Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_14-cv-02463/USCOURTS-azd-4_14-cv-02463-0/pdf.json

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

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WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Carrie Ann Marshall, 

Plaintiff, 

v. 

Carolyn W. Colvin, 

Acting Commissioner of Social Security, 

Defendant. 

No. CV-14-02463-TUC-BGM 

ORDER 

Currently pending before the Court is Plaintiff’s Opening Social Security Brief 

Filed Pursuant to LRCiv. 16.1 (Doc. 12). Defendant filed her Brief (“Response”) (Doc. 

19), and Plaintiff filed her Reply Social Security Brief Filed Pursuant to LRCiv. 16.1 

(“Reply”) (Doc. 22). Plaintiff brings this cause of action for review of the final decision 

of the Commissioner for Social Security pursuant to 42 U.S.C. § 405(g). The United 

States Magistrate Judge has received the written consent of both parties, and presides 

over this case pursuant to 28 U.S.C. § 636(c) and Rule 73, Federal Rules of Civil 

Procedure. 

 . . . 

 . . . 

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I. BACKGROUND 

A. Procedural History

 On September 19, 2011, Plaintiff filed an application for Social Security Disability 

Insurance Benefits (“DIB”) alleging disability as of January 1, 2004 due to chronic pain, 

multiple foot surgeries, arthritis, and a pain management implant (spinal cord stimulator). 

See Administrative Record (“AR”) at 24, 26, 41, 43, 54–56, 58–60, 65–67, 78, 83, 113, 

126, 140, 167, 176, 178, 182, 183, 189. Plaintiff’s date last insured was December 31, 

2009. Id. at 24, 26, 54–55, 59, 65–67, 78, 83, 126, 167, 176, 190. The Social Security 

Administration (“SSA”) denied this application on January 17, 2012. Id. at 24, 54–64, 

78–82. On March 9, 2012, Plaintiff filed a request for reconsideration, and on August 10, 

2012, SSA denied Plaintiff’s application upon reconsideration. Id. at 65–76, 82, 83–86. 

On September 18, 2012, Plaintiff filed her request for hearing. Id. at 24, 86. On 

February 15, 2013, a hearing was held before Administrative Law Judge (“ALJ”) Laura 

Speck Havens. AR at 24, 37–53. On March 28, 2013, the ALJ issued an unfavorable 

decision. Id. at 21–33. On May 18, 2013, Plaintiff requested review of the ALJ’s 

decision by the Appeals Council, and on September 9, 2014, review was denied. Id. at 1–

3, 20. On November 6, 2014, Plaintiff filed this cause of action. Compl. (Doc. 1). 

B. Factual History 

 Plaintiff was forty-four (44) years old at the time of the administrative hearing and 

thirty-four (34) at the time of the alleged onset of her disability. AR at 32, 37, 41, 55, 66, 

113, 126, 167, 176, 189. Plaintiff obtained a high school diploma and attended 

approximately one year of college. Id. at 32, 42, 141. Prior to her alleged disability, 

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Plaintiff worked as a software purchasing manager. Id. at 32, 44, 63, 118–19, 141–42, 

159–61. Since that time she has worked briefly as a front desk clerk, in payroll, and as a 

promotions assistant. Id. at 30, 32, 42–43, 119–20, 130–32, 159–66. 

 On December 6, 2011, Plaintiff filled out an Exertional Daily Activities 

Questionnaire, indicating that on an average day she does “light house work [sic][,] 

grocery 1/week approx [sic] 1 Hour[,] [and] cook [sic] maybe once a day[.]” Id. at 155. 

Plaintiff reported that her “pain limits [her] ability to do much for any length of time — 

standing, sitting, walking[,] [and] [w]eather changes make the pain much worse.” AR at 

155. Plaintiff further reported that she “no longer ha[s] any stamina and [she] do[esn’t] 

sleep but about 5 hours/week.” Id. Plaintiff indicated that her “spinal cord stimulator 

[i]mplant . . . limits her lifting . . . [to not] more than 50 [pounds].” Id. at 156. Plaintiff 

reported doing laundry, cooking, or cleaning once per week. Id. Plaintiff further 

reported being able to drive a manual transmission for approximately one hour. Id. 

Plaintiff also indicated that she is unable to sleep, and although she is tired during the 

day, she is unable to take naps. AR at 155. Throughout the report, Plaintiff stressed her 

previous high level of activity as compared with her current condition. Id. at 155–57. 

 On appeal, Plaintiff completed a Disability Report – Appeal (Form SSA-3441), 

indicating that “[a]s a result of the surgeries, [she] periodically get stress fractures in [her] 

feet.” Id. at 178. Plaintiff further reported that “this happens on a semi-regular basis[,] . . 

. [which] has been a fairly regular occurrence since completing the foot surgeries.” Id. 

Plaintiff also stated that “[i]n addition to physical stress, this causes tremendous 

emotional stress for both [her]self and [her] husband.” Id. at 179. Plaintiff reported 

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doing “less and less around the house[,] [and] [her] husband is responsible for most of the 

cleaning, cooking[,] and overall household maintenance.” AR at 182. Additionally, 

Plaintiff stated that she “never know[s] in advance how [she] will be feeling[,] . . . 

mak[ing] planning ahead almost impossible.” Id. Plaintiff reported not getting “more 

than 10 hours of sleep in a week as a result of this.” Id. at 183. 

 1. Plaintiff’s Testimony

 At the administrative hearing, Plaintiff testified that she has a high school diploma 

and approximately one (1) year of college, is able to read the newspaper, and perform 

simple adding and subtracting. AR at 42. Plaintiff further testified that she was fired in 

2004, because she was unable to perform her duties and was let go. Id. Although she 

filed for unemployment benefits at that time, she did not receive them. Id. Plaintiff also 

testified that since that time she worked briefly for Arizona Natural Woman and then for 

Citadel Broadcasting. Id. at 42–43. Plaintiff confirmed that she suffers from arthritis, 

chronic pain, and depression. Id. at 43. 

 Plaintiff testified that in the 2004–2009 time frame, she was on “fairly heavy doses 

of morphine[.]” AR at 44. As a result, she “was really inconsistent.” Id. Plaintiff 

testified that she occasionally did household chores, including small amounts of cooking, 

dish washing, laundry, and grocery shopping. Id. at 44–45. Plaintiff further testified that 

she was able to dress and bathe herself. Id. at 45. Plaintiff also testified that she enjoyed 

making jewelry, but was only able to sit for approximately forty-five (45) minutes to an 

hour at a time. Id. Plaintiff also testified that she watched approximately three (3) hours 

of television per day, did not exercise, and drove infrequently. AR at 45–46. 

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 Plaintiff testified that she had problems eating and sleeping, reporting some 

stomach issues due to medications and “terrible, terrible insomnia.” Id. at 46. Plaintiff 

further testified only sleeping approximately ten (10) to (twelve) hours per week. Id. 

Plaintiff also testified that she was on several medications during the 2004–2009 time 

period, including Percocet, OxyContins, morphine, Promethazine, Temazepam, 

Cyclobenzapril, Naproxen Sodium, and Lexapro. Id. at 47–48. Plaintiff testified that she 

saw a therapist once or twice per week during the same period. Id. at 48. 

 Plaintiff estimated that she had eleven (11) surgeries from 2004–2009. AR at 48. 

Plaintiff testified that most of these were to her right foot, but the last “batch were for a . . 

. neurotransmitter.” Id. at 49. Plaintiff further testified that she was able to walk or stand 

for very short periods and was wheelchair bound for approximately three (3) months after 

one surgery. Id. Plaintiff also testified that the pain in her feet made it difficult to sit. Id. 

at 49–50. Plaintiff testified that she cannot lift more than fifty (50) pounds due to the 

stimulator. Id. at 50. She described her daily pain level during the 2004–2009 period, 

while on medication, as a seven (7) out of ten (10), with ten (10) being the worst pain. 

AR at 50. Plaintiff further described the pain as sharp and shooting. AR at 50. 

 Plaintiff testified that since 2009 her condition has improved because she is no 

longer recovering from surgeries, but “gotten worse overall.” Id. at 51. Plaintiff further 

testified that the fusion in her foot causes back and ankle problems, the weather bothers 

her due to her arthritis, and although the “box in [her] back is helpful for the nerve pain, . 

. . it hurts being . . . , like sitting.” Id. Plaintiff also testified that the loss of her job was 

probably the “hardest part” for her, and that she began seeing a therapist again 

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approximately one (1) year prior to the hearing to cope with the depression. Id. at 51–52. 

Plaintiff testified that she stopped taking all of the opiates in 2010, but “since then the 

insomnia has gotten worse.” Id. at 52. Plaintiff further testified that the insomnia causes 

her to be unable to “think straight” or concentrate. Id. 

 2. Lay Witness Testimony 

 Plaintiff’s husband, Robert Marshall, did not testify at the administrative hearing, 

but the ALJ accepted a February 15, 2003 letter written by him into evidence. AR at 40, 

185–87. Mr. Marshall described his wife as “a determined and motivated person.” Id. at 

185. Mr. Marshall also reported that “living with extreme flexibility ha[d] become [their] 

‘new’ reality.” Id. at 187. 

 3. Plaintiff’s Medical Records

 On January 23, 2003 by Ira L. Gluck, D.C. at Catalina Chiropractic Center. AR at 

300–4. Her neurological assessment was unremarkable. Id. at 302. Upon orthopedic 

examination, Mr. Gluck noted moderate restriction in Plaintiff’s right and left lateral 

flexion of her cervical spine, as well as mild restriction of rotation right and left. Id. at 

302–3. Additionally, Mr. Gluck noted neck pain upon compression test of Plaintiff’s 

cervical spine in lateral flexion right and left. Id. at 303. Mr. Gluck further noted spasm, 

tenderness, articular fixation, and malposition of Plaintiff’s spine upon clinical 

examination, assessing cervicobrachial syndrome; cervical myalgia/myofascitis; and 

thoracic rib/intercostal strain. Id. Plaintiff saw Mr. Gluck regularly in 2003, there are no 

records for 2004, but Plaintiff returned in 2005. AR at 307–8. The bulk of Mr. Gluck’s 

Clinical Evaluation summaries, however, are dated in 2008. Id. at 309–18. 

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 On January 23, 2004, Plaintiff saw Ario Keyarash,1 M.D. for a “follow-up of her 

first MTP [(Metatarsophalangeal)] fusion.” Id. at 222. Dr. Keyarash reported that 

Plaintiff was “doing better after her desensitization and physical therapy[,] [but] [s]he 

continues to have some pain including what appears to be transfer of metatarsalgia under 

the second metatarsal head[,] [and] . . . great toe pain.” Id. 

 On March 24, 2004, Plaintiff followed-up with Dr. Keyarash for “her right foot 

multiple surgeries.” Id. at 221, 364, 426. Dr. Keyarash reported that she “ha[d] started to 

have problems involving the second and third and fourth metatarsals[,] [but] [h]er first 

ray is doing well[,] [and] [she] ha[d] no symptomatology.” AR at 221, 426. Dr. 

Keyarash further reported “[o]n physical examination . . . [Plaintiff] ha[d] palpable 

tenderness markedly on the second, third and fourth metatarsal shafts with palpable 

callus.” Id. Dr. Keyarash assessed “[s]tress fractures to the right foot[,]” although the xrays did not show any fractures. Id. Dr. Keyarash placed Plaintiff in a walking boot. Id. 

On the same date, Dr. Keyarash dictated a letter to Sun Life Financial regarding 

Plaintiff’s long term disability claim. Id. at 219–20. Dr. Keyarash outlined Plaintiff’s 

previous bunion surgery and subsequent complications, as well as the corrective surgeries 

that he performed. AR at 219. Dr. Keyarash further reported that Plaintiff had 

“developed multiple stress fractures of the same foot . . . [and] that from the time of her 

original surgery up to now she has been unable to ambulate on her right foot, and to 

operate a motor vehicle, as she has been in a boot or a cast.” Id. 

 

1

 Dr. Keyarash is alternatively noted as Ario Kiarash, M.D. in the Administrative Record, 

these names will be used interchangeably. 

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 On April 8, 2004, Plaintiff saw Dr. Keyarash “for evaluation of her old walking 

boot.” Id. at 217. Dr. Keyarash reported that “[t]here was no evidence of new injury, 

wounds or skin breakdown . . . [and] [a] new walking static boot was provided” to 

Plaintiff. Id. On April 21, 2004, Plaintiff again saw Dr. Keyarash and “[s]he report[ed] 

that most of the pain in her lesser toe metatarsals ha[d] decreased.” Id. at 216, 364, 425. 

Dr. Keyarash “told her that for the time being since her symptoms are improving we will 

continue current management . . . [and she should] wean herself out of the boot within the 

next couple of weeks.” AR at 216, 425. 

 On May 21, 2004, Plaintiff saw Dr. Keyarash “for follow-up after her stress injury 

to the second and third metatarsals.” Id. at 215, 364, 424. Plaintiff “report[ed] that she 

continues to have significant pain in the ball of her foot involving her metatarsal heads . . 

. starting mostly under the second and then transferring more and more to the outside.” 

Id. at 215, 424. Dr. Keyarash reported “[o]n physical examination the wounds are 

benign[,] [t]here is no erythema, induration, no drainage[,] [but] [s]he does have 

significant tenderness to palpation under her metatarsal heads.” Id. Dr. Keyarash 

assessed “[s]ignificant metatarsalgia with clear mechanical reasons after her multiple 

surgeries[,]” and indicated that Plaintiff was “a candidate for Weil osteotomy of all the 

metatarsals[.]” Id. 

On June 21, 2004, Plaintiff was seen by Michael C. Jean, M.D. regarding 

epigastric discomfort, including pain, nausea, and vomiting. AR at 422–23. On June 22, 

2004, Plaintiff underwent an abdominal ultrasound regarding the epigastric pain, nausea, 

and vomiting. Id. at 372. The ultrasound was normal, “with no evidence of gallstones or 

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biliary dilatation.” Id.

 On July 6, 2004, Plaintiff had surgery at the Tucson Orthopedic Institute Surgical 

Facility. Id. at 225–27. Dr. Keyarash performed a metatarsophalangeal capsulotomy and 

tenorrhaphy on Plaintiff’s second through fifth toes of her right foot; a Weil osteotomy of 

Plaintiff’s second through fifth metatarsals of her right foot; and a resection of the head, 

proximal phalanx of Plaintiff’s right, second toe. Id. at 214, 225–26. On July 16, 2004, 

Plaintiff saw Dr. Keyarash for “her first postoperative visit after MTP capsulotomy 

tenorrhaphy with second through fifth toes with Weil osteotomies and resection of the 

head of the proximal phalanges of the second toe.” AR at 213, 421. Dr. Keyarash 

reported that “[o]n physical examination the wounds are benign[,] [n]o erythema, 

induration and no drainage[,] [and] [t]he pin sites are clear.” Id. Dr. Keyarash also 

reported that the “[x]-rays show well reduced deformities with hardware in place[,] [and 

Plaintiff was] doing well.” Id.

 On August 11, 2004, Plaintiff underwent an air contrast upper GI study, which 

was normal. Id. at 371. On August 13, 2004, Plaintiff saw Dr. Keyarash “for her second 

postoperative visit after MTP capsulotomy and tenorrhaphy, second through fifth toes 

Weil osteotomies and resection of the head of the proximal phalanx of the second toe.” 

Id. at 212, 363, 420. Dr. Keyarash reported that “[o]n physical examination, the wounds 

are benign[,] [n]o erythema or induration[,] [n]o drainage[,] . . . [with] some swelling 

which is appropriate for her stage of healing postop.” AR at 212, 420. Plaintiff’s “[x]-

rays show well-reduced deformities with hardware in place[,] [and] [t]he fifth metatarsal 

osteotomy is not completely healed . . . [and she is] [i]mproving postoperatively. Id. On 

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August 23, 2004, Plaintiff was seen regarding her medications. Id. at 363. 

 On September 13, 2004, Plaintiff again saw Dr. Keyarash “for follow-up of her 

right foot surgeries.” Id. at 211. Plaintiff reported “that her symptomology has improved 

. . . [and] she has been a little more tolerant weightbearing on the involved foot[,] . . . 

[but] reports . . . still ha[ving] significant pain at the end of the day.” Id. Dr. Keyarash 

reported that “[o]n physical exam wounds are benign[,] [n]o erythema, induration[,] . . . 

[or] drainage.” AR at 211. Dr. Keyarash further reported that Plaintiff “ha[d] swelling 

which is appropriate for her stage of healing postop[,] [with] [t]he extensor tendons . . . 

still not functioning quite well . . . [and] [x]-rays show[ing] well healing corrected 

forefoot deformities.” Id. On September 15, 2004, Dr. Keyarash wrote a second letter to 

SunLife Insurance Company to assist “in reevaluating [their] original assessment.” AR at 

208. Dr. Keyarash reported that Plaintiff’s “current level of impairment and limitations 

are more severe now than they were at the time of her inability to return to work on those 

three occasions stated.” Id. Dr. Keyarash further reported that Plaintiff could “stand and 

walk for about one hour a day maximum with 10-15 minute intervals followed by rest.” 

Id. at 209. Dr. Keyarash also stated that “[a]s far as her sitting ability, she can sit for 

about two hours before she has to elevate her foot[,] [o]therwise the patient has to be in a 

reclined position with her foot elevated to decrease the swelling.” AR at 209. Dr. 

Keyarash indicated that “[f]or the duration [Plaintiff] has been on narcotics mostly in the 

form of Percocet tablets[,] [and] [d]ue to the effect of these medications her cognitive 

function has also been effected including her ability it [sic] think clearly, speak clearly, 

type clearly and perform her normal job functions required in her position.” Id. Plaintiff 

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received samples of Lexapro this same date, and again on October 11, 2004. Id. at 363. 

 On November 10, 2004, Plaintiff followed-up with Dr. Keyarash regarding her 

Weil osteotomies. Id. at 206. Dr. Keyarash reported that “[o]n physical examination the 

wounds are benign[,] [n]o erythema, induration and no drainage.” Id. Dr. Keyarash 

further reported that Plaintiff “continues to have some swelling and she continues to be 

tender to palpation under her metatarsal heads, especially under the fifth one and fourth 

one[,] . . . [which] corresponds to an area where the screw seems to be extending too far 

from her Weil osteotomy.” AR at 206. Dr. Keyarash assessed “[s]ymptomatic 

hardware” and “plan[ned] for removal.” Id. On November 15, 2004, Plaintiff received 

samples of Lexapro. Id. at 362. On November 23, 2004, Dr. Keyarash removed the deep 

implant in Plaintiff’s right foot as the hardware had become painful. Id. at 205, 223–24. 

 On December 8, 2004, Plaintiff followed-up with Dr. Keyarash regarding “her 

hardware removal[.]” Id. at 204, 419. Dr. Keyarash reported that “[o]n physical 

examination the wounds are benign[,] [n]o erythema, induration and no drainage[,] [and] 

. . . no tenderness on palpation on the plantar aspect of [Plaintiff’s] foot.” AR at 204, 

419. Dr. Keyarash assessed that Plaintiff was “[d]oing well postop.” Id. On December 

21, 2004, Plaintiff received samples of Lexapro and Flexeril. Id. at 362. On December 

30, 2004, Plaintiff follow-up with Dr. Keyarash was noted stating Plaintiff was “doing 

well[.]” Id.

 On January 7, 2005, Plaintiff returned to Dr. Keyarash for another follow-up “of 

her hardware removal.” Id. at 203. Dr. Keyarash reported “[o]n physical examination, 

the patient is tender to palpation in her first intermetatarsal space[,] [and] [p]lantarly, the 

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pain that was under the screw head is gone.” AR at 203. Dr. Keyarash assessed that 

Plaintiff “is coming along nicely.” Id. On January 11, 2005, Plaintiff received a 

prescription for Flexeril. Id. at 362. On February 15, 2005, Plaintiff again received 

samples of Lexapro and Flexeril. Id. at 362. 

 On March 18, 2005, Plaintiff returned to Dr. Keyarash “for a final visit for 

evaluation of her left foot.” Id. at 202, 416. Plaintiff “report[ed] [that] she is more 

functional than she has been for a long time.” Id. Dr. Keyarash reported that “[o]n 

physical examination today she ambulates much better in terms of her gait but she 

continues to complain of pain mostly under the first and second rays[,] [and] [l]aterally 

most of her pain is gone.” AR at 202, 416. Dr. Keyarash further reported that Plaintiff’s 

“[x]-rays show consolidation of all of her osteotomies[,] [and] [a]lignment of the lesser 

toes is optimal.” Id. Dr. Keyarash assessed “[c]ontinued residual symptomatology, first 

ray right foot, after multiple operations . . . [and] discharge[d] her from care.” Id. On 

March 22, 2005, Plaintiff was seen regarding her allergies. Id. at 362. Plaintiff received 

samples of Lexapro and a prescription for Flexeril. Id.

 On June 8, 2005, Plaintiff returned to Dr. Keyarash “for follow-up of her foot 

pain.” AR at 201, 415. Plaintiff “report[ed] that she has been doing well[,] [but] . . . has 

had some pain under the fifth metatarsal.” Id. Dr. Keyarash reported that “[o]n physical 

examination plantarly under the fifth metatarsal the patient has some prominence and 

there is also a little prominent area under the fourth metatarsal which more closely 

represents the patient’s area of symptomatology.” Id. Dr. Keyarash planned to “treat her 

symptomatology only.” Id. On June 14, 2005, Plaintiff was seen at Pima Osteopathic for 

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foot pain following surgery. Id. at 360. 

 On September 10, 2005, Plaintiff followed-up with Dr. Kiarash regarding her foot. 

AR at 231. Examination showed normal gait, normal range of motion in the ankle, 

sutalar joint, midfoot, and in the MTP joints bilaterally. Id. at 231, 326. Dr. Kiarash 

noted that Plaintiff’s first MTP was “still a little more tender and stiff.” Id. On 

September 12, 2005, Plaintiff underwent a “[r]ight middle trigger finger release.” Id. at 

230, 232–43. Dr. Kiarash performed the surgery, which was unremarkable. See id. On 

September 15, 2005, Plaintiff received a prescription for Flexeril and one for Citalopram 

the following day. AR at 360. On September 23, 2005, Plaintiff followed up with 

Southwest Orthopaedic Surgery Specialists regarding the trigger finger release surgery. 

Id. at 322. Patient notes indicate that her “[w]ound is benign, no erythema, enduration, 

drainage, there is swelling, which is normal for stage of heeling [sic] post op.” Id.

 On October 21, 2005, Plaintiff returned to Southwest Orthopaedic Surgery 

Specialists for follow-up reporting “her trigger finger improved a couple of weeks ago 

and she has had no episodes of triggering.” Id. at 323. Patient notes indicate that the 

“[w]ound is benign, no erythema, enduration, drainage, there is swelling, which is normal 

for stage of heeling [sic] post op.” Id. On November 15, 2005, Plaintiff received a 

prescription for Piroxicam. AR at 360. 

 On December 21, 2005, Plaintiff was seen at Southwest Orthopaedic Surgery 

Specialists for a follow-up. Id. at 324. Plaintiff reported that she was “[v]ery happy with 

the trigger finger relief.” Id. Plaintiff further reported that “she has had problems with 

her foot[,] and [h]as a new job working payrol [sic].” Id.

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 On March 13, 2006, Plaintiff was seen by Judy A. Hiell, N.M.D. for an initial 

consultation regarding Plaintiff’s recent weight gain, foot pain, depression, and for a 

general check-up. Id. at 248–55, 462. On April 10, 2006, Plaintiff sought samples of 

Lexapro and Flexeril. AR at 360. Plaintiff also saw NMD Hiell on the same date 

regarding her weight gain, continued foot pain, and depression. Id. at 463. On April 11, 

2006, Plaintiff was seen regarding her medications and was given prescriptions for 

Ultracet and Percocet. Id. at 361. 

 On May 9, 2006, Plaintiff received a prescription for Vicodin. Id. at 361. On May 

23, 2006, Plaintiff followed up at Southwest Orthopaedic Surgery Specialists regarding 

surgery on her right foot. Id. at 325. Plaintiff reported that she “continues to have pain, 

[with] no significant change since last visit.” AR at 325. Assessment of Plaintiff’s foot 

was unremarkable, but the first MTP was noted to “still [be] a little more tender and 

stiff.” Id. Plaintiff was referred for pain management. Id. On May 10, 2006, Plaintiff 

saw NMD Hiell for a check-up, including a rash on her lower face area. Id. at 464. On 

May 25, 2006, Plaintiff received a prescription for Temazepam. Id. at 359. 

 On July 10, 2006, Plaintiff was seen by NMD Hiell. AR at 465. Plaintiff 

complained that her “foot really bother[s] her a lot [with] weather changes[.]” Id. 

Plaintiff further reported that her facial rash went away on its own. Id. Plaintiff was 

began homeopathies for her night sweats and hot flashes. Id. On July 25, 2006, Plaintiff 

saw Randall S. Prust, M.D. regarding her “right foot pain, particularly across the dorsal 

surface of the MTP joint associated with skin sensitivity, temperature changes, color 

changes, and increased pain upon walking that feels like it is in the bones.” Id. at 411–

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13. In describing her history to Dr. Prust, Plaintiff reported that “[t]he pain is generally 

worse in the afternoon, evening, and night[,] [and] [i]t does interrupt her sleep[,] [and] 

[s]he tosses and turns somewhat.” AR at 411. Upon physical examination, Dr. Prust 

noted “edema between [Plaintiff]s] first and second digit tarsal area consistent with where 

the end of the screw is[.]” Id. at 412. Dr. Prust further reported “range of motion limited 

at the toes with skin sensitivity to light touch on the dorsum of the foot, slightly more 

than the plantar surface of the foot[,] [and] [n]o other edematous areas noted.” Id. 

Plaintiff’s “[r]ange of motion of the ankle is full [,] [but] [t]he patient does some 

guarding[,] [s]he keeps her foot dorsiflexed instead [of] in a neutral position when 

sitting.” Id. at 413. Plaintiff’s assessment include the “possibility of complex regional 

pain syndrome, type I reflex sympathetic dystrophy in the area” which was to be ruled 

out using a lumbar sympathetic block. Id.

 On August 15, 2006, Plaintiff saw Randall Prust, M.D. regarding her right foot 

pain. AR at 410. Dr. Prust’s impressions included “[c]omplex regional pain syndrome, 

type 1 (reflex sympathetic dystrophy), right lower extremity[;] . . . [p]ossible neuralgia, 

right lower extremity[;] . . . [s]tatus post multiple foot surgeries[;] [and] GERD 

[(gastroesophageal reflux disease)].” Id. Dr. Prust performed a lumbar sympathetic 

block on the right and Plaintiff “had total pain relief following the block with no more 

allodynia or hypersensitivity.” Id. On August 23, 2006, Plaintiff saw NMD Hiell for a 

check up. Id. at 466. 

 On September 8, 2006, Plaintiff was seen by Dr. Prust regarding her right foot 

pain. AR at 407–08. Plaintiff reported not having had any long-term results. Id. at 407. 

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Plaintiff also reported that “since her last visit, she developed a headache the next day 

after the [lumbar sympathetic] block.” Id. Dr. Prust opined that “[g]iven the fact that she 

had 100% pain relief initially after the block but it did not last, [he] [was] not inclined to 

do more blocks but [] certainly would like to consider the [spinal cord] stimulator.” Id. at 

408. On September 18, 2006, Plaintiff saw NMD Hiell for a check-up. Id. at 467. On 

September 22, 2006, Plaintiff again saw Dr. Prust regarding her right foot pain. AR at 

406. Plaintiff returned to discuss a spinal cord stimulator. Id.

 On October 18, 2006, Plaintiff’s records indicate that she was told by Dr. Prust 

and PA Judkins to consider a spinal cord stimulator. Id. at 359. On November 3, 2006, 

Plaintiff received a prescription for Flexeril. Id. at 359. On November 27, 2006, four (4) 

views of Plaintiff’s lumbar spine were taken. Id. at 370. “There [was] no evidence of 

fracture or dislocation[,] [and] [d]isk spacing [was] maintained.” AR at 370. 

 On December 21, 2006, Plaintiff saw Dr. Prust regarding her right foot pain, 

which “was gone essentially with the stimulator, but it stopped working.” Id. at 401. 

After the temporary lead had been placed “she was virtually totally pain-free.” Id. After 

discussing what had happened prior to the unit ceasing to work, Dr. Prust decided to “do 

a fluoroscopy . . . and the leads [were] pulled back all the way out of the epidural space.” 

Id. Dr. Prust opted for a permanent system in light of her previous excellent result. Id. 

On December 28, 2006, Plaintiff was again seen by Dr. Prust regarding her foot pain, and 

was “70% to 75% better overall.” AR at 398–99. Dr. Prust noted that he had “spent a 

long time discussing her medicines with her . . . she was using a 120 Percocet every 

couple of weeks with Dr. Kiarash and she is down to using 15 to 20 per week now[,] 

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[s]he was very pleased with the results of the stimulator and the fact she had it done.” Id.

at 398. Dr. Prust reported that “[n]eurologically, [Plaintiff] [was] markedly improved as 

far as allodynia and hypersensitivity and the wounds are clean and dry with no evidence 

of infection.” Id. Dr. Prust removed the sutures and taught Plaintiff how to reprogram 

the spinal cord stimulator. Id. 

 On February 6, 2007, Plaintiff received a prescription for Percocet. Id. at 356. On 

February 12, 2007, Plaintiff was seen at Rincon Anesthesia regarding her “right foot pain, 

much improved with the spinal cord stimulator.” AR at 397. Plaintiff’s “[s]pinal cord 

stimulator was reprogrammed” in an attempt “to see if she could get some better 

stimulation into the foot[.]” Id. On March 5, 2007, Plaintiff received 10 mg samples of 

Lexapro. Id. at 356. On April 9, 2007, Plaintiff asked to pick up prescriptions for 

Percocet, Allegra, and Temazepam, and received samples of Requip and Lexapro. Id. at 

355. 

 On May 8, 2007, Plaintiff returned to Southwest Orthopaedic Surgery Specialists 

for an “evalation [sic] of her left knee.” Id. at 327. Plaintiff reported that her “knee has 

bothered er [sic] over the past 6 months.” AR at 327. Plaintiff rated her pain as between 

2–4 on a scale of 1 through 10, with 10 being the worst pain. Id. Review of the knee was 

unremarkable, and the treatment plan indicated that “[w]hile [Plaintiff’s] symptoms are 

minimal . . . they may be exacerbated by her left foot problems and the fact that she 

favors that side.” Id. There was no need for “management medically or surgically” and 

Plaintiff was instructed “to get on an exercise bike or walk in a pol [sic] to keep the knee 

ROM [(range of motion)] intact.” Id. On May 21, 2007, Plaintiff received prescriptions 

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for Percocet and Requip, as well as additional samples of Lexapro. Id. at 355. 

 On June 7, 2007, Plaintiff received samples of Requip. AR at 355. On June 19, 

2007, Plaintiff was given prescriptions for Lexapro and Percocet. Id. On June 21, 2007, 

Plaintiff was given a prescription for Phenergan. Id. On July 30, 2007, Plaintiff was 

given a prescription for Percocet, as well as Lexapro samples. Id. On August 17, 2007, 

Plaintiff was given samples of Lexapro and Requip. Id. On August 20, 2007, Plaintiff 

was given a prescription for Temazepam. AR at 355. On August 29, 2007, Plaintiff 

received a prescription for Percocet. Id. 

On October 2, 2007, Plaintiff received samples of Lexapro and Requip, as well as 

prescription for Percocet and Roxicodone. Id. at 354. On October 19, 2007, Plaintiff’s 

chart indicates an upcoming appointment regarding a possible pain patch. Id. On 

October 24, 2007, Plaintiff was seen regarding medication concerns and received a 

prescription for OxyContin. Id. at 353. On October 25, 2007, Plaintiff received samples 

of Lexapro. AR at 353. 

 On November 1, 2007, Plaintiff received a prescription for Promethazine. Id. at 

352. On November 5, 2007, Plaintiff received samples of Lexapro. Id. On November 6, 

2007, Plaintiff received prescriptions of OxyContin and Roxicodone. Id. On November 

21, 2007, Plaintiff received additional samples of Lexapro and Requip. Id. On 

November 21, 2007, Plaintiff received another prescription for Roxicodone. AR at 352. 

On December 6, 2007, Plaintiff received a prescription for OxyContin. Id. On December 

11, 2007, Plaintiff received a prescription for Percocet, and samples of Lexapro and 

Requip the following day. Id. at 351. On December 27, 2007, Plaintiff received 

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additional samples of Lexapro and a written prescription for the same the next day. Id. at 

350. 

 On January 10, 2008, Plaintiff was seen for a medication consult, she received 

prescriptions for Lexapro, Temazepam, and Raxicodone at or shortly before the 

appointment. Id. Plaintiff was given a five (5) day prescription of MS Contin. AR at 

350. On January 21, Plaintiff received a prescription for MS Contin. Id. at 349. On 

January 22, 2008, Plaintiff returned to Southwest Orthopaedic Surgery Specialists for 

bilateral foot pain. Id. at 328. Plaintiff was seen by Jason M. Humphrey, P.A.-C., who 

assessed a non-infectious ingrown toenail on Plaintiff’s right great toe and metatarsalgia 

at her left 2nd metatarsal, which was tender on examination. Id. On January 30, 2008, 

three views of Plaintiff’s right foot were taken. Id. at 369. “Postoperative changes 

[were] described[,] . . . [and] [n]o fracture or other bony abnormalities [were] seen.” AR 

at 369. On February 21, 2008, Plaintiff received a prescription for MS Contin. Id. at 

349. On February 26, 2008, Plaintiff was seen regarding her medications. Id. On March 

20, 2008 Plaintiff received a prescription for MS Contin and samples of Lexapro. Id. at 

348. On April 9, 2008, Plaintiff received a prescription for Promethazine and one for 

Cyclobenzaprine the following day. Id. at 347. On April 14, 2008, Plaintiff received 

samples of Lexapro and Levoxyl. AR at 347. On April 21, 2008, Plaintiff received a 

prescription for MS Contin and Temazepam. Id. On April 28, 2008, Plaintiff was seen 

by Kenneth Judkins, P.A.-C. and Randall Prust, M.D. regarding her right foot pain. Id. at 

457–58. PA Judkins reports that Plaintiff “has stabilized under medications with the use 

of the stimulator.” Id. at 457. Plaintiff reported that “she gets 50% pain relief with the 

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stimulator, with morphine . . . [s]he is up all of the other 50% covered.” Id. Plaintiff 

further reported that “[s]he is using the Celebrex more for her knees and her foot at this 

point.” AR at 457. PA Judkins reported “allodynia on light touch[,] [and] . . . some 

edema in the area of the foot.” Id.

 On May 6, 2008, Plaintiff was seen by Dr. Kiarash for “follow up of right foot 

pain[,]” which Plaintiff reported was unchanged and generalized. Id. at 329. Dr. 

Kiarash’s review was unremarkable, noting “[i]t is a year after the last visit and she still 

has problems with her contralateral foot and knee due to favoring her right foot.” Id. 

Plaintiff was also seen by Sander D. Zwart, M.D. on this same date regarding her 

hypothyroidism. Id. at 390–91. On May 19, 2008, Plaintiff received a prescription for 

MS Contin. AR at 346. 

 On June 4, 2008, Plaintiff received samples of Levoxyl and Lexapro, then 

received a prescription for Roxicodone the following day. Id. at 346. On June 17, 2008, 

Plaintiff received a prescription for MS Contin. Id. Plaintiff also underwent a 

Computerized Tomography (“CT”) Scan of her cervical spine and head, this same date, 

as a result of a motor vehicle collision. Id. at 367–68. A “mild reversal of cervical 

lordosis” was noted, but “[n]o evidence of fracture of [sic] subluxation[,] [n]o 

prevertebral soft tissue swelling[,] [and] [t]he facet joints [were] normally aligned.” Id. at 

367. “There [was] a slight osseous ridging at C5-6 and C6-7[,] [but] [n]o significant 

osseous canal or foraminal compromise.” AR at 367. Additionally, the CT showed “no 

acute intracranial hemorrhage[,] [n]o mass effect or midline shift[,] [n]o hydrocephalus[,] 

. . . [and] [n]o edema in the brain parenchyma.” Id. at 368. The CT scan was otherwise 

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unremarkable. Id. On June 19, 2008, Plaintiff received a prescription for Promethazine. 

Id. at 346. 

 On July 9, 2008, Plaintiff saw NMD Hiell for a check-up. Id. at 468. Plaintiff 

reported being in a motor vehicle accident the prior month. AR at 468. Plaintiff 

complained of fatigue, weight issues, constipation, tightness in her hips and shoulders, 

poor sleep, cold feet, dry skin, and memory issues. Id. On July 17, 2008, Plaintiff 

received a prescription for MS Contin. Id. at 346. On July 18, 2008, Plaintiff was rear 

ended in a motor vehicle accident. Id. at 345. Plaintiff exhibited whiplash symptoms and 

was given a prescription for Flexaril. Id. On the same date, Plaintiff received a 

prescription for Lexapro. AR at 345. On July 28, 2008, Plaintiff saw PA Judkins and Dr. 

Prust regarding her continuing right foot pain. Id. at 455–56. Plaintiff reported having 

been in a motor vehicle accident since her last appointment. Id. at 455. Plaintiff further 

reported that her right lateral ankle hurt, and the notes indicate that there was “a little 

swelling . . . probably consistent with sprain-strain in the ankle.” Id. Plaintiff reported 

using herbal formulations, and her physical examination was otherwise unremarkable. 

Id. Plaintiff was seen on the same date by NMD Hiell and discussed her continuing 

symptoms of perimenopause. AR at 469. 

 On July 26, 2010, PA Humphrey entered a note reviewing Plaintiff’s August 8, 

2008 x-rays. Id. at 330. PA Humphrey noted that the x-rays showed “a well healed and 

stable 1st MTP fusion with multiple screws at the fusion as well as what appears to be a 

distal osteotomy.” Id. PA Humphreys further noted that software and hardware issues in 

the office resulted in the office notes associated with Plaintiff’s August 8, 2008 and 

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September 17, 2008 visits becoming irretrievable. Id. On August 15, 2008, Plaintiff 

received a prescription for MS Contin, as well as samples of Lexapro. Id. at 345. On 

August 28, 2008, Plaintiff was seen by PA Judkins and Dr. Prust regarding her 

“continuing right foot pain.” AR at 453–54. Plaintiff reported to “doing well with her 

digestive supplements.” Id. at 453. Plaintiff further reported “that the last set of storms 

hurt her much less than typical and she is doing well[,] [but] needs some reprogramming 

with the stimulator.” Id. PA Judkins notes that Plaintiff is “[o]therwise, stable and 

stationary.” Id. On August 27, 2008, Plaintiff was seen by NMD Hiell. Id. at 470. 

Plaintiff complained of memory issues and discussed dietary changes. AR at 470. 

 On September 12, 2008, Plaintiff received a prescription for MS Contin. Id. at 

345. On September 16, 2008, Plaintiff received prescriptions for Cyclobenzaprine and 

Temazepam. Id. at 344. On October 17, 2008, Plaintiff received a prescription for MS 

Contin. Id. at 344. On November 12, 2008, Plaintiff saw NMD Hiell and discussed her 

perimenopause symptoms. Id. at 471. On November 14, 2008, Plaintiff received a 

prescription for MS Contin and samples of Lexapro. AR at 344. On November 24, 2008, 

Plaintiff received a prescription for Percocet for her break through pain. Id. 

 On December 3, 2008, Plaintiff was seen by PA Judkins and Dr. Prust regarding 

her continued right foot pain. Id. at 451–52. Plaintiff reported a “continued pain at a 

level of 3 in the right toes.” Id. at 451. Plaintiff reported using a variety of herbal 

supplements which “give[] her more pain relief with less stomach problems.” Id. On 

December 4, 2008, Plaintiff saw NMD Hiell for a check-up, and again on December 15, 

2008. AR at 472. On December 12, 2008, Plaintiff received a prescription for MS 

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Contin. Id. at 344. On December 18, 2008, Plaintiff received a prescription for Restoril 

and one for Percocet the following day. Id.

 On January 9, 2009, Plaintiff received prescriptions for MS Contin and 

Roxicodone. Id. at 344. On January 14, 2009, Plaintiff was seen regarding her 

medications and neck pain. Id. at 343. On January 22, 2009, Plaintiff received a 

prescription for Avinza. AR at 343. On February 19, 2009, Plaintiff received 

prescriptions for Avinza and Oxycodone. Id. On February 23, 2009, Plaintiff received a 

prescription for Percocet for break through pain. Id. On March 5, 2009, Plaintiff 

received a prescription for Temazepam. Id. at 342. On March 13, 2009, Plaintiff 

received a prescription for Avinza. Id. On April 9, 2009, Plaintiff received a prescription 

for Avinza and Lexapro. AR at 342. On April 29, 2009, Plaintiff saw NMD Hiell for a 

check-up. Id. at 473. 

 On May 6, 2009, Plaintiff received a prescription for Avinza and samples of 

Lexapro. Id. at 342. On June 4, 2009, Plaintiff received a prescription for Avinza. Id. 

On July 2, 2009, Plaintiff received a prescription for Avinza. Id. at 341. On July 10, 

2009, Plaintiff received a prescription for Restoril. AR at 341. On July 23, 2009, 

Plaintiff received prescriptions for Cyclobenzaprine and Promethazine. Id. On July 31, 

2009, Plaintiff received a prescription for Avinza. Id. On August 4, 2009, Plaintiff 

received prescriptions for Percocet and Restoril. Id. at 341. On August 27, 2009, 

Plaintiff received a prescription for Avinza and samples of Lexapro. Id.

 On September 3, 2009, Plaintiff received prescriptions for Restoril and 

Promethazine. AR at 341. On September 11, 2009, Plaintiff received a prescription for 

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Promethazine. Id. at 340. On September 14, 2009, Plaintiff received a prescription for 

Cyclobenzaprine. Id. On September 25, 2009, Plaintiff received prescriptions for Avinza 

and Percocet. Id. On October 8, 2009, Plaintiff received a prescription for 

Cyclobenzaprine. AR at 340. On October 12, 2009, Plaintiff received a prescriptions for 

Promethazine and another for Cyclobenzaprine. Id. On October 16, 2009, Plaintiff 

received a prescription for Restoril. Id. On October 20, 2009, Plaintiff received a 

prescription for Promethazine. Id. On October 27, 2009, Plaintiff was seen regarding her 

medications. Id. at 339. 

 On November 4, 2009, Plaintiff saw NMD Hiell for a check-up. AR at 474. 

Plaintiff reported sleeping a lot, as well as weight gain. Id. On November 9, 2009, 

Plaintiff received a prescription for Cyclobenzaprine. Id. at 339. On November 20, 

2009, Plaintiff again saw NMD Hiell regarding her diet, decreased energy, weight gain, 

and hot flashes. Id. at 475. On November 23, 2009, Plaintiff received another 

prescription for Cyclobenzaprine. Id. at 338. On November 25, 2009, Plaintiff received 

a prescription for Avinza. AR at 339. On November 30, 2009, Plaintiff received a 

prescription for Temazepam. Id. at 338. 

 On December 3, 2009, Plaintiff was seen by PA Judkins and Dr. Prust for her right 

foot pain. Id. at 449–50. PA Judkins notes indicate that Plaintiff “was last seen on June 

3, 2009 briefly, she has done well since then[,] [but] . . . continues to have some issues 

with pain about the middle of the early morning area.” Id. at 449. PA Judkins further 

noted that Plaintiff “continue[d] to do well with the stimulator itself.” Id. Additionally, 

Plaintiff reported “her pain is about 6 today[,] . . . the weather seems to have something 

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to do with this.” AR at 449. On December 16, 2009, Plaintiff received a prescription for 

Lexapro. Id. at 338. On December 21, 2009, Plaintiff received a prescription for 

Cyclobenzaprine. Id. On December 22, 2009, Plaintiff received prescriptions for Avinza 

and Percocet. Id.

 On June 3, 2013, Dr. Prust filled out a Reflex Sympathetic Dystrophy 

(RSD)/Complex Regional Pain Syndrome, Type I (CRPS) Medical Source Statement.2

 

Id. at 194–97. Dr. Prust indicated that he had contact with Plaintiff from July 25, 2006 to 

the present. AR at 194. Dr. Prust indicated that Plaintiff suffers from RSD/CRPS and 

“persistent complaints of pain that are typically out of proportion to the severity of any 

documented precipitant.” Id. Dr. Prust indicated that Plaintiff had swelling, 

osteoporosis, changes in skin color or texture, skin temperature changes, and involuntary 

movements of the affected region at some point during his treatment of her. Id. Dr. Prust 

also documented Plaintiff’s right foot neuralgia and decreased range of motion with 

fusion. Id. Dr. Prust’s prognosis for Plaintiff was fair. Id. Dr. Prust indicated that 

Plaintiff’s impairments could be expected to last at least twelve (12) months and 

identified her symptoms and signs as: burning, aching or searing pain initially localized 

to the site of injury; increased sensitivity to touch; joint stiffness; restricted mobility; 

muscle spasm; impaired appetite; abnormal sensations of heat or cold; muscle pain; 

muscle atrophy; impaired sleep; and chronic fatigue. AR at 194. Dr. Prust also identified 

associated limitations as: reduced ability to attend to tasks; reduced ability to persist in 

tasks; depression; social withdrawal; and anxiety. Id. at 195. Dr. Prust indicated 

2

 This is a check-the-box form. 

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drowsiness or sedation as a side effect of Plaintiff’s medications. Id. Dr. Prust opined 

that Plaintiff could not walk the length of any city blocks without rest or severe pain, 

could sit for twenty (20) minutes at one time, and could stand for thirty (30) minutes at 

one time. Id. Dr. Prust further opined that Plaintiff could sit for approximately four (4) 

hours in an eight (8) hour work day, and stand or walk for about two (2) hours in the 

same day. Id. at 195. Dr. Prust opined that Plaintiff would need a job that permitted 

shifting positions at will from sitting, standing or walking, and would need to include 

periods of walking around during an eight (8) hour work day. AR at 195. Dr. Prust 

stated that Plaintiff must walk every ten (10) minutes for approximately ten (10) minutes. 

Id. Dr. Prust opined that Plaintiff would need to take unscheduled breaks during the 

work day, and that this would occur more than every ten (10) minutes and Plaintiff would 

have to rest for ten (10) minutes before returning to work. Id. Dr. Prust stated that 

muscle weakness, chronic fatigue, and pain/paresthesias, numbness were the causes for a 

need for breaks. Id. at 196. Dr. Prust stated that Plaintiff’s leg should be elevated to 

heart level for approximately three (3) hours of an eight (8) hour work day due to pain 

and swelling. Id. Dr. Prust opined that Plaintiff could frequently lift less than ten (10) 

pounds; occasionally lift ten (10) pounds; rarely lift twenty (20) pounds; and never lift 

fifty (50) pounds. AR at 196. Dr. Prust further opined that Plaintiff should rarely twist 

and stoop (bend) and should never crouch or squat. Id. Dr. Prust estimated that Plaintiff 

would be “off task” twenty-five (25) percent or more of the work day, but is capable of 

high stress work. Id. at 197. Dr. Prust opined that Plaintiff’s impairments would likely 

produce “good days” and “bad days,” and that these would occur more than four (4) days 

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per month. Id. Dr. Prust further opined that Plaintiff’s impairments were reasonably 

consistent with the symptoms and functional limitations listed, and that her limitations 

would have applied by at least December 31, 2009. Id.

II. STANDARD OF REVIEW

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

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

1383(c)(3); Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 2008). This Court may 

“set aside the Commissioner’s denial of disability insurance benefits when the ALJ’s 

findings are based on legal error or are not supported by substantial evidence in the 

record as a whole.” Tackett v. Apfel, 180 F.3d 1094, 1097 (9th Cir. 1999) (citations 

omitted); see also Treichler v. Comm’r of Soc. Sec. Admin., 775 F.3d 1090, 1098 (9th 

Cir. 2014). 

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

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

871, 873 (9th Cir. 2003)); see also Garrison v. Colvin, 759 F.3d 995, 1009 (9th Cir. 

2014). Further, substantial evidence is “such relevant evidence as a reasonable mind 

might accept as adequate to support a conclusion.” Parra v. Astrue, 481 F.3d 742, 746 

(9th Cir. 2007). Where “the evidence can support either outcome, the court may not 

substitute its judgment for that of the ALJ.” Tackett, 180 F.3d at 1098 (citing Matney v. 

Sullivan, 981 F.2d 1016, 1019 (9th Cir. 1992)); see also Massachi v. Astrue, 486 F.3d 

1149, 1152 (9th Cir. 2007). Moreover, the court may not focus on an isolated piece of 

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supporting evidence, rather it must consider the entirety of the record weighing both 

evidence that supports as well as that which detracts from the Secretary’s conclusion. 

Tackett, 180 F.3d at 1098 (citations omitted). 

III. ANALYSIS 

 The Commissioner follows a five-step sequential evaluation process to assess 

whether a claimant is disabled. 20 C.F.R. § 404.1520(a)(4). This process is defined as 

follows: Step one asks is the claimant “doing substantial gainful activity[?]” If yes, the 

claimant is not disabled; step two considers if the claimant has a “severe medically 

determinable physical or mental impairment[.]” If not, the claimant is not disabled; step 

three determines whether the claimant’s impairments or combination thereof meet or 

equal an impairment listed in 20 C.F.R. Pt. 404, Subpt. P, App.1. If not, the claimant is 

not disabled; step four considers the claimant’s residual functional capacity and past 

relevant work. If claimant can still do past relevant work, then he or she is not disabled; 

step five assesses the claimant’s residual functional capacity, age, education, and work 

experience. If it is determined that the claimant can make an adjustment to other work, 

then he or she is not disabled. 20 C.F.R. § 404.1520(a)(4)(i)-(v). 

 In the instant case, the ALJ found that Plaintiff met the insured status requirements 

of the Social Security Act through December 31, 2009, and was not engaged in 

substantial gainful activity since her alleged onset date of January 1, 2004. AR at 26. At 

step two of the sequential evaluation, the ALJ found that “the claimant had the following 

severe impairments: arthritis; right foot chronic pain (20 CFR 404.1520(c)).” Id. At step 

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

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

in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525 and 

404.1526).” Id. at 29. At step four, the ALJ found that Plaintiff had: 

the residual functional capacity to perform a wide range [of] sedentary 

work; she was able to sit for 6 hours out of an 8-hour day; stand for 2 hours 

out of an 8-hour day; walk for 2 hours out of an 8-hour day; lift and/or 

carry 20 pounds occasionally and 10 pounds frequently; occasionally climb 

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

balance, stoop, kneel and crouch; never crawl. 

Id. The ALJ determined, however, that “claimant was unable to perform any past 

relevant work (20 CFR 404.1565).” Id. at 32. Accordingly, at step five, the ALJ found 

that “if the claimant had the residual functional capacity to perform the full range of 

sedentary work, considering the claimant’s age, education, and work experience, a 

finding of ‘not disabled’ would be directed by Medical-Vocational Rule 201.28.” AR at 

33. The ALJ further found that “the additional limitations had little or no effect on the 

occupational base of unskilled sedentary work[,] [and] [a] finding of ‘not disabled’ is 

therefore appropriate under the framework of this rule.” Id. Accordingly, the ALJ found 

that “[t]he claimant was not under a disability, as defined in the Social Security Act, at 

any time from January 1, 2004, the alleged onset date, through December 31, 2009, the 

date last insured (20 CFR 404.1520(g)).” Id.

 Plaintiff asserts that her DIB claim should not have been denied at Step Five, 

because the Appeals Council should have evaluated the Medical Source Statement of her 

treating physician, Randall Prust, M.D. pursuant to the standards set out in Garrison v. 

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Colvin, 759 F.3d 995 (9th Cir. 2014). Pl.’s Opening Br. (Doc. 12) at 6. 

A. Non-reviewable Appeals Council Decision

 Plaintiff argues that the Appeals Council erred in its evaluation of the Medical 

Source Statement submitted by Randall S. Prust, M.D. Pl.’s Opening Br. (Doc. 12) at 6. 

In denying Plaintiff’s request for review, the Appeals Council stated that “[i]n looking at 

your case, we considered the reasons you disagree with the decision and the additional 

evidence listed.” AR at 1. The Appeals Council “found that this information does not 

provide a basis for changing the Administrative Law Judge’s decision.” Id. at 2. 

 The Ninth Circuit Court of Appeals has unequivocally held that “we do not have 

jurisdiction to review a decision of the Appeals Council denying a request for review of 

an ALJ’s decision because the Appeals Council decision is a non-final agency action.” 

Brewes v. Comm’r of Soc. Sec. Admin., 682 F.3d 1157, 1161 (9th Cir. 2012); see also 

Taylor v. Comm’r of Soc. Sec. Admin., 659 F.3d 1228, 1231 (9th Cir. 2011). “When the 

Appeals Council declines review, ‘the ALJ’s decision becomes the final decision of the 

Commissioner,’ . . . and the district court reviews that decision for substantial evidence, 

based on the record as a whole[.]” Brewes, 682 F.3d at 1161–62 (citations omitted). 

“[W]hen the Appeals Council considers new evidence in deciding whether to review a 

decision of the ALJ, that evidence becomes part of the administrative record, which the 

district court must consider when reviewing the Commissioner’s final decision for 

substantial evidence.” Id. at 1163 (citations omitted). 

 This Court does not have jurisdiction to review the Appeals Council’s decision, 

but must review the ALJ’s decision based on the administrative record as a whole, which 

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now includes Dr. Prust’s Medical Source Statement. See Brewes, 682 F.3d at 1163; see 

also Burrell v. Colvin, 775 F.3d 1133, 1136 (9th Cir. 2014). 

B. The ALJ’s Decision

 “Where ‘the evidence can reasonably support either affirming or reversing a 

decision, we may not substitute our judgment for that of the [ALJ].’” Garrison v. 

Comm’r of Soc. Sec. Admin., 759 F.3d 995, 1010 (9th Cir. 2014) (citations omitted) 

(alterations in original); see also Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002) 

(“Where the evidence is susceptible to more than one rational interpretation, one of which 

supports the ALJ’s decision, the ALJ’s conclusions must be upheld”). 

 1. Plaintiff’s Credibility

 “To determine whether a claimant’s testimony regarding subjective pain or 

symptoms is credible, an ALJ must engage in a two-step analysis.” Lingenfelter v. 

Astrue, 204 F.3d 1028, 1035–36 (9th Cir. 2007). First, “a claimant who alleges disability 

based on subjective symptoms ‘must produce objective medical evidence of an 

underlying impairment which could reasonably be expected to produce the pain or other 

symptoms alleged[.]’” Smolen v. Chater, 80 F.3d 1273, 1281–82 (9th Cir. 1996) 

(quoting Bunnell v. Sullivan, 947 F.2d 341, 344 (9th Cir. 1991) (en banc) (internal 

quotations omitted)); see also Ghanim v. Colvin, 763 F.3d 1154, 1163 (9th Cir. 2014). 

Further, “the claimant 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, 80 F.3d at 1282 

(citations omitted). “Nor must a claimant produce ‘objective medical evidence of the 

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pain or fatigue itself, or the severity thereof.’” Garrison v. Colvin, 759 F.3d 995, 1014 

(9th Cir. 2014) (quoting Smolen, 80 F.3d at 1282). “[I]f 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.’” Lingenfelter, 504 F.3d at 1036 (quoting Smolen, 80 F.3d at 1281); 

see also Burrell v. Colvin, 775 F.3d 1133, 1137 (9th Cir. 2014) (rejecting the contention 

that the “clear and convincing” requirement had been excised by prior Ninth Circuit case 

law). 

 “Factors that an ALJ may consider in weighing a claimant’s credibility include 

reputation for truthfulness, inconsistencies in testimony or between testimony and 

conduct, daily activities, and ‘unexplained, or inadequately explained, failure to seek 

treatment or follow a prescribed course of treatment.’” Orn v. Astrue, 495 F.3d 625, 636 

(9th Cir. 2007) (quoting Fair v. Bowen, 885 F.2d 597, 603 (9th Cir. 1989)); see also 

Ghanim, 763 F.3d at 1163. “While ALJs obviously must rely on examples to show why 

they do not believe that a claimant is credible, the data points they choose must in fact

constitute examples of a broader development to satisfy the applicable ‘clear and 

convincing’ standard.” Id. at 1018 (emphasis in original) (discussing mental health 

records specifically). “Inconsistencies between a claimant’s testimony and the claimant’s 

reported activities provide a valid reason for an adverse credibility determination. 

Burrell, 775 F.3d at 1137 (citing Light v. Soc. Sec. Admin., 119 F.3d 789, 792 (9th Cir. 

1997)). 

 Here, the ALJ pointed to inconsistencies between Plaintiff’s testimony and her 

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medical records stating: 

The claimant testified to severe functional limitations that affected her 

activities of daily living. However, the record does not support such 

limitations. The claimant reported in a March 2005 follow-up appointment 

with Dr. Ario Kiarash that she was more functional than she had been for a 

long time. She ambulated better in terms of gait. In September 2005, he 

reported that the claimant’s gait was normal. She was able to heel and toe 

walk bilaterally. She was able to perform single stance heel rise bilaterally. 

Range of motion of the right ankle and mid foot was normal. Left knee 

symptoms were described as minimal in May 2007. Again, gait was 

normal and the claimant was able to heel and toe walk. Dr. Kiarash 

recommended riding an exercise bike or walking in a pool. Gait and 

strength in the lower extremities was reported as normal by Dr. Randall 

Prust in April 2008. The claimant reported to him to May 2010 that she 

had fallen off an elliptical machine. These facts are inconsistent with the 

claimant’s testimony as to limited ability to do household chores or to 

exercise during the time period at issue. 

AR at 30; see also AR at 42–52, 155–57, 178–83, 202, 231, 326–27, 416, 457–58. The 

ALJ further noted that “[d]iagnostic imaging is also inconsistent with disabling functional 

limitations[,]” relying on x-rays from May 2006, May 2007, and August 2008, as well as 

x-rays from July 2012. Id. at 31, 325, 327, 330. Finally, the ALJ noted that Plaintiff 

initially “reported a 70-75 percent relief of symptoms[.]” Id. at 31, 398–99. 

Subsequently, Dr. Kiarash “consistently reported pain relief at 50 percent with the most 

of the balance of the claimant’s pain treated with narcotics.” Id. at 31, 457. Plaintiff 

further “testified that she was able to wean herself from opiates independently by 2010.” 

Id. at 31, 52. The ALJ concluded “that the claimant’s testimony with regard to the 

severity and functional consequences of her symptoms is not fully credible.” Id. at 31. 

 The Court finds that the ALJ stated sufficient specific reasons for not fully 

crediting Plaintiff’s pain testimony, supported by substantial evidence. Moreover, Dr. 

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Prust’s medical source statement does not change this assessment. In the Medical Source 

Statement, Dr. Prust indicated that Plaintiff had swelling, osteoporosis, changes in skin 

color or texture, skin temperature changes, and involuntary movements of the affected 

region at some point during his treatment of her. AR at 194. The medical records do not 

contain any indication of osteoporosis or involuntary movements of the affected region. 

Furthermore, at Dr. Prust’s initial consultation with Plaintiff, Dr. Prust noted “edema 

between the first and second digit tarsal area consistent with where the end of the screw is 

. . . [n]o other edematous areas noted.” Id. at 412. Dr. Prust also charted that Plaintiff’s 

“[s]kin is slightly more dusky in coloration over the right versus the left, but no frank 

color changes.” Id. at 413. On April 28, 2008, Plaintiff saw PA Judkins and Dr. Prust 

and reported that “she gets 50% pain relief with the stimulator, with morphine . . . [s]he is 

up all of the other 50% covered.” Id. at 457. PA Judkins reported “allodynia on light 

touch[,] [and] . . . some edema in the area of the foot.” Id. On July 28, 2008, PA Judkins 

and Dr. Prust reported that there was “a little swelling . . . probably consistent with 

sprain-strain in the ankle” caused by a recent motor vehicle accident. AR at 455. 

 Dr. Prust identified her symptoms and signs as: burning, aching or searing pain 

initially localized to the site of injury; increased sensitivity to touch; joint stiffness; 

restricted mobility; muscle spasm; impaired appetite; abnormal sensations of heat or cold; 

muscle pain; muscle atrophy; impaired sleep; and chronic fatigue. Id. at 194. There is no 

evidence in the medical records, however, of impaired appetite, muscle atrophy, or 

chronic fatigue. 

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evidentiary conflict in the record that could be resolved either for or against the claimant. 

The medical source statement itself, however, is not consistent with Dr. Prust’s own 

medical records. As such, the Court finds that the information presented to the Appeals 

Council did not change the evidentiary record. “Where the evidence is susceptible to 

more than one rational interpretation, one of which supports the ALJ’s decision, the 

ALJ’s conclusion must be upheld.” Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 

2002). 

 2. Lay Witness Testimony

 The Ninth Circuit Court of Appeals has unequivocally stated that “competent lay 

witness testimony ‘cannot be disregarded without comment,’ Nguyen [v. Chater], 100 

F.3d [1462,] 1467 [(9th Cir. 1996)], and that in order to discount competent lay witness 

testimony, the ALJ ‘must give reasons that are germane to each witness.’ Dodrill [v 

Shalala], 12 F.3d [915,] 919 [(9th Cir. 1993)].” Molina, 674 F.3d at 1114 (emphasis in 

original); see also Bruce v. Astrue, 557 F.3d 1113, 1115 (9th Cir. 2009). 

 Here, the ALJ addressed the statement submitted by Plaintiff’s husband Robert 

Marshall, dated February 2003. AR at 31. The ALJ gave this statement “limited weight” 

noting that “the limitations are not substantiated by the overall medical evidence and 

activities of daily living.” Id. Inconsistency with medical evidence is a germane reason 

for discrediting lay witness testimony. Bayliss v. Barnhart, 427 F.3d 1211, 1218 (9th Cir. 

2005). Dr. Prust’s medical source statement does not change this assessment. See 

Section III.B.1., supra. 

 . . . 

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 3. Residual Functional Capacity 

 “In determining a claimant's RFC, an ALJ must consider all relevant evidence in 

the record, including, inter alia, medical records, lay evidence, and ‘the effects of 

symptoms, including pain, that are reasonably attributed to a medically determinable 

impairment.’ See SSR 96–8p, 1996 WL 374184, at *5; accord 20 C.F.R. §§ 

404.1545(a)(3), 416.945(a)(3).” Robbins v. Soc. Sec. Admin., 466 F.3d 880, 883 (9th Cir. 

2008). Here, the ALJ properly weighed Plaintiff’s testimony, the statement of Plaintiff’s 

husband, and the medical evidence and derived the RFC from this analysis, as well as 

John Fahlberg, M.D.’s review of Plaintiff’s medical records. See AR at 29–32, 74–76. 

 “[T]he key question is not whether there is substantial evidence that could support 

a finding of disability, but whether there is substantial evidence to support the 

Commissioner’s actual finding that claimant is not disabled.” Jamerson v. Chater, 112 

F.3d 1064, 1067 (9th Cir. 1997). Although the limitations Dr. Prust places on Plaintiff 

are greater than those outlined in the ALJ’s RFC finding, “an ALJ need not accept the 

opinion of a doctor if that opinion is brief, conclusory, and inadequately supported by 

clinical findings.” Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th Cir. 2005) (citing 

Tonapetyan v. Halter, 242 F.3d 1144, 1149 (9th Cir.2001)). As discussed in Section 

III.B.1., supra, Dr. Prust’s 2013 medical source statement is inconsistent with his own 

medical records and the clinical evidence as a whole. The Court finds that the 

information presented to the Appeals Council did not change the evidentiary record. 

“Where the evidence is susceptible to more than one rational interpretation, one of which 

supports the ALJ’s decision, the ALJ’s conclusion must be upheld.” Thomas v. Barnhart, 

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278 F.3d 947, 954 (9th Cir. 2002). 

IV. CONCLUSION 

“All that Marshall is requesting in this case is that it be remanded to the ALJ, so 

the ALJ can [evaluate Dr. Prust’s 2013 medical source statement] under the Garrison 

guidelines.” Pl.’s Reply (Doc. 22) at 2. For the reasons discussed above, the Court 

denies Plaintiff’s request and affirms the Commissioner’s decision. Accordingly, IT IS 

HEREBY ORDERED that: 

 1) Plaintiff’s Opening Brief (Doc. 12) is DENIED; 

 2) The Commissioner’s decision is AFFIRMED; and 

 3) The Clerk of the Court shall enter judgment, and close its file in this matter. 

 Dated this 21st day of March, 2016. 

Honorable Bruce G. Macdonald 

United States Magistrate Judge 

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