, back pain, anxiety, and medication refills. (Tr. 316-25, 456-

58.) Dr. Kidane diagnosed Plaintiff with back pain, high blood pressure, diabetes, 

obesity, voice hoarseness, and noted generalized anxiety disorder. (Tr. 336, 402, 405, 

408, 411, 414, 417, 419, 423, 432, 435, 438, 441, 444, 447, 450.) Plaintiff saw 

Dr. Kidane periodically during 2010 and 2011 with the same complaints (but mainly back 

pain), and for medication refills. (Tr. 384-455 (Dr. Kidane’s treatment records from June 

2010 to November 2011).) Dr. Kidane reported that examinations typically showed a 

“limited active ROM (range of motion),” full strength in Plaintiff’s legs, and intact 

reflexes and sensation. (Tr. 384-455.) A December 2010 x-ray of Plaintiff’s back 

showed “minimal degenerative changes of the lower lumbar spine.” (Tr. 371.) A 

February 2012 x-ray of his back showed the same findings. (Tr. 562.) 

 In October 2010, as part of a term of probation, Plaintiff started mandatory 

substance abuse treatment at Lifewell Behavioral Wellness. (Tr. 492.) In an initial selfCase 2:13-cv-01573-BSB Document 18 Filed 05/15/14 Page 2 of 12
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report, Plaintiff stated that he could do all activities of daily living (Tr. 342), that he 

wanted “to get back to dealing antiques” (Tr. 345), and that he wanted to “either get 

social security or start a business.” (Tr. 352.) A mental status examination showed that 

Plaintiff was talkative, slightly sluggish and anxious, displayed appropriate thought 

content, was optimistic, oriented times four (person, place, time, situation), able to recall 

three objects immediately and after three minutes, had limited judgment and impulse 

control, and displayed poor insight. (Tr. 357-58.) Therapists diagnosed Plaintiff with 

opioid dependence. (Tr. 359-60.) Plaintiff participated in approximately ten group 

therapy sessions for his substance abuse between November 2010 and February 2011. 

(Tr. 493-548.) Plaintiff missed many scheduled therapy sessions. (Tr. 493, 496, 499, 

502, 503, 504, 508, 513, 516, 517-21, 534, 542, 543-48.) In April 2011, therapists closed 

Plaintiff’s case due to lack of contact. (Tr. 492.) Plaintiff also received treatment for 

physical and mental complaints at Correctional Health Services while incarcerated in the 

Arizona Department of Corrections. (Tr. 302-13, 550-61, 563-70.) 

B. Medical Opinion evidence 

 In December 2010, Paul Drinkwater, M.D., performed a consultative physical 

examination of Plaintiff. On examination, Dr. Drinkwater noted an active range of 

motion in Plaintiff’s lumbar spine, and no tenderness, tightness, muscle spasms or 

scoliosis. (Tr. 365.) He noted that Plaintiff was negative for fibromyalgia tender points. 

(Id.) Dr. Drinkwater further found that Plaintiff could tandem walk, heel walk, toe walk, 

stand on one leg and then the other, and get on and off the examination table without 

difficulty. (Tr. 364.) He also noted that Plaintiff had normal muscle tone, bulk, and 

strength in his lower extremities, and had a functional range of motion in his hips, knees, 

and ankles. (Tr. 366.) 

 Dr. Drinkwater noted that Plaintiff reported fibromyalgia, but there were no 

records documenting that diagnosis and his findings on examination were inconsistent 

with a fibromyalgia diagnosis. (Id.) Dr. Drinkwater diagnosed diabetes in “questionable 

control,” high blood pressure under control, and “nonspecific back problems with a slight 

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decrease in range” of motion. (Id.) Dr. Drinkwater opined that Plaintiff could lift and/or 

carry up to twenty pounds occasionally and up to ten pounds frequently, and stand and/or 

walk six to eight hours in an eight-hour workday. (Tr. 367.) He also found that Plaintiff 

could frequently reach, handle, finger, feel, and climb ramps and stairs; occasionally 

stoop, kneel, and climb ladders; should never crouch, crawl, or climb ropes and scaffolds; 

and should avoid working around heights, chemicals, dust, fumes, and gases. (Tr. 366-

67.) 

 Also in December 2010, Marcel Van Eerd, Psy.D., performed a psychological 

evaluation of Plaintiff. (Tr.392.) Plaintiff reported to Dr. Van Eerd that he watched 

television, managed his hygiene, shopped, paid bills, and read. (Tr. 373.) Plaintiff also 

reported a history of cannabis, cocaine, and opiate use and reported that he was on 

probation requiring drug and mental health treatment at the time of the evaluation. 

(Tr. 374.) Dr. Van Eerd noted that Plaintiff scored 26/30 on a mini mental status 

examination. He also noted that Plaintiff was skilled at social functioning, appeared 

manipulative at times, showed fair cooperation and adequate willingness to participate, 

but was also avoidant at times, displayed a worried and tearful expression, had fair 

organization of thought content, had poor credibility due to an exaggeration of 

difficulties, was hyper-vigilant, had low energy, a depressive mood, and a slow pace. 

(Tr. 375.) 

 Dr. Van Eerd diagnosed polysubstance dependence and mood disorder, and noted 

that Plaintiff’s abilities were limited by reduced attention, concentration, motivation, and 

effort. (Tr. 375.) Dr. Van Eerd completed a psychological/psychiatric medical source 

statement opining that Plaintiff had: (1) mild limitations in understanding and 

remembering simple work-like instructions; (2) “moderate limitation in sustaining 

routines with slowed pace [and] difficulty managing supervision indicating a fair ability 

to make work decisions and fair management of stress”; (3) “mild limitations in 

interacting with others with adequate one to one behavior [and a] fair ability to manage 

critique and follow work rules”; and (4) “mild limitations in managing new information 

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[and being] able to recognize and respond to normal hazards with an adequate ability to 

follow up with goals and plans independently.” (Tr. 376). 

 Later that month, state agency psychologist Rosalia Pereyra, Psy.D., reviewed the 

medical records and opined that Plaintiff had non-severe mental limitations, meaning 

they did not significantly affect his ability to perform work-related activities. (Tr. 88-89.) 

 In January 2011, state agency physician Vicki Kalen, M.D., reviewed the medical 

records and opined that Plaintiff could perform the equivalent of a range of medium work 

with some additional postural and environmental limitations. (Tr. 101-03.) 

 In December 2011, Dr. Alvarez at the Maricopa County Correctional Health 

Services completed a form in connection with Plaintiff’s incarceration indicating that 

Plaintiff needed to sleep in the lower bunk and could not perform “off-facility work.”2

 

(Tr. 549.) 

III. The Administrative Hearing 

 Plaintiff was almost forty-seven years old and was represented by counsel at the 

administrative hearing. (Tr. 23, 30.) He was incarcerated at the time of the hearing and 

testified telephonically. (Tr. 32, 176.) Plaintiff testified that as the result of a 2005 car 

accident he had back pain that radiated to his toes and hands and restricted his movement. 

(Tr. 43-45.) He estimated that he could sit for about an hour, stand for thirty minutes at a 

time, walk for a quarter of a mile at once, and lift about fifteen pounds. (Tr. 45-46, 48.) 

He said that due to his diabetes, depression, anxiety, and bipolar disorder, he was 

depressed, easily overwhelmed, short-tempered, and had difficulty concentrating and 

understanding. (Tr. 46-47.) 

 Vocational expert Nathan E. Dean, M.Ed., also testified at the hearing. In 

response to questioning from the ALJ, the vocational expert testified that an individual 

with the limitations in the ALJ’s residual functional capacity (RFC) assessment would be 

 

2

 This form does not include Dr. Alvarez’s full name. 

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unable to perform Plaintiff’s past relevant work, but could perform other work existing in 

significant numbers in the national economy.3

 (Tr. 16, 58-62.) 

IV. The ALJ’s Decision 

 A claimant is considered disabled under the Social Security Act if he is unable “to 

engage in 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.” 

42 U.S.C. § 423(d)(1)(A); see also 42 U.S.C. § 1382c(a)(3)(A) (nearly identical standard 

for supplemental security income disability insurance benefits). To determine whether a 

claimant is disabled, the ALJ uses a five-step sequential evaluation process. See

20 C.F.R. §§ 404.1520, 416.920. 

A. Five-Step Evaluation Process 

 In the first two steps, a claimant seeking disability benefits must initially 

demonstrate (1) that he is not presently engaged in a substantial gainful activity, and (2) 

that his disability is severe. 20 C.F.R. § 404.1520(a)(4)(i) and (ii). If a claimant meets 

steps one and two, he may be found disabled in two ways at steps three through five. At 

step three, he may prove that his impairment or combination of impairments meets or 

equals an impairment in the Listing of Impairments found in Appendix 1 to Subpart P of 

20 C.F.R. pt. 404. 20 C.F.R. § 404.1520(a)(4)(iii). If so, the claimant is presumptively 

disabled. If not, the ALJ determines the claimant’s residual functional capacity (RFC). 

20 C.F.R. § 404.1520(e). At step four, the ALJ determines whether a claimant’s RFC 

precludes him from performing his past work. 20 C.F.R. § 404.1520(a)(4)(iv). If the 

claimant establishes this prima facie case, the burden shifts to the government at step five 

to establish that the claimant can perform other jobs that exist in significant number in the 

national economy, considering the claimant’s RFC, age, work experience, and education. 

 

3

 Plaintiff’s past relevant work included auto glass repairer, construction 

superintendent, and building repairer. (Tr. 22-23.) 

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20 C.F.R. § 1520(a)(4)(v). If the government does not meet this burden, then the 

claimant is considered disabled within the meaning of the Act. 

B. The ALJ’s Application of Five-Step Evaluation Process 

 Applying the five-step sequential evaluation process, the ALJ found that Plaintiff 

had not engaged in substantial gainful activity since April 14, 2010, the amended alleged 

disability onset date. (Tr. 14.) At step two, the ALJ found that Plaintiff had the 

following severe impairments: “obesity; fibromyalgia with low back pain; diabetes 

mellitus; hypertension; mood disorder with anxiety; and polysubstance abuse, in recent 

remission (20 C.F.R. § 404.1520(c) and 416.92(c).)” (Id.) At the third step, the ALJ 

found that the severity of those impairments did not meet or medically equal the criteria 

of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr 14-15.) The 

ALJ next concluded that Plaintiff retained the RFC “to perform light work as defined in 

20 C.F.R.§ 404.1567(b) and 416.967(b) except the claimant should avoid climbing 

ladders, ropes and scaffolds, and crawling.” (Tr. 16.) The ALJ also found that Plaintiff 

“could occasionally engage in stooping, crouching, and kneeling, and that he could 

frequently engage in climbing ramps and stairs, and balancing.” (Id.) The ALJ further 

found that Plaintiff “should avoid concentrated exposure to irritants, such as fumes, 

odors, dusts, and gases; [and should avoid] exposure to chemicals and unprotected 

heights.” (Id.) Finally, the ALJ found that Plaintiff was limited to “simple, unskilled 

tasks.” (Id.) At step four, the ALJ found that Plaintiff could not perform his past relevant 

work. (Tr. 22.) The ALJ concluded that, considering Plaintiff’s “age, education, work 

experience, and [RFC], there [were] jobs that exist in significant numbers in the national 

economy that [Plaintiff] could perform.” (Tr. 23.) Accordingly, the ALJ concluded that 

Plaintiff was not disabled within the meaning of the Act. (Tr. 23-24.) 

V. Standard of Review

 The district court has the “power to enter, upon the pleadings and transcript of 

record, a judgment affirming, modifying, or reversing the decision of the Commissioner, 

with or without remanding the cause for a rehearing.” 42 U.S.C. § 405(g). The district 

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court reviews the Commissioner’s final decision under the substantial evidence standard 

and must affirm the Commissioner’s decision if it is supported by substantial evidence 

and it is free from legal error. Ryan v. Comm’r of Soc. Sec. Admin., 528 F.3d 1194, 1198 

(9th Cir. 2008); Smolen v. Chater, 80 F.3d 1273, 1279 (9th Cir. 1996). Even if the ALJ 

erred, however, “[a] decision of the ALJ will not be reversed for errors that are 

harmless.” Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005). 

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

preponderence; it is “such relevant evidence as a reasonable mind might accept as 

adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971) 

(citations omitted); see also Webb v. Barnhart, 433 F.3d 683, 686 (9th Cir. 2005). In 

determining whether substantial evidence supports a decision, the court considers the 

record as a whole and “may not affirm simply by isolating a specific quantum of 

supporting evidence.” Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007) (internal 

quotation and citation omitted). 

 The ALJ is responsible for resolving conflicts in testimony, determining 

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

Cir. 1995). “When the evidence before the ALJ is subject to more than one rational 

interpretation, [the court] must defer to the ALJ’s conclusion.” Batson v. Comm’r of Soc.

Sec. Admin., 359 F.3d 1190, 1198 (9th Cir. 2004) (citing Andrews, 53 F.3d at 1041). 

VI. Analysis of Plaintiff’s Claims 

 Plaintiff argues that, based on the weight the ALJ assigned the medical source 

opinion evidence, he erred in formulating Plaintiff’s RFC. Plaintiff also argues that the 

ALJ erred in assessing his credibility. (Doc. 15 at 2.) 

A. Dr. Van Eerd’s Opinion 

 Dr. Van Eerd examined Plaintiff on December 15, 2010 in connection with his 

application for disability benefits. (Tr. 372-77.) Dr. Van Eerd opined that Plaintiff had 

mild limitations in remembering and understanding simple work instructions, mild 

limitations in interacting with others, a fair ability to make work decisions and follow 

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work rules, a fair ability to manage stress, a fair ability to manage criticism, a fair ability 

to follow work rules, and mild limitations managing new information. (Tr. 376.) He also 

found that Plaintiff had “a moderate limitation in sustaining routines with slowed pace,” 

and moderate difficulty in managing supervision. (Id.) The ALJ assigned this opinion 

“great weight.” (Tr. 20.) 

 Plaintiff argues that the ALJ erred by failing to include in the RFC the specific 

moderate limitation of pace found in Dr. Eerd’s opinion, which the ALJ assigned “great 

weight.”4

 (Doc. 15 at 5-6, Tr. 20.) Instead, the ALJ formulated an RFC that limited 

Plaintiff to jobs requiring “the ability to perform simple, unskilled work.” (Tr. 16.) 

Consequently, the hypothetical the ALJ posed to the vocational expert also did not 

include the specific moderate limitation of pace that Dr. Van Eerd assessed. (Tr. 60-61.) 

 Plaintiff argues that ALJ’s use of the term “simple, unskilled” work did not 

encompass Dr. Van Eerd’s findings regarding Plaintiff’s moderate limitations of pace, 

and that his implicit rejection of Dr. Van Eerd’s opinion was error. The Commissioner 

responds that Plaintiff’s argument was rejected in Stubbs-Danielson v. Astrue, 539 F.3d 

1169, 1173-74 (9th Cir. 2008). (Doc. 16 at 10.) In Stubbs-Danielson, the Ninth Circuit 

held that “an ALJ’s assessment of a claimant adequately captures restrictions related to 

concentration, persistence, or pace where the assessment is consistent with restrictions 

identified in the medical testimony.” Id. at 1174. There, the record contained some 

evidence of the claimant’s slow pace, but the only “concrete” functional limitation 

provided by the medical sources was a medical source opinion that, despite that slow 

pace, the claimant could perform “simple tasks.” Id. at 1173-74. The ALJ assessed an 

RFC that limited the claimant to “simple, routine, repetitive sedentary work.” Id. at 

1173. The Ninth Circuit concluded that the ALJ did not err in that formulation of the 

 

4

 Plaintiff also argues that the ALJ erred by failing to include Dr. Van Eerd’s assessed limitation of “not getting work done.” However, Dr. Van Eerd did not find such 

a limitation. (Tr. 376.) Accordingly, the ALJ did not err for failing to include in the RFC a limitation that Dr. Van Eerd did not find. 

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RFC because it was consistent with the medical record and, as a result, the ALJ not err in 

posing hypothetical questions to the vocational expert. Id. 

 This case, however, is more analogous to Brink v. Comm’r. of Soc. Sec. Admin., 

343 Fed. App’x 211 (9th Cir. 2009), which distinguished Stubbs-Danielson.

5

 In Brink, as 

in this case, the ALJ accepted medical evidence that the claimant had moderate difficulty 

with concentration, persistence, or pace, but posed hypothetical questions to the 

vocational expert based on an RFC that “referenced only ‘simple, repetitive work,’ 

without including limitations on concentration, persistence, and pace.” Id. at 212. In 

finding error and rejecting the Commissioner’s argument based on Stubbs-Danielson, the 

Ninth Circuit explained that: 

In Stubbs-Danielson . . . , we held that an “assessment of a 

claimant adequately captures restrictions related to 

concentration, persistence, or pace where the assessment is consistent with the restrictions identified in the medical 

testimony.” Id. at 1174. The medical testimony in StubbsDanielson, however, did not establish any limitations in concentration, persistence, or pace. Here, in contrast, the medical evidence establishes, as the ALJ accepted, that Brink does have difficulties with concentration, persistence, or pace. Stubbs-Danielson, therefore, is inapposite. 

Id. 

 The Court finds that the reasoning of Brink is persuasive and supports the 

conclusion that Stubbs-Danielson is not controlling here. See also Bentancourt v. Astrue, 

2010 WL 4916604, at *3-4 (C.D. Cal. Nov.27, 2010) (when the ALJ accepted medical 

evidence of the plaintiff’s limitations in maintaining concentration, persistence, or pace, a 

hypothetical question to the vocational expert including the plaintiff’s restriction to 

“simple, repetitive work,” but excluding the plaintiff’s difficulties with concentration, 

persistence, or pace resulted in a vocational expert’s conclusion that was “based on an 

incomplete hypothetical question and unsupported by substantial evidence.”); Melton v. 

Astrue, 2010 WL 3853195, at *8 (D. Or. 2010), aff’d., 442 Fed. App’x 339 (9th Cir. 

 

5

 Although Brink is an unpublished decision and thus only of persuasive value, its discussion of Stubbs-Danielson is instructive. 

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2011) (ALJ erred in her assessment of the plaintiff’s RFC when the assessment included 

the plaintiff’s restriction to simple, repetitive tasks, but did not include the plaintiff’s 

mild-to-moderate limitations in maintaining concentration, persistence, or pace). 

 Here, as in Brink, the ALJ accepted Dr. Van Eerd’s opinion that Plaintiff had 

“moderate limitations with concentration, persistence, and pace” (Tr. 20), but the RFC 

only referred to “the ability to perform simple, unskilled tasks.” (Tr. 16.) That RFC is 

incomplete considering the ALJ’s assignment of “great weight” to Dr. Van Eerd’s 

opinion. Plaintiff’s RFC, which the ALJ subsequently used to question the vocational 

expert about Plaintiff’s ability to perform past relevant work and other work in the 

national economy, did not adequately reflect Dr. Van Eerd’s opinion regarding the 

functional impact of Plaintiff’s mental impairments on his ability to perform work in an 

eight-hour day. The ALJ said that he gave “great weight” to this opinion. (Tr. 19.) 

Accordingly, the ALJ erred in formulating the RFC and the error was not harmless 

because the vocational expert’s testimony, upon which the ALJ relied to make his 

disability determination, was based on an RFC that did not include all of Plaintiff’s 

limitations. See Stout v. Comm’r of Soc. Sec., 454 F.3d 1050, 1055 (9th Cir. 2006) (an 

ALJ’s error is harmless when it is “irrelevant to the ALJ’s ultimate disability 

conclusion.”); Andrews v. Shalala, 53 F.3d 1035, 1044 (9th Cir. 1995) (for the vocational 

expert’s testimony to constitute substantial evidence, the hypothetical question posed 

must “consider all of the claimant’s limitations”). 

B. Remand 

 Because neither the ALJ nor Plaintiff’s counsel posed a question to the ALJ that 

accurately reflected all of Plaintiff’s limitations, including the limitations that Dr. Van 

Eerd assessed and the ALJ adopted, the Court remands this matter to the ALJ for 

formulation of an accurate RFC that reflects all of Plaintiff’s limitations, including his 

mental limitations.6

 See Harman v. Apfel, 211 F.3d 1172, 1173-74 (9th Cir. 2000) 

 6

 Upon questioning by Plaintiff’s counsel, the vocational expert testified that if a hypothetical individual was “off task for two hours three times a day,” work would not be available. (Tr. 62.) Plaintiff’s counsel explained that the “off-task” limitation was based 

on Plaintiff’s testimony. (Tr. 62-63.) Upon further questioning by Plaintiff’s counsel, 

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(stating that the decision to remand for further development of the record or for an award 

of benefits is discretionary, and remand is appropriate when there are outstanding issues 

to be resolved before a disability determination can be made). In view of this ruling, the 

Court does not reach Plaintiff’s other claims of error. 

 Accordingly, 

IT IS ORDERED that this case is reversed and remanded to the ALJ for further 

proceedings consistent with this Order. The Clerk of Court shall enter judgment in favor 

of Plaintiff and against the Commissioner and shall terminate this case. 

 Dated this 15th day of May, 2014. 

 the vocational expert testified that a hypothetical person who worked at a pace that required “more than the usual 15-minute break and then the 30-minute break at lunch in 

two hour increments in the usual work day,” and who was unable to get “work done within the allotted time” would be unable to perform jobs existing in significant numbers in the national economy. (Tr. 63-64.) Dr. Van Eerd’s assessment does not include these 

limitations. (Tr. 376.) 

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