Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_18-cv-05104/USCOURTS-cand-3_18-cv-05104-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:1383 Review of HHS Decision

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Northern District of California

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

R.C.,

1

Plaintiff,

v.

NANCY BERRYHILL,

Defendant.

Case No. 18-cv-05104-JCS 

ORDER REGARDING MOTIONS FOR 

SUMMARY JUDGMENT

Re: Dkt. Nos. 17, 20

I. INTRODUCTION

Plaintiff R.C. (“R.C.” or “Plaintiff”) brought this action seeking judicial review of the final 

decision of Defendant Nancy Berryhill, Commissioner of Social Security (the “Commissioner” or 

“Defendant”), denying R.C.’s application for Title II, Social Security Disability Insurance 

(“SSDI”) disability benefits and Title XVI, Supplemental Security Income (“SSI”) disability 

benefits. R.C. argues that the administrative law judge (“ALJ”) improperly rejected medical 

evidence and R.C.’s testimony. The parties have filed cross motions for summary judgment 

pursuant to Civil Local Rule 16-5. For the reasons stated below, R.C.’s motion is GRANTED, the 

Commissioner’s motion is DENIED, and the case is REMANDED for further administrative 

proceedings in accordance with this order.2 

1 Because opinions by the Court are more widely available than other filings, and this order 

contains potentially sensitive medical information, this order refers to the plaintiff only by his 

initials. This order does not alter the degree of public access to other filings in this action provided 

by Rule 5.2(c) of the Federal Rules of Civil Procedure and Civil Local Rule 5-1(c)(5)(B)(i).

2 The parties have consented to the jurisdiction of the undersigned magistrate judge for all 

purposes pursuant to 28 U.S.C. § 636(c).

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II. BACKGROUND

A. R.C.’s Background

1. Personal History

R.C. was born in August 1958. Administrative Record (“AR,” dkt. 12) at 174. R.C. 

alleges that his disability began on June 15, 2013 based on degenerative disc disease of cervical 

spine.3 Id. at 174, 198. R.C.’s date of last insured for Title II benefits was March 31, 2014. Id. at 

188, 194. His highest grade of school completed is the 12th grade. Id. at 199. He worked as a 

household mover from 1993 to 2009, when he was laid off. Id. at 198, 199. In 2013, R.C. admits 

to having worked part time as a cleaner for two months. Id. at 38-39. In 2014, R.C. worked parttime as a mover for three months until he was involved in an auto accident June 2014. Id. at 35-

37, 40. 

2. Medical Records

On August 5, 2012, R.C. had x-rays of his cervical spine taken that showed mild to 

moderate degenerative disk changes and mild degenerative facet changes. AR at 385. 

On October 30, 2012, R.C. went to the emergency room with complaints of lower back 

pain. Id. at 307. He said that he had experienced lower back pain for the last year, but this pain 

was worse than baseline. Id. R.C. stated that he was a household mover. Id. During the physical 

examination, the doctor noted normal range of motion and normal muscle tone. Id. at 308. The 

doctor further noted that R.C. had no neurological deficit. Id. The doctor diagnosed the back pain 

as likely a musculoskeletal spasm. Id. at 309. R.C. was told to start taking Flexeril for muscle 

spasms and Motrin for pain. Id. at 337.

On September 30, 2013, R.C. went to the emergency room and complained of headaches 

and some neck pain. Id. at 360. However, the medical records reflect that R.C. later denied neck 

pain. Id. at 361. R.C. denied having any back pain. Id. at 362. During the physical examination, 

the doctor noted normal range of motion. Id. 

3

In the disability report, R.C. indicated that “[i]n 6/2013, i was in a vehicle accident and have 

been unable to look for work since.” AR at 198. He stated that he believed his conditions became 

severe enough to keep him from working on June 15, 2013. Id. As discussed later in this opinion, 

it appears R.C. was involved in the vehicle accident in 2014 not 2013. Id. at 369

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On October 25, 2013, R.C. saw a doctor because of head pain and wanted a CT scan. Id. at 

405. The active problem list contained in the medical records included lumbago, sciatic, and 

cervicalgia. Id. The doctor ordered R.C. to take Naprosyn, an anti-inflammatory drug. Id. at 406. 

On November 7, 2013, R.C. had a CT head scan that found mild bilateral ethmoid sinus disease. 

Id. at 386

On February 24, 2014, R.C. was seen at the emergency room for chest pain, shortness of 

breath, and abdominal pain. Id. at 363. R.C. denied having any neck or back pain. Id. at 365. 

During the physical examination, the doctor noted normal range of motion. Id. at 365-366. R.C. 

received chest x-rays. Id. at 387. 

On July 08, 2014, R.C. went to the hospital and complained about headaches and neck 

pain. Id. at 369. He stated that he was involved in a car accident three weeks prior. Id. R.C. 

“was sleeping in his big rig truck and was hit by a car, caught himself, did not fall to the ground, 

did not LOC” and was seen at that time.4 Id. According to the medical records, R.C. felt that his 

headaches and neck pains were worse since the accident. Id. The medical records reflect diffuse 

neck and back pains but no numbness or weakness. Id. Upon examination, R.C. had mild 

discomfort on range of motion of the neck and tenderness to palpation. Id. at 370. However, R.C. 

exhibited normal gait, intact motor and sensory examination, normal coordination, and normal 

muscle tone. Id. at 370-371. R.C. had another CT head scan that showed: “1. No accurate 

intracranial hemorrhage or mass effect. 2. Sinus disease.” Id. at 387-388. 

On July 22, 2014, R.C. saw a physician and complained of persistent neck and lower back 

pain after his car accident. Id. at 407. R.C. was “requesting 3 more weeks off.” Id. Upon 

physical examination, the doctor found that R.C. had full range of motion but noted that R.C. was 

symptomatic for Lumbago and mildly symptomatic for Cervicalgia. Id. at 408. In R.C.’s 

assessment plan, the doctor noted that R.C. should take Flexeril, Naprosyn, and Norco. Id. a 408-

409. 

On October 6, 2014, R.C. was again treated for neck pain and lower back pain. Id. at 410. 

4 Although the doctor notes that R.C. was seen at the time of the car accident, the administrative 

record does not contain any medical records from that time period.

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The doctor noted that R.C. had been seen at the ER “last week” and was given 20 tablets of Norco. 

Id. R.C. was symptomatic for lumbago and cervicalgia. Id. at 411. However, R.C. had no 

costovertebral angle tenderness and negative straight leg raising test. Id. The doctor discontinued 

Norco and prescribed Tylenol #3 instead. Id. R.C. also continued Lioresal (treating muscle 

spasms) and Naprosyn (anti-inflammatory drug). Id. at 411-412. 

On November 13, 2014, R.C. was treated for intermittent headaches and associated 

tingling down his left arm. Id. at 371. The medical records noted that the pain “radiates to the left 

neck and left shoulder, worse with certain movements, improved with ‘pulling on the head.’” Id.

at 373. The medical records also note that R.C. reported “tingling to the top of the shoulder to the 

mid humerus.” Id. However, R.C. denied weakness and stated that it did not spread to his hand. 

Id. During the review of systems, the doctor noted that R.C. was positive for back pain. Id. at 

374. However, the doctor noted that R.C. was negative for neck pain and neck stiffness. Id. 

Upon physical examination, the doctor noted that R.C. had normal range of motion. Id. at 374-75. 

On December 11, 2014, R.C. went to the doctor with complaints of neck pain. Id. at 412. 

However, R.C. requested a note to be able to go back to work without any restrictions.5 Id. Upon 

physical examination, the doctor noted that R.C. had full range of motion. Id. at 413. The doctor 

noted that R.C. was asymptomatic for lumbago but symptomatic for cervicalgia. Id. at 413-414. 

On February 6, 2015, R.C. was seen at the emergency department for neck pain. Id. at 

475. On February 10, 2015, R.C. went to the doctor complaining of neck pain. Id. at 415. The 

medical records note that R.C.’s chronic pain was slowly progressive over several years and pain 

was always present. Id. R.C.’s pain was variable in intensity with some radiation down upper 

arms to just above elbows. Id. The pain did not affect R.C.’s strength in his hands. Id. Dr. Burns 

examined R.C. and noted that R.C. sat stiffly and kept his head still. Id. at 415. Dr. Burns also 

noted increase tone in R.C.’s neck in all directions and a reduced range of motion. Id. Dr. Burns 

gave R.C. a Toradol injection for neck pain and continued him on Naprosyn and Norco. Id. at 

416. Dr. Burns ordered an abdomen x-ray that showed “[f]airly prominent degenerative changes 

5

It is unclear where R.C. was working at the time because, at the administrative hearing, R.C. 

testified that he had not worked since June 2014, after the car accident. AR at 35-37, 40. 

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involving the spine with spurring and sclerosis.” Id. at 429. 

On February 18, 2015, R.C. saw Dr. Burns for a follow up appointment. Id. at 417. The 

medical records indicate that R.C. had neck pain occasionally radiating into his left upper 

extremity with numbness in the fingers of his left hand. Id. R.C. also had sciatica on his left side 

with radiation into is leg. Id. The records also note that R.C. had right knee pain. Id. R.C. told 

the doctor that the medications did not help much. Id. Dr. Burns prescribed Flexeril for muscle 

spasms. Id. at 418. Dr. Burns referred R.C. to physical therapy. Id.

On March 4, 2015, Dr. Burns treated R.C. for flank pain and neck pain. Id. at 419. The 

medical records reflect that the medications were helping some. Id. 

An MRI performed on March 15, 2015 indicated minimal posterior disc-osteophyte 

complex a C2-3, moderate right central disc protrusion and narrowing of the subarachnoid space 

without cord compression at C4-5, and moderate left central disc protrusion and moderate left 

neural foraminal stenosis at C6-7. Id. at 471. 

On March 25, 2015, R.C. saw Dr. Burns for back and neck pain. Id. at 437. R.C. also 

complained of left hip pain that radiates into his lateral thigh. Id. R.C. said that medications help 

a little and Toradol injections helped for a couple of days. Id. Upon physical examination, Dr. 

Burns noted that R.C. did not have focal spams in his back. Id. at 438. However, R.C.’s back was 

tender, and he was unable to flex or extend due to pain. Id. Dr. Burns administered another 

Toradol injection. Id. R.C. started Gabapentin for nerve pain. Id. at 439. An x-ray of R.C.’s left 

hip showed mild joint space narrowing, consistent with degenerative joint disease. Id. at 448. 

On April 7, 2015, R.C. saw Dr. Burns and told him that he was still having lots of neck 

pain, low back pain, and bilateral hip pain. Id. at 439. R.C. said that his pain is worse when 

walking. Id. R.C. also reported “intermittent LLQ cramping, brief and sharp, worse with bending 

at waist.” Id. Tylenol was not helping but norco was somewhat effective. Id. R.C. was asking 

for light duty at work. 6 Id. Dr. Burns increased R.C.’s dose of Gabapentin and added Ultram for 

pain. Id. at 440-441. Dr. Burns diagnosed R.C. with osteoarthritis. Id. at 441. 

6 Again, it is unclear where R.C. was working at the time because, at the administrative hearing, 

R.C. testified that he had not worked since June 2014, after the car accident. AR at 35-37, 40. 

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On April 24, 2015, R.C. began physical therapy for his neck. Id. at 456. R.C. complained 

of “[n]eck pain and UT (R more than L) pain and in arms.” Id. R.C. stated his neck pain began a 

year and a half ago. Id. R.C. reported bilateral hand numbness and tingling. Id. at 457. He 

reported difficulty turning his neck, reaching and lifting, and sleeping at night. Id. The physical 

therapist observed “[d]ecreased muscle length noted in: Pectoralis Minor:B and Pectoralis 

Major:B.” Id. at 459. The physical therapist also noted, “[m]ild difficulty with overhead reaching 

and mod difficulty with back hand reaching with RUE.” Id. at 459. According to the outpatient 

physical therapy improvement in movement assessment log, R.C. had moderate difficulty walking 

long distances and reaching. Id. at 460. R.C. also had much difficulty lifting 20 pounds. Id. The 

physical therapist assessed physical impairments including range of motion limitations and pain. 

Id. The physical therapist also found functional limitations including “function endurance, position 

and household activities reaching and lifting.” Id. The medical records indicate that R.C. 

“[p]resents with signs/symptoms consistent with neck pain with h/o disc protrusion.” Id.

On May 6, 2015, Dr. Burns noted that R.C.’s neck pain persisted, and R.C. wanted to see 

neurosurgery to discuss further options for pain relief. Id. at 441. R.C. stated that Gabapentin has 

been helping. Id. Dr. Burns diagnosed R.C. with cervical spondylosis. Id. at 442. On May 31, 

2015, R.C. complained of leg pain and right hip pain that was worse with weigh-bearing. Id. at 

443. R.C. stated that the medications were not helping. Id. On July 1, 2015, Dr. Burns noted that 

R.C. had less pain in his right hip. Id. at 445. 

On July 2, 2015, the fifth session (out of the six recommended sessions), the physical 

therapist found that R.C. had met all his goals. Id. at 470. The therapist noted that R.C. was able 

to turn his neck with increase range of motion of 65 degrees and had had 50% decreased neck 

pain. Id. In addition, R.C. was able to sleep through the night without waking up from neck pain. 

Id. R.C. still reported that he could not do lifting, which brought pain back. Id. at 469. R.C. was 

discharged early. Id. at 470. 

On July 21, 2015, Dr. Burns filled out a work/school note for R.C., indicating that R.C. “is 

being evaluated & rated for chronic neck and low back pain with sciatica; imaging studies suggest 

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moderate disc disease of the spine, non-surgical at this time.” 7 Id. at 476. 

On August 19, 2015, Dr. Burns examined R.C. who was complaining that he had washed 

his car over the weekend and awoke the next day with a stiff and sore neck. Id. at 549. R.C. 

denied radiation into his arms or hand. Id. Dr. Burns noted that R.C.’s neck had “ROM about 

25% to R, 75% to L, flexion 90%, extension 50%.” Id. at 549. Dr. Burns further noted that R.C.’s 

neck was “[f]ocally tender over R upper trap with trigger point present and increase overall tone.” 

Id. R.C. was given an injection and refills of his medications. Id. at 549-550.

On September 8, 2015, Dr. Burns filled out a statement. Id. at 544. In the statement, Dr. 

Burns opined that R.C. suffered from chronic lower back pain and neck pain with spondylosis. Id. 

The doctor listed R.C.’s prognosis as “fair.” Id. Dr. Burns indicated that R.C.’s impairments 

lasted or were expected to last at least twelve months. Id. The doctor indicated R.C. suffered 

from depression, loss of interest in activities, decreased energy, and sleep disturbances, which 

affected R.C.’s physical symptoms. Id. at 545. Dr. Burns opined that R.C.’s pain or other 

symptoms were severe enough to occasionally interfere with his attention and concentration. 8 Id. 

The doctor also opined that R.C. could walk four blocks without rest or severe pain, could sit for 

two hours at one time, and could stand for two hours at one time. Id. Dr. Burns indicated that 

R.C. would be able to sit a total of two hours in an 8-hour workday, stand a total of two hours, and 

walk a total of two hours. Id. Dr. Burns also opined that R.C. would need periods of walking 

around during an 8-hour workday and would need to walk for 10 minutes every hour. Id. Dr. 

Burns opined that R.C. would need a job that permits shifting positions at will because of pain. Id.

at 546. However, he did not believe R.C. would need to take unscheduled breaks or need to keep 

his legs elevated. Id. Dr. Burns believed R.C. could lift 10 pounds frequently, 20 pounds 

occasionally, and 50 pounds rarely. Id. Dr. Burns believed R.C. could rarely look down and 

occasionally turn head right or left, look up, or hold head in static position.9 Id. Dr. Burns opined 

7

It is unclear why Dr. Burns wrote this work/school note because, at the administrative hearing, 

R.C. testified that he had not worked since June 2014 after the car accident. AR at 35-37, 40. 

8

“Occasionally” is defined as 6% to 33% of an 8-hour working day. AR at 545.

9

“Rarely” is defined as 1% to 5% of an 8-hour working day, “occasionally” is defined as 6% to 

33% of an 8-hour working day, and “frequently” is defined as 34% to 66% of an 8-hour working 

day. AR at 545. 

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that R.C. could occasionally twist, rarely stoop, crouch/squat, or climb stairs, and never climb 

ladders. Id. at 547. However, R.C. did not have significant limitations with reaching, handling, or 

fingering. Id. Dr. Burns opined that R.C. would likely have “good days” and “bad days” and 

would likely be absent from work about three days per month. Id. Dr. Burns opined that the 

limitation identified first began on February 24, 2014. Id. 

On October 21, 2015, R.C. was treated for neck pain and reported that he was experiencing 

more spasms. Id. at 551. R.C. said that some of the medication helped. Id. Dr. Burns noted, 

“increased tone in upper trapezius muscles, flexion full, extension and B rotation about 50% 

normal.” Id. at 551. Dr. Burns increased Gabapentin. Id. at 552. On November 20, 2015, R.C. 

was again seen for neck pain. Id. at 553. On December 21, 2015, R.C. experienced neck pain and 

numbness. Id. at 554. He wanted to continued physical therapy. Id. On February 1, 2016, R.C. 

reported that the medications were helping but told Dr. Burns that he wanted to try physical 

therapy and pool therapy. Id. at 556. On March 9, 2016, R.C. reported that his neck pain is stable 

but he experienced intermittent lower left quadrant cramping. Id. at 558. However, on April 27, 

2016, R.C. reported that he was still having neck pain and stiffness. Id. at 561. R.C. stated that 

some good days and not so good days but he reported pain medications helped. Id. at 561-562.

R.C.’s lumbar spine x-ray dated September 6, 2016 indicated that R.C. had degenerative 

changes in the lower lumbar spine with facet arthropathy, notably at C3-C4 and C4-C5. Id. at 586. 

However, there was no acute compression deformities and no evidence of spondylolysis or 

spondylolisthesis. Id. On September 14, 2016, R.C. went to the doctor to receive more pain 

medication and requested a “stronger agent.” Id. at 566. The medical records indicated that R.C. 

was positive for back pain but negative for neck pain and neck stiffness. Id. Dr. Burns indicated 

that R.C. had normal range of motion in his neck and back. Id. at 566-567. Dr. Burns noted 

“[t]enderness to palpation and spasticity of the lumbar paraspinal musculature.” Id. at 567. 

However, R.C. had no weakness in the lower extremities bilaterally, normal range of motion in the 

neck, had negative straight leg raising test, had normal sensation, had normal strength and range of 

motion in the lower extremities, and a normal neurological exam. Id. at 566-567. Dr. Burns 

recommended R.C. treat with ice and rest. Id. 

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Although they did not examine R.C., state agency medical consultants E. Trias, M.D., and 

A. Volterra, M.D., reviewed the medical evidence and provided opinions on April 10, 2015, and 

July 16, 2015, respectively. Id. at 21, 64-71, 72-81, 82-91, 92-105. Dr. Trias opined that R.C.’s 

statements regarding intensity, persistence, and functionally limiting effects of the symptoms were 

not substantiated by the objective medical evidence and R.C.’s statements were only partially 

credible. Id. at 68. Dr. Trias opined that R.C. could occasionally lift 50 pounds and frequently lift 

25 pounds. Id. at 69. In addition, Dr. Trias opined that R.C. could stand about 6 hours in an 8-

hour workday and sit about 6 hours in an 8-hour workday. Id. Dr. Trias found that R.C. could 

perform medium exertional work. Id. at 70, 78. Dr. Volterra opined that “[e]vidence in the 

current file for the period from AOD to DLI regarding the clmt’s physical musculoskeletal 

allegations supports physically non-severe.” Id. at 98. Dr. Volterra opined limitations of climbing 

ramps and stairs frequently and ropes, ladders, and scaffolds occasionally; frequent stooping, 

crouching, and crawling; and limited overhead reaching bilaterally. Id. at 21, 88-90, 99-101. In 

the Dr. Volterra recommended, “IE for T2 and a L RFC with occ OH reach for T16. . . [R.C.’s] 

more recent L hip imaging and neck pain would limit him to a LRFC.” Id. at 86, 97. In 

discussing his DIB claim, Dr. Volterra stated, “CLMT IS FOUND CREDIBLE TO 

ALLEGATIONS BUT NOT FOR T2 TIME PERIOD SHOWS HX OF BACK PAIN AND IS 

OVERALL NON-SEVERE.” Id. at 88. However, he later found that the “preponderance of 

overall evidence supports a medium RFC with postural and manipulative limitations” for both 

R.C.’s Title II and Title XVI claim. Id. at 87, 98. Both doctors found that R.C. could perform 

medium exertional work. Id. at 70, 78, 91, 102.

B. Initial Denial of Application

On February 2, 2015, R.C. applied for a period of disability and disability insurance 

benefits. Administrative Record (“AR,” dkt. 12) at 180. R.C. also applied for Social Security and 

Supplemental Security Income disability benefits on February 2, 2015.10 Id. at 174. In both 

10 The ALJ’s decision states that R.C. applied for a period of disability and disability insurance 

benefits as well as social security income on “December 22, 2014.” AR at 13. In addition, R.C.’s 

motion lists the date of his application as February 21, 2015 even though applications cited are 

dated February 2, 2015. Pl.’s Mot. at 2. This discrepancy is not material to the outcome of the 

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applications, R.C. alleged that his disability began on June 15, 2013. Id. at 174, 180. The 

Commissioner denied both applications on April 10, 2015. Id. at 106-110. The Commissioner 

noted that R.C.’s said that he was unable to work because of back, neck, and knee injury but found 

that R.C. should have been able to and currently should be able to perform work that is less 

demanding than his past occupation. Id. Thus, the Commissioner determined that disability was 

not established on or before March 31, 2014 and currently. Id. The Commissioner also denied 

R.C.’s request for reconsideration on July 16, 2015. Id. at 113-122. As to R.C.’s request for 

reconsideration for Social Security disability benefits, the Commissioner noted that “[t]he medical 

evidence shows as of 03/31/2014, the date [R.C.] was last insured for disability benefits, [R.C.] 

did not have a severe impairment that prevented work activity.” Id. at 113. As to R.C.’s request 

for reconsideration for Supplemental Security Income payments, the Commissioner found that, 

“[t]he medical evidence shows that although [R.C. does] have discomfort, [R.C. is] still able to 

move about and to use [his] arm, hands and leg in a satisfactory manner. The records show no 

indication of loss of control or muscle wasting in [his] arms or legs due to nerve damage as a 

result of [his] back and neck condition.” Id. at 118. 

C. Administrative Hearing 

R.C. requested a hearing before an ALJ and a hearing was held on October 24, 2016. Id. at 

29-63. At the hearing, the ALJ asked R.C. questions regarding his employment history. Id. at 35-

41. In 2009, R.C. worked as a mover for a moving company. Id. at 40. For two months in 2013 

R.C. did cleaning jobs for his cousin for about three to four hours a day, three days a week. Id. at 

38. R.C. would clean the floors and restrooms at a bank. Id. at 38-39. +R.C. stated that from 

April to June 2014 he worked as a part-time household mover for approximately 25 hours a week. 

Id. at 35, 37. R.C. said that the items he was carrying were “[v]ery heavy” and sometimes “about 

100 pounds.” Id. at 37. R.C. noted that he moved not only boxes but also “dressers, refrigerators, 

everything.” Id. at 37. R.C. stated that he stopped working because he was in an automobile 

accident in June 2014. Id. 

present motion. 

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As for his medical condition, R.C. testified that the automobile accident re-injured his neck 

and back and made those injuries worse. Id. at 40. R.C. stated that he previously treated his neck 

pain with physical therapy and continued to do exercises. Id. at 41-42. When asked if R.C. had 

any limitations on how far he could move his arms R.C. stated he “could go all the way up.” Id. at 

43. However, he stated that he “can move them but it would be a lot of pain with it.” Id. R.C. 

testified that he has pain in his shoulder that goes down to his hands. Id. at 55. He stated that as a 

result of his neck pain, he has trouble with his hands. Id. He also stated that he would get cramps 

in his fingers and cannot bend them sometimes. Id. at 45. Sometimes R.C. is unable to close his 

hand. Id. at 55. R.C. estimated that this happens every other day and stated that it occurs in both 

hands. Id. R.C. said that he treated his back pain with physical therapy but that the doctors have 

not talked to him about surgery. Id. at 44. R.C. also stated that he experiences pain in his kneecap 

when he stands and would get pain down his leg. Id. at 45. R.C. stated that he experiences 

sciatica in his right leg may once or twice a week. Id. at 54. When he is experiencing sciatica, he 

is unable to get out of bed and stays in bed all day. Id. When asked if he had any other conditions 

that he believed prevented him from being able to work, R.C. also stated that he started 

experiencing vertigo a couple of months ago. Id. at 44. 

R.C. stated that he is not able to help out with household chores like sweeping, mopping, 

or doing the dishes. Id. at 46. R.C. testified that he is not able to vacuum at all because it is bad 

for his neck and back. Id. R.C. stated that he is unable cook and relies on his sister and girlfriend 

to make his meals. Id. R.C. stated that he is unable to do dishes because it is too much standing. 

Id. at 46-47. R.C. testified that he is unable to do yard work and relies on his brother-in-law. Id.

at 47. R.C. also cannot go to the grocery store and his sister goes grocery shopping and his sister 

or brother-in-law carries the groceries from the car to the house. Id. R.C. testified that he does not 

do any lifting at all. Id. at 51. He is able to lift eight or nine pounds but it is a strain on his neck 

and back. Id. R.C. can make his bed every day. Id. at 46. R.C. is also able to do a little dusting. 

Id. at 51. R.C. states that he used to do everything around the house but then the doctor told him 

he could not do it. Id. at 52. R.C. has a driver’s license and sometimes drives to his doctor’s 

appointments. Id. at 47. When he does not drive, his girlfriend drives him. Id. R.C. estimated 

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that he drives to his doctor’s appointments about three times a year. Id. at 48. 

R.C. testified that he would not be able to do a job where he would be required to lift 50 

pounds because he would have too much back and neck pain. Id. at 52. R.C. testified that he can 

sit for about an hour and a half before he needs to change position. Id. at 48. He further stated 

that he can stand for about two hours before he needs to change positions. Id. The ALJ asked 

R.C. why he could not do dishes if he was able to stand for two hours and R.C. responded, 

“[m]oving around the kitchen, it’s — I thought you were talking about just straight standing.” Id.

at 49. R.C. stated that his leg pain compels him to sit down after standing for about two hours. Id. 

R.C. estimated that he would need to take an hour or an hour and 15 minutes break before 

standing again because that is how long it would take for his leg to stop hurting. Id. at 52. 

On a typical day, R.C. testified that he would get up in the morning and take a shower. Id.

at 49. R.C. recently started using a stool in the shower because he gets dizzy and does not want to 

fall. Id. at 55-56. R.C. would also take his dog on a walk. Id. at 49. R.C. stated that his dog 

walks are around 30 minutes and spans about one block. Id. at 50. R.C. does not need to use a 

cane or a walker. Id. R.C. stated that on the walks he will stop five or six times to let the dog 

smell the bushes. Id. at 53. R.C. also stated that he did not need to sit down or lay down after the 

walk because “[i]t’s only a 30-minute walk.” Id. R.C. will also ride around in the car with his 

girlfriend and testified that he can sit in the car for approximately an hour and a half. Id. at 50. 

R.C. testified that he had trouble sleeping at night because of neck pain and that he has to take an 

hour and a half to two-hour nap once a day. Id. at 56. R.C. goes to church weekly. Id. at 51.

Thomas Linville, a vocational expert, also testified at the administrative hearing. The ALJ 

asked Linville the following hypothetical:

[P]lease assume a hypothetical individual the same age, educational 

background and professional experience as the claimant. Please 

assume that this hypothetical individual is subject to the following 

limitations. The exertional level of medium with the use of ramps 

and stairs limited to no more than frequent; the use of ropes, 

scaffolds, and ladders at no more than occasional; and that stooping, 

kneeling, crouching, crawling are all no more than frequent. Given 

these limitations, could such a hypothetical individual perform any 

of the past work as claimant? 

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Id. at 58-59. Based on that hypothetical, Linville opined that the person described could not do 

R.C.’s past work. Id. at 59. Linville opined that looking at medium unskilled work, the person 

described could work as an “industrial cleaner,” “kitchen helper,” or “salvage laborer.” Id. at 59. 

Linville opined that nothing about R.C.’s past work would transfer down to medium. Id. at 60. 

R.C.’s attorney asked Linville the following hypothetical: 

[I]n addition to hypothetical number one, if a person needed to take 

a rest break for about an hour after two hours of standing or walking, 

so a rest break for an hour after each of two hour settings of standing 

or walking, would that be tolerated in a work environment? 

Id. at 60. Linville responded that such limitation reduced the eight-hour day substantially and 

would probably create a situation where a person is not going to be suitably involved or suitable 

productive to sustain work. Id. R.C.’s attorney asked Linville a second hypothetical:

[I]n addition[] to hypothetical number one, if we kept the medium; 

the standing and walking for six hours, sitting for six hours; and the 

lifting requirements by we changed. . . if we have inability to look 

down in a sustained – with the sustained function of the neck in a 

looking down position, we’ll limit that to rarely; turning the head 

left or right, looking up, or holding a head in any static position to 

occasionally. Additionally, for postural limitations we would have 

a limitation to occasional twisting with rarely stooping, rarely 

crouching and squatting, no ladders, and rarely climbing stairs, how 

does that affect the medium unskilled occupational jobs that are 

available?

Id. at 60-61. Linville responded that this hypothetical would eliminate most of the medium jobs 

that are unskilled. Id. at 61. 

D. Legal Background for Determination of Disability

To qualify for Title II benefits, the claimant must prove disability prior to the last insured 

date. 42 U.S.C. 423(a)(1)(A); Morgan v. Sullivan, 945 F.2d 1079, 1080 (9thCir. 1991). Title XVI 

benefits are available to persons who are disabled and meet certain income thresholds. 20 C.F.R. 

§ 416.202. When a claimant alleges a disability and applies to receive Social Security benefits, 

the ALJ evaluates the claim using a sequential five step process. 20 C.F.R. § 404.1520(a)(4). At 

step one, the ALJ determines whether the applicant is engaged in “substantial gainful activity.” 20 

C.F.R. § 404.1520(a)(4)(I). Substantial gainful activity is “work activity that involves doing 

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significant physical or mental activities . . . that the claimant does for pay or profit.” 20 C.F.R. § 

220.141(a)–(b). If the claimant is engaging in such activities, the claimant is not disabled; if not, 

the evaluation continues at step two. 

At step two, the ALJ considers whether the claimant has a severe and medically 

determinable impairment. Impairments are severe when “there is more than a minimal limitation 

in [the claimant’s] ability to do basic work activities.” 20 C.F.R. § 404.1520(c). If the claimant 

does not suffer from a severe impairment, she is not disabled; if she does have a severe 

impairment, the ALJ proceeds to step three. 

At step three, the ALJ turns to the Social Security Administration’s listing of severe 

impairments (the “Listing”). See 20 C.F.R. § 404, subpt. P, app. 1. If the claimant’s alleged 

impairment meets one of the entries in the Listing, the claimant is disabled. If not, the ALJ moves 

to step four. 

At step four, the ALJ assesses the claimant’s residual functional capacity, or RFC, to 

assess whether the claimant could perform her past relevant work. 20 C.F.R. § 404.1520(a)(1). 

The RFC is a determination of “the most [the claimant] can do despite [the claimant’s] 

limitations.” 20 C.F.R. § 404.1520(a)(1). The ALJ considers past relevant work to be “work that 

[the claimant] has done within the past fifteen years, that was substantial gainful activity, and that 

lasted long enough for [the claimant] to learn how do to it.” 20 C.F.R. § 404.11560(b)(1). If the 

claimant is able to perform past relevant work, she is not disabled; if she is not able to perform 

such past relevant work, the ALJ continues to step five. In the case of claimants who are fifty-five 

or older, are restricted to sedentary work, have no transferable skills, and have not completed any 

relevant vocational education, the Commissioner will usually not offer any evidence of work 

meeting the claimant’s RFC and the ALJ will decide disability based on the claimant’s ability to 

perform past work. 20 C.F.R. § 404, subpt. P, app. 2 § 201.00(d). 

At the fifth and final step, the burden shifts from the claimant to prove disability to the 

Commissioner to “identify specific jobs existing in substantial numbers in the national economy 

that the claimant can perform despite her identified limitations.” Meanel v. Apfel, 172 F.3d 1111, 

1114 (9th Cir. 1999) (citing Johnson v. Shalala, 60 F.3d 1428, 1432 (9th Cir. 1995)). If the 

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Commissioner is able to identify such work, then the claimant is not disabled; if not, the claimant 

is disabled and entitled to benefits. 20 C.F.R. § 404.1520(g)(1).

E. The ALJ’s Decision

On February 17, 2017, the ALJ issued an order finding that R.C. was not disabled. Id. at 

10-24. The ALJ determined that R.C. met the insured status requirements of the Social Security 

Act through March 31, 2014. AR at 15. The ALJ found that R.C. had not engaged in substantial 

gainful activity since June 15, 2013, the alleged onset date. Id. Although R.C. worked after the 

alleged disability onset date, the ALJ determined that this work did not raise to the level of 

substantial gainful activity. Id. This was because, while R.C.’s testified that his earnings were at 

or near substantial gainful activity level in 2014, given the lack of an earnings record, the ALJ 

found that it was difficult to state definitively. Id. The ALJ found that R.C.’s disc protrusion in 

the cervical spine was a severe impairment. Id. at 16. The ALJ also determined that R.C.’s 

impairments did not meet or equal the severity of one of the listed impairments in the Listing, 

specially rejecting Listing 1.04 for disorders of the back. Id.

In assessing R.C.’s residual functional capacity, the ALJ acknowledge that he was to 

follow a two-step process in which he must first determine whether there is an underlying 

medically determinable physical or mental impairment that could reasonably be expected to 

produce R.C.’s pain or other symptoms. Id. at 16-17. Then, the ALJ must evaluate the intensity, 

persistence, and limiting effects of the R.C.’s symptoms to determine the extent to which they 

limit R.C.’s functioning. Id. The ALJ described R.C.’s symptom testimony as follows:

The claimant makes the following allegations regarding the 

intensity, persistence, and limiting effects of his symptoms. The 

claimant alleges disability due to back and neck injury with 

difficulty walking and standing; much pain in his back; right knee 

goes numb; pain comes and goes in lower left side, front, and back; 

and increased pain with sweating. He testified that he stopped 

working as a mover in 2014 after he had an auto accident in June 

2014 and his neck pain worsened. He stated that as a mover, he was 

working about 25 hours per week moving boxes, dishes, clothes, 

refrigerators, “everything”; lifting and carrying up to 100 pounds. 

He reported that he has arthritis through his neck and back, as well 

as numbness in his legs and arms. He testified that his lower back 

hurts and shoots down his right leg (“sciatica”) about twice per 

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week, at which time he is not able to get out of bed. He reported 

that he is not longer able to walk very far and cannot walk for more 

than 15 minutes. He testified that he does not use a cane or walker. 

He stated that he has more back and knee pain when he walks, but 

he is in constant pain. He testified that he can sit for an hour and a 

half and then must change positions. He testified that he can stand 

for about two hours, but then has to take a break for an hour and a 

half so that the pain in his legs stops. He reported that he cannot 

carry more than 15 pounds. He testified that he can lift his arms 

over his head but is very painful. He testified that pain does down 

his arms and he can barely hold anything. He testified that he gets 

cramps in his fingers. He testified that he has had physical therapy 

for the discs in his back, but there has been no talk of surgery. He 

testified that it is hard to sleep because of neck pain and he has to 

take a nap for an hour and a half a day. 

The claimant stated that he lives with his sister. He stated that his 

daily activities are limited. He testified that on a typical day, he gets 

up, takes his dog for a slow walk for about 30 minutes for a block 

with the dog stopping five or six times, and might go for a drive with 

his girlfriend. He stated that he can sit in a car for an hour and a 

half. He testified that he uses a stool in the shower because he gets 

dizzy and does not want to fall. He testified that he cannot do chores 

and does not vacuum because of pain, but he makes his bed daily 

and can do a little dusting. He testified that he cannot cook or do 

dishes because he cannot stand too long with moving around, and 

his sister or girlfriend does it. He stated that his brother and sisterin-law do the grocery shopping and carry in the groceries. He 

testified that he has a diver’s licenses, but is girlfriend drives him to 

doctor appointments. He stated that he goes to church weekly. 

Id. at 17-18. 

The ALJ stated that “the objective findings in this case fail to provide strong support for 

the claimant’s allegations of disabling symptoms and do not support the existence of limitations 

greater than those reported above.” Id. at 18. To support this conclusion, the ALJ summarized 

R.C.’s medical history. The ALJ began by noting that R.C. had x-rays of the cervical spine in 

August 2012 that showed mild to moderate degenerative disc disease with mild degenerative facet 

changes. Id. The ALJ acknowledged that R.C. presented to the emergency room in October 2012 

for complaints of lower back pain with onset of one year. Id. However, the ALJ noted that 

“[p]hysical examination was normal with normal range of motion and muscle tone and no 

neurologic deficient noted.” Id. 

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The ALJ observed that “[a]lthough the claimant asserts onset of disability in June 2013, 

there is no evidence of any injury or worsening of condition at or around that time. Moreover, 

there is not even evidence of treatment sought at that time.” Id. The ALJ states that R.C. sought 

no medical treatment until September 2013 and October 2013, which was unrelated to his asserted 

disabling conditions and R.C. was noted to “specifically deny neck and back pain.” Id. The ALJ 

noted that at the time, there were no abnormalities on musculoskeletal or neurological 

examinations. Id. The ALJ noted that R.C. was examined for various unrelated condition 

between October 2013 to June 2014. Id. The ALJ specifically stated that in 2014, R.C. “again 

denied back or neck pain and was noted to have normal musculoskeletal and neurologic physical 

exam finding.” Id. 

The ALJ then discussed R.C.’s July 2014 examinations after R.C. had been involved in an 

automobile accident. The ALJ stated R.C. was noted to have “some mild discomfort on range of 

motion of the neck and bilateral paraspinous tenderness to palpation of the neck and back. He was 

noted to have normal gait, intact motor and sensory, and normal coordination and muscle tone. He 

was diagnosed with back/neck pain/strain/sprain.” Id. The ALJ stated that at R.C.’s follow up 

examination, R.C. “presented with complaints of persistent low back and neck pain since the 

accident. He was noted to request three more weeks off.” Id. The ALJ notes that R.C. had “full 

range of motion of the musculoskeletal and no costovertebral angle tenderness of the back.” Id. 

The ALJ further states that R.C. “was assessed as ‘mildly symptomatic.’” Id. 

The ALJ summarized R.C.’s treatment for the remainder of 2014, noting that R.C. returned 

to the emergency room in October 2014 for persistent low back and neck pain but was noted to 

have no costovertebral angle tenderness of the back and negative straight leg examination. Id. at 

18-19. The ALJ noted that in December 2014, the doctor assessed R.C.’s lumbago “to be 

asymptomatic but cervicalgia was still symptomatic.” Id. at 19. R.C. was given a work release 

note and was to continue with his current medications. Id.

The ALJ discussed R.C.’s February 2015 examinations and acknowledged that R.C. 

reported that “the pain had been slowly progressing over several years.” Id. The ALJ noted that 

R.C. had stated that “the pain was always present, variable in intensity, and with some radiation 

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down upper arms to just above elbows” but that R.C. “denied any effect on the strength of his 

hands and no numbness or weakness.” Id. The ALJ stated that in the record, R.C. “was noted to 

sit stiffly and keep his head still.” Id. Further the ALJ recognized that “[r]ange of motion of the 

neck was noted to be at 74 percent expected.” Id. 

The ALJ discussed R.C.’s follow up examination later in the month where R.C. 

complained of “neck pain, occasionally radiating to the left upper extremity with numbness into 

the left hand fingers” and “left-side sciatica with radiation into the left and persistent right knee 

pain.” Id. The ALJ notes that R.C. was referred to physical therapy and was to have an MRI of 

the cervical spine. The MRI conducted in March showed “moderate right central disc protrusion 

at C4-5 with narrowing of the subarachnoid place but no cord compression; and moderate left 

central disc protrusion at C6-7 with moderate left neuroforaminal stenosis.” Id. The ALJ 

acknowledged that in April 2015, R.C. was diagnosed with osteoarthritis of the neck and referred 

to physical therapy. Id. The ALJ briefly notes that R.C. successful met all of his physical therapy 

goals in five of the six sessions. Id. 

The ALJ noted that in July 2015, R.C. was provided with a work note but acknowledges 

that it is not clear what the purpose of the note was. Id. The ALJ notes that the doctor stated that 

R.C. “is being evaluated and treated for chronic neck and low back pain with sciatica; and that 

imaging studies suggest moderate disc disease of the spin[e], but he was ‘non-surgical’ at that 

time.” Id.

The ALJ discussed R.C.’s August 2015 examination and noted that R.C. complained of a 

stiff, sore neck but “denied any radiation to the arms or hands.” Id. at 19. The ALJ further noted 

that the records showed that R.C. was “noted to have some decreased range of motion of the neck 

and tenderness of the right trapezius, but nonfocal neurological exam.” Id. The ALJ decision 

noted that R.C. continued to receive treatment for his neck and back pain in 2015 and 2016 and 

R.C. stated that his medications were helping. Id. at 19-20. The ALJ acknowledged that on March 

9, 2016, R.C. reported that his neck pain is stable. Id. at 20. The ALJ further noted that R.C. had 

reported that he had some good days and some not so good during his examination in April 2016. 

Id.

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The ALJ discussed R.C.’s September 14, 2016 examination where R.C. requested more 

pain medication and a stronger agent. Id. at 20. The ALJ noted that R.C. “was specially noted to 

have no bilateral weakness to lower extremities and no bowl/bladder incontinence or retention.” 

Id. The ALJ further stated that: 

[R.C.] was noted to be negative for neck pain and neck stiffness, but 

positive for back pain. He was noted to have normal range of motion 

of his neck. He was noted to have tenderness to palpation and 

spasticity of the lumbar paraspinal musculature, but no swelling, 

costovertebral angel tenderness, or stepoffs. Straight leg raise was 

noted to be normal bilaterally with normal sensation in the L4, L5, 

and S1 dermatomes bilaterally and normal strength and range of 

motion in the lower extremities. It was noted that his back pain was 

most likely a musculature flare with low suspicion for cord 

compression given normal neuro exam. 

Id. The ALJ stated that x-rays showed no acute compression deformities and no evidence of 

spondylolysis or spondylolisthesis, but did have degenerative changes in the lower lumbar spine 

with facet arthropathy. Id. 

After consideration of the evidence, the ALJ found that R.C.’s medically determinable 

impairments could reasonably be expected to cause the alleged symptoms but that R.C.’s 

statements concerning the intensity, persistence, and limiting effects of these symptoms are not 

entirely consistent with the medical evidence and other evidence in the record. Id. at 20. 

Specially, the ALJ noted that “[e]ven after the lapse of the claimant’s date last insured, he was 

working in capacities that require a high level of exertion, e.g., a mover.” Id. The ALJ noted that 

“throughout the claimant’s medical record he has shown full strength, a normal gain, and a normal 

range of motion throughout.” Id. The ALJ also noted that “[p]hysical therapy for [R.C.’s] neck 

was noted to be successful and he was even discharged early due to meeting his goals.” Id. The 

ALJ also considered the fact that there was no evidence that R.C. followed through with his 

request for additional physical therapy or the referrals to neurosurgery or rheumatology. Id. The 

ALJ further noted that R.C.’s condition was specially noted to be non-surgical and that there were 

frequent reports that his prescribed medications for pain were helping. Id. The ALJ further found:

The claimant’s own admitted activities of daily living are 

inconsistent with his asserted level of disabling limitations. He 

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reported that he lives with his sister, whom he relies on to do 

cooking and grocery shopping, but he makes his bed and does some 

dusting, is able to walk his dog for up to 30 minutes per day, can 

ride in a car for up to one and a half hours, and attends church 

services regularly. Given the claimant’s presentation in multiple 

physical exams, his work as a mover throughout much of his 

asserted period of disability, and his activities of daily living, the 

DDS assessed residual functional capacity of Medium exertional 

level work is found compelling. 

Id. at 20-21. 

The ALJ discussed Dr. Burns’ September 8, 2015 medical source statement regarding 

R.C.’s limitations but stated that the ALJ gives little to no weight to Dr. Burns’ opinion because: 

Dr. Burns asserts conditions for which there is no treatment or 

diagnosis (e.g., depression); asserts contradictory information (e.g., 

that the claimant can walk four city blocks, but maximum work 

capacity throughout the day is two hours standing and two hours 

sitting); there is no treatment or findings consistent with these 

limitations (see Exh. 3F, 4F, 5F, 10F). Moreover Dr. Burns’ opinion 

is directly contrary to his own treatment’s notes at Exhibit 10F/20 in 

September 2016, which showed full range of motion and strength in 

the back for negative straight leg raise and full strength in the lower 

extremities despite his report of tenderness in the back and 

continued pain. 

Id. at 21. The ALJ instead gave “great weight” to the opinions of the State agency medical 

consultants because “they are consistent with the record as a whole as described in detail herein, 

including overall normal physical exam findings throughout the period at issue and inconsistent 

actives of daily living with asserted disability limitations.” Id.

The ALJ found that R.C. was unable to perform any past relevant work. Id. at 21-22. The 

ALJ determined that R.C. was an individual closely approaching advance age, on the alleged 

disability onset date and subsequently changed age categories to advance age. Id. at 22. The ALJ 

found that R.C. had at least a high school education and was able to communicate in English. Id. 

The ALJ further found that transferability of job skills was not material to the determination of 

disability because “using the Medical Vocational Rules as a framework supports a finding that the 

claimant is ‘not disabled.’ Whether or not the claimant has transferable job skills.” Id. The ALJ 

found that there are jobs that exist that R.C. could perform, namely as an “industrial cleaner”, 

“kitchen helper,” or “salvage laborer.” Id. at 22-23. Thus, the ALJ determined that R.C. was not 

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disable from June 15, 2013 through the date of the ALJ’s decision. Id. at 23. 

R.C. requested a review of the ALJ’s decision, but his request was denied. Id. at 1-6. 

Thus, the ALJ’s decision became the final decision of the Commissioner. R.C. subsequently 

requested judicial review. 

F. Motions for Summary Judgment

In his motion for summary judgment (Pl.’s Mot., dkt. 17), R.C. argues that the ALJ erred 

in rejecting Dr. Burns’ opinion absent clear and convincing reasons. Id. at 8-10. In addition, R.C. 

argues that the ALJ improperly found that R.C.’s statements concerning the intensity, persistence, 

and limiting effects of these symptoms were not entirely consistent with the medical evidence and 

other evidence in the record. Id. at 10. R.C. argues that the ALJ failed to identify clear and 

convincing reasons, based on the record, why the limitations R.C. described do not exist. Id. at 

13. Finally, R.C. argues that the ALJ’s step five finding is not supported by substantial evidence. 

Id. at 13. 

R.C. argues that he was age 55 as of his date last insured for Title II benefits, which was 

3/31/14. The ALJ found R.C. cannot perform any of his past relevant work and the VE testified 

there would be no transferable skills. Id. at 59-60. Given R.C.’s age, his high school education, 

and his work history, R.C. argues that if he is limited to light work, he would be deemed disabled 

pursuant to 20 C.F.R. § 404, Subpart P, Appendix 2, Rule 202.06. R.C. requests this Court reverse 

the ALJ’s decision and remand for award of benefits, or, as a lesser alternative, remand this case 

for a new hearing and further administrative proceedings. Id. at 14. 

The Commissioner argues that based on the record evidence, the ALJ permissibly found 

Dr. Burns’ opinion inconsistent with the bulk of the record evidence and the ALJ permissibly gave 

more weight to the State agency reviewing consultants’ opinions over the opinion of Dr. Burns. 

Comm’r’s Mot., dkt. 20, at 9-10. The Commissioner also argues that substantial evidence 

supported the ALJ’s evaluation of Plaintiff’s subjective allegations of disabling symptoms. Id. at 

10. The Commissioner argues that the ALJ properly found that there was a lack of objective 

support for R.C.’s allegations, R.C.’s statements of disabling symptoms were inconsistent with 

evidence that treatment measures effectively improved his condition and symptoms, R.C.’s 

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complaints were inconsistent with his lack of treatment, R.C.’s allegations of disability were 

inconsistent with the evidence based on doctor statements and opinions, and R.C.’s testimony of 

disability was inconsistent with the record evidence. Id. at 11-13. Finally, the Commissioner 

argues that substantial evidence supported the ALJ’s step five finding. Id. at 14. The 

Commissioner argues that R.C.’s request to remand for payment and essentially credit-as-true Dr. 

Burns’ medical opinion is inappropriate. Id. at 15. The Commissioner requests that the Court 

grant the Commissioner’s motion for summary judgment and deny R.C.’s motion. Id. In the 

alternative, the Commissioner request that the Court remand the case to the agency for additional 

investigation or explanation. Id.

In his reply, R.C. argues that the Commissioner’s assertion that the ALJ needed to provide 

only specific and legitimate reasons to discount the opinion of R.C.’s treating doctor because this 

opinion was “contradicted” by the opinions of the non-examining state agency physicians is 

improper. Reply, dkt. 21, at 1-2. Instead, R.C. argues that the ALJ needed to prove clear and 

convincing reasons if he wished to discount Dr. Burns’ opinion. Id. at 2. R.C. also argues that 

neither the ALJ nor the Commissioner has attempted to explain how the objective medical 

evidence, R.C.’s activities, or R.C.’s limited treatment are inconsistent with the limitations R.C. 

described in his testimony which establish disability. Id. at 5. Finally, R.C. argues that the ALJ’s 

step five finding is not supported by substantial evidence because the hypothetical questions posed 

to the vocational expert did not set out all the limitations and restrictions of the particular claimant. 

Id. at 5. 

III. ANALYSIS

A. Legal Standard

District courts have jurisdiction to review the final decisions of the Commissioner and may 

affirm, modify, or reverse the Commissioner’s decisions with or without remanding for further 

hearings. 42 U.S.C. § 405(g); see also 42 U.S.C. § 1383(c)(3). 

When reviewing the Commissioner’s decision, the Court takes as conclusive any findings 

of the Commissioner that are free of legal error and supported by “substantial evidence.” 

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

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conclusion” and that is based on the entire record. Richardson v. Perales, 402 U.S. 389, 401. 

(1971). “‘Substantial evidence’ means more than a mere scintilla,” id., but “less than 

preponderance.” Desrosiers v. Sec’y of Health & Human Servs., 846 F.2d 573, 576 (9th Cir. 

1988) (citation omitted). Even if the Commissioner’s findings are supported by substantial 

evidence, the decision should be set aside if proper legal standards were not applied when 

weighing the evidence. Benitez v. Califano, 573 F.2d 653, 655. (9th Cir. 1978) (quoting Flake v. 

Gardner, 399 F.2d 532, 540 (9th Cir. 1978)). In reviewing the record, the Court must consider 

both the evidence that supports and the evidence that detracts from the Commissioner’s 

conclusion. Smolen v. Chater, 80 F.3d 1273, 1279 (9th Cir. 1996) (citing Jones v. Heckler, 760 

F.2d 993, 995 (9th Cir. 1985)). 

Although the Court may “review only the reasons provided by the ALJ in the disability 

determination and may not affirm the ALJ on a ground upon which [the ALJ] did not rely,” 

Garrison v. Colvin, 759 F.3d 995, 1010 (9th Cir. 2014), “harmless error analysis applies in the 

social security context.” Marsh v. Colvin, 792 F.3d 1170, 1173 (9th Cir. 2015). “[W]here the 

circumstances of the case show a substantial likelihood of prejudice, remand is appropriate so that 

the agency can decide whether reconsideration is necessary. By contrast, where harmlessness is 

clear and not a borderline question, remand is not appropriate.” McLeod v. Astrue, 640 F.3d 881, 

888 (9th Cir. 2011) (footnotes, citations, and internal quotation marks omitted). If the Court 

identifies defects in the administrative proceeding or the ALJ’s conclusions, the Court may 

remand for further proceedings or for a calculation of benefits. See Garrison, 759 F.3d at 1019–

21.

B. Medical Opinion Evidence

1. Legal Background

“Cases in this circuit distinguish among the opinions of three types of physicians: (1) those 

who treat the claimant (treating physicians); (2) those who examine but do not treat the claimant 

(examining physicians); and (3) those who neither examine nor treat the claimant (non-examining 

physicians).” Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995). “[T]he opinion of a treating 

physician is . . . entitled to greater weight than that of an examining physician, [and] the opinion of 

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an examining physician is entitled to greater weight than that of a non-examining physician.” 

Garrison, 759 F.3d at 1012. 

“To reject [the] uncontradicted opinion of a treating or examining doctor, an ALJ must 

state clear and convincing reasons that are supported by substantial evidence.” Ryan v. Comm’r 

of Soc. Sec., 528 F.3d 1194, 1198 (9th Cir. 2008) (citations omitted). “[T]he opinion of a nonexamining physician cannot by itself constitute substantial evidence that justifies the rejection of 

the opinion of either an examining physician or a treating physician.” Id. at 1202 (quoting Lester, 

81 F.3d at 831). The Ninth Circuit has emphasized the high standard required for an ALJ to reject 

an opinion from a treating or examining doctor, even where the record includes a contradictory 

medical opinion: 

“If a treating or examining doctor’s opinion is contradicted by 

another doctor’s opinion, an ALJ may only reject it by providing 

specific and legitimate reasons that are supported by substantial 

evidence.” Id. This is so because, even when contradicted, a treating 

or examining physician’s opinion is still owed deference and will 

often be “entitled to the greatest weight . . . even if it does not meet 

the test for controlling weight.” Orn v. Astrue, 495 F.3d 625, 633 

(9th Cir. 2007). An ALJ can satisfy the “substantial evidence” 

requirement by “setting out a detailed and thorough summary of the 

facts and conflicting clinical evidence, stating his interpretation 

thereof, and making findings.” Reddick [v. Chater, 157 F.3d 715, 

725 (9th Cir. 1998)]. “The ALJ must do more than state conclusions. 

He must set forth his own interpretations and explain why they, 

rather than the doctors’, are correct.” Id. (citation omitted). 

Where an ALJ does not explicitly reject a medical opinion or set 

forth specific, legitimate reasons for crediting one medical opinion 

over another, he errs. See Nguyen v. Chater, 100 F.3d 1462, 1464 

(9th Cir. 1996). In other words, an ALJ errs when he rejects a 

medical opinion or assigns it very little weight while doing nothing 

more than ignoring it, asserting without explanation that another 

medical opinion is more persuasive, or criticizing it with boilerplate 

language that fails to offer a substantive basis for his conclusion. 

See id.

Garrison, 759 F.3d at 1012–13.

2. The Standard that the ALJ Must Meet When Rejecting a Treating 

Physician’s Opinion

As an initial matter, despite the guidance in Garrison, the parties dispute which test the 

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Court should apply in evaluating this claim. R.C. argues that the ALJ was required to provide 

clear and convincing reasons for rejecting the opinion of R.C.’s treating physician, Dr. Burns, 

because “when the opinion of a non-examining doctor is the only opinion which contradicts the 

treating doctors’ opinions, the treating doctors’ opinions are considered uncontradicted, because 

the non-examining doctor’s opinion is not substantial evidence.” Reply, dkt. 21, at 1-2 (emphasis 

in original). However, the Commissioner argues that the Court need only find that the ALJ 

provided specific and legitimate reasons for discounting Dr. Burns’ opinion. Comm’r’s Mot., dkt. 

20, at 5-6. 

The Court agrees with Commissioner that the ALJ needed only provide specific and 

legitimate reasons supporting his opinion. The Ninth Circuit applies the “specific and legitimate 

reason test” in cases in which a non-treating, non-examining physician's opinion conflicts with a 

treating physician's opinion. See, e.g., Cain v. Barnhart, 74 F. App'x 755, 756 (9th Cir. 2003). 

Furthermore, in some cases, a non-examining medical advisor’s testimony may be used, in part, to 

reject the opinion of an examining or treating physician. Lester, 81 F.3d at 831. “Opinions of a 

non-examining, testifying medical advisor may serve as substantial evidence when they are 

supported by other evidence in the record and are consistent with it.” Morgan v. Commissioner, 

169 F.3d 595, 600 (9th Cir. 1999).

R.C. cites Winans v. Bowen, for the proposition that a treating physician’s opinion can be 

“uncontradicted evidence” despite the contrary opinions of the non-examining physicians. 853 

F.2d 643 (9th Cir. 1987). However, that case does not support R.C.’s position that the clear and 

convincing reasons standard should apply. In that case, the Ninth Circuit stated that “[i]f the ALJ 

wishes to disregard the opinion of the treating physician, he ... must make findings setting forth 

specific, legitimate reasons for doing so that are based on substantial evidence in the record.” 

Winans v. Bowen, 853 F.2d 643, 647 (9th Cir. 1987) (internal quotation marks and citation 

omitted). R.C.’s other cited case, Gallant v. Heckler, is distinguishable because in that case, the 

non-examining, non-treating physician's opinion was “contradicted by all other evidence in the 

record.” 753 F.2d 1450, 1454 (9th Cir. 1984). 

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3. Dr. Burns’ Opinion Evidence

The ALJ acknowledged that: 

Dr. Burns opined that the claimant could walk four city blocks 

without rest or severe pain; sit, stand, and walk a total only two hours 

each out of an eight-hour workday; and must walk every 60 minutes 

as well as a job that permits shifting positions at will from sitting, 

standing, or walking....Dr. Burns opined that the claimant would be 

able to lift 20 pounds occasionally and 10 pounds frequently and 

would have limitations in moving the head and postural movements. 

Lastly, Dr. Burns opined that the claimant would likely be absent 

about three days per month from work as a result of his impairments 

or treatment. 

AR at 21. As described in more detail above, Dr. Burns opined that R.C. had limitations 

including, rarely looking down and occasionally turning his head right or left, looking up, or 

holding head in static position. AR at 544-47. Dr. Burns opined that these limitations began on 

February 24, 2014, which is after the date of alleged onset. Id. at 547. The ALJ gave “little to no 

weight” to the opinion of R.C.’s treating physician, Dr. Burns. The ALJ discredited Dr. Burns’ 

opinion because the ALJ found: (1) Dr. Burns asserted conditions for which there is no treatment 

or diagnosis (e.g., depression); (2) Dr. Burns asserted contradictory information (e.g., that the 

claimant can walk four city blocks, but maximum work capacity throughout the day is two hours 

standing and two hours sitting); and (3) there is no treatment or findings consistent with these 

limitations. Id. at 21. The ALJ gave “great weight” to the opinions of the State agency medical 

consultants. Id. The Court finds that the ALJ did not provide specific and legitimate reasons for 

discrediting Dr. Burns’ opinion. 

The ALJ’s first reason for discrediting Dr. Burns’ medical opinion was that Dr. Burns 

asserted conditions for which there is no treatment or diagnosis (e.g., depression). In Dr. Burns’ 

September 8, 2015 medical opinion statement, in response to the prompt: “[i]dentify psychological 

conditions and/or symptoms affecting your patient’s physical condition,” Dr. Burns checked boxes 

indicating R.C. had depression, loss of interest in activities, decreased energy, and sleep 

disturbance. Id. at 545. However, R.C.’s medical records do not contain any treatment or 

diagnosis for depression. R.C. argues that Dr. Burns did not opine R.C. had a separate impairment 

of depression, but that depression and loss of interest in activities were additional symptoms of 

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R.C.’s physical impairment. Pl.’s Mot., dkt 17, at 10. The Commissioner did not address R.C.’s 

argument in its motion. R.C. is not alleging disability as a result of depression and, thus, while it 

may be ambiguous whether Dr. Burns intended to opine that R.C. had depression, the fact that Dr. 

Burns checked certain boxes in his medical opinion statement is not a legitimate reason to 

discredit his opinion. 

The ALJ’s second reason for discrediting Dr. Burns was that Dr. Burns asserted 

contradictory information (e.g., that the claimant can walk four city blocks, but maximum work 

capacity throughout the day is two hours standing and two hours sitting). The ALJ never explains 

how Dr. Burns’ assertion is contradictory. The Commissioner also fails to address how these 

statements are contradictory. The ALJ’s finding is conclusory and not legitimate. 

The ALJ’s third reason for rejecting Dr. Burns’ opinion on R.C.’s limitations was that 

“there is no treatment or findings consistent with these limitations.” Id. The ALJ did not provide 

any specific explanation on why he came to this conclusion. Furthermore, the ALJ did not 

specifically indicate for each limitation listed in Dr. Burns’ opinion, why the ALJ believed that 

there is no treatment or findings consistent with that limitation.

As discussed above, the ALJ acknowledged that the x-rays of the cervical spine from 

August 2012 showed mild to moderate degenerative disc changes and mild degenerative facet 

changes and R.C. complained of lower back pain in October 2012. Id. at 18, 308, 385. As the 

ALJ observed, at the time of Plaintiff’s alleged onset date of June 2013, there was no record or 

evidence of an injury or worsening of condition. Id. at 18. However, on September 30, 2013, 

R.C. may have experienced some neck pain but the medical records are inconsistent as to this 

claim. Compare id. at 360, with id. at 361. 

After R.C. was involved in a car accident in June 2014, and after his date last insured, R.C. 

was treated numerous times for persistent back and neck pain. The ALJ acknowledged that on 

July 8, 2014, that the medical records indicate that R.C. had “some mild discomfort on range of 

motion of the neck and bilateral paraspinous tenderness to palpation of the neck and back.” Id. 

When summarizing the medical evidence in the decision, the ALJ did not acknowledge that R.C. 

was also seen on November 13, 2014, for intermittent headaches and associated tingling down his 

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left arm. Id. at 371. The medical records noted that the pain “radiates to the left neck and left 

shoulder, worse with certain movements.” Id. at 373. 

When the ALJ discussed R.C.’s February 2015 examinations, the ALJ acknowledged that 

the record noted that R.C. complained of “some radiation down upper arms” and that R.C. “was 

noted to sit stiffly and keep his head still.” Id. at 19. Further the ALJ recognized that “[r]ange of 

motion of the neck was noted to be at 74 percent expected.” Id. The ALJ did not acknowledge 

that the doctor also found that R.C.’s neck had increased tone in all directions. Id. at 415. The 

ALJ also did not acknowledge that the doctor ordered an abdomen x-ray that showed “[f]airly 

prominent degenerative changes involving the spine with spurring and sclerosis.” Id. at 429. 

The ALJ discussed R.C.’s follow up examination later in the month where R.C. 

complained of “neck pain, occasionally radiating to the left upper extremity with numbness into 

the left hand fingers” and “left-side sciatica with radiation into the left and persistent right knee 

pain.” Id. at 19. The ALJ notes that R.C. was referred to physical therapy and was to have an MRI 

of the cervical spine. However, the ALJ did not acknowledge that R.C. was seen again on March 

4, 2015 for flank and neck pain. Id. at 419. The ALJ acknowledged that an MRI performed on 

March 15, 2015 indicated minimal posterior disc-osteophyte complex a C2-3, moderate right 

central disc protrusion and narrowing of the subarachnoid space without cord compression at C4-

5, and moderate left central disc protrusion and moderate left neural foraminal stenosis at C6-7. 

Id. at 20, 471. The ALJ did not acknowledge that on March 25, 2015, R.C. saw a doctor for back 

and neck pain and complained of left hip pain that radiates into his lateral thigh. Id. at 437. Upon 

physical examination, the doctor noted that R.C.’s back was tender, and he was unable to flex or 

extend due to pain. Id. at 438. 

While the ALJ acknowledged that in April 2015, R.C. was diagnosed with osteoarthritis of 

the neck and referred to physical therapy, the ALJ did not acknowledge that R.C. told his doctor 

that he was still having lots of neck pain, low back pain, and bilateral hip pain that was worse 

when walking. Id. at 439. The ALJ also did not discuss the physical therapy evaluation where 

physical therapist noted, “[m]ild difficulty with overhead reaching and mod difficulty with back 

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hand reaching with RUE” and moderate difficulty walking long distances and reaching. 11 Id. at 

459-460. R.C. also had much difficulty lifting 20 pounds. Id. The physical therapist found 

functional limitations including “function endurance, position and household activities reaching 

and lifting.” Id. Even after the successful completion of his physical therapy, R.C. still reported 

that he could not do lifting, which brought pain back. Id. at 469. 

The ALJ decision does not acknowledge that on May 31, 2015, R.C. complained of leg 

pain and right hip pain that was worse with weigh bearing. Id. at 443. The ALJ discussed R.C.’s 

August 2015 examination and noted that R.C. complained of a stiff, sore neck but “denied any 

radiation to the arms or hands.” Id. at 19. The ALJ further noted that the records showed that 

R.C. was “noted to have some decreased range of motion of the neck and tenderness of the right 

trapezius, but nonfocal neurological exam.” Id.

The ALJ decision did not acknowledge that on October 21, 2015, when R.C. was treated 

for neck pain, his doctor noted, “increased tone in upper trapezius muscles, flexion full, extension 

and B rotation about 50% normal.” Id. at 551. While the ALJ acknowledged that on March 9, 

2016, R.C. reported that his neck pain is stable, the decision did not acknowledge on April 27, 

2016, R.C. again reported that he was still having neck pain and stiffness. Id. at 561.

The ALJ decision acknowledged that R.C.’s lumbar spine x-ray dated September 6, 2016 

indicated that R.C. had degenerative changes in the lower lumbar spine but there was no acute 

compression deformities and no evidence of spondylolysis or spondylolisthesis. Id. at 20. 

The ALJ does not explain why the findings detailed in his decision as well as the 

additional evidence on the record would not constitute treatment or findings consistent with the 

limitations outlined by Dr. Burns. Arguably, the medical evidence may have been sparse in 

establishing treatment or findings consistent with the limitations in Dr. Burns’ opinion prior to 

R.C.’s date of last insured of March 31, 2014 for R.C.’s Title II claim because the records only 

11 This Court recognizes that a physical therapist is not an “acceptable medical source” as defined 

by the Social Security regulations. See 20 C.F.R. §§ 404.1513(a), 416.913(a); compare with 20 

C.F.R. §§ 404.1513(d), 416.913(d) (discussing “other sources”). However, an ALJ may not 

discount “other” medical sources without explanation, but less weight may be afforded such 

medical sources if the ALJ provides “germane” reasons. See Ghamin v. Colvin, 763 F.3d 1154, 

1161 (9th Cir. 2014); Molina v. Astrue, 674 F.3d 1104, 1114 (9th Cir. 2012). 

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show one x-ray from August 2012 related to R.C.’s disc changes and one, potentially two, doctor’s 

visits for pain. However, the ALJ’s reasons were not legitimate to reject the limitations assessed 

by Dr. Burns as of the September 8, 2015 date when Dr. Burns filled out the opinion. 

The ALJ noted that he found Dr. Burns’ opinion from September 2015 is “directly contrary 

to his own treatment notes . . . in September 2016, which showed full range of motion and strength 

in the back for negative straight leg raises and full strength in the lower extremities despite his 

report of tenderness in the back and continued pain.” Id. at 21. The Ninth Circuit has recognized, 

however, that “[t]he primary function of medical records is to promote communication and 

recordkeeping for health care personnel—not to provide evidence for disability determinations. 

[The Ninth Circuit] therefore [does] not require that a medical condition be mentioned in every 

report to conclude that a physician’s opinion is supported by the record.” Orn v. Astrue, 495 F.3d 

625, 634 (9th Cir. 2007). When “the record contains numerous reports from [the claimant’s] 

health care providers, as well as results from medical tests and laboratory findings, that support the 

questionnaires completed by [the treating physicians],” it is erroneous to focus on a single day of 

treatment notes, particularly when the treatment records as a whole support a different conclusion. 

Id. For example, although the medical records do show that in September 2016 R.C. had full 

range of motion, records from other examinations reflect visits where R.C. had limited range of 

motion. Id. at 370, 415, 460, 549. Furthermore, the examination findings the ALJ cites from 2016 

are not inconsistent with R.C. having neck pain and pain in his lower back related to the arthritis 

present in the x-ray of his lumbar spine. The ALJ never explained why a lack of neurological 

signs, such as a straight leg raise test, would indicate that R.C. did not have the limitations 

contained in Dr. Burns’ opinion. Specifically, the ALJ does not explain why strength in the back,

negative straight leg raises, and full strength in the lower extremities would indicate that R.C. did 

not have the limitations with regards to lifting, looking down, turning his head right or left, 

looking up, or holding head in static position, and other postural movements. Therefore, the ALJ 

has erred as a matter of law by failing to properly weigh the opinion of R.C.’s treating physician.

The Commissioner also cites the state agency consultants’ opinions that R.C. could 

perform medium exertional work, and that consultant Dr. Volterra opined limitations of climbing 

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ramps and stairs frequently and ropes, ladders, and scaffolds occasionally; frequent crouching and 

crawling; and limited overhead reaching bilaterally. Comm’r’s Mot. at 9. The ALJ stated that he 

gives “great weight” to the consultants’ opinions “as they are consistent with the record as a whole 

des described in detail herein, including overall normal physical exam findings throughout the 

periods at issue and inconsistent activities of daily living with asserted disabling limitations.” AR 

at 21. Under Ninth Circuit precedent, “[t]he opinion of a nonexamining physician cannot by itself 

constitute substantial evidence that justifies the rejection of the opinion of either an examining 

physician or a treating physician.” Lester v. Chater, 81 F.3d 821, 831 (9th Cir. 1995), as amended 

(Apr. 9, 1996). When considering the period prior to the last date of insured, March 31, 2014, Dr. 

Volterra, the non-examining physician, stated, “[e]vidence in the current file for the period AOD 

to DLI regarding the clmt’s physical musculoskeletal allegations support physically non-severe; 

TP exams report normal/supple neck and normal M/S ROM, normal neuro exam, negative ROS 

for back pain (9/13 and 2/14).” AR at 86. As discussed above, the evidence in the record does 

arguably support Dr. Volterra’s conclusions. However, for the period after the date of last insured, 

Dr. Volterra’s recommendations appear to be inconsistent, stating, “[r]ecommend...L RFC with 

occ OH reach for T16...his more recent L hip imaging, and neck pain would limit him to a LRFC” 

but ultimately recommending medium RFC. Id. at 97-98. Furthermore, because the ALJ has not 

identified sufficient reasons to discredit Dr. Burns’ opinion regarding R.C.’s limitations for the 

time period after R.C.’s June 2014 automobile accident, the contrary opinions of Drs. Trias and 

Volterra cannot take precedence.

In sum, the ALJ erred in discounting Dr. Burns’ opinion generally, although the ALJ may 

have not necessarily erred in discounting Dr. Burns’ opinion regarding the time period prior to the 

date of last insured.

C. R.C.’s Testimony 

1. Legal Standard

Although the ALJ is responsible for evaluating credibility, the Ninth Circuit has 

formulated a two-step test for considering a claimant’s testimony regarding the severity of 

subjective symptoms: 

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First, the ALJ must determine whether the claimant has presented 

objective medical evidence of an underlying impairment “which 

could reasonably be expected to produce the pain or other symptoms 

alleged.” Bunnell v. Sullivan, 947 F.2d 341, 344 (9th Cir. 1991) (en 

banc) (internal quotation marks omitted). The claimant, however,

“need not show that her impairment could reasonably be expected 

to cause the severity of the symptom she has alleged; she need only 

show that it could reasonably have caused some degree of the 

symptom.” Smolen v. Chater, 80 F.3d 1273, 1282 (9th Cir. 1996). 

“Thus, the ALJ may not reject subjective symptom testimony . . . 

simply because there is no showing that the impairment can 

reasonably produce the degree of symptom alleged.” Id.; see also

Reddick [v. Chater, 157 F.3d 715, 722 (9th Cir. 1998)] (“[T]he 

Commissioner may not discredit the claimant’s testimony as to the 

severity of symptoms merely because they are unsupported by 

objective medical evidence.”). 

Second, if the claimant meets this first test, and there is no evidence 

of malingering, “the ALJ can reject the claimant’s testimony about 

the severity of her symptoms only by offering specific, clear and 

convincing reasons for doing so.” Smolen, 80 F.3d at 1281; see also

Robbins [v. Soc. Sec. Admin., 466 F.3d 880, 883 (9th Cir. 2006)] 

(“[U]nless 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.”). 

Lingenfelter v. Astrue, 504 F.3d 1028, 1036 (9th Cir. 2007).12

The ALJ found that R.C.’s “medically determinable impairments could reasonably be 

expected to cause the alleged symptoms; however, the claimant’s statements concerning the 

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

medical and other evidence in the record.” AR at 20. The ALJ did not make a finding of 

malingering. The ALJ was therefore required to “offer[] specific, clear and convincing reasons” to 

reject R.C.’s testimony regarding the severity of his symptoms. Smolen v. Chater, 80 F.3d 1273, 

1281 (9th Cir. 1996). “General findings are insufficient.” Reddick v. Chater, 157 F.3d 715, 722 

(9th Cir.1998) (internal quotation marks omitted).

12 The Commissioner here states an objection for the record to the Ninth Circuit’s “clear and 

convincing” standard, but recognizes that this Court is bound by Ninth Circuit authority. 

Comm’r’s Mot. at 10 n.4.

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1. R.C.’s testimony

First, The ALJ states that “the objective findings in this case fail to provide strong support 

of claimant’s allegations of disabling symptoms and do not support the existence of limitations 

greater than those reported above.” AR at 18. In presenting this boilerplate justification for 

rejecting R.C.’s testimony, the ALJ disregarded the rule that “the Commissioner may not discredit 

the claimant’s testimony as to the severity of symptoms merely because they are unsupported by 

objective medical evidence.” Reddick, 157 F.3d at 722; see also Light v. Soc. Sec. Admin., 119 

F.3d 789, 792 (9th Cir. 1997) (“In this case, the ALJ disbelieved Light because no objective 

medical evidence supported Light’s testimony regarding the severity of subjective symptoms from 

which he suffers, particularly pain. An ALJ may not discredit a claimant’s subjective testimony on 

that basis.”); 20 C.F.R. § 404.1529(c)(2) (providing that the Commissioner will “not reject [a 

claimant’s] statements about the intensity and persistence of . . . pain or other symptoms or about 

the effect [those] symptoms have on [the claimant’s] ability to work solely because the available 

objective medical evidence does not substantiate [the claimant’s] statements.”). 

Later in his decision, after summarizing the medical evidence, the ALJ noted “throughout 

the claimant’s medical record he has shown full strength, a normal gait, and normal range of 

motion throughout . . . through to September 2016.” AR at 20. First, as described above, the 

medical record shows that R.C. had difficulty lifting after the automobile accident in June 2014. 

See id. at 459-460, 469. Further, the medical record does not consistently show normal range of 

motion after the automobile accident in June 2014. Rather, there are instances where R.C. 

presented with decreased range of motion and discomfort. See id. at 370, 415, 460, 549. Further, 

to the extent R.C. did present with full strength, a normal gait, and normal range of motion, these 

are merely examples of areas where R.C.’s testimony as to the extent of her subjective symptoms 

exceeded what could be determined by objective evidence alone. Having determined that R.C.’s 

symptoms could reasonably be caused by her impairments, the ALJ was not free to reject 

testimony as to the severity of those symptoms only on the basis that such severity was not 

supported by objective evidence. See Lingenfelter, 504 F.3d at 1036; Reddick, 157 F.3d at 722; 

Light, 119 F.3d at 792. Moreover, the ALJ did not explain why full strength, a normal gait, and 

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normal range of motion is incompatible with significant neck and back pain and the alleged 

resulting limitations especially as to R.C.’s limitations regarding lifting, looking down, turning his 

head right or left, looking up, or holding his head in static position.

The second reason that the ALJ gives in discounting R.C.’s testimony is that “[e]ven after 

the lapse of the claimant’s date last insured, he was working in capacities that require a high level 

of exertion, e.g., a mover . . . The claimant stated that he worked as a mover through at least June 

2014 and that he had to stop due to injuries suffered in an auto accident.” Id. R.C. stated that 

from April to June 2014 he worked as a part-time household mover for approximately 25 hours a 

week. Id. at 35, 37. R.C. testified that while he was working as a mover, the items he was 

carrying were “[v]ery heavy” and sometimes “about 100 pounds.” Id. at 37. The ALJ was entitled 

to find Plaintiff’s testimony of disability inconsistent with the record evidence, where Plaintiff 

engaged in work activity after his alleged onset date, of performing heavy work as a mover until 

June 2014, after a car accident, AR at 20, 20, 35-36, 39-40, 58. See 20 C.F.R. § 404.1529(c)(3)(i) 

(when evaluating information about claimant’s symptoms, ALJ may consider a claimant’s daily 

activities); Thomas v. Barnhart, 278 F.3d 947, 958-59 (9th Cir. 2002) (when evaluating Plaintiff’s 

statements, ALJ may consider “inconsistencies either in [claimant’s] testimony or between [his] 

testimony and [his] conduct,” as well as her daily activities). R.C. does not address this reason in 

his motion for summary judgment or his reply. This reason is clear and convincing as to discredit 

R.C.’s claim of disability prior to June 2014 but after June 2014, there is no evidence of any 

further employment. 

The third reason that the ALJ gives in discrediting R.C.’s testimony is that physical 

therapy was noted to be successful and there is no evidence that R.C. ever followed through with 

the additionally requested physical therapy, nor did he follow through with the referrals to 

neurosurgery or rheumatology. AR at 20. The ALJ noted that R.C.’s condition was non-surgical. 

Id. In addition, the ALJ noted that there were frequent reports that his prescribed medications for 

pain were helping. Id. While physical therapy was successful and R.C. was discharge early, at his 

last session, R.C. still complained of pain whenever he did lifting. Id. at 469. Furthermore, one 

month after completing physical therapy, on August 19, 2015, R.C. was again seen for neck pain 

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after washing his car and Dr. Burns noted that R.C. had decreased range of motion in his neck. Id.

at 549. Dr. Burns further noted that R.C.’s neck was “[f]ocally tender over R upper trap with 

trigger point present and increase overall tone.” Id. While there is no evidence that R.C. followed 

through with getting additional physical therapy or with a rheumatology specialist, R.C. continued 

to receive treatment regularly from his doctor for his neck and back pain throughout 2015 and 

2016. Furthermore, while the ALJ states that there are reports that R.C.’s medications were 

helping, numerous reports on the record show that the R.C. felt that the medications were only 

helping a little or were not in fact helping. See id. at 417, 419, 437, 439, 443. In the latest medical 

record, R.C. requested his doctor prescribe a “stronger agent” for his pain. Id. at 566. R.C. never 

claimed that medication fully alleviates his pain, and the ALJ never asked R.C. about his 

medications at the hearing. 

Finally, the ALJ found that R.C.’s own admitted activities of daily living are inconsistent 

with his assert level of disabling limitations because R.C. makes his bed and does some dusting, is 

able to walk his dog for up to 30 minutes a day, can ride in a car for up to one and a half hours, 

and attends church services regularly. Id. at 20. The testimony cited by the ALJ is not 

inconsistent with R.C.’s testimony that in general, he cannot stand or walk for more than about 2 

hours or sit for more than about 90 minutes in an 8-hour day. None of the activities the ALJ listed 

demonstrate an ability to sustain medium exertional level work.

While the ALJ may have provided clear and convincing reasons to discredit R.C.’s 

testimony regarding his limitations prior to June 2014, the ALJ did not provide clear and 

convincing reasons to discredit Plaintiff's testimony as his limitations for the time period after

R.C. stopped working in 2014. 

D. The ALJ’s Step Five Finding 

Finally, R.C. argues that the ALJ’s determination that he could perform medium work was 

legal error because the ALJ’s hypotheticals were defective. In Embrey v. Bowen, 849 F.2d 418, 

423 (9th Cir. 1988), the Ninth Circuit stated that hypothetical questions posed to the vocational 

expert must set out all the limitations and restrictions of the particular claimant. If the vocational 

expert’s hypothetical assumptions are incomplete or lack support in the record, the opinion based 

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thereon has no evidentiary value. 

Here, the ALJ never distinguished between R.C.’s Title II claim, which required R.C. to 

establish disability prior to March 31, 2014, and R.C.’s Title XVI claim, required R.C. to be 

disabled and meet certain income thresholds. When posing his hypothetical questions to the 

vocational expert, the ALJ never posed a hypothetical setting out all the limitations and 

restrictions of R.C. prior to March 31, 2014 and another one setting out all of R.C.’s limitations 

and restrictions as of the hearing date. However, the ALJ omitted the limitations assessed by 

R.C.’s treating doctor and discounted R.C.’s testimony, in part, because of a perceived lack of 

treatment and findings prior to the car accident that occurred in June 2014 and because of R.C.’s 

work as a mover up until June 2014. While the ALJ may have properly discredited Dr. Burns’ 

opinion and R.C.’s testimony regarding R.C.’s limitations prior to R.C.’s date of last insured, as 

discussed above, the ALJ improperly discredited Dr. Burns opinion and R.C.’s testimony 

regarding his current limitations. 

Dr. Burns opined that R.C. could walk four blocks without rest or severe pain, could sit for 

two hours at one time, and could stand for two hours at one time. AR at 545. Dr. Burns indicated 

that R.C. would be able to sit a total of two hours in an 8-hour workday, stand a total of two hours, 

and walk a total of two hours. Id. Dr. Burns also opined that R.C. would need periods of walking 

around during an 8-hour workday and would need to walk for 10 minutes every hour. Id. Dr. 

Burns opined that R.C. would need a job that permits shifting positions at will because of pain. Id.

at 546. Dr. Burns believed R.C. could lift 10 pounds frequently, 20 pounds occasionally, and 50 

pounds rarely. Id. Dr. Burns believed R.C. could rarely look down and occasionally turn head 

right or left, look up, or hold head in static position. Id. Dr. Burns opined that R.C. could 

occasionally twist, rarely stoop, crouch/squat, or climb stairs, and never climb ladders. Id. at 547. 

Dr. Burns opined that R.C. would likely be absent from work about three days per month. Id. 

The ALJ’s hypothetical, however, did not mention many of these limitations. See id. at 59, 

543-547. While the ALJ “need not include all claimed impairments in his hypotheticals, he must 

make specific findings explaining his rationale for disbelieving any of the claimant’s subjective 

complaints not included in the hypothetical.” Light v. Soc. Sec. Admin., 119 F.3d 789, 793 (9th 

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Cir. 1997). The ALJ did not address the limitations contained within Dr. Burns’ opinion in depth 

and gave no reasons for rejecting Dr. Burn’s opinion beyond the general reasons discussed above. 

The ALJ did not make a specific finding explaining his rationale for not including R.C.’s 

limitations with respect to sustained flexion of neck limitations in his hypotheticals. The ALJ 

therefore erred in failing to include R.C.’s limitations in his hypotheticals to the vocational expert. 

Ninth Circuit precedent dictates that this error is not harmless: 

[A]n ALJ is not free to disregard properly supported limitations . . . . Such 

a failure [to include a claimant’s validly determined limitations] cannot be 

deemed harmless because, if the ignored testimony is credited, a proper 

hypothetical would have included limitations which, the record suggests, 

would have been determinative as to the vocational expert's 

recommendation to the ALJ. 

Robbins v. Soc. Sec. Admin., 466 F.3d 880, 886 (9th Cir. 2006). Here, the Court knows what the 

vocational expert’s response would have been to a hypothetical including all R.C.’s limitations 

because R.C.’s attorney posed one. Id. at 60–61 (presenting additional hypotheticals, including 

one corresponding to Dr. Burns’ assessment of R.C.’s limitations). The vocational expert’s

response was that R.C.’s limitations as outlined would “eliminate most of the medium jobs that are 

unskilled.” Id. at 61. Based on that response, the Court concludes that the ALJ’s error in relying 

on an incomplete hypothetical RFC was not harmless. See Robbins, 466 F.3d at 886.

E. Remand for Further Proceedings

The Ninth Circuit follows the “credit as true” rule, a three-part test that allows the Court to 

remand to the ALJ to calculate and award benefits when: (1) “the ALJ failed to provide legally 

sufficient reasons for rejecting evidence, whether claimant testimony or medical opinion”; (2) 

“there are [no] outstanding issues that must be resolved before a disability determination can be 

made” and “further administrative proceedings would [not] be useful”; and (3) “on the record 

taken as a whole, there is no doubt as to disability.” Leon v. Berryhill, 880 F.3d 1041, 1045 (9th 

Cir. 2017) (citations and internal quotation marks omitted); see also Garrison, 759 F.3d at 1021 

(holding that a district court abused its discretion in declining to apply the “credit as true” rule to 

an appropriate case). The “credit-as-true” rule does not apply “when the record as a whole creates 

serious doubt as to whether the claimant is, in fact, disabled within the meaning of the Social 

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Security Act,” Garrison, 759 F.3d at 1021, when “there is a need to resolve conflicts and 

ambiguities,” Treichler v. Comm’r of Soc. Sec. Admin., 775 F.3d 1090, 1101 (9th Cir. 2014), or 

when there is ambiguity about when the claimant’s disability began that is not solved by the 

record credited as true. See Dominquez v. Colvin, 808 F.3d 403, 409 (9th Cir. 2015). 

Here, as discussed above, the ALJ failed to provide legally sufficient reasons for rejecting 

Dr. Burns’ opinion and R.C.’s testimony. However, there are outstanding issues that must be 

resolved through further administrative proceedings and the record raises serious doubt as to 

whether R.C. is truly disabled prior to date of last insured and even after his automobile accident. 

As discussed above, the only evidence of R.C.’s back and neck pain prior to the accident is an xray from August 2012 suggesting mild to moderate degenerative disc disease with mild 

degenerative facet changes and one, potentially two, doctor’s visits where R.C. complained of 

pain. At the time of the alleged onset, there is no evidence of any injury or worsening of 

condition. Furthermore, R.C. testified that he worked as a mover carrying items “about 100 

pounds” up until the automobile accident in June 2014. R.C. testified that his condition worsened 

after the accident. The record is not fully developed regarding what R.C.’s limitations were on 

March 31, 2014, R.C.’s date of last insured, and when R.C. began experiencing the limitations that 

allegedly prevent him from returning to work. Thus, the Court cannot hold that the ALJ would be 

required to find R.C. disabled on remand. Accordingly, the Court will remand this case for further 

administrative proceedings consistent with this order.

IV. CONCLUSION

For the reasons discussed above, R.C.’s motion is GRANTED, the Commissioner’s motion 

is DENIED, and the case is REMANDED for further administrative proceedings consistent with 

this decision. The Clerk is instructed to enter judgment in favor of R.C. and to close the file.

IT IS SO ORDERED.

Dated: April 23, 2020

JOSEPH C. SPERO

United States Magistrate Judge

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