Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_10-cv-00544/USCOURTS-azd-4_10-cv-00544-0/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 (DIWC)

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UNITED STATES DISTRICT COURT 

DISTRICT OF ARIZONA 

Estevan Luis Duran Montez, 

 Plaintiff, 

vs. 

Michael J. Astrue, Commissioner of the

Social Security Administration, 

 Defendant. 

CV 10-0544-TUC-FRZ (JR) 

REPORT AND 

RECOMMENDATION 

 

 Plaintiff Estevan Luis Duran Montez brought this action pursuant to 42 U.S.C. 

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

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

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

appeal: whether the Administrative Law Judge (ALJ) failed to accord the appropriate 

weight to treating physician testimony; and whether the ALJ improperly evaluated 

Plaintiff’s pain testimony. Pending before the court is an Opening Brief filed by 

Plaintiff (Doc. 19), the Commissioner’s Opposition (Doc. 20), and Plaintiff’s Reply 

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Brief (Doc. 21). Based on the pleadings and the administrative record submitted to 

the Court, the Magistrate Judge recommends that the District Court, after its 

independent review, remand this case for further proceedings. 

I. PROCEDURAL HISTORY 

 Plaintiff filed an application for disability insurance benefits in July 2007, 

alleging disability since October 16, 2006, due to injuries he sustained in a 

motorcycle accident on that date. (Administrative Record (AR) 35, 131-35, 676-81.) 

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

and upon reconsideration. (AR 67-69, 72-75, 77-79.) Plaintiff requested a hearing 

before an ALJ. (AR 80-81.) On July 22, 2009, he appeared with counsel and testified 

before an ALJ. (AR 28-66.) In a decision issued on November 10, 2009, the ALJ 

concluded that Plaintiff was not disabled within the meaning of the SSA. (AR 12-

27.) The Appeals Council denied Plaintiff’s request for review of the ALJ’s 

decision. (AR 1-4.) This appeal followed. 

II. FACTUAL HISTORY 

 A. Plaintiff’s Background 

Plaintiff was born on May 26, 1954, making him 52 years-old at the alleged 

onset of his disability and 55 at the time of the hearing. (AR 33, 148.) He has a high 

school education and some college. (AR 33.) He worked for 18 years as a 

surgical/patient technician at a hospital. (AR 33, 153-54.) 

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B. Medical Records 

 On October 16, 2006, Plaintiff was in a motorcycle accident and sustained a 

dislocated left thumb, a neck strain, back pain and aggravation of pre-existing right 

shoulder pain. (AR 152, 232-36.) On referral from his treating physician, 

Christopher Wintzer, M.D., Plaintiff began seeing Arlo Brakel, M.D., a 

neurosurgeon, for his musculoskeletal complaints and, in October, Plaintiff began 

seeing Joseph Sheppard, M.D., for his thumb injury. (AR 627-650 

 Plaintiff’s first visit to Dr. Brakel was on December 28, 2006. (AR 271-74.) 

The doctor found Plaintiff had a reduced range of motion of this neck and right 

shoulder, blunted right triceps reflexes, and signs of possible cervical radiculopathy. 

Plaintiff also had a reduced range of motion of his low back, positive straight leg 

raise testing (a sign of radiculopathy), blunted ankle jerks, and a painful gait. (Id.) 

After examination, Dr. Brakel’s impression included a cervical sprain with suspicion 

of root compression, suspicion of a mid-thoracic compression fracture, lumbar 

sprain, right brachial plexopathy, rib contusions and dislocation of the left thumb 

requiring reduction and casting. (AR 274.) Dr. Brakel indicated that Plaintiff was 

disabled from his employment due to the thumb dislocation and due to “ongoing 

spinal disorders that have not been accurately identified or diagnosed.” He 

recommended MRI studies of the cervical and thoracic spine and CT scanning of the 

lumbar spine. (Id.) 

 In January 2007, Plaintiff saw Dr. Sheppard about his thumb and the Plaintiff 

reported improved motion and function but continued strength deficit. (AR 645.) In 

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April, Dr. Sheppard noted that Plaintiff’s left thumb had intermittent symptoms of 

instability and “mild” subluxation, but preserved mobility and intact sensation. (AR. 

644.) 

 On January 25, 2007, the MRI and CT studies recommended by Dr. Brakel 

were performed. (AR 276-78.) The lumbar CT scan revealed left foraminal 

narrowing with impingement of the exiting left L5 nerve root and “a shallow broad 

based posterior disc bulge” at the same level. (AR 276.) The MRI of the cervical 

spine revealed foraminal narrowing and disc osteophyte complex at C5-6 and C6-7 

with thinning of the cerebral spinal fluid space. (AR 278.) On February 21, 2007, 

Dr. Brakel reviewed the studies with the Plaintiff and noted that he continued to 

experience neck pain and low back pain, radiating from the right buttock down the 

thigh, but without weakness. (AR 268.) 

 As for the studies, Dr. Brakel noted that they were “very illuminating.” He 

reported that the cervical spine imaging showed “advanced degenerative disc disease 

at C5-6 and C6-7 with annular end plate spurring and uncovertebral joint 

hypertrophy resulting in a degree of cross sectional and foraminal stenosis.” (AR 

268.) Dr. Brakel interpreted the lumbar imaging as showing a bilateral “potential for 

L5 root impingement in its neural exit foramen at L5-S1 where there is significant 

facet arthropathy encroaching upon the neural exit.” He noted the disc protrusion at 

L3-4 and L4-5 and stenosis of the cross sectional area of the canal. (Id.) On 

examination, Dr. Brakel noted a moderately decreased range of motion in the neck 

with signs of radiculopathy, blunted triceps and biceps reflexes, and some reduced 

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strength due to pain. (AR 269.) He recommended continued conservative therapies, 

such as aqua therapy and cervical traction, but provided an epidural steroid injection 

for the lumbar anomaly. Dr. Brakel scheduled him for another visit in March “before 

a determination for ability to return to work is made.” (AR 269-70.) 

 In March 2007, Dr. Brakel completed a form in connection with Plaintiff’s 

claim for long-term disability benefits. (AR 259-261.) He stated that Plaintiff had 

been placed “off work” since his motorcycle accident on October 16, 2006, and that 

he remained totally disabled from his occupation as a patient care technician. (AR 

260.) The doctor found that Plaintiff could lift/carry 10 pounds and push/pull 20 

pounds; sit 20 minutes at a time for 6 hours total, stand 5 minutes at a time for 2 

hours total, and walk 10 minutes at a time for 2 hours total. He indicated Plaintiff 

should not bend, stoop, crouch, crawl, or kneel, and that he should do “minimal” 

overhead reaching. He noted no limitations on fine fingering or gross handling 

activities. (AR 260-61.) 

 Later that month, in an office record dated March 29, 2007, Dr. Brakel 

reported that when the Plaintiff turned his head to the right, there is radiation down 

the right arm, and that his low back pain occasionally radiated down his right leg. 

(AR 266.) The Plaintiff had a diffusely reduced range of motion in the neck, 

shoulder and lumbar spine. (Id.) The doctor reiterated the Plaintiff’s spinal 

abnormalities, and noted that there was some delay in obtaining approval for aqua 

therapy and a steroid injection. The Plaintiff was kept off work until July 2007 when 

Dr. Brakel expected to provide an updated evaluation. (AR 267.) 

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 From April to July 2007, steroid injection therapy was administered to 

Plaintiff’s lower back. (AR 275, 283-84.) He reported that his pain was reduced 

from 7/10 to 6/10 on the visual analogue scale. (AR 283-84.) Plaintiff also tried 

physical therapy from May to June 2007. An October 2007 noted indicates that he 

was discharged from further physical therapy because no further treatment was 

“authorized per insurance or per physician. (AR 332.) On discharge, the physical 

therapist noted that the Plaintiff’s pain had slightly decreased, but remained at 6-

7/10, and stated that the goal of enabling him to return to his activities of daily living 

were not achieved. (Id.) 

 In October 2007, Dr. Sheppard noted that Plaintiff’s left thumb was healing, 

but “with very mild subluxation without significant instability” and intact tendon 

function. (AR 646-50.) 

 On November 2007 and January 2008, neurosurgeon Niteen Andakar, M.D., 

an associate of Dr. Brakel’s, saw Plaintiff for a surgical consultation. (AR 374-75.) 

He reviewed the imaging studies from January 2007 and stated that the Plaintiff’s 

MRI showed he “does have disk osteophyte complexes, however, these are off to the 

left side.” On the CT scan of the lumbar spine, Dr. Andakar found “significant face 

arthropathy at the [L5-S1] facet joints,” and “some moderate stenosis . . . .” (AR 

374.) A new MRI was ordered and continued “to show facet joint changes,” but the 

doctor did not see “any severe foraminal or central stenosis” at the L5-S1 level. (AR 

376). The doctor suggested that the Plaintiff wean himself from the Percocet he was 

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taking, continue to pursue conservative treatment such as epidural steroid shots and 

acupuncture. (AR 375-76.) 

 On December 13, 2007, the Plaintiff saw Edward Suarez, M.D., a state agency 

physician. (AR 357-363.) After examining the Plaintiff, Dr. Suarez concluded that 

he was “basically normal” with only mild cervical spine and lumbosacral spine 

disease. He found that the Plaintiff’s shoulder separation left him with “minimal 

discomfort at 160 degrees of forward elevation.” (AR 359.) Dr. Suarez opined that 

Plaintiff had no limitations, except for lifting of 40-45 pounds occasionally and 35-40 

pounds frequently. (AR 359, 353-55.) He indicated that Plaintiff “was basically 

normal. He is driving. He should be able to return to any activity that he chooses.” 

(AR 359.) 

 On January 24, 2008, Plaintiff had a second surgery on his left thumb to 

address “loosening of his fusion site and painful retained hardware.” (AR 382-83.) 

On February 28, 2008, the thumb was healing well, and the pain was improved, but 

Plaintiff was still in a cast and restricted from doing any lifting or pushing for a 

month. (AR 395.) A month later, Plaintiff reported that he was satisfied with his 

progress, but that he was still experiencing pain and weakness in the thumb. (AR 

552.) On follow-up in May, Plaintiff was satisfied with the function of his left 

thumb, but reported increasing symptoms in his right thumb. Dr. Sheppard discussed 

ligament reconstruction and fusion and the Plaintiff indicated that he would like to 

proceed with surgical intervention on the right thumb. (AR 632.) 

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 From March to May 2008, Plaintiff underwent acupuncture treatments for his 

musculoskeletal pain with Chun Wah Ho, M.D. Dr. Ho reported that Plaintiff 

suffered from chronic lower back pain, without radiculopathy or muscle atrophy. 

(AR 401, 436.) 

 In April 2008, Charles Fina, M.D., a state agency physician, completed a 

Physical Residual Functional Capacity Assessment and found Plaintiff could 

lift/carry 20 pounds occasionally and 10 pounds frequently; stand/walk or sit about 6 

hours each in an 8-hour day; frequently balance, stoop, kneel, crouch, and crawl; 

frequently reach with his right arm and handle and finger with his left hand; 

occasionally climb ramps and stairs; but never climb ladders, ropes, or scaffolds. 

 On June 19, 2008, Dr. Sheppard performed right thumb surgery for posttraumatic carpometacarpal joint arthritis. (AR 482-83.) Eleven days later, the doctor 

reported that he was healing without complication (AR 543.), and on July 29, 2008, 

the doctor reported that his wound was healed, the thumb was stable, and there was 

“minimal pain with axial loading.” (AR 628, 662.) 

 Dr. Brakel saw Plaintiff later in June 2008 for an updated evaluation. Dr. 

Brakel noted that he remained disabled “due to multiple health problems, with 

particular contribution from a motorcycle accident . . . in which he sustained multiple 

musculoskeletal, joint and spinal injuries.” (AR 812.) He noted that despite 

intensive conservative therapies, Plaintiff continued “to experience neck pain with 

radiation to the right arm; Low back pain radiates to his legs—predominantly to the 

right.” (Id.) Dr. Brakel conducted a neurological examination and reported: 

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Upper extremity strength is symmetric at 5/5 in all muscle groups; 

Sensation is intact in all modes in all dermatomes. Reflexes are 2+ and 

symmetric at biceps, triceps and brachioradialli. There is no 

incoordination. Fine motor movements of hands are intact and 

coordinated. There is no evidence of peripheral nerve impingement. 

Range of motion of neck is diffusely decreased; Positive Spurling’s 

sign to the Right; right triceps reflex is blunted relative to left. Range 

of motion of the lumbar spine is limited in flexion secondary to 

induction of lumbar spasm. Ankle jerks are blunted relative to knee 

jerks. Positive straight leg raising on right at 70 degrees. Gait is 

antalgic on the right. No fasciculation or limb wasting is noted. No 

bowel or bladder control issues are raised. 

(AR 813-14.) 

 On September 2, 2008, Plaintiff saw Dr. Sheppard on follow-up for his right 

thumb and with a complaint of right shoulder pain. Dr. Sheppard noted “what 

appears to be an AC separation and rotator cuff irritation,” and recommended an 

arthrogram to determine the integrity of Plaintiff’s rotator cuff. (AR 627.) The 

radiologist’s impression included a finding “in the right acromioclavicular joint 

suggestive of chronic ligamentus disruption,” and “[d]egenerative changes in the 

right glenhhumeral joint.” (AR 664.) Plaintiff’s right thumb was reported by the 

radiologist as stable in appearance. (AR 661.) 

 On September 3, 2008, Plaintiff saw Dr. Brakel, who reported that Plaintiff 

continued to suffer from neck pain syndrome, with significant degenerative disc 

disease and spondylosis at C5-6 and C6-7, and low back syndrome with advanced 

degenerative disc disease with high-grade stenosis at L4-5 and feature of right L5 

radiculopathy. Dr. Brakel stated that Plaintiff “remains totally disabled from his 

work position and this is for the foreseeable future.” (AR 688.) 

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 A month later, on October 2, 2008, Dr. Brakel completed a form noting that 

Plaintiff had lumbar and cervical stenosis and radicular pain from both. He reported 

Plaintiff’s pain level as moderate and precluding “detailed/complex skills.” (AR 

682.) He opined that Plaintiff did not have the ability for “simple grasping” and 

could not use his hands for repetitive motion. Dr. Brakel estimated that Plaintiff 

could never lift more than 10 pounds, could rarely lift 5-10 pounds, and could 

occasionally lift less than 5 pounds. He believed that the Plaintiff could sit for four 

hours and stand for two during an eight-hour day. (AR 683.) 

 During the same period, Dr. Ho completed a similar form and indicated that 

Plaintiff suffered from “severe” pain associated with his lumbar and cervical spine 

and his wrists that precluded skilled tasks, but not unskilled tasks. Dr. Ho stated that 

Plaintiff could lift 0-4 pounds occasionally and 5-10 pounds rarely; could sit two 

hours a day and stand/walk one hour a day; could occasionally bend and reach above 

shoulder level; could not squat, crawl, or climb; could not grasp, push, pull, or do 

fine manipulation with either hand; and need to change positions during the day. AR 

561-63. 

 Plaintiff next saw Dr. Brakel on November 5, 2008. His evaluation largely 

remained the same and he noted that Plaintiff’s persistent radiculopathies had not 

responded to conservative management. Dr. Brakel requested MRI studies to assess 

the anatomy of Plaintiff’s cervical and lumbar spines. He also noted that he would 

review past EMG studies. (AR 766.) 

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 On November 11, 2008, Plaintiff saw Christopher Wintzer, M.D., in relation 

to his claim for private long-term disability benefits. Dr. Wintzer reported that 

Plaintiff had a full range of motion of his arms, but grinding with right shoulder with 

motion, reduced range of motion and grip strength in his hands, and reduced range of 

motion of the back. (AR 694-96). He opined that Plaintiff could lift up to 9 pounds, 

sit 30 minutes for 2 hours total and could stand/walk 20 minutes for 2 hours total; 

occasionally bend, and never squat, crawl, climb, reach above should level, do simple 

grasping, pushing/pulling, or fine manipulation with his right hand, or engage in 

repetitive motion tasks with either hand. He indicated that Plaintiff should also avoid 

heights and machinery. (AR 690-91). 

 In a radiology report covering an arthrogram study of the right shoulder 

performed on November 3, 2008, it was reported that there was no evidence of “fullthickness or high-grade partial-thickness articular surface rotator cuff tear.” (AR 

770-71). An MRI on the same date revealed evidence of a acromioclavicular 

separation, evidence of adhesive capsulitis, a partial tear of the muscle and tendon, 

and degenerative fraying. (AR 772). Based on the studies, Dr. Sheppard 

recommended a course of rotator cuff strengthening and continued non-operative 

management. (AR 768). 

 Nerve studies of Plaintiff’s hands on November 24, 2008, showed mild right 

and mild-moderate left carpal tunnel syndrome, but did not explain Plaintiff’s 

continued complaints of right fourth and fifth digit parathesias. Polyphasia was 

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found in the first dorsal interosseus muscles on the right and were reported as 

indicating chronic distal ulnar nerve injury. (AR 817-19). 

 Dr. Brakel again saw Plaintiff on December 17, 2008 to review the MRI study 

of his cervical spine. He noted a “rather substantial degree of degenerative 

abnormality at C5-6 and C6-7,” and disc and osteophyte protrusion, and his 

impression was largely unchanged. (AR 779-80). A subsequent MRI of the lumbar 

spine , conducted in March 2009, showed disc bulging and mild foraminal narrowing 

at L3-5 and degenerative disease with mild left foraminal narrowing at L5-S1. (AR 

853-54). 

 On March 17, 2009, Plaintiff had a second surgery on his right thumb. (AR 

825-26). Subsequent records show progressive consolidation of the right thumb, and 

after the cast was removed, Plaintiff was advised to avoid rigorous pinching, lifting, 

pushing, pulling, or carrying. (AR 841-43). 

 In June 2009, Dr. Brakel saw Plaintiff and his impressions were unchanged. 

He indicated that Plaintiff would be seen quarterly thereafter. (AR 847-50). In July 

2009, Plaintiff was given an epidural steroid injection in the area of his lumbar spine 

to address his low back and right leg pain. (AR 857). 

 Plaintiff returned to Dr. Sheppard for follow-up after the revision of his right 

thumb surgery. In June 2009, he had no complaints of pain, but radiographs showed 

incomplete consolidation and the doctor was “fearful that if he does not progress to 

fusion, then iliac crest bone grafting will be necessary.” (AR 861). By July, 

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radiographs showed progressive consolidation and Plaintiff reported gradual 

improvement in strength and pain symptoms. (AR 860). 

C. Hearing Testimony 

 1. Plaintiff’s Testimony

 Plaintiff testified that he was in a motorcycle accident on October 16, 2006. 

(AR 35, 38). He reported having pain in his neck that radiated into his right arm and 

fingers, pain in his low back that radiated down his right leg, pain in his right 

shoulder, and pain in both thumbs. (AR 39, 49). He reported two surgeries on his 

right thumb and two surgeries on his left thumb (AR 38-40), and that a third surgery 

on his right thumb was possible. (AR. 46). He testified that his right thumb was 

“weak,” and that Dr. Brakel and advised him to “take it easy” with lifting and 

moving anything with that hand. (AR 48). He said he had received injections in his 

low back and that surgery was possible. (Id.) He reported that he could stand for 

only 15 to 30 minutes, walk for 15 minutes, and sit for 30 to 45 minutes. (AR 40-

41). 

 Plaintiff reported his daily activities as including watering outdoor plants, 

loading the dishwasher, straightening the house, looking after his three dogs, reading 

the newspaper, watching television, and sometimes attending church. (AR 41-42). 

He had a few friends whom he sometimes visited for dinner. (Id.) He reported using 

a knife and fork to eat and that he had difficulty getting dressed so he usually wears 

shorts and slip-on sandals. (AR 44-45). He has problems gripping and writing and 

generally writes only short notes. (AR 44). He sits in his recliner for approximately 

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four hours in the daytime and intermittently lays down or walks due to the pain in his 

lower back, neck and right leg. (AR 49). He also has trouble concentrating and 

remembering information and often needs help from his fiancé. (AR 50). 

 2. Vocation Expert Testimony

 The ALJ asked Vocation Expert (VE) Ruth Van Fleet whether there would be 

any jobs for an individual of Plaintiff’s age (55) and education (high school and some 

college), with Plaintiff’s work experience (patient technician), with the following 

limitations: 

• lift/carry 35 pounds occasionally and 40 pounds frequently; 

• occasionally bend; 

• avoid work above shoulder height with the right arm; 

• occasionally engage in fine or gross manipulation and fingering; 

 and 

• avoid excessive dust, fumes, or gases 

(AR 55-56, 60-61). The VE testified that such an individual could not perform 

Plaintiff’s past work, but could perform other occupations in the national economy, 

including home attendant companion and security guard. (AR 58). The VE noted 

that he could work in these occupations if his pain levels were moderate but 

controlled, but could not do this work if his pain levels were characterized as 

“severe.” (AR 59). 

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D. ALJ’s Decision 

 The ALJ found that Plaintiff had the following severe impairments: 

cervical/lumbar spine disorder, right shoulder disorder, and status post surgeries on 

both thumbs. (AR 14-20.) Based on testimony from a vocational expert, the ALJ 

concluded that Plaintiff could not return to his past relevant work, but found that 

“considering the [Plaintiff’s] age, education, work experience, and residual functional 

capacity, [he] is capable of making a successful adjustment to other work that exists 

in significant numbers in the national economy.” (AR 26.) 

III. STANDARD OF REVIEW

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

as: 

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

medically determinable physical or mental impairment which can be 

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

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

20 C.F.R. § 404.1505. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

404, subpt. P, app.2 (the “grids”). 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cir.1990). 

III. DISCUSSION 

 Plaintiff argues that the Commissioner’s denial of benefits is not supported by 

substantial evidence. Plaintiff’s Opening Brief (Doc. 19), pp. 12-16. He contends 

that the ALJ failed to accord the proper weight to the testimony of his treating 

physicians and failed to properly apply the excess symptom analysis. Id. The 

Commissioner responds that the ALJ properly considered and evaluated the medical 

source opinions and Plaintiff’s credibility, and that the decision is supported by 

substantial evidence. Defendant’s Memorandum in Opposition to Opening Brief

(Doc. 20), pp. 13-23. 

A. Evaluation of medical opinions 

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

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

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

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

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

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

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

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

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

Cir.1983)). “The ALJ Can ‘meet this burden by setting out a detailed and thorough 

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

thereof, and making findings.” Thomas v. Barnhart, 278 F.3d 947, 957 (9th

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

serve as substantial evidence when the opinions are consistent with independent 

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

 In the decision, the ALJ extensively relies on Dr. Suarez’s opinions to 

discount the opinions of all of the treating physicians generally, and those of Dr. 

Brakel specifically, by characterizing Dr. Suarez’s opinion as “generally consistent 

with the medical evidence.” (AR 22-24.) To properly rely on Dr. Suarez’s opinions 

as a non-treating physician, the ALJ was obligated to illustrate how those opinions 

were consistent with independent clinical findings or other evidence in the record. 

Thomas, 278 F.3d at 957. However, rather than explain how Dr. Suarez’s opinions 

were supported by other evidence in the record, the ALJ merely conclusively states 

that Dr. Suarez’s opinion would be given “substantial persuasive weight” because it 

“is generally consistent with the medical evidence.” (AR 24.) An examination of his 

opinions, however, indicates that Dr. Suarez’s opinion was riddled with oversight 

and unexplained inconsistencies. 

 Dr. Suarez’s opinion was that Plaintiff’s “only limitation will be lifting over 

40 to 45 pounds occasionally, 35 to 40 pounds frequently, and was basically normal,” 

and “should be able to return to any activity that his [sic] chooses.” (AR 359.) In 

reaching this conclusion, Dr. Suarez completed a medical source statement wherein 

he indicated that Plaintiff could frequently climb, stoop, kneel, crouch, crawl, reach, 

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handle, finger and feel. (AR 354.) Despite the fact that much, if not all, of these 

conclusions are unsupported by anything the Court can locate in the record, Dr. 

Suarez offered nothing in the section of the statement that is provided for that 

purpose. (See AR 354.) 

 Specifically, Dr. Suarez says nothing about Dr. Brakel’s consistent opinion 

that Plaintiff was disabled due to his ongoing issues with his spinal disorders. (See

AR 274.) He fails to recognize that Dr. Brakel, relying on MRI and CT studies, 

found foraminal narrowing, a disc bulge, and nerve impingement in the lumbar spine, 

and foraminal narrowing and disc osteophyte complex in the cervical spine, and that 

Plaintiff was experiencing neck and low back pain with radiation down the thigh. 

(AR 267, 268.) Dr. Suarez also ignores that Plaintiff had steroid injections and 

physical therapy to deal with his pain. (AR 275, 332.) In short, Dr. Suarez’s finding 

that Plaintiff was “basically normal,” and could frequently crouch, crawl, stoop and 

kneel, is entirely inconsistent with the determination by Dr. Brakel’s, who was 

relying largely on clinical evidence, that Plaintiff was suffering from advanced 

degenerative cervical disc disease, and potential nerve impingement and significant 

facet arthropathy in the lumbar spine. (AR 268, 260-61.) Dr. Brakel specifically 

limited Plaintiff to lifting no more than ten pounds, and determined that he was 

unable to sit for more than 20 minutes at a time, stand for five minutes, and walk for 

ten. (AR 260-61.) He specifically stated that Plaintiff should not bend, stoop, 

crouch, crawl, or kneel. (Id.) 

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 Given that the opinions of Drs. Brakel and Suarez were at odds, the ALJ was 

required to offer a detailed and thorough summary of specific reasons supported by 

substantial evidence before rejecting the opinion of Dr. Brakel. See Carmickle, 533 

F.3d at 1164. Because the ALJ did not identify the facts and clinical evidence that 

might support Dr. Suarez’s wholesale rejection of Dr. Brakel’s opinion, Thomas v. 

Barnhart, 278 F.3d 947, 957 (9th Cir.2002), the Court rejects the ALJ’s conclusion 

and recommends that the District Court reject the ALJ’s conclusion. 

 B. Evaluation of Plaintiff’s Testimony 

 Plaintiff also challenges the ALJ’s conclusion that his allegations regarding 

the severity of his pain symptoms were exaggerated and contends that the ALJ failed 

to make specific findings justifying the decision. Opening Brief, p. 14. In making 

the credibility determination, the ALJ engages in a two-step analysis. Vasquez v. 

Astrue, 572F.3d 586, 591 (9th Cir. 2009). First, the ALJ must evaluate whether there 

is “’objective medical evidence of an underlying impairment which could reasonably 

be expected to produce the pain or other symptoms alleged.’” Id. (quoting 

Lingenfelter v. Astrue, 504 F.3d 1028, 1036 (9th Cir. 2007)). If such evidence is 

found, the ALJ must provide “specific, clear and convincing reasons” in order to 

reject the claimant’s testimony regarding pain severity. Taylor v. Comm’r of Soc. 

Sec. Admin., 659 F.3d 1228, 1234 (9th Cir.2011). In evaluating the claimant’s 

testimony, “[t]he ALJ may consider many factors in weighing a claimant’s 

credibility, including (1) ordinary techniques of credibility evaluation, such as the 

claimant’s reputation for lying, prior inconsistent statements concerning the 

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symptoms, and other testimony by the claimant that appears less than candid; (2) 

unexplained or inadequately explained failure to seek treatment or to follow a 

prescribed course of treatment; and (3) the claimant’s daily activities. If the ALJ’s 

finding is supported by substantial evidence, the court may not engage in secondguessing.” Tommasetti v. Astrue, 533 F.3d 1035, 1039 (9th Cir. 2008) (citations and 

internal quotation marks omitted). 

 Here, the ALJ found that Plaintiff did suffer from “underlying medically 

determinable impairments that could possibly produce some pain or other 

symptoms.” (AR 22.) However, the ALJ doubted the claimed severity of Plaintiff’s 

pain because Plaintiff testified that he cared for pets, did some household chores, 

watered outdoor plants, watched television, went for walks, drove a car, went to 

church and visited with friends and relatives. (Id.) Of course, the ALJ can rely on 

can consider the inconsistency between a claimed disability and the claimant’s ability 

to engage in daily activities. Lingenfelter, 504 F.3d at 1040. However, a claimant 

need not “vegetate in a dark room” in order to be eligible for benefits. Cooper v. 

Bowen, 815 F.2d 557, 561 (9th Cir. 1987) (internal citations and quotes omitted). 

 Turning to the transcript, what little testimony the ALJ obtained about the 

specifics of Plaintiff’s activities suggests that he does very little. While the ALJ 

noted that Plaintiff cared for pets, he did this by sitting outside and watching them 

while drinking coffee. (AR 42.) He would go visit people or go to church 

“sometimes” and “not on a regular basis.” (AR 41-42.) After emphasizing these less 

than demanding tasks, the ALJ entirely ignores Plaintiff’s testimony that his 

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girlfriend helps him dress and he wears shorts and sandals to make dressing easier. 

(AR 44-45.) He has trouble with zippers and buttons. (AR 45.) He sits in a recliner 

for approximately four hours during the day, but has to lay down or get up and walk 

due to pain in his lower back, neck, and right leg. (AR 49.) 

 When considering Plaintiff’s activities, the ALJ ignored many of his 

inabilities and exaggerated the extent of his abilities. More important, however, is 

that he described Plaintiff to the VE as having slight pain that was entirely controlled 

by medication. (AR 55-56.) The record does not support that characterization. No 

mention was made as to how such activities as watching dogs and television indicate 

capacities that are transferable to a work setting. See Morgan v. Comm’r Soc. Sec. 

Admin., 169 F.3d 595, 600 (9th Cir. 1999). A fair reading of Plaintiff’s abilities and 

limitations would lead a reasonable person to conclude that his pain symptoms were 

not exaggerated and that the nature of his activities were not such that his credibility 

was undermined. 

3. Remedy 

 The decision whether to remand a matter pursuant to sentence four of 42 

U.S.C. § 405(g) or to order an immediate award of benefits is within the discretion of 

the district court. Harman v. Apfel, 211 F.3d 1172, 1178 (9th Cir. 2000). Ordinarily, 

when a court reverses an administrative agency determination, the proper course is to 

remand to the agency for additional proceedings. Moisa v. Barnhart, 367 F.3d 882, 

886 (9th Cir. 2004). Generally, an award of benefits is appropriate only when: 

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

rejecting such evidence, (2) there are no outstanding issues that must be 

resolved before the 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. 

Smolen v. Chater, 80 F.3d at 1292. An award of benefits is appropriate where no 

useful purpose would be served by further administrative proceedings, or where the 

record has been fully developed. Varney v. Sec’y of Health & Human Servs., 859 

F.2d 1396, 1399 (9th Cir. 1988). The Ninth Circuit has explained that “where the 

ALJ improperly rejects the claimant’s testimony regarding his limitations, and the 

claimant would be disabled if his testimony were credited,” the testimony could be 

credited as true, and an award of benefits directed. Connett v. Barnhart, 340 F.3d 

871, 876 (9th Cir. 2003). 

 Here, the ALJ improperly rejected the opinion of Plaintiff’s treating physician, 

Dr. Brakel, by failing to offer specific reasons supported by substantial evidence 

before rejecting the opinion. The ALJ also improperly rejected Plaintiff’s pain 

testimony due to his purported ability to perform activities inconsistent with his 

alleged symptoms. It is clear that, viewing the record as a whole and crediting Dr. 

Brakel’s opinion and Plaintiff’s testimony, Plaintiff would be found disabled. 

 Additionally, the Ninth Circuit has also emphasized that “[a]llowing the 

Commissioner to decide the issue again would create an unfair ‘heads we win; tails, 

let’s play again’ system of disability benefits adjudication,” and unfairly “delay much 

needed income for claimants who are unable to work and are entitled to benefits.” 

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Benecke v. Barnhart, 379 F.3d 587, 594 (9th Cir. 2004). Thus, the Court will 

recommend that the District Court remand this matter for an award of benefits. 

IV. RECOMMENDATION

 For the foregoing reasons, the Magistrate Judge recommends the District 

Court, after its independent review, enter an order remanding the case to the ALJ for 

an award of benefits. 

 Pursuant to Federal Rule of Civil Procedure 72(b)(2), any party may serve and 

file written objections within 14 days of being served with a copy of this Report and 

Recommendation. If objections are not timely filed, they may be deemed waived. 

The parties are advised that any objections filed are to be identified with the 

following case number: CV-10-544-TUC-FRZ. 

 Dated this 8th day of January, 2013. 

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