Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_11-cv-00812/USCOURTS-azd-4_11-cv-00812-0/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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IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Rosemary Valenzuela, 

Plaintiff, 

vs.

Carolyn W. Colvin, Acting Commissioner

of the Social Security Administration, 

Defendant. 

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No. CV 11-812-TUC-HCE

ORDER

Plaintiff has filed the instant action seeking review of the final decision of the

Commissioner of Social Security pursuant to 42 U.S.C. § 405(g). The Magistrate Judge has

jurisdiction over this matter pursuant to the parties’ consent. See 28 U.S.C. § 636(c).

Pending before the Court are Plaintiff’s Opening Brief (Doc. 16) (hereinafter

“Plaintiff’s Brief”), Defendant’s Opposition to Plaintiff’s Opening Brief (Doc. 21)

(hereinafter “Defendant’s Brief”), and Plaintiff’s Reply Brief (Doc. 24). The Court takes

judicial notice that Michael J. Astrue is no longer Commissioner of the Social Security

Administration (hereinafter “SSA”). Pursuant to Rule 25(d) of the Federal Rules of Civil

Procedure, the Court substitutes the new Acting Commissioner of the SSA, Carolyn W.

Colvin, as the named Defendant in this action. For the following reasons, the Court will

remand this action for further administrative proceedings.

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I. PROCEDURAL HISTORY

On July 24, 2008, Plaintiff protectively filed with the SSA an application for disability

insurance benefits under Titles II and XVIII of the Social Security Act. (TR. 125-26).

Plaintiff alleges that as of March 31, 2008, she has been unable to work due to: a torn rotator

cuff in her right shoulder; high blood pressure; bulging discs; numbness, tingling, and

swelling in her right hand and arm; fatigue; and constipation. (TR. 145). Plaintiff’s

application was denied initially and on reconsideration, after which Plaintiff requested a

hearing before an administrative law judge. (TR. 80-83, 85-89). The matter came on for

hearing on February 23, 2010 before Administrative Law Judge (hereinafter “ALJ”) M.

Kathleen Gavin. (TR. 43-75). At the hearing, Plaintiff, who was represented by counsel, and

Vocational Expert (hereinafter “VE”) Tracy Young testified. On May 26, 2010, the ALJ

issued her decision denying Plaintiff’s claim. (TR. 14-29). Plaintiff appealed, and on

October 26, 2011, the Appeals Council denied Plaintiff’s request for review thereby

rendering the ALJ’s October 26, 2011decision the final decision of the Commissioner. (TR.

5-8). Plaintiff then initiated the instant action. 

II. INTRODUCTION

Plaintiff was born on July 14, 1961, and was 46 years of age at the time of her alleged

disability onset date. (TR. 27, 125). Plaintiff has a high school education. (TR. 150). 

Plaintiff last worked as an assistant cook from 2007 through 2008. (TR. 153). Her past

work experience includes cashier at various businesses, fast food fryer, hostess, housekeeper

at a motel and a nursing home, and slot attendant at a casino. (Id.). 

III. THE ALJ’S FINDINGS

A. Claim Evaluation

SSA regulations require the ALJ to evaluate disability claims pursuant to a five-step

sequential process. 20 C.F.R. §§404.1520, 416.920. The first step requires a determination

of whether the claimant is engaged in substantial gainful activity. 20 C.F.R. §§ 404.1520(b),

416.920(b). If the claimant is not engaged in substantial gainful activity, then ALJ the

proceeds to step two which requires a determination of whether the claimant has a medically

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RFC is defined as that which an individual can still do despite his or her limitations.

20 C.F.R. §§ 404.1545, 416.945.

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severe impairment or combination of impairments. 20 C.F.R. §§ 404.1520(c), 416.920(c).

If the ALJ makes a finding of severity, then the ALJ proceeds to step three which requires

a determination of whether the impairment meets or equals one of several listed impairments

that the Commissioner acknowledges are so severe as to preclude substantial gainful activity.

20 C.F.R. §§ 404.1520(d), 416.920(d); 20 C.F.R. Pt. 404, Subpt. P, App.1. If the claimant’s

impairment meets or equals one of the listed impairments, then the claimant is presumed to

be disabled and no further inquiry is necessary. If a decision cannot be made based on the

claimant’s then current work activity or on medical facts alone because the claimant’s

impairment does not meet or equal a listed impairment, then evaluation proceeds to the fourth

step. The fourth step requires the ALJ to consider whether the claimant has sufficient

residual functional capacity (hereinafter “RFC”)1

 to perform past work. 20 C.F.R. §§

404.1520(e), 416.920(e). If the claimant cannot perform any past work due to a severe

impairment, then the ALJ must move to the fifth step which requires consideration of the

claimant’s RFC to perform other substantial gainful work in the national economy in view

of claimant’s age, education, and work experience. 20 C.F.R. §§ 404.1520(f). 416.920(f).

B. The ALJ's Decision 

The ALJ considered Plaintiff’s claim through Step 5 of the sequential evaluation

process. In pertinent part, the ALJ found that Plaintiff “has the following severe

impairments: degenerative disc disease of the lumbar spine; obesity; myalgia; depression;

somatoform disorder; post traumatic stress disorder (PTSD)...”, but that Plaintiff did not have

an impairment or combination of impairments that meets or medically equals one of the listed

impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (TR. 19, 22). The ALJ further

determined that Plaintiff:

has the residual functional capacity to perform work at the light exertional

level; she is able to do simple work with minimum contact with the general

public; she should do no repetitive overhead work; no climbing of ropes,

ladders or scaffolding; no unprotected heights; no hazardous equipment due

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The ALJ based her finding that Plaintiff could do other work on the VE testimony.

(TR. 28-29). The VE identified the following “representative occupations...”: “production

worker (e.g., production assembler, found in the Dictionary of Occupational Titles (DOT)

at 706.687-010)...; production helper (e.g., advertising material distributor DOT 230.687-

010)...; and inspector (e.g., garment inspector DOT 789.687-070)....” (TR. 28).

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to her balance issues; and other postural functions can be performed

occasionally. 

(TR. 23). The ALJ concluded that although Plaintiff was unable to perform past relevant

work, Plaintiff could perform other work that exists in significant numbers in the national

economy.2

 (TR. 27-28). Consequently, the ALJ found that Plaintiff was not disabled under

the Social Security Act. (TR. 29).

IV. DISCUSSION

A. Argument

Plaintiff asserts that the ALJ improperly rejected opinions from Plaintiff’s treating

physicians regarding her physical and mental limitations. (Plaintiff’s Brief, pp. 8-10). 

Plaintiff also argues that the ALJ improperly discounted her credibility and improperly

rejected lay witness statements. (Id. at pp. 11-13). 

Defendant contends that the ALJ reasonably considered and weighed the opinions

from the medical sources. (Defendant’s Brief, pp. 10-16). Defendant also contends that the

ALJ reasonably determined that Plaintiff’s allegations concerning the limiting effects of her

symptoms were not credible. (Id. at pp. 16-21). Defendant further argues that the ALJ

properly rejected the lay witness statements. (Id. at pp. 21-22). 

 B. Standard of Review

An individual is entitled to disability insurance benefits if he or she meets certain

eligibility requirements and demonstrates the inability 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 twelve months. 42 U.S.C. §§ 423, 1382. “‘A claimant will be found

disabled only if the impairment is so severe that, considering age, education, and work

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experience, that person cannot engage in any other kind of substantial gainful work which

exists in the national economy.’” Penny v. Sullivan, 2 F.3d 953, 956 (9th Cir. 1993) (quoting

Marcia v. Sullivan, 900 F.2d 172, 174 (9th Cir. 1990)).

To establish a prima facie case of disability, the claimant must demonstrate an

inability to perform his or her former work. Lockwood v. Commissioner of Social Security,

616 F.3d 1068, 1071 (9th Cir. 2010). Once the claimant meets that burden, the Commissioner

must come forward with substantial evidence establishing that the claimant is not disabled.

Id. The factual findings of the Commissioner shall be conclusive so long as they are based

upon substantial evidence and there is no legal error. 42 U.S.C. §§ 405(g), 1383(c)(3);

Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 2008). This Court may “set aside the

Commissioner’s denial of disability insurance benefits when the ALJ’s findings are based

on legal error or are not supported by substantial evidence in the record as a whole.” Tackett

v. Apfel, 180 F.3d 1094, 1097 (9th Cir. 1999) (citations omitted). 

Substantial evidence is “‘more than a mere scintilla[,] but not necessarily a

preponderance.’” Tommasetti, 533 F.3d at 1038 (quoting Connett v. Barnhart, 340 F.3d 871,

873 (9th Cir. 2003)); see also Tackett, 180 F.3d at 1098. Further, substantial evidence is

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

conclusion.” Parra v. Astrue, 481 F.3d 742, 746 (9th Cir. 2007). Where “the evidence can

support either outcome, the court may not substitute its judgment for that of the ALJ.”

Tackett, 180 F.3d at 1098 (citing Matney v. Sullivan, 981 F.2d 1016, 1019 (9th Cir. 1992)).

Moreover, the Commissioner, not the court is, is charged with the duty to weigh the

evidence, resolve material conflicts in the evidence and determine the case accordingly.

Matney, 981 F.2d at 1019. However, the Commissioner's decision “‘cannot be affirmed

simply by isolating a specific quantum of supporting evidence.’” Tackett, 180 F.3d at 1098

(quoting Sousa v. Callahan, 143 F.3d 1240, 1243 (9th Cir.1998)). Rather, the court must

“‘consider the record as a whole, weighing both evidence that supports and evidence that

detracts from the [Commissioner’s] conclusion.’” Id. (quoting Penny, 2 F.3d at 956). 

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Plaintiff’s other medications include: Meclizine HCL, Methocarbamol, Cymbalta,

Levoxyl, Morphine Sulfate, Gabapentin, Lactulose, Ultram, Lisinopril, and Loratadine. (TR.

240). 

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C. Analysis

1. Credibility Assessment

Plaintiff testified that she cannot work because of pain from her neck down her back

to her legs. (TR. 52). She suffers from muscle spasms and numbness from her lower back

down her legs. (Id.). She also feels pain in both shoulders and has swelling and tingling in

her wrists. (TR. 48). She experiences dizziness and loss of balance. (TR. 48, 56). She uses

a walker and wears wrist braces, both of which were prescribed by her doctors. (TR. 56).

In addition to taking medication, such as Percocet3

, she undergoes injections to her shoulders

and hands, acupuncture treatment, and she also uses heat and ice. (TR. 54, 57 (see also TR.

55 (medication makes Plaintiff “really drowsy”)). Due to back pain, Plaintiff cannot lift and

carry more than 5 pounds. (TR. 56-57). 

Plaintiff also suffers from depression which she believes is caused from having been

repeatedly sexually abused by her father when she was a child. (TR. 58; see also TR. 602

(Plaintiff was sexually abused by her father from the time she was six years of age to when

she was 16 years of age)). Plaintiff experiences flashbacks, anxiety, anger, panic attacks, and

becomes agitated with strangers. (TR. 60, 63). She stays at home and does not go out if she

does not have to because she “get[s] angry” and has “been blowing up quite a bit....” (TR.

60). 

At times, Plaintiff has difficulty dressing herself due to pain and stiffness in her

shoulders. (TR. 62, 209). Plaintiff goes grocery shopping with her boyfriend, and he does

most of the cooking. (TR. 61-62). Plaintiff has not driven since 2008 due to blackouts and

drowsiness from medication. (TR. 63). 

The ALJ found that Plaintiff’s “testimony with regard to the severity and functional

consequences of her symptoms was not fully credible...” as follows:

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Defendant argues that the “clear and convincing” standard for discounting credibility

exceeds that required in Bunnell v. Sullivan, 947 F.2d 341, 345-346 (9th Cir. 1991) (en banc)

where the Ninth Circuit stated that an ALJ’s credibility findings must be supported by the

record and “‘must be sufficiently specific to allow a reviewing court to conclude the

adjudicator rejected the claimant’s testimony on permissible grounds and did not arbitrarily

discredit a claimant’s testimony regarding pain.’” (Defendant’s Brief, pp. 16-17 (quoting

Bunnell, 947 F.2d at 345-346 (internal quotation marks and citations omitted)). Defendant

points out that no Ninth Circuit panel applying the clear and convincing standard has sat en

banc and, therefore, Bunnell has not been overturned. (Id.). Defendant’s position is

unavailing. First, “a requirement of ‘clear and convincing reasons’ is distinct from a clear

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[I]n reviewing the medical record as a whole, there are a number of other

inconsistencies contained therein which cast doubt regarding the credibility of

the claimant’s testimony. Two common side effects of prolonged and/or

chronic pervasive pain are weight loss and diffuse atrophy or muscle-wasting.

There is no record of the claimant having lost weight since the alleged date of

disability onset. There is also no record in any of the clinic notes regarding

diffuse atrophy or muscle-wasting. It can also be inferred that, although

claimant undoubtedly experiences some degree of pain, that pain has

apparently not altered the use of his [sic] muscles and joints to the extent that

it has resulted in diffuse atrophy or muscle-wasting. The record documents the

claimant’s weight consistently in the 180-pound range.

As to the effectiveness of treatment, the claimant’s testimony as to

debilitating symptoms would indicate a failure of treatment. However, the

claimant is not fully credible. There is no evidence of intensification of

treatment which could be expected if the claimant were suffering as alleged.

(TR. 25).

Plaintiff argues that the ALJ’s reasons for discrediting her testimony are inadequate

because intensified treatment would not improve her condition given the nature of her

impairments. (Plaintiff’s Brief, p. 11). Plaintiff also points out that lack of muscle atrophy

and weight loss are not material to her case. (Id.).

When assessing a claimant’s credibility, the “ALJ is not required to believe every

allegation of disabling pain or other non-exertional impairment.” Orn v. Astrue, 495 F.3d

625, 635 (9th Cir. 2007) (internal quotation marks and citation omitted). However, where, as

here, the claimant has produced objective medical evidence of an underlying impairment that

could reasonably give rise to the symptoms and there is no affirmative finding of

malingering, the ALJ’s reasons for rejecting the claimant’s symptom testimony must be clear

and convincing.4

 Carmickle v. Commissioner, Social Security Admin., 533 F.3d 1155, 1160-

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[and] convincing evidentiary standard. Cf. Bayliss v. Barnhart, 427 F.3d 1211, 1216) (9th

Cir.2005) (‘To reject an uncontradicted opinion of a treating or examining doctor, an ALJ

must state clear and convincing reasons that are supported by substantial evidence.’ ...).”

Provencio v. Astrue, 2012 WL 2344072, *11 n. 5 (D.Ariz. June 20, 2012). Second, as

Defendant points out, Bunnell itself requires that the ALJ “specifically make findings...” that

are supported by the record, to support the conclusion that the claimant’s allegations of

severity are not credible. Bunnell, 947 F.2d at 345. Further, these findings must be

“sufficiently specific to allow a reviewing court to conclude that the...” ALJ rejected the

testimony on permissible grounds. Id. at 345-346. The District Court for the District of

Arizona has noted that “[s]ubsequent cases have merely explained that ‘unless an ALJ makes

a finding of malingering based on affirmative evidence thereof, he or she may only find an

applicant not credible by making specific findings as to credibility and stating clear and

convincing reasons for each.’ Robbins v. Soc. Sec. Admin., 466 F.3d 880, 883 (9th Cir.2006)

(emphasis added); see also Lingenfelter v. Astrue 504 F.3d 102[8], 1036 (9th Cir.2007).

Thus, the cases applying the ‘clear and convincing’ standard in no way overturn Bunnell.

Numerous cases have applied the ‘clear and convincing’ standard, and this Court is in no

position to overrule them. See, e.g., Taylor v. Comm'r of Soc. Sec. Admin., [659 F.3d] 1228,

1234 (9th Cir.2011); Vasquez v. Astrue, 572 F.3d...[586, 591 (9th Cir. 2009)]; Lingenfelter,

504 F.3d at 1036; Orn, 495 F.3d at 635; Robbins, 466 F.3d at 883; Smolen v. Chater, 80

F.3d...[ 1273, 1281 (9th Cir. 1996)]; Dodrill [v. Shalala], 12 F.3d...[915, 918 (9th Cir. 1993)].”

Provencio, 2012 WL 2344072 at *11 n.5. Moreover, as discussed below, although the ALJ

set forth specific reasons for rejecting Plaintiff’s credibility, those reasons are not

permissible and/or supported by the record. Thus, the ALJ’s credibility finding fails under

Defendant’s proposed standard as well as the “clear and convincing” standard.

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61 (9th Cir. 2008) (“We have consistently held that where the record includes objective

medical evidence establishing that the claimant suffers from an impairment that could

reasonably produce the symptoms of which he complains, an adverse credibility finding must

be based on ‘clear and convincing reasons[]’” unless there is affirmative evidence of

malingering); Tommasetti, 533 F.3d at 1040; Orn, 495 F.3d at 635; Robbins, 466 F.3d at

883. “The ALJ must state specifically which symptom testimony is not credible and what

facts in the record lead to that conclusion.” Smolen, 80 F.3d at 1284; see also Orn, 495 F.3d

at 635 (the ALJ must provide cogent reasons for the disbelief and cite the reasons why the

testimony is unpersuasive). In assessing the claimant’s credibility, the ALJ may consider

ordinary techniques of credibility evaluation, such as the claimant’s reputation for lying,

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prior inconsistent statements about the symptoms, and other testimony from the claimant that

appears less than candid; unexplained or inadequately explained failure to seek or follow a

prescribed course of treatment; the claimant’s daily activities; the claimant’s work record;

observations of treating and examining physicians and other third parties; precipitating and

aggravating factors; and functional restrictions caused by the symptoms. Lingenfelter, 504

F.3d at 1040; Robbins, 466 F.3d at 884; Smolen, 80 F.3d at 1284.

Plaintiff is correct that, on the instant record, the ALJ’s reference to Plaintiff’s lack

of weight loss, diffuse atrophy or muscle wasting does not undermine Plaintiff’s credibility.

Neither the ALJ nor Defendant cite to any statement by any medical provider of record

indicating that diffuse atrophy or the other side effects mentioned by the ALJ would

necessarily accompany Plaintiff’s impairments. The Ninth Circuit has affirmed the denial of

benefits where, inter alia, the plaintiff alleged she had to maintain a fetal position all day

because of constant pain but she exhibited no physical signs including muscle atrophy of a

totally incapacitated person. Meanel v. Apfel, 172 F.3d 1111, 1114 (9th Cir. 1999). Plaintiff’s

case is distinguishable from Meanel. Plaintiff does not claim to be totally incapacitated.

Moreover, the instant record reflects that Plaintiff attended physical therapy for her right

shoulder beginning in 2007. (See TR. 302). By July 8, 2008, Plaintiff had completed 25

visits and, because Plaintiff’s “symptom reduction has been slow” a request was submitted

for additional physical therapy visits “to assist reduce pain”. (TR. 296-97 (also requesting

a cervical traction device)). In December 2008, Plaintiff was referred to physical therapy,

this time, for low back and left knee pain, and the record reflects that physical therapy was

ongoing through at least April 2009, when six additional visits were requested. (See TR.

480-482; see also TR. 209 (in December 2008 Plaintiff stated that she attends physical

therapy approximately twice a week and that she attempts home “therapy exercises, as

prescribed by my doctor....”)). Additionally, Plaintiff moves about her home during the day

seeing to her personal needs, caring for her pets, and performing light household chores

punctuated with rest periods. (TR. 209-13). Arguably, these activities forestalled diffuse

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The physical therapy note reflects that Plaintiff suffered from lumbar radiculopathy

as well as left knee pain. (TR. 482).

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atrophy and/or muscle wasting. There is no basis on this record to disbelieve Plaintiff

because she did not exhibit signs of diffuse atrophy or muscle wasting.

Nor should Plaintiff be disbelieved because she did not lose weight. No evidence of

record supports the conclusion that Plaintiff’s impairments would have resulted in weight

loss. Plaintiff stated that she was less mobile due to her condition. (TR. 210 (“My mobility,

flexibility, and ambulation has been significantly impacted by my condition.”)). Further, the

ALJ included obesity in her findings of Plaintiff’s severe impairments established by the

medical evidence. (TR. 19) Just as the ALJ has used Plaintiff’s lack of weight loss to

undermine her pain testimony, so could Plaintiff’s continued obesity be attributed to

inactivity caused by pain resulting from her impairments. The record simply does not support

the ALJ’s reliance on lack of weight loss to discredit Plaintiff’s credibility. Consequently,

the ALJ’s reliance on same to discredit Plaintiff’s credibility was in error.

Additionally, the substantial evidence of record does not support the ALJ’s reliance

on lack of “evidence of intensification of treatment...” to discount Plaintiff’s credibility.

(TR. 25). Plaintiff underwent rotator cuff surgery in 2008. (TR. 250-51). Subsequent to

arthroscopic left knee scope in March 2009, Plaintiff underwent a course of physical therapy

culminating, in April 2009, in a request for additional visits and a TENS unit.5

 (See TR. 482

(“We also highly recommend that she receive a TENS Unit to assist pain management....”);

(TR. 533 (in February 2009, Plaintiff’s treating physician indicated he “will order a TENS

unit to see if it will help her chronic back pain. Continue percocet/morphine...”, and he

considered steroid injections to Plaintiff’s knee)). The record also reflects that Plaintiff has

received injections in her hands and shoulders. (TR. 57, 550). In sum, the record reflects

that Plaintiff has sought treatment for her impairments and resultant symptoms and she has

undergone a range of treatments, including invasive approaches such as shoulder surgery and

arthroscopic left knee scope. Further, she is taking strong painkillers such as Percocet and

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Morphine. Moreover, in March 16, 2009, on a follow-up visit subsequent to an arthroscopic

left knee scope, Plaintiff’s physician noted that “these degenerative changes are pretty much

irreversible although we do [sic] clean up the joint.” (TR. 472; see also TR. 248 (Dr. Swe’s

2007 diagnosis of degenerative arthritis in the knees)). Neither Defendant nor the ALJ cite

other “intensifi[ed]” (TR. 25) treatment options available to treat Plaintiff. 

In sum, the reasons cited by the ALJ for discounting Plaintiff’s subjective complaints

are not supported by clear and convincing evidence.

2. Limitation on use of upper extremities

With regard to Plaintiff’s upper extremities, the ALJ found that Plaintiff should do no

repetitive overhead work, but did not find any other limitations despite limitations indicated

by Plaintiff’s treating doctors. (TR. 23; see also TR. 513, 545). Plaintiff argues that in

reaching this determination, the ALJ improperly relied upon the opinion from consulting

examining doctor, Jerome Rothbaum, M.D.

On September 30, 2008, Dr. Rothbaum stated:

It is anticipated within the 12-month period of time the claimant will not have

any problems with handling, fingering, and feeling, nor problems with

reaching with the left arm. She may still have some residual difficulty with

complete ability to extend the right arm and shoulder to a full 165 degrees

even at that time. 

(TR. 416). Dr. Rothbaum did not indicate whether Plaintiff was frequently, occasionally, or

totally limited with regard to handling, fingering, or feeling. (See id.). The ALJ noted that

Dr. Rothbaum “opined that within 12 months, the claimant should not have any problems

with handling, fingering and feeling, nor problems reaching with the left arm.” (TR. 26).

The ALJ gave Dr. Rothbaum’s opinion “substantial weight as being based on a thorough

examination and review of the record. It is consistent with the evidence at the hearing level.”

(Id.). Plaintiff challenges the ALJ’s finding because “the Commissioner is ignoring the

consistent findings of multiple treating and examining doctors, including Dr. Rothbaum[,]

and relying on Dr. Rothbaum’s speculative comments into the future.” (Plaintiff’s Brief, p.

9).

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Plaintiff also complained about back and knee pain at this time. However, for

purposes of the instant discussion, review of the pertinent records is limited to Plaintiff’s

upper extremities.

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As early as 2007, Plaintiff complained of joint pain mainly in her hands and wrists

that sometimes radiated to her forearms, arms, and neck.6

 (TR. 246). For these complaints,

Plaintiff’s primary care doctor, Adalberto Renteria, M.D., referred her to rheumatologist

Kyaw Swe, M.D. (Id.). On examination, Dr. Swe found Plaintiff had trace synovitis in her

metacarpophalangeal joints; reduced range of movement in her right shoulder; and mild

sublaxation in her wrists bilaterally, though range of movement in her wrists was good. (TR.

247-48). Dr. Swe noted that a wrist x-ray showed no fractures or erosions and that an April

2007 nerve conduction study showed no evidence of carpal tunnel syndrome. (TR. 248). Dr.

Swe diagnosed Plaintiff with inflammatory arthritis in her hands and wrists. (Id.). Dr. Swe

also diagnosed right subacromial bursitis. (Id.). Plaintiff was already taking Percocet for

pain and Dr. Swe added piroxicam. (TR. 246, 248). 

 Later, in February 2008 when Plaintiff saw Joseph E. Sheppard, M.D., for rotator cuff

injury, she also complained of “some swelling in the right hand.” (TR. 344). In July 2008,

on follow-up for rotator cuff repair, Plaintiff complained of swelling in her wrist and hand.

(TR. 339). Dr. Sheppard found that Plaintiff had mild diffuse tenderness along her forearm

and that her finger motion was full. (Id.). Dr. Sheppard’s assessment was status-post rotator

cuff reconstruction with satisfactory progress and right wrist and hand swelling of

indeterminate etiology. (Id.). Examination of Plaintiff’s shoulder revealed 160 degrees of

forward flexion, 150 degrees of abduction, and grade 4/5 strength, all with normal sensation.

 (Id.). He indicated that “from the shoulder standpoint I think [it] is okay to return” to her

work as an assistant cook. (Id.). He recommended that she continue with a home exercise

program. (Id.). 

On September 29, 2008, Plaintiff reported to her primary care physician, Dr. Renteria,

that she had fallen and was experiencing right hand pain that radiated to her left arm. (TR.

382). On physical examination, Dr. Renteria found right shoulder tenderness, swelling in the

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right hand as well as moderate pain with motion. (TR. 383). Dr. Renteria’s diagnosis

included shoulder pain and contusion of the wrist. (Id.). He wrapped Plaintiff’s right wrist

in an ace bandage and advised Plaintiff to use an arm sling for one week. (Id.). Plaintiff was

to continue on Percocet and prescribed muscle relaxers. (Id.). 

The following day, September 30, 2008, Dr. Rothbaum, conducted a consultative

medical examination of Plaintiff. (TR. 411-14). Plaintiff’s chief complaints included

shoulder pain and inability to rotate her shoulder effectively subsequent to rotator cuff injury

and surgery, swelling of her right hand for the past year, and a recent fall on her right hand

causing her to wrap her wrist in an ace bandage. (TR. 412). On examination, when Dr.

Rothbaum removed Plaintiff’s ace bandage, he noted she was moderately tender over the mid

shaft of the right fourth metacarpal and there was no evidence of synovitis. (TR. 413). Dr.

Rothbaum’s impression included: status post repair, rotator cuff tear, right shoulder; and

recent hand injury, possible metacarpal fracture. (TR. 414). Although Dr. Rothbaum did not

specifically describe limitations on handling, fingering, and feeling, he “anticipated within

the 12-month period of time the claimant will not have any problems with handling,

fingering, and feeling, nor problems reaching with the left arm.” (TR. 416).

Subsequent to her visit to Dr. Rothbaum, Plaintiff continued to complain to treating

providers about wrist and hand pain. (See TR. 550 (in January 2009 Plaintiff received

injection to her wrists); TR. 519 (on April 28, 2009, Dr. Renteria indicated that Plaintiff,

who was wearing a wrist brace, suffered from bilateral wrist pain); TR. 543 (on April 26,

2009, Plaintiff who was wearing wrist braces, complained that her arms hurt from the

shoulders down to her hands); TR. 544 (in May 2009 Plaintiff reported her wrists hurt when

she was potting plants); TR. 679 (in December 2009, Plaintiff complained of bilateral wrist

pain); TR. 657-58 (in January 2010, Plaintiff had acupuncture treatment for complaints of

shoulder pain radiating to her wrists).

As the ALJ noted, Plaintiff’s treating medical providers, Drs. Renteria and Garcia,

opined that Plaintiff was unable to push and pull, or do fine manipulation or repetitive tasks

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The doctors differed in their opinion as to whether Plaintiff could grasp: Dr. Renteria

indicated she could, and Dr. Garcia indicated she could not. (See TR. 513, 545).

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with her left and right hands. (See TR. 26; see also TR. 513 (Dr. Renteria); 545 (Dr.

Garcia)).7

 The ALJ rejected these opinions because:

They are too restrictive when viewed in light of the contemporaneous

treatment records and diagnostic testing results. They are inconsistent with the

overall record. The treatment records primarily summarize the claimant's

subjective complaints, diagnoses and treatment, but do not present objective

clinical or laboratory diagnostic findings that support such limited

assessments. For example, in July 2008, the claimant was deemed able to

return to her work as an assistant cook.

(TR. 26). The ALJ instead gave substantial weight to Dr. Rothbaum’s opinion that Plaintiff’s

problems with handling, fingering, and feeling were not expected to last more than 12

months. (Id.).

Generally, the ALJ cannot reject a treating physician’s opinion, even if it is

contradicted by the opinions of other non-treating doctors, unless she provides “specific and

legitimate reasons” supported by substantial evidence in the record. Rollins v. Massanari,

261 F.3d 853, 856 (9th Cir. 2001) (citing Reddick v. Chater, 157 F.3d 715, 720 (9th Cir.

1998)). Additionally, “an opinion of disability premised to a large extent upon the claimant’s

own accounts of [her] symptoms and limitations may be disregarded, once those complaints

have themselves been properly discounted.” Andrews v. Shalala, 53 F.3d 1035, 1043 (9th Cir.

1995); see also Tonapetyan v. Halter, 242 F.3d. 1144, 1149 (9th Cir. 2001) (same). On the

instant record as discussed supra, at IV.C.1., the ALJ did not properly discount Plaintiff’s

credibility. Therefore, to the extent that the ALJ rejected Drs. Renteria’s and Garcia’s

opinions because they were based on Plaintiff’s subjective complaints, such rejection is in

error. See Sousa, 143 F.3d at 1244-45 (“Because this improper discreditation of the lay

testimony [of plaintiff and her husband] formed the basis for the rejection of [plaintiff’s

doctor’s] analysis, that rejection fails.”)

Further, although the ALJ relies on Dr. Sheppard’s release of Plaintiff back to work

after rotator cuff repair, Dr. Sheppard is clear that Plaintiff is released to work “from the

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8

Given the proximity in time between Plaintiff’s fall and her appointment with Dr.

Rothbaum, it may well be that Dr. Rothbaum attributed any limitations he found to the recent fall

rather than to some other underlying cause and, thus, opined that Plaintiff’s condition would

improve within 12 months once she healed from injury caused by the fall. The record simply does

not reflect his rationale.

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shoulder standpoint....” (TR. 339 (although Dr. Sheppard indicated Plaintiff had full finger

motion, he also indicated wrist swelling of indeterminate etiology)). 

The record is clear that Dr. Swe diagnosed Plaintiff with a combination of

inflammatory arthritis in her hands and wrists in August 2007. (TR. 248). In July 2008, Dr.

Sheppard noted wrist swelling. (TR. 339). On September 29, 2008, after Plaintiff had fallen,

Dr. Renteria found swelling in her right hand along with moderate pain on movement. (TR.

382-83). When Plaintiff saw examining Dr. Rothbaum the following day, he noted moderate

tenderness over the mid shaft of the right fourth metacarpal and his assessment included

possible metacarpal fracture with limitations not lasting more than 12 months. (TR. 413-14).

Regardless, Plaintiff continued to complain about and receive treatment for hand and wrist

pain through 2010. However, as Defendant correctly points out, although Plaintiff’s doctors

note her complaints, they do not indicate objective observations concerning Plaintiff’s wrists

or hands other than that she is wearing wrist braces. (See Defendant’s Brief, pp. 10-11).

Likewise, although Dr. Rothbaum suggested manipulative limitations, he did not indicate a

specific reason to support his opinion that such limitations would not last more than 12

months.8

 What is clear is that Plaintiff was diagnosed in 2007 with inflammatory arthritis

in her hands and wrists (see TR. 248) and there is nothing in the record to support the

conclusion that such diagnosis was mistaken or that the condition has abated over time.

Instead, Plaintiff has consistently complained about hand and wrist pain and she has received

treatment for same.

Dr. Rothbaum’s opinion can be read to indicate that at the time of the 2008 consulting

examination, Plaintiff had some manipulative limitations with regard to her upper

extremities. Arguably, this opinion is consistent with opinions from Drs. Renteria and Garcia

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9

Although the ALJ did not find that Plaintiff suffered from a severe impairment

regarding her hands and wrists, the ALJ “[i]n assessing RFC,...must consider limitations and

restrictions imposed by all of an individual’s impairments, even those that are not ‘severe.’

While a ‘not severe’ impairment(s) standing alone may not significantly limit an individual’s

ability to do basic work activities, it may–when considered with limitations or restrictions

due to other impairments–be critical to the outcome of a claim. For example, in combination

with limitations imposed by an individual’s other impairments, the limitations due to such

a ‘not severe’ impairment may prevent an individual from performing past relevant work or

may narrow the range of other work that the individual may still be able to do.” SSR 96-8p,

1996 WL 374184, *5 (July 2, 1996).

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that Plaintiff had such limitations. A divergence occurs based on Dr. Rothbaum’s opinion

that the limitations would not last more than 12 months. The proximity in time between

Plaintiff’s fall and Dr. Rothbaum’s examination calls into question Dr. Rothbaum’s

assessment concerning the duration of Plaintiff’s manipulative limitations. Given Dr. Swe’s

2007 diagnosis and Plaintiff’s continued complaints of wrist and hand pain through 2010, the

ALJ’s decision to accept Dr. Rothbaum’s 2008 opinion that such limitations would resolve

within 12 months without having a specific basis therefor is especially troubling considering

that all three jobs the ALJ, through VE testimony, identified Plaintiff could do require

“handling” which may include “fasten[ing] parts together by hand, or using handtools or

portable power tools” (DOT 706.687-010), use of scissors to trim garments, and folding

garments. (DOT 789.687-070). See Dictionary of Occupational Titles–Parts (4th ed., Rev.

1991) (stating that “7” listed as the sixth digit in the worker function code of the

occupational definition indicates that “handling” things is involved); see also DOT 230.687-

010 (stating that an advertising material distributor distributes merchandise samples,

coupons). 

On the instant record, the ALJ’s adoption Dr. Rothbaum’s opinion that the specified

limitations on Plaintiff’s upper extremities would not last more than 12 months is not

supported by specific and legitimate reasons.9

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3. Plaintiff’s Mental Limitations

Sharon Megalthery, M.D., Plaintiff’s treating psychiatrist, assessed “M[ajor]

D[epressive] D[isorder], chronic, recurrent without psychotic features, P[ost] T[raumatic]

S[tress] S[yndrome] with dissociation; G[eneralized] A[nxiety] D[isorder]; Somatoform

Disorder Not Otherwise Specified; Trichotillomania.” (TR. 605). Dr. Megalthery opined

that Plaintiff was moderately limited, when triggered, in: activities of daily living;

maintaining social functioning; and concentration, persistence or pace. (TR. 701). Dr.

Megalthery also found that Plaintiff has experienced two episodes of decompensation, each

of extended duration. (Id.). At the hearing, when Plaintiff’s counsel asked the VE if a

person who had moderate restrictions in activities of daily living, maintaining social

functioning, and in concentration, persistence and pace could perform the jobs identified, the

VE answered “No....” (TR. 72).

When considering Dr. Megalthery’s opinion regarding Plaintiff’s moderate limitations

(see TR. 701), the ALJ stated, in pertinent part:

This assessment is given evidentiary weight to the extent it is consistent with

the above residual functional capacity finding the claimant capable of simple

work with limited contact with the general public. The undersigned notes that

there is no evidence of any episodes of decompensation in the record.

(TR. 27).

Plaintiff initially argued that the ALJ’s rejection of Dr. Megalthery’s opinion “without

comment” was erroneous given that the opinion was uncontroverted and could be rejected

only for clear and convincing reasons. (Plaintiff’s Brief, p. 10). Defendant countered that

the ALJ in fact adopted Dr. Megalthery’s opinion that Plaintiff had moderate

difficulties in maintaining social functioning and that she had moderate

deficiencies of concentration, persistence or pace. (T[R]. 23, 701). Indeed,

when evaluating Plaintiff’s mental impairment...the ALJ reasonably found that

Plaintiff had moderate difficulties with social functioning and moderate

difficulties maintaining concentration, persistence, or pace in accordance with

Dr. Megalthery’s opinion (T[R]. 23, 701)....The ALJ then reasonably

accounted for Plaintiff’s limitations in social functioning and maintaining

concentration, persistence, or pace by limiting her to jobs that involved only

simple work with minimum contact with the general public in his [sic] residual

functional capacity finding....The ALJ, however, declined to adopt Dr.

Megalthery’s opinion that Plaintiff had moderate restriction in activities of

daily living and that she had experienced one or two episodes of

decompensation, each of extended duration.

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(Defendant’s Brief, pp. 14-15). Plaintiff replies that the ALJ “failed to give any reasons for

rejecting parts of the doctor’s opinion. While not obligated to accept the doctor’s opinion,

the ALJ must give pertinent reasons for rejecting some parts of the opinion and not others.”

(Plaintiff’s Reply, p. 4). 

Given Plaintiff’s concession that the ALJ accepted some “parts” and rejected other

portions of Dr. Megalthery’s opinion, what is left for consideration, then, is the ALJ’s

findings that Plaintiff was not moderately restricted in activities of daily living and there was

no evidence of episodes of decompensation.

The opinions of treating physicians, like Dr. Megalthery, are generally given greater

weight than those of other physicians because of the treating physicians' intimate knowledge

of the claimant's condition. Aukland v. Massanari, 257 F.3d 1033, 1037 (9th Cir.2001).

Further, to reject the uncontroverted opinion of a treating physician, the ALJ is required to

provide clear and convincing reasons. Connett, 340 F.3d at 874. The parties do not dispute

that Dr. Megalthery’s opinion was uncontroverted. The ALJ’s statement that Dr.

Megalthery’s “assessment is given evidentiary weight to the extent it is consistent with the...”

ALJ’s RFC finding (TR. 27) does not fulfill the ALJ’s burden of stating clear and

convincing reasons why Dr. Megalthery’s opinion was rejected with regard to restrictions

on Plaintiff’s daily activities. In rejecting a doctor’s opinion, “[t]he ALJ must do more than

offer [her] conclusions. [She] must set forth [her] own interpretations and explain why they,

rather than the doctor[‘]s[], are correct.” Reddick, 157 F.3d at 725. Elsewhere in her

decision, the ALJ, without referring to Dr. Megalthery’s assessment, concluded that Plaintiff

was only mildly restricted in activities of daily living: “The claimant is able to prepare simple

meals, care for her pets, do some limited household chores, go outside and drive on

occasion.” (TR. 23). However, the ALJ has noted Plaintiff’s testimony that she last drove

in 2008 (TR. 25) and the ALJ omitted reference to Plaintiff’s testimony that she must rest

when doing household chores and that she takes more time than is typically required to

accomplish them. The ALJ has provided no clear and convincing reasons why her own

conclusions concerning Plaintiff’s daily activities should be accorded more weight than

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10Defendant argues that the form completed by Dr. Megalthery is not used in the RFC

assessment, but is instead pertinent to rating the severity of mental impairments as steps 2

and 3. (Defendant’s Brief, p. 15). At step 2, the ALJ determined that Plaintiff had only mild

restrictions in activities of daily living, despite Dr. Megalthery’s opinion that such limitations

were moderate. (See TR. 22-23). The ALJ’s finding at step 2 informed her subsequent RFC

assessment. Yet, the ALJ never provided sufficient reasons for discounting Dr. Megalthery’s

opinion that Plaintiff was moderately restricted in activities of daily living.

11The regulations provide that:

Episodes of decompensation are exacerbations or temporary increases in

symptoms or signs accompanied by a loss of adaptive functioning, as

manifested by difficulties in performing activities of daily living, maintaining

social relationships, or maintaining concentration, persistence, or pace.

Episodes of decompensation may be demonstrated by an exacerbation in

symptoms or signs that would ordinarily require increased treatment or a less

stressful situation (or a combination of the two). Episodes of decompensation

may be demonstrated by an exacerbation in symptoms or signs that would

ordinarily require increased treatment or a less stressful situation (or a

combination of the two). Episodes of decompensation may be inferred from

medical records showing significant alteration in medication; or

documentation of the need for a more structured psychological support system

(e.g., hospitalizations, placement in a halfway house, or a highly structured and

directing household); or other relevant information in the record about the

existence, severity, and duration of the episode.

20 C.F.R. Pt. 4, Subpt. P, App. 1 §12.00(C)(4).

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treating Dr. Megalthery’s opinion. Defendant states that Plaintiff was able to visit with her

children, go grocery shopping with her boyfriend, and was assessed Global Assessment of

Functioning scores “that ranged from 60 to 75, which either indicated that her symptoms

ranged from being moderate to being transient....” (Defendant’s Brief, p. 15). Defendant’s

post-hoc justifications cannot serve as sufficient predicate for agency action. See Pinto v.

Massanari, 249 F.3d 840, 848 (9th Cir. 2001) (“we cannot affirm the decision of an agency

on a ground that the agency did not invoke in making its decision.”); Vista Hill Found. v.

Heckler, 767 F.2d 556, 559 (9th Cir. 1985) (same).10 

The ALJ also stated that the record did not reflect evidence of decompensation. (TR.

27).11 Plaintiff does not cite to evidence that suggests this finding is in error. 

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4. Lay Witness Testimony

Plaintiff contends that the ALJ rejected statements from lay witnesses without

providing any reason. (Plaintiff’s Brief, p. 12). Lay testimony regarding a claimant’s

symptoms is competent evidence that the ALJ must consider unless “he or she expressly

determines to disregard such testimony and gives reasons germane to each witness for doing

so.” Lewis v. Apfel, 236 F.3d 503, 511 (2001) (citation omitted). 

Plaintiff submitted lay witness statements from her daughter, Veronica Canez, and a

friend, Melissa Monreal. (Defendant’s Brief, p. 21). Defendant asserts that “Plaintiff ignores

that the ALJ specifically noted that these lay witness statements essentially supported the

testimony of Plaintiff that she had disabling symptoms and limitations; yet the ALJ rejected

these lay witness statements because they were not substantiated by the overall medical

evidence, as discussed in the evaluation of Plaintiff’s credibility.” (Id.). In light of the

Court’s decision supra, at IV.C.1., that the ALJ improperly rejected Plaintiff’s credibility

which, in turn, may have affected the ALJ’s assessment of the medical evidence, the ALJ’s

reasons for rejecting the lay witness testimony is undermined on the instant record.

5. Remand

Plaintiff requests that the Court either reverse the Commissioner’s decision and grant

benefits or, alternatively, remand for further proceedings. (Plaintiff’s Brief, p.1; Plaintiff’s

Reply, p. 6).

"'[T]he decision whether to remand the case for additional evidence or simply to

award benefits is within the discretion of the court.'" Rodriguez v. Bowen, 876 F.2d 759, 763

(9th Cir. 1989) (quoting Stone v. Heckler, 761 F.2d 530, 533 (9th Cir. 1985)). "Remand for

further administrative proceedings is appropriate if enhancement of the record would be

useful." Benecke v. Barnhart, 379 F.3d 587, 593, (9th Cir. 2004) (citing Harman v. Apfel,

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211 F.3d 1172, 1178 (9th Cir. 2000)). Conversely, remand for an award of benefits is

appropriate where:

(1) the ALJ failed to provide legally sufficient reasons for rejecting the

evidence; (2) there are no outstanding issues that must be resolved before a

determination of disability can be made; and (3) it is clear from the record that

the ALJ would be required to find the claimant disabled were such evidence

credited.

Benecke, 379 F.3d at 593(citations omitted). Where the test is met, "we will not remand

solely to allow the ALJ to make specific findings....Rather, we take the relevant testimony

to be established as true and remand for an award of benefits." Id. (citations omitted). 

 Here, remand for an immediate award of benefits is inappropriate given that the

record remains unclear regarding limitations, if any, on Plaintiff’s upper extremities. The

proximity in time between Plaintiff’s fall and Dr. Rothbaum’s examination calls into question

Dr. Rothbaum’s opinion that limitations on handling, fingering, and feeling would resolve

within 12 months, thus requiring further development of the record. See Tonapetyan, 242

F.3d at 1150 (the ALJ has a duty to develop the record fully and fairly, even when the

claimant is represented by counsel). Moreover, the ALJ has not met her burden of stating

clear and convincing reasons for rejecting Dr. Megalthery’s opinion regarding Plaintiff’s

restrictions in activities of daily living. Based on the VE’s testimony, whether Plaintiff is

mildly or moderately restricted in activities of daily living may affect whether Plaintiff is

able to perform other work. (See TR. 72). As Defendant points out, at steps 4 and 5, the ALJ

must make “a more detailed [mental RFC] assessment by itemizing various functions

contained in the broad categories found in paragraphs B and C of the adult mental disorders

listings in12.00 of the Listing of Impairments...” and summarized in the form similar to that

completed by Dr. Megalthery. (Defendant’s Brief, pp. 14-15 (quoting SSR 96-8p, 1996 WL

374184 at *4 (1996))). Further, “[i]n cases where the testimony of the vocational expert has

failed to address a claimant’s limitations as established by improperly discredited evidence,

[the Ninth Circuit has] consistently...remanded for further proceedings rather than payment

of benefits.” Harmon, 211 F.3d at 1180 (citation omitted); see also Hill v. Astrue, 698 F.3d

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1153, 1162 (9th Cir. 2012). Alternatively, on remand, “the...[Commissioner] may decide to

award benefits.” See McAllister v. Sullivan, 888 F.2d 599, 604 (9th Cir. 1989).

V. CONCLUSION

For the foregoing reasons, remand for further proceedings is necessary to consider

whether Plaintiff is disabled under the Social Security Act. Accordingly, 

IT IS ORDERED that the Commissioner’s final decision in this matter is

REMANDED for further proceedings consistent with this Order.

The Clerk of Court is DIRECTED to:

(1) amend the docket to reflect that Carolyn W. Colvin, Acting Commissioner of

the Social Security Administration, has been substituted as the named

Defendant in this action pursuant to Fed.R.Civ.P. 25(d); and

(2) enter judgment and close this case.

DATED this 15th day of March, 2013.

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