Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_18-cv-01573/USCOURTS-casd-3_18-cv-01573-0/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

SYLVIA LOPEZ,

Plaintiff,

v.

NANCY A. BERRYHILL, 

Acting Commissioner of Social Security,

Defendant.

Case No.: 18cv1573-WQH-LL

REPORT AND 

RECOMMENDATION REGARDING 

CROSS-MOTIONS FOR SUMMARY 

JUDGMENT

[ECF Nos. 11, 12]

On July 11, 2018, Plaintiff Sylvia Lopez filed a complaint pursuant to 42 U.S.C. 

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

(“Commissioner”) denying her applications for a period of disability and disability 

insurance benefits and for supplemental security income (“SSI”). ECF No. 1. Now pending 

before the Court and ready for decision are the parties’ cross-motions for summary 

judgment. ECF Nos. 11, 12.

This Report and Recommendation is submitted to the Honorable William Q. Hayes, 

United States District Judge, pursuant to 28 U.S.C. § 636(b) and Civil Local Rule 72.1(c) 

of the United States District Court of the Southern District of California. For the reasons 

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set forth below, the Court RECOMMENDS that Plaintiff’s motion for summary judgment 

be GRANTED, that the Commissioner’s cross-motion for summary judgment be 

DENIED, and that judgment be entered reversing the decision of the Commissioner and 

remanding this matter for further administrative proceedings.

I. PROCEDURAL BACKGROUND

On June 5, 2014, Plaintiff filed an application for a period of disability and disability 

insurance benefits under the Social Security Act, Title II. ECF No. 8, Administrative 

Record (“AR”) at 218–29. On July 1, 2014, Plaintiff filed an application for SSI under the 

Social Security Act, Title XVI. Id. at 230–36. Plaintiff alleged disability beginning on 

May 4, 2014 due to fibromyalgia/arthritis, severe pains in [her] bones all over body, 

diabetes stage II, and high blood pressure. Id. at 270. The claims were denied initially on 

October 16, 2014, and upon reconsideration on January 16, 2015, resulting in Plaintiff’s 

request for an administrative hearing. Id. at 170–71.

On November 30, 2016, an administrative hearing was held before Administrative 

Law Judge (“ALJ”) Jay E. Levine. Id. at 84–103. Plaintiff appeared at the hearing with 

counsel, and testimony was taken from her and a vocational expert (“VE”). Id. In a written 

decision dated March 7, 2017, the ALJ determined that Plaintiff had not been under a 

disability, as defined in the Social Security Act, from May 4, 2014 through the date of 

ALJ’s decision. Id. at 59–68. The ALJ’s decision became the final decision of the 

Commissioner on May 23, 2018 when the Appeals Council denied Plaintiff’s request for 

review. Id. at 1–7. 

On July 11, 2018, Plaintiff filed a complaint seeking judicial review by the federal 

district court. ECF No. 1. On December 1, 2018, Plaintiff filed a motion for summary 

judgment.

1 ECF No. 11-1 (“Pl.’s Mot.”). On December 31, 2018, Defendant timely filed a 

cross-motion for summary judgment. ECF No. 12-1 (“Def.’s Mot.”). On January 14, 2019, 

 

1 Plaintiff was required to file a motion for summary judgment by November 30, 2018. ECF No. 9. The 

Court accepted the late filing. Defendant did not request an extension of related dates. See Docket. 

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Plaintiff filed an opposition to the cross-motion and reply to Defendant’s opposition.2

ECF No. 12 (“Pl.’s Reply”). Defendant filed a reply to Plaintiff’s opposition on 

January 29, 2019.

3 ECF No. 15 (“Def.’s Reply”).

II. SUMMARY OF THE ALJ’S FINDINGS

In the decision, the ALJ followed the Commissioner’s five-step sequential 

evaluation process. See 20 C.F.R. §§ 404.1520, 416.920. At step one, the ALJ found that 

Plaintiff had not engaged in substantial gainful activity since May 4, 2014, her alleged 

onset date. AR at 64. At step two, the ALJ found that Plaintiff had the following severe 

impairments: diabetes mellitus, type II; left rotator cuff tear; and fibromyalgia. Id. At step 

three, the ALJ found that Plaintiff did not have an impairment or combination of 

impairments that met or medically equaled the severity of one of the impairments listed in 

the Commissioner’s Listing of Impairments. Id. at 64–65. Next, the ALJ determined that 

Plaintiff has the residual functional capacity (“RFC”) to perform the full range of light 

work as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b).4Id. at 65–67. In making the

RFC determination, the ALJ stated, inter alia, the following:

The claimant alleged disability based on fibromyalgia/arthritis, stage II 

diabetes mellitus, micro albuminuria, high blood pressure, restless leg 

syndrome, and neuropathy in her feet (1E; 8E; Hearing Testimony). She 

asserted her impairments cause her to experience severe pain all over her body 

including in her bones, wrist, shoulder joint, hip, and legs (1E; 4E). She also 

 

2 Plaintiff was required to file her opposition and reply by January 11, 2019. ECF No. 9. The Court 

accepted the late filing. Defendant did not request an extension of related dates. See Docket.

3 Defendant was required to file her reply by January 25, 2019. ECF No. 9. The Court accepted the late 

filing.

4 The Code of Federal Regulations cited define “light work” as follows:

Light work involves lifting no more than 20 pounds at a time with frequent lifting or 

carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very 

little, a job is in this category when it requires a good deal of walking or standing, or when 

it involves sitting most of the time with some pushing and pulling of arm or leg controls. 

To be considered capable of performing a full or wide range of light work, you must have 

the ability to do substantially all of these activities. If someone can do light work, we 

determine that he or she can also do sedentary work, unless there are additional limiting 

factors such as loss of fine dexterity or inability to sit for long periods of time.

20 C.F.R. §§ 404.1567(b) and 416.967(b).

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reported side effects from medication including sleepiness, tiredness, and lack 

of strength (4E). The claimant further alleged she wakes up with hand cramps 

(8E). The claimant testified that she also experiences headaches, instability 

while walking, leg spasms, and fatigue from exertion (Hearing Testimony). 

She alleged she must lie down throughout the day (Hearing Testimony). The 

claimant also reported she falls down frequently and limps (Hearing 

Testimony). 

After careful consideration of the evidence, I find that the claimant’s 

medically determinable impairments could reasonably be expected to cause 

the alleged symptoms; however, the claimant’s statements concerning the 

intensity, persistence and limiting effects of these symptoms are not entirely 

consistent with the medical evidence and other evidence in the record for the 

reasons explained in this decision.

Id. at 65–66. 

At step four, the ALJ accepted the vocation expert’s testimony that characterized the 

claimant’s prior work as a Parts Order and Stock Clerk and found that Plaintiff was capable 

of performing her past relevant work as a Parts Order and Stock Clerk as actually and 

generally performed. Id. at 67–68. The ALJ concluded that Plaintiff was not disabled from 

May 4, 2014 through March 7, 2017, the date of the decision. Id. at 68. 

III. DISPUTED ISSUE

The sole disputed issue that Plaintiff is raising as the grounds for reversal and an 

order directing payment of benefits or remand is whether the ALJ failed to properly 

evaluate Plaintiff’s testimony concerning pain, symptom, and level of limitation. Pl.’s Mot. 

at 11–12.

IV. STANDARD OF REVIEW

Section 405(g) of the Social Security Act permits unsuccessful applicants to seek 

judicial review of the Commissioner’s final decision. 42 U.S.C. § 405(g). The scope of 

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

by substantial evidence and contains no legal error. Id.; see also Trevizo v. Berryhill, 871 

F.3d 664, 674 (9th Cir. 2017) (citing Benton ex rel. Benton v. Barnhart, 331 F.3d 1030, 

1035 (9th Cir. 2003)). 

/ / /

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Substantial evidence is “more than a mere scintilla, but may be less than a 

preponderance.” Lewis v. Apfel, 236 F.3d 503, 509 (9th Cir. 2001) (citation omitted). It is 

“relevant evidence that, considering the entire record, a reasonable person might accept as 

adequate to support a conclusion.” Id. (citation omitted); see also Howard ex rel. Wolff v. 

Barnhart, 341 F.3d 1006, 1011 (9th Cir. 2003). “In determining whether the [ALJ’s] 

findings are supported by substantial evidence, [the court] must review the administrative 

record as a whole, weighing both the evidence that supports and the evidence that detracts 

from the [ALJ’s] conclusion.” Reddick v. Chater, 157 F.3d 715, 720 (9th Cir. 1998) 

(citations omitted). Where the evidence can reasonably be construed to support more than 

one rational interpretation, the court must uphold the ALJ’s decision. Trevizo, 871 F.3d 

at 674–75 (citing Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007)). This includes deferring 

to the ALJ’s consistency determinations and resolutions of evidentiary conflicts. See

Lewis, 236 F.3d at 509. “We review only the reasons provided by the ALJ in the disability 

determination and may not affirm the ALJ on a ground upon which he did not rely.” 

Garrison v. Colvin, 759 F.3d 995, 1010 (9th Cir. 2014).

Section 405(g) permits a court to enter judgment affirming, modifying, or reversing 

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

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

V. DISABILITY HEARING AND DECISION

A. Plaintiff’s Hearing Testimony

On November 30, 2016, Plaintiff, represented by counsel, appeared at the hearing 

before the ALJ. AR at 86. Plaintiff testified that for twenty-one years, she held the same 

job for an electronics company, working as a stock clerk printing out documentations. Id.

at 87–88. As part of her job, she had to lift a ream of paper weighing five pounds and put 

it on a cart. Id. at 88–89. Plaintiff stopped working there because she was laid off. Id.

at 90. Plaintiff stated that towards the end of her employment as a stock clerk, “with the 

medicine they gave [her] for fibromyalgia, [she] couldn’t do it anymore.” Id. at 92–93.

/ / /

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Plaintiff testified that after she was laid off, she worked as a caregiver but only lasted 

about a month because she “didn’t have the muscles to do it” and when she knew she could 

not lift the patient, her doctor told her that she could not do that job any more. See id. at 

93–94. Regarding medications, Plaintiff stated that she takes metformin for diabetes,

gabapentin for fibromyalgia, and Topamax for headaches. Id. at 94–95. Plaintiff also stated 

that she takes ropinirole for restless leg syndrome. Id. at 100; see also id. at 659, 740. She 

testified that the Topamax helps with the headaches, but she has to lay down because she 

gets drowsy or “not stable walking.” Id. at 95. 

When asked what she does in a typical day, Plaintiff stated she makes her bed and 

tries to do things in the house like dusting, but she gets tired. Id. She stated that fatigue is 

the biggest thing that would prevent her from working and that the medicine always makes 

her sleepy. Id. at 95–96. She further stated that she “tr[ies] not to fall deep asleep” during 

the day, and normally sleeps from 8:30 at night until 7:30 in the morning. Id. at 96. Plaintiff 

testified that she tries to take little walks but cannot walk far because she has neuropathy 

in her legs and she falls. Id. Plaintiff further testified that she cooks “very little” and that 

her granddaughter comes over and makes dinner. Id. at 98. Plaintiff stated that she does the 

laundry, but her husband takes the basket down the stairs for her. See id. at 98–99. Plaintiff 

testified that she bathes without difficulties, but because of the torn rotator cuff in her arm, 

she has a difficult time putting on some items of clothing. Id. at 99. 

Plaintiff stated that her health has deteriorated since she was laid off. Id. When asked 

when her “health took a nosedive,” Plaintiff answered, “[P]robably within the last six 

months.” Id. at 97. She testified the neuropathy in her feet developed maybe three months 

ago and that she did not have it when she was working. Id. Plaintiff testified that besides 

the pain in her feet and headaches, she also has pain in her shoulders, and at night, she 

“get[s] real bad pain inside [her] wrist bones.” Id. at 98. Plaintiff further testified that in 

2014, she was diagnosed with meralgia paresthetica in her right leg, that it is painful and 

causes her to limp. Id. at 100. Plaintiff states that she has restless leg syndrome, which 

keeps her up at night. Id.

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B. ALJ’s Evaluation of Intensity, Persistence, and Limiting Effects of 

Plaintiff’s Symptoms

In the ALJ’s decision, he stated the following regarding his evaluation of Plaintiff’s 

“statements about the intensity and persistence of symptoms, such as pain and her alleged 

limitations”:

Despite her allegations, the claimant reported she could do errands, 

walk short distances, stand for 1 hour at a time, sit for 2 hours at a time, and 

do light housekeeping chores without assistance (4E). She testified that she 

takes little walks during the day; she cooks a little bit; she washes laundry; 

and she has no difficulty showering (Hearing Testimony). The claimant also 

testified that she was laid off from work due to the company losing business, 

rather than because of her impairments (Hearing Testimony). These 

statements suggest the claimant is more capable than she alleged.

Similarly, the objective medical evidence fails to provide strong 

support for the claimant’s allegations of disabling symptoms and limitations. 

The claimant’s records show most examinations were benign (e.g., 8F/28, 33–

34, 52, 187); the claimant’s allegations of headaches were intermittent at best 

and a magnetic resonance imaging (MRI) study of the brain was normal (8F/9, 

54, 65); the claimant declined surgery for her left shoulder (8F/164); and 

abdominal complaints were unconfirmed by a CT scan and there was evidence 

of normal gastric emptying (8F/12).

Nevertheless, the claimant did undergo a magnetic resonance imaging 

(MRI) study of the left upper extremity in October 2015 showing a full 

thickness supraspinatus tendon tear (8F/11). She was also diagnosed with 

fibromyalgia after some tenderness and trigger points were observed in June 

2015 (8F/39). She was also diagnosed with restless leg syndrome in July 2015 

(8F/49). A neurological examination in July 2015 also showed decreased 

sensation in the toes but a normal gait (8F/69–71). The claimant also exhibited 

decreased range of motion in the left shoulder in February 2016 and 

tenderness of the shoulder in April 2016 (8F/152, 164). At an exam in January 

2015, the claimant also exhibited clenching of both hands, but no visible signs 

of tremor and normal strength throughout her extremities (7F/2).

As for the opinion evidence, at the initial and reconsideration levels, 

State agency medical consultants reviewed the evidence of record. These 

consultants opined the claimant could perform medium exertional work with 

6 hours of standing/walking and 6 hours of sitting in an 8-hour workday. The 

initial level consultant opined the claimant could perform frequent postural 

activities but not climbing of ladders/ropes/scaffolds. The reconsideration 

level consultant opined the claimant could perform unlimited balancing; 

frequent climbing of ramps/stairs, stooping, kneeling, crouching, and 

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crawling; and occasional climbing of ladders/ropes/scaffolds. (1A; 2A; 6A; 

7A). 

After reviewing the record as a whole, I find that the records support 

limiting the claimant to a light level of work with an option to alternate 

between sitting and standing at will. The claimant’s testimony and reports in 

the record do not support her capacity to lift or carry at the medium level. 

Therefore, I accord little weight to the State agency opinions. Further, I find 

that postural limitations are not appropriate since the claimant did not allege 

any problems other than getting up from a bending position and poor balance. 

The claimant’s allegations of poor balance and frequent falls are not well 

supported by the record and there is not objective evidence to show problems 

with bending. As such, I do not find that any specific postural limitations are 

necessary. 

AR at 66–67. 

VI. DISCUSSION

Plaintiff argues that (1) the ALJ’s reliance on Plaintiff’s activities of daily living to 

reject her testimony concerning pain, symptoms, and level of limitation do not constitute a 

specific, clear and convincing reason supported by substantial evidence; (2) the ALJ’s 

reliance on the fact that Plaintiff was laid off from her job—rather than stopping work due 

to her disabilityto reject her testimony concerning pain, symptom, and level of limitation 

lacks the support of substantial evidence; and (3) the ALJ improperly rejected Plaintiff’s 

testimony based on the objective medical evidence. Pl.’s Mot. at 6, 7, 9.

Defendant contends that the ALJ properly found Plaintiff’s statements concerning 

the intensity, persistence, and limiting effects of her symptoms were not entirely consistent 

with medical and other evidence in the record. Def.’s Mot. at 8.

A. Relevant Law

The Ninth Circuit has established a two-part test for evaluating a claimant’s 

subjective symptoms. See Lingenfelter v. Astrue, 504 F.3d 1028, 1036 (9th Cir. 2007). 

“First, the ALJ must determine whether the claimant has presented objective medical 

evidence of an underlying impairment which could reasonably be expected to produce the 

pain or other symptoms alleged.” Id. (internal quotation marks and citation omitted). The 

claimant, however, need not prove that the impairment reasonably could be expected to 

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produce the alleged degree of pain or other symptoms; the claimant need only prove that 

the impairment reasonably could be expected to produce some degree of pain or other 

symptom. Id. If the claimant satisfies the first element and there is no evidence of 

malingering, then the ALJ “can [only] reject the claimant’s testimony about the severity of 

her symptoms . . . by offering specific, clear and convincing reasons for doing so.” Id.

(internal quotation marks and citation omitted). General findings are insufficient; the ALJ 

must identify the discounted subjective symptoms testimony and the evidence that supports 

the ALJ’s reasons for the weight given. See Reddick, 157 F.3d at 722 (internal citation 

omitted); see also Soc. Sec. Ruling 16-3p Titles II & XVI: Evaluation of Symptoms in 

Disability Claims, SSR 16-3P (S.S.A. Oct. 25, 2017).

5 The ALJ’s findings must be 

“sufficiently specific to permit the court to conclude that the ALJ did not arbitrarily 

discredit [Plaintiff’s] testimony.” Thomas v. Barnhart, 278 F.3d 947, 958 (9th Cir. 2002).

When weighing the claimant’s testimony, an “ALJ may consider . . . reputation for 

truthfulness, inconsistencies in testimony or between testimony and conduct, daily 

activities, and unexplained, or inadequately explained, failure to seek treatment or follow 

a prescribed course of treatment.” Orn v. Astrue, 495 F.3d 625, 636 (9th Cir. 2007) (internal 

quotation marks and citation omitted). An ALJ also may consider the claimant’s work 

record and testimony from doctors and third parties regarding the “nature, severity, and 

effect of the symptoms” of which the claimant complains. Thomas, 278 F.3d at 958–59 

(internal quotation marks and citation omitted); see also 20 C.F.R. § 404.1529(c). If the 

ALJ’s finding is supported by substantial evidence, the court may not second-guess his or 

her decision. See Thomas, 278 F.3d at 959; Carmickle v. Comm’r Soc. Sec. Admin., 533 

F.3d 1155, 1162–63 (9th Cir. 2008) (where the ALJ’s assessment of a claimant’s testimony

 

5 Although Social Security Rulings do not have the force of law, “they constitute Social Security 

Administration interpretations of the statute it administers and of its own regulations,” and the Court defers 

to them “unless they are plainly erroneous or inconsistent with the Act or regulations.” Quang Van Han 

v. Bowen, 882 F.2d 1453, 1457 (9th Cir. 1989) (citations omitted).

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is supported by substantial evidence, it will not be disturbed even where some of the 

reasons for discrediting a claimant’s testimony were improper). 

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

reasonably be expected to cause the alleged symptoms, and he did not claim that Plaintiff 

was malingering. See AR at 65–68. Thus, the Court considers the second part of the Ninth 

Circuit’s two-part test: whether the ALJ gave specific, clear and convincing reasons for 

discounting Plaintiff’s testimony.

B. Activities of Daily Living

Plaintiff argues that none of her activities would exceed the limitations identified by 

Plaintiff. Pl.’s Mot. at 6. Plaintiff further argues that the ALJ fails to explain how Plaintiff’s

activities of daily living are inconsistent with her testimony or inconsistent with a 

disability, and thus fails to constitute a specific, clear and convincing reason supported by 

substantial evidence. Id. at 7. Defendant argues that the ALJ properly found that Plaintiff’s 

daily activities “suggested [she] [was] more capable than she alleged.” Def.’s Mot. at 16 

(citing AR at 66). 

“While a claimant need not vegetate in a dark room in order to be eligible for 

benefits, the ALJ may discredit a claimant’s testimony when the claimant reports 

participation in everyday activities indicating capacities that are transferable to a work 

setting.” Molina v. Astrue, 674 F.3d 1104, 1112–13 (9th Cir. 2012) (internal quotation 

marks and citations omitted). “Even where those activities suggest some difficulty 

functioning, they may be grounds for discrediting the claimant’s testimony to the extent

that they contradict claims of a totally debilitating impairment.” Id. at 1113; see also

Valentine v. Comm’r Soc. Sec. Admin., 574 F.3d 685, 693 (9th Cir. 2009) (finding no legal 

error when the ALJ recognized that although evidence did not suggest claimant could work, 

it “suggest[ed] that [his] late claims about the severity of his limitations were 

exaggerated”). 

Here, the ALJ erred by failing to provide clear and convincing reasons for 

discounting Plaintiff’s pain and symptom testimony based on her daily activities. First, the 

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ALJ identified Plaintiff’s pain and symptom allegations described during the November 

20, 2016 hearing [AR 84–103], and in the record from her Disability Report form 

[AR 269–75 (1E)], January 27, 2015 Disability Report Appeal form [AR 310–15 (8E)], 

and her June 20, 2014 Pain Questionnaire [AR 297–99 (4E)]. AR at 65. They included 

allegations of severe pain all over, headaches, fatigue, medication side effects of sleepiness 

and lack of strength, hand cramps, leg spasms, instability while walking, frequent falls, 

limping, and the need to lie down throughout the day. Id. Next, the ALJ found that despite 

Plaintiff’s allegations, she could do activities such as errands, short walks, light 

housekeeping chores, a little cooking, laundry, showering without difficulty, standing for 

one hour at a time, and sitting for two hours at a time. Id. at 66 (citing AR 84–103 (Hearing 

Testimony), 297–99 (4E)). The ALJ then provided a one-sentence explanation of his 

assessment: that the daily activities “suggest the claimant is more capable than she 

alleged.” Id.

The ALJ failed to explain how the activities conflict with Plaintiff’s allegations. That 

Plaintiff can do some limited activities is not inconsistent with her allegations of pain, 

fatigue, and a need to lie down during the day. See Garrison v. Colvin, 759 F.3d 995, 1016 

(9th Cir. 2014) (“We have repeatedly warned that ALJs must be especially cautious in 

concluding that daily activities are inconsistent with testimony about pain, because 

impairments that would unquestionably preclude work and all the pressures of a workplace 

environment will often be consistent with doing more than merely resting in bed all day.”). 

Nor are these activities per se evidence of a capability of performing sustained work. See

Smolen v. Chater, 80 F.3d 1273, 1284 n.7 (9th Cir. 1996) (“The Social Security Act does 

not require that claimants be utterly incapacitated to be eligible for benefits, and many 

home activities may not be easily transferable to a work environment where it might be 

impossible to rest periodically or take medication.” (citation omitted)). Therefore, the 

supposed inconsistency between Plaintiff’s allegations and her activities of daily living 

does not satisfy the requirement of a clear and convincing reason to find Plaintiff’s claims

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of pain and limiting symptoms unbelievable, and thus is not supported by substantial 

evidence.

C. Laid Off From Job

Plaintiff argues that the ALJ’s reliance on Plaintiff leaving her job as a stock clerk 

due to being laid off, as opposed to a disabling limitation, lacks the support of substantial 

evidence because the ALJ “fails to acknowledge [Plaintiff’s] deterioration after she was 

laid off from her second to last job and before her alleged onset date.” Pl.’s Mot. at 9. 

Defendant argues that “the ALJ was entitled to consider the fact that she adequately 

performed her job at the time of the lay-off and did not leave the job due to her 

impairments.” Def.’s Mot. at 18. 

The ALJ did not err in determining that Plaintiff’s lay-off from work was one factor 

that suggested Plaintiff was not totally debilitated. The ALJ stated that Plaintiff’s testimony 

that she was laid off from work due to the company losing business, rather than because of 

her impairments was one reason that suggested Plaintiff “is more capable than she alleged.” 

Pl.’s Mot. at 66. The ALJ may properly consider as one factor in assessing a claimant’s 

subjective pain and symptom testimony that a claimant did not leave a job due to disability, 

and thus, could have the functional capacity to do past work. See Key v. Heckler, 754 

F.2d 1545, 1552 (9th Cir. 1985) (finding that claimant could do other work or past work 

based partly on testimony that claimant lost his last job not because of a disability but 

because “[his] time ran out with the State of California”). The ALJ did consider Plaintiff’s 

allegations of deteriorating health, but he considered them in light of Plaintiff’s daily 

activities and the objective medical evidence. Thus, the ALJ provided a clear and 

convincing reason supported by substantial evidence that Plaintiff’s lay-off was a factor 

suggesting that she could return to her past work. 

D. Objective Medical Evidence

Plaintiff argues that (1) the ALJ summarizes the medical evidence, but fails to 

explain what testimony is unsupported and why; (2) the ALJ misrepresents the record by 

stating that “most examinations were benign”; and (3) because the ALJ’s other reasons for 

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discounting Plaintiff’s testimony is insufficient, it cannot be rejected based solely on a lack 

of objective medical evidence. Pl.’s Mot. at 9–10. Defendant argues that the ALJ cited to 

objective evidence throughout the record that was inconsistent with Plaintiff’s allegations 

of pain and limiting symptoms. Def.’s Mot. at 11.

The ALJ erred by failing to provide clear and convincing reasons for discounting 

Plaintiff’s pain and symptom testimony based on objective medical evidence that he found 

did not provide strong support for Plaintiff’s allegations. AR at 66. First, although the ALJ 

stated that the record showed “most examinations were benign,” three of the four physical

examinations cited by the ALJ were not entirely benign.6 See id. The two exams in Exhibit 

8F on pages 28 and 33 to 34 were conducted on May 12, 2015 and May 26, 2015 

respectively. Id. at 716, 721–22. They both indicated “some pain on palpation of right 

thigh” and “[p]ositive diffuse tenderness to palpation throughout back, neck, muscles.” Id.

The exam in Exhibit 8F at page 52 was conducted on July 24, 2015 and indicated that 

Plaintiff had a rash. Id. at 740. The ALJ does not mention examples of other examinations, 

including the following, that were not entirely benign: (1) on May 6, 2014, the physical 

exam indicated “patient appears uncomfortable,” “strength is weak in bilateral lower 

extremity secondary to pain,” “[u]nable to do knee raises or extension of the knees against 

resistance” and “unable to stand up without using her arms from a seated position”

[id. at 372]; (2) on May 9, 2014, the physical exam appeared normal, but the rheumatology 

doctor indicated in her assessment that “[p]atient has elevated CRP with normal 

sedimentation rate, headaches and scalp tenderness, visual changes, and diffuse body 

tenderness” [id. at 411, 414]; (3) on August 26, 2014, the physical exam indicated that 

“[p]atient appears uncomfortable” and [t]enderness on palpation to the distal quadricep 

 

6 Defendant offers additional arguments expanding on the “mostly benign exams” reason, including that 

(1) findings of a “normal gait” and “no strength deficit” directly contrast with Plaintiff’s allegations of leg 

spasms or difficulty walking, and (2) findings of “tenderness” do not equate to disability. Def.’s Mot. at 

12. However, the ALJ did not offer those reasons in the disability determination, and so the Court may 

not consider them. Garrison v. Colvin, 759 F.3d at 1010 (“We review only the reasons provided by the 

ALJ in the disability determination and may not affirm the ALJ on a ground upon which he did not rely.”).

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muscle bilaterally” [id. at 557]; (4) on September 2, 2014, the physical exam indicated 

“[t]enderness on palpation to the bottom third of her right thigh with severe point 

tenderness” [id. at 562]; (5) on October 14, 2014, the physical exam by the neurology 

doctor indicated “testing revealed: [a] distinct reduction to light touch and pin in the distal 

distribution of the right lateral femoral cutaneous nerve” and his assessment stated that 

“patient has chronic pain due to myofascial pain, multiple arthritic and bursae symptoms 

but her new symptoms are quite clearly related to Neuralgia Paresthetica, the syndrome of 

entrapment of the right lateral femoral cutaneous nerve at the anterior superior iliac spine” 

[id. at 640]; and (6) on January 21, 2015, the emergency room physical exam indicated 

Plaintiff “appears to have some element of bilateral carpal pedal spasm” and “some 

clenching of both of her hands” and a chest x-ray indicated “calcific tendinitis of the left 

shoulder” [id. at 680, 687–88].

Next, the ALJ stated that “claimant’s allegations of headaches were intermittent at 

best and a magnetic resonance imaging (MRI) study of the brain was normal.”7Id. at 66. 

The MRI was normal; however, headaches were mentioned at doctor visits on May 9, 2014 

[id. at 414], May 12, 2015 [id. at 713], July 7, 2015 [id. at 697], July 27, 2015 [id. at 746], 

July 30, 2015 [id. at 668], September 24, 2015 [id. at 788], April 5, 2016 [id. at 844], and 

April 19, 2016 [id. at 852]. Then the ALJ stated that Plaintiff declined surgery for her left 

shoulder.8Id. at 66. However, the doctor noted that her shoulder is painful but “[p]atient is 

not interested in any surgery [as] she would not be able to go without use of her left arm 

for that long.” Id. at 849, 852. The ALJ further noted that Plaintiff’s “abdominal complaints 

were unconfirmed by a CT scan and there was evidence of normal gastric emptying,” but 

the ALJ failed to explain what limiting symptom this conflicts with. Id. at 66. The ALJ also 

 

7 Again, Defendant offers additional reasons for discounting Plaintiff’s allegations of headaches, such as 

Dr. Hossein Ansari’s opinion on the headaches, but the ALJ did not cite to those reasons or offer them, 

and so the Court may not consider them. See Def.’s Mot. at 12–13; Garrison v. Colvin, 759 F.3d at 1010.

8 Yet again, Defendant offers an additional reason for rejecting Plaintiff’s testimony regarding shoulder 

pain—findings made by an orthopedic surgeon—that the ALJ did not offer or cite, and so the Court may 

not consider it. See Def.’s Mot. at 13; Garrison v. Colvin, 759 F.3d at 1010.

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stated the following diagnoses for Plaintiff: (1) an MRI in October 2015 showing a full 

thickness tendon tear in her left upper extremity; (2) fibromyalgia; (3) restless leg 

syndrome in July 2015;9(4) July 2015 exam showing decreased sensation in her toes but a 

normal gait; (5) decreased motion in the left shoulder in February 2016 and tenderness of 

the shoulder in April 2016; (6) January 2015 exam showing clenching of both hands but 

normal strength and no tremors. Id. at 66–67. 

Because the record contradicts some of the ALJ’s findings and the ALJ fails to 

explain other findings, the ALJ’s claim that the objective medical evidence fails to provide 

strong support for Plaintiff’s allegations of disabling symptoms and limitations is not 

supported by substantial evidence. Furthermore, regarding Plaintiff’s allegations of pain or 

limiting symptoms related to fibromyalgia, the Ninth Circuit has cautioned that 

fibromyalgia symptoms are often misunderstood: 

Fibromyalgia is “a rheumatic disease that causes inflammation of the fibrous 

connective tissue components of muscles, tendons, ligaments, and other 

tissue.” Benecke, 379 F.3d at 589. Typical symptoms include “chronic pain 

throughout the body, multiple tender points, fatigue, stiffness, and a pattern 

of sleep disturbance that can exacerbate the cycle of pain and fatigue.” Id. at 

590. What is unusual about the disease is that those suffering from it have 

“muscle strength, sensory functions, and reflexes [that] are normal.” Rollins 

v. Massanari, 261 F.3d 853, 863 (9th Cir. 2001) (Ferguson, J., dissenting) 

(quoting Muhammad B. Yunus, Fibromyalgia Syndrome: Blueprint for a 

Reliable Diagnosis, Consultant, June 1996, at 1260). “Their joints appear 

normal, and further musculoskeletal examination indicates no objective joint 

swelling.” Id. (quoting Yunus, supra, at 1260). Indeed, “[t]here is an absence 

of symptoms that a lay person may ordinarily associate with joint and muscle 

pain.” Id. The condition is diagnosed “entirely on the basis of the patients' 

reports of pain and other symptoms.” Benecke, 379 F.3d at 590. “[T]here are 

no laboratory tests to confirm the diagnosis.” Id.

[. . .]

 

9 Defendant offers another explanation for discounting Plaintiff’s allegations regarding restless leg 

syndrome—that Plaintiff reported that medication helped the symptoms—but the ALJ did not offer that 

explanation, nor cite to it, and so the Court cannot consider it. See Def.’s Mot. at 13–14; Garrison v. 

Colvin, 759 F.3d at 1010.

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Therefore, diagnosis of fibromyalgia does not rely on X-rays or MRIs. 

Further, SSR 12-2P recognizes that the symptoms of fibromyalgia “wax and 

wane,” and that a person may have “bad days and good days.” SSR 12-2P, at 

*6. In light of this, the ruling warns that after a claimant has established a 

diagnosis of fibromyalgia, an analysis of her RFC should consider “a 

longitudinal record whenever possible.” Id.

Revels v. Berryhill, 874 F.3d 648, 656–57 (9th Cir. 2017).

E. Medical Opinion Evidence

Plaintiff does not coherently argue that the ALJ erred in his assessment of Plaintiff’s 

pain and symptom allegations based on the medical opinion evidence. See Pl.’s Mot. at 

10–11.10 However, the Court notes that although the ALJ claims that he made his 

determination of Plaintiff’s residual functional capacity “[a]fter reviewing the record as a 

whole,” he is silent on the Residual Functional Capacity Questionnaire completed by 

Plaintiff’s treating physician Sabrina A. Falquier, M.D. on September 23, 2014. 

AR at 626–27. Her questionnaire responses corroborate Plaintiff’s allegations of pain and 

limiting symptoms. See id. To essentially give little weight to a treating physician’s opinion 

by ignoring it is legal error. Garrison, 759 F.3d at 1012–13 (“[A]n ALJ errs when he rejects 

a medical opinion or assigns it little weight while doing nothing more than ignoring it, 

asserting without explanation that another medical opinion is more persuasive, or 

criticizing it with boilerplate language that fails to offer a substantive basis for his 

conclusion.”).

F. Remand Versus Award Benefits

“The decision whether to remand a case for additional evidence, or simply to award 

benefits[,] is within the discretion of the court.” Trevizo v. Berryhill, 871 F.3d at 682 

(quoting Sprague v. Bowen, 812 F.2d 1226, 1232 (9th Cir. 1987)). “Remand for further 

administrative proceedings is appropriate if enhancement of the record would be useful.” 

 

10 Instead, Plaintiff argues that the ALJ could not have properly relied on the opinions of the consultative 

examiner, Russell Crider, M.D., and the non-examining State agency consultants. Pl.’s Mot. at 10–11. 

However, the ALJ did not rely on those medical opinions because he was silent on Dr. Crider’s opinion, 

and he gave little weight to the opinions of the State agency medical consultants. AR at 67. 

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Benecke v. Barnhart, 379 F.3d 587, 593 (9th Cir. 2004) (emphasis omitted). “[A] reviewing 

court is not required to credit claimants' allegations regarding the extent of their 

impairments as true merely because the ALJ made a legal error in discrediting their 

testimony.” Brown-Hunter v. Colvin, 806 F.3d 487, 495 (9th Cir. 2015) (internal quotation 

marks and citation omitted). A remand for an immediate award of benefits is appropriate 

only in rare circumstances. Id.

In this case, the ALJ erred by (1) failing to provide clear and convincing reasons 

supported by substantial evidence for discounting Plaintiff’s allegations regarding pain and 

limiting symptoms, and (2) assigning little weight to the medical opinion of Plaintiff’s 

treating physician. Additionally, after the ALJ found that Plaintiff could perform her past 

work at step four of the sequential evaluation process, he did not proceed to step five, to 

determine whether Plaintiff could perform other work in the national economy. Therefore, 

the Court finds that it would be useful to enhance the administrative record. 

VII. CONCLUSION

For the reasons set forth above, this Court RECOMMENDS that Plaintiff’s Motion 

for Summary Judgment be GRANTED, that Defendant’s Cross-Motion for Summary 

Judgment be DENIED, and that judgment be entered REVERSING the decision of the 

Commissioner and REMANDING this matter for further administrative proceedings.

IT IS HEREBY ORDERED that any written objections to this Report and 

Recommendation must be filed with the Court and served on all parties on or before June 

28, 2019. The document should be captioned “Objections to Report and 

Recommendation.”

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

the Court and served on all parties on or before July 12, 2019. The parties are advised that 

/ / /

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failure to file objections within the specified time may waive the right to raise those 

objections on appeal of the Court’s order. Turner v. Duncan, 158 F.3d 449, 455 (9th Cir. 

1998); Martinez v. Ylst, 951 F.2d 1153, 1157 (9th Cir. 1991). 

IT IS SO ORDERED.

Dated: June 14, 2019

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