Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_15-cv-02325/USCOURTS-casd-3_15-cv-02325-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:0405id Review of HHS Decision (SSID)

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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

Melissa Claire Gilleon,

Plaintiff,

v.

Carolyn W. Colvin, Acting Commissioner 

of Social Security,

Defendant.

Case No.: 15cv2325-BEN-BGS

REPORT AND 

RECOMMENDATION

I. PROCEDURAL BACKGROUND

Melissa Claire Gilleon (“Plaintiff”) filed an application for disability insurance 

benefits on March 28, 2012, alleging disability commencing on January 25, 2010. (ECF 

No. 12, Administrative Record “AR” at 65, 188-189.) Her claim was originally denied 

on June 26, 2012 (id. at 64-77) and upon reconsideration on December 10, 2012. (Id. at

78-91.) After a hearing on October 21, 2013, (id. at 28-57) and a supplemental hearing 

on January 13, 2014 (id. at 58-63), Administrative Law Judge (“ALJ”) James P. Nguyen

issued a decision denying the application on February 18, 2014. (Id. at 10-27.) 

On July 21, 2015, the Appeals Council denied Plaintiff’s request for review, 

making the ALJ’s decision the final agency decision. (Id. at 7-9.) This Court has 

jurisdiction pursuant to 42 U.S.C. §§ 405(g), 1383(c). Plaintiff filed her Motion for 

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Summary Judgment on May 13, 2016. (ECF No. 16.) In her motion for summary 

judgment, Plaintiff submits, for the first time, a Veterans Affairs (“VA”) letter dated 

April 26, 2016, which reverses its prior determination and finds Plaintiff seventy percent 

disabled. (ECF No. 16-2.) Plaintiff argues that this reversal by the VA constitutes new 

evidence that should be considered on remand.1 (ECF No. 16-1 at 4.) Plaintiff also 

argues that the ALJ’s rejection of a treating physician’s opinion was not supported by 

substantial evidence. (Id. at 6.) Defendant filed her cross Motion for Summary

Judgment on July 11, 2016. (ECF No. 21-1.) Plaintiff filed a reply on July 25, 2016. 

(ECF No. 23.) Defendant filed a reply on August 1, 2016. (ECF No. 24.) 

II. LEGAL STANDARD FOR DETERMINATION OF A DISABILITY

In order to qualify for disability benefits, an applicant must show that: (1) he or she 

suffers from a medically determinable physical or mental impairment that can be 

expected to result in death, or that has lasted or can be expected to last for a continuous 

period of not less than twelve months; and (2) the impairment renders the applicant 

incapable of performing the work that he or she previously performed or any other 

substantially gainful employment that exists in the national economy. See 42 U.S.C. §§ 

423(d)(1)(A), (2)(A). An applicant must meet both requirements to be “disabled.” Id.

The applicant has the burden to establish disability. Terry v. Sullivan, 903 F.2d 1273, 

1275 (9th Cir. 1990).

The Secretary of the Social Security Administration set forth a five-step sequential 

evaluation process for determining whether a person has established his or her eligibility 

for disability benefits. See 20 C.F.R. §§ 404.1520, 416.920. The five steps in the process 

are as follows:

 

1 Plaintiff’s Motion for Remand and/or Summary Judgment attached a letter from the Department of 

Veterans Affairs. This letter references a “Rating Decision” which purportedly provides a detailed 

explanation of the VA’s decision, the evidence considered, and the reasons for the decision. (ECF No. 

16-2 at 2.) However, Plaintiff did not attach the Rating Decision. The Court ordered Plaintiff to 

supplement the record with the Rating Decision on August 3, 2016. (ECF No. 25.) Plaintiff did so on 

August 5, 2016. (ECF No. 26.)

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1. Is the claimant presently working in a substantially gainful activity? If so, then 

the claimant is not disabled within the meaning of the Social Security Act. If 

not, proceed to step two. See 20 C.F.R. §§ 404.1520(b), 416.920(b).

2. Is the claimant’s impairment severe? If so, proceed to step three. If not, then 

the claimant is not disabled. See 20 C.F.R. §§ 404.1520C, 416.920C.

3. Does the impairment “meet or equal” one or more of the specific impairments 

described in 20 C.F.R. Pt. 404, Subpt. P, App. 1? If so, then the claimant is 

disabled. If not, proceed to step four. See 20 C.F.R. §§ 404.1520(d), 

416.920(d).

4. Is the claimant able to do any work that he or she has done in the past? If so, 

then the claimant is not disabled. If not, proceed to step five. See 20 C.F.R. §§ 

404.1520(e), 416.920(e).

5. Is the claimant able to do any other work? If so, then the claimant is not 

disabled. If not, then the claimant is disabled. See 20 C.F.R. §§ 404.1520(f), 

416.920(f).

Bustamante v. Massanari, 262 F.3d 949, 954 (9th Cir. 2001).

The claimant bears the burden of proof during steps one through four. Id. at 953. 

The Commissioner bears the burden of proof at step five of the process, where the 

Commissioner must show the claimant can perform other work that exists in significant 

numbers in the national economy, “taking into consideration the claimant’s residual 

functional capacity, age, education, and work experience.” Tackett v. Apfel, 180 F.3d 

1094, 1100 (9th Cir. 1999); see also 20 C.F.R. § 404.1566 (describing “work which 

exists in the national economy”). If the Commissioner fails to meet this burden, then the 

claimant is disabled. If, however, the Commissioner proves that the claimant is able to 

perform other work that exists in significant numbers in the national economy, then the 

claimant is not disabled. Bustamante, 262 F.3d at 953-54.

III. MEDICAL RECORDS AND EVALUATIONS PRE-HEARING

The Court has synthesized Plaintiff’s medical records for the purpose of providing 

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context to its analysis of the issues. This summary, however, does not purport to be 

exhaustive of every detail contained in the administrative record. Specifically, Plaintiff’s 

medical record contains a number of documents related to a laparoscopic hysterectomy

(AR 530-66, 602, 715-20) and an incisional ventral hernia. (Id. at 608-12, 615-16, 619-

24, 708, 711-14). Although the ALJ considered these records (id. at 15-16), they are not 

the source of any dispute between the parties. As a result, those records are not included 

in this section, but are mentioned in section IV(C), which summarizes the ALJ’s decision. 

A. Treatment Records from 2011

Dimitri Perivoliotis, Ph.D., Psychologist authored a Psychology Initial Evaluation 

Note regarding Plaintiff on December 9, 2011. (Id. at 387.) This report states that 

Plaintiff presented with Major Depressive Episodes & Mania. (Id. at 383.) Notes on this 

diagnosis state that Dr. Willward was steadily increasing her dose of antidepressants 

“with good benefit.” (Id.) The notes state that Plaintiff has “lingering sx of guilt (about 

poor decisions regarding financial investments – 2 failed businesses), worthlessness 

(about failed marriage), and impaired concentration. Possible past MDEs secondary to 

losing businesses and severe marital discord with ex-husband.” (Id.) Plaintiff was 

presented with Posttraumatic Stress Disorder, describing “chronic sx of re-experiencing 

(intense distress around male doctors and men in general) . . ., anxiety when in VA 

hospital (I found her pacing a hallway next to the waiting room); physiological reactivity 

in presence of triggers; avoidance (avoiding thoughts, triggers, detachment from men); 

and increased arousal (impaired concentration). Also was victim of domestic violence by 

husband, who blamed her for the MST.” (Id. at 383-84.)

Plaintiff also presented with Obsessive-Compulsive Disorder, specifically the 

compulsive behavior of dermatillomania wherein she “picks her hands and face, 

sometimes to the point of bleeding and scarring, as a method to maintain concentration 

(denies that she uses it to alleviate distress). She wore gloves to the interview to prevent 

picking but took them off. There were minimal signs of the picking on her hands/face.” 

(Id. at 384.) Plaintiff also reported being preoccupied with cleanliness. (Id.) Plaintiff 

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“denied any feared consequences if she does not complete the compulsive behaviors and 

they do not appear to be motivated by fear . . . Behaviors do not appear to be highly rigid 

or ritualized and do not cause distress.” (Id.)

Plaintiff also presented with Attention-Deficit Disorder. (Id.) Plaintiff reported 

chronic hyperactivity, and impulsivity. (Id.) Notes state that neither symptom appear to 

be due to mania. (Id.) She also has equivocal complaints of inattention but it is noted 

that she graduated college with a BS in biology with “average” grades and became a 

dental hygienist. (Id.)

The following diagnostic impressions were listed: 

Axis I: Posttraumatic Stress Disorder, Major Depressive Disorder, recurrent, 

moderate; r/o Obsessive Compulsive Disorder; r/o Attention-Deficit 

Hyperactivity Disorder Not Otherwise Specified; Axis II: Deferred; Axis III: 

Arrhythmia (see chart); Axis IV: Inadequate social support, unemployment; 

Axis V: Global Assessment of Functioning, current = 60. 

(Id. at 386-87)

B. Treatment Records from 2012

Carolyn B. Allard, Ph.D. clinical psychologist, supervised a MST Clinic Intake 

Evaluation of Plaintiff conducted by Sage Schuitevoerder, Ph.D., Clinical Research 

Therapist, on January 4, 2012. (Id. at 377.) Notes from this evaluation state, in part: “Pt. 

stated that she tends to have difficulty motivating herself to engage in pleasant activities. 

‘There are things that make me happy. I force myself to do those things.’ Patient 

endorsed feeling disconnected from others and has a limited social network.” (Id. at 

379.) With respect to physiological arousal it states, “Patient endorsed difficulty 

concentrating. She denied irritability or anger outbursts. Pt. stated that when triggered, 

she feels on guard, wary of others, her mouth gets dry, hearts (sic) races, has trouble 

breathing.” (Id.) Notes from this evaluation also state that:

[Plaintiff] endorsed symptoms consistent with Major Depression such as: 

lethargy, overeating, feeling guilty, difficulty concentrating, and feeling 

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restless/fidgety. No thoughts of suicide. 

Patient stated that she sometimes picks at her skin to the point of bleeding. 

Patient was wearing gloves during the interview to avoid engaging in this 

behavior. Patient also stated that she tends to excessively focus on 

cleanliness; however will ‘force’ herself not to clean or vacuum for days at a 

time.

(Id.)

Dr. Allard noted the following diagnoses: Axis I: Posttraumatic Stress Disorder, 

Chronic (MST); Major Depressive Disorder, recurrent, moderate r/o Obsessive 

Compulsive Disorder; Axis II: Deferred; Axis III: Arrhythmia (see chart); Axis IV: 

Inadequate social support, unemployment; Axis V: Global Assessment of Functioning, 

current = 60. (Id. at 381)

Plaintiff attended CPT group therapy on January 24, 2012 with therapists Sheeva 

Mostoufi and Cassidy A. Gutner, M.A. (Id. at 376.) Plaintiff contributed personal 

information and was attentive during discussions. (Id.) Plaintiff’s mood was 

“euthymic.” (Id.) Plaintiff’s assessment states “progressing as expected” and “continues 

to be impaired.” (Id.)

Plaintiff attended CPT group therapy on January 31, 2012 with therapists Sheeva 

Mostoufi and Cassidy A. Gutner, M.A. (Id. at 374) Plaintiff contributed personal 

information and was attentive during discussions. (Id.) Plaintiff’s mood was 

“euthymic.” (Id.) Plaintiff’s assessment states “progressing as expected” and “continues 

to be impaired.” (Id. at 375.)

Plaintiff attended CPT group therapy on February 7, 2012 with therapists Sheeva 

Mostoufi and Cassidy A. Gutner, M.A. (Id. at 371.) Plaintiff contributed personal 

information and was verbal during discussions. (Id. at 373.) Plaintiff’s mood was 

“euthymic.” (Id.) Plaintiff’s assessment states “progressing as expected.” (Id.)

Plaintiff attended CPT group therapy on February 14, 2012 with therapists Sheeva 

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Mostoufi and Cassidy A. Gutner, M.A. (Id. at 371.) Plaintiff contributed personal 

information and was verbal during discussions. (Id.) Plaintiff’s mood was “euthymic.” 

(Id.) Plaintiff’s assessment states “progressing as expected” and “continues to be 

impaired.” (Id. at 372.)

Plaintiff attended CPT group therapy on February 21, 2012 with therapists Sheeva 

Mostoufi and Cassidy A. Gutner, M.A.. (Id. at 369.) Plaintiff contributed personal 

information and was verbal during discussions. (Id. at 370.) Plaintiff’s mood was 

“euthymic.” (Id.) Plaintiff’s assessment states “continues to be impaired.” (Id.)

Also on February 21, 2012 Cassidy Gutner, M.A. entered a note regarding 

Plaintiff’s “Comprehensive Mental Health Treatment Plan.” (Id. at 368.) This entry was 

signed by Carolyn B. Allard, Clinical Psychologist. (Id. at 369.) Ms. Gutner diagnosed 

Plaintiff with the following: Axis I: Posttraumatic Stress Disorder; Major Depressive 

Disorder, recurrent, moderate; Axis II: Deferred; Axis III: Arrhythmia; Axis IV: 

Inadequate social support, unemployment; Axis V: Global Assessment of Functioning, 

current = 60. (Id. at 368.) Ms. Gutner noted the following “problems” regarding 

Plaintiff’s PTSD: “decrease re-experiencing symptoms. Increase interest in hobbies and 

social activities. Specify: Veteran reports being isolated as a result of her symptoms and 

would like to go out more often. Decrease feelings of attachment. Improve 

concentration.” (Id.)

Plaintiff attended CPT group therapy on February 28, 2012 with therapists Sheeva 

Mostoufi and Cassidy A. Gutner, M.A. (Id.) Plaintiff contributed personal information 

and was verbal during discussions. (Id. at 367.) Plaintiff’s mood was “euthymic.” (Id.) 

Plaintiff’s assessment states “progressing as expected.” (Id.)

Plaintiff attended CPT group therapy on March 6, 2012 with therapists Sheeva 

Mostoufi and Cassidy A. Gutner, M.A. (Id. at 365) Plaintiff contributed personal 

information and was verbal during discussions. (Id. at 366.) Plaintiff’s mood was 

“euthymic.” (Id.) Plaintiff’s assessment states “progressing as expected.” (Id.)

Plaintiff attended CPT group therapy on March 13, 2012 with therapists Sheeva 

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Mostoufi and Cassidy A. Gutner, M.A. (Id. at 363) Plaintiff contributed personal 

information and was verbal during discussions. (Id. at 364.) Plaintiff’s mood was 

“euthymic.” (Id.) Plaintiff’s assessment states “progressing as expected.” (Id.)

Plaintiff attended CPT group therapy on March 20, 2012 with therapists Sheeva 

Mostoufi and Cassidy A. Gutner, M.A. (Id.) Plaintiff contributed personal information. 

(Id. at 362.) Plaintiff’s mood was “euthymic.” (Id.) Plaintiff’s assessment states 

“progressing as expected.” (Id. at 361.)

Plaintiff attended CPT group therapy on March 27, 2012 with therapists Sheeva 

Mostoufi and Cassidy A. Gutner, M.A. (Id. at 360) Plaintiff contributed personal 

information and was verbal during discussions. (Id.) Plaintiff’s mood was “euthymic.” 

(359.) Plaintiff’s assessment states “progressing as expected.” (Id. at 361.)

Plaintiff attended Cognitive Processing Therapy (“CPT”) group therapy on April 

10, 2012 with therapists Sheeva Mostoufi and Cassidy A. Gutner, M.A. April 10, 2012. 

(Id. at 359.) Plaintiff contributed personal information and was verbal during 

discussions. (Id.) Plaintiff’s mood was “euthymic.” (Id.) Plaintiff’s assessment states 

“progressing as expected.” (Id.)

Dr. Barbara Perry wrote a Psychiatry Outpatient Note regarding Plaintiff on May 

8, 2012, which states that Plaintiff has “PTSD, depression, MST, R/O ADHD, OCD.” 

(Id. at 355.) The note further states that Plaintiff “improved with bupropion 150 gam, 

then levelled off, buspar 20 tid helpful for anxiety, psych testing c/w PTSD rather than 

ADHD although family hx of ADHD, now in granddaughter wiht(sic) blindness, plan to 

increase Ritalin. Walk in am helpful, sertraline switch to am vs. pm.” (Id.) During a 

“Mental Status Examination,” Dr. Parry noted that Plaintiff was “calm, cooperative [and] 

pleasant.” (Id. at 357.) Plaintiff reportedly stated her mood was “okay.” (Id.) 

Dr. Barbara Perry wrote a Psychiatry Outpatient Note regarding Plaintiff on 

December 18, 2012, which states that Plaintiff “[s]till [has] some residual depression. 

Will increase buproprion to 450mg qam, cont sertraline 200mg.” (Id. at 677.) The note 

further states that Plaintiff’s “mood [was] slightly depressed, affect congruent with mood. 

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Denied suicidal and homicidal thoughts during the interview and in recent past. Denies 

delusions and hallucinations at the present time. Cognitive skills, including memory 

functions and concentration grossly intact. Insight and judgment not impaired.” (Id. at 

678) Dr. Parry provided the following assessment of Plaintiff: Axis I: PTSD, Axis II: 

n/a; Axis III: sleep apnea, cardiac arrhythmia, Axis IV, granddaughter’s illness, Axis V: 

80. (Id.)

C. Treatment Records from 2013

Dr. Barbara Perry wrote a treatment note regarding Plaintiff on April 23, 2013, 

which states that Plaintiff 

improved with bupropion 150 qam, then levelled off, buspar 20 tid helpful 

for anxiety, psych testing c/w PTSD rather than ADHD although family hx 

of ADHD, now in granddaughter wiht(sic) blindness, plan to increase 

Ritalin. Walk in am helpful, sertraline switch to am vs. pm. Buproprion 

increase to 300mg associated with much improvement, bupirone not that 

helpful but wishes to maintain, switch to sertraline in the am improved sleep. 

Getting w/u for sleep apnea and arrhythmia. 

(Id. at 617.) Dr. Parry’s Mental Status Examination notes state that Plaintiff was 

[a]lert, fully oriented and cooperative. Speech normal in rate and rhythm, 

thought process coherent, and goal directed. Mood euthymic, affect 

congruent with mood. Denies suicidal ideation and homicidal thoughts 

during the interview and in recent past. Denies delusions and hallucinations 

at the present time. Cognitive skills, including memory functions and 

concentration, grossly intact. Insight and judgment not impaired. 

(Id. at 618.) Dr. Parry provided the following assessment: Axis I: PTSD; Axis II: 

n/a; Axis III: sleep apnea, cardiac arrhythmia; Axis IV: granddaughter’s illness; 

Axis V: 80. (Id. at 618-19)

Dr. Barbara Perry wrote a Psychiatry Outpatient Note regarding Plaintiff on 

July 23, 2013. (Id. at 704.) Dr. Parry’s Mental Status Examination notes state that 

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Plaintiff was 

[a]lert, fully oriented and cooperative. Speech normal in rate and rhythm, 

thought process coherent, and goal directed. Mood stressed, affect 

congruent with mood. Denies suicidal and homicidal thoughts during the 

interview and in recent past. Denies delusions and hallucinations at the 

present time. Cognitive skills, including memory functions and 

concentration, grossly intact. Insight and judgment not impaired. 

(Id. at 705). Dr. Parry provided the following assessment: Axis I: PTSD; Axis II: 

n/a; Axis III: sleep apnea, cardiac arrhythmia; Axis IV: granddaughter’s illness; 

Axis V: 80. (Id.)

Dr. Barbara Perry wrote a Psychiatry Outpatient Note regarding Plaintiff on 

October 1, 2013. (Id. at 699.) Dr. Parry’s Mental Status Examination notes state 

that Plaintiff was 

[a]lert, fully oriented and cooperative. Speech normal in rate and rhythm, 

thought process coherent, and goal directed. Mood euthymic, affect 

congruent with mood. Denies suicidal ideation and homicidal thoughts 

during the interview and in recent past. Denies delusions and hallucinations 

at the present time. Cognitive skills, including memory functions and 

concentration, grossly intact. Insight and judgment not impaired. 

(Id. at 698-99). Dr. Parry noted the following assessment: Axis I: PTSD, MST; 

Axis II: n/a; Axis III: sleep apnea, cardiac arrhythmia, s/p hysterectomy, 

oophoriectomy (sic), abdominal hernia; Axis IV: granddaughter’s illness, denial of 

benefits, son with TBI; Axis V: 80. (Id. at 699.)

Dr. Barbara Perry wrote a Psychiatry Outpatient Note regarding Plaintiff on 

October 15, 2013. (AR 695.) The note states, in part, 

Will increase bupropion to 450mg qam, cont. sertraline 200 mg. Only uses 

alprazolam rarely for anxiety, not buspar . . . 9 yo granddaughter hurt in gocart accident at camp, she took her to Children’s hospital (vs. camp 

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counselors), doing OK but with(sic) PTSD (“Post-Traumatic Stress 

Disorder”), pt upset that camp left decision up to child . . . Requests 

Trazadone for sleep as Benadryl not helpful. Alprazolam uses minimally for 

stress during day, not sleep. 

(Id.) Dr. Parry’s Mental Status Examination notes state that Plaintiff was 

[a]lert, fully oriented and cooperative. Speech normal in rate and rhythm, 

thought process coherent, and goal directed. Mood euthymic, affect 

congruent with mood. Denies suicidal ideation and homicidal thoughts 

during the interview and in recent past. Denies delusions and hallucinations 

at the present time. Cognitive skills, including memory functions and 

concentration, grossly intact. Insight and judgment not impaired. 

(Id. at 696.) Dr. Parry noted the following assessment: Axis I: PTSD, MST; Axis 

II: n/a; Axis III: sleep apnea, cardiac arrhythmia, s/p hysterectomy, oophoriectomy 

(sic), abdominal hernia; Axis IV: granddaughter’s illness, denial of benefits, son 

with TBI; Axis V: 80. (Id. at 697.)

D. Medical Opinion Evidence

1. Dr. Parry’s Mental Residual Functional Capacity Assessment

In support of her disability application, Plaintiff submitted a Mental Residual 

Functional Capacity Assessment completed by Dr. Barbara Parry. (Id. at 441-42.) Dr. 

Parry opined that Plaintiff has moderate limitations in her ability to: (1) Understand and 

remember very short and simple instructions; (2) Carry out very short and simple 

instructions; (3) Make simple work-related decisions; (4) Ask simple questions or request 

assistance; (5) Maintain socially appropriate behavior and to adhere to basic standard of

neatness and cleanliness; (6) Be aware of normal hazards and take appropriate 

precautions. (Id. at 441-42.) 

Dr. Parry further stated that Plaintiff has marked limitations in her ability to: (1) 

Remember locations and work like procedures; (2) Understand and remember detailed 

instructions; (3) Carry out detailed instructions; (4) Maintain attention and concentration 

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for extended periods; (5) Perform activities within a schedule, maintain regular 

attendance, and be punctual within customary tolerances; (6) Sustain an ordinary routine 

without special supervision; (7) Work in coordination with or proximity to others without 

being distracted by them; (8) Complete a normal workday and workweek without 

interruptions from psychologically based symptoms and to perform at a consistent pace

without an unreasonable number and length of rest periods; (9) Interact appropriately 

with the general public; (10) Accept instructions and respond appropriately to criticism 

from supervisors; (11) Get along with coworkers or peers without distracting them or 

exhibiting behavioral extremes; (12) Respond appropriately to changes in the work 

setting; (13) Travel in unfamiliar places or use public transportation; (14) Set realist goals 

or make plans independently of others. (Id. at 441-42.)

Dr. Parry added the following handwritten statement: “Ms. Gilleon suffers from 

Post-Traumatic Stress Disorder and Major Depression as a result of military sexual 

trauma. Despite her active participation in psychological, behavioral and 

pharmacological treatment, she continues to have significant limitations in understanding 

and memory, in sustained concentration and persistence, social interaction and 

adaptation.” (Id. at 443.) 

2. VA Disability Evaluation by Dr. Cara Eggers

Dr. Eggers completed an evaluation of Plaintiff for VA disability benefits on June 

11, 2013. (Id. at 602.) Dr. Eggers reported that, based on her revaluation, Plaintiff had a 

diagnosis of PTSD that conforms to the DSM-IV criteria. (Id. at 588.) Dr. Eggers 

characterized the diagnosis as “chronic, mild.” (Id.) Dr. Eggers’ notes state that 

Plaintiff’s “Depression is well-controlled with meds . . . No current diagnosis of 

depression.” (Id. at 589.) With respect to panic attacks, Dr. Eggers writes, “The Veteran 

describes panic attacks when exposed to trauma-reminders; no separate diagnosis of 

Panic Disorder is warranted.” (Id.) Dr. Eggers states that Plaintiff’s insomnia is 

accounted for by her PTSD. (Id.) Dr. Eggers concludes that she “do[es] not find this 

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Veteran is unemployable due to PTSD symptoms. Last GAF2score by her treating 

psychiatrist (Dr. Parry) was 80; sees Dr. Parry every few months.” (Id. at 589-90.) Dr. 

Eggers gave Plaintiff a GAF score of 70, noting “GAF 70 is for mild impairments in 

social and occupational functioning related to PTSD.” (Id. at 590.) 

Dr. Eggers assessed that Plaintiff had “occupational and social impairment due to 

mild or transient symptoms which decrease work efficiency and ability to perform 

occupational tasks only during period of significant stress, . . . symptoms controlled by 

medication.” (Id. at 592.)

Dr. Eggers wrote the following for Plaintiff’s relevant mental health history:

The Veteran states she requested mental health services in the military but 

was not provided with it. She then started psychotherapy about 20 years ago 

with a private practitioner through Tricare. Also went through some marital 

counseling. Started psychotherapy in the San Diego VA in 2011; see intake 

 

2 The Global Assessment of Functioning (GAF) score is a scale reflecting “psychological, social, and 

occupational functioning on a hypothetical continuum of mental health-illness.” Diagnostic and 

Statistical Manual of Mental Disorders 34 (4th ed. 2000). The GAF scale ranges from 1 to 100 and is 

used by clinicians to indicate his or her overall judgment of a person’s psychological, social, and 

occupational functioning on a scale devised by the American Psychiatric Association. American 

Psychiatric Association, Diagnostic & Statistical Manual of Mental Disorders (Text Revision, 4th ed. 

2000) (DSM-IV-TR). A GAF of 31-40 indicates “[s]ome impairment in reality testing or 

communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several 

areas, such as work, school, family relations, judgment, thinking or mood (e.g., depressed man avoids 

friends, neglects family and is unable to work[.]).” A GAF of 41-50 indicates “[s]erious symptoms (e.g., 

suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, 

occupational, or school functioning (e.g., no friends, unable to keep a job).” A GAF of 51-60 indicates 

“[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR 

moderate difficultly in social, occupational, or school functioning (e.g., few friends, conflicts with peers 

or co-workers).” Id. A GAF of 61-70 indicates “[s]ome mild symptoms (e.g., depressed mood and mild 

insomnia) OR some difficultly in social, occupational, or school functioning . . . but generally 

functioning pretty well, has some meaningful interpersonal relationships.” Id. It should be noted that 

the Ninth Circuit has observed that “[t]he Commissioner has determined the GAF scale “does not have a 

direct correlation to the severity requirements in [the Social Security Administration’s] mental disorders 

listings.” 65 Fed. Reg. 50, 746, 50, 765 (Aug. 21, 2000).” McFarland v. Astrue, 288 Fed.Appx. 357, 

359 (9th Cir. 2008)(unpub.). In fact, GAF scoring has been removed from the DSM V for “lack of 

conceptual clarity.” Phillips v. Colvin, 61 F.Supp.3d 925, 931 n.2 (N.D. Cal. 2014).

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note dated 12-9-11. Currently by Dr. Parry, and is prescribed Wellbutrin, 

sertraline, Xanax. Last seen my Dr. Parry, psychiatrist with the following 

diagnosis: 

Assessment: Axis I: PTSD; Axis II: n/a; Axis II: sleep apnea, cardiac 

arrhythmia; Axis IV: granddaughter’s illness; Axis V: 80

(Id. at 595.)

Dr. Eggers recounted a “stressor” that Plaintiff “described as traumatic” which 

involved a sexual assault during her time in the Navy. (Id. at 596-97.) Dr. Eggers then 

identified the following diagnostic criteria for PTSD, referred to as Criteria A-F, from the 

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition: 

Criterion A: (1) The Veteran has been exposed to a traumatic event where both of 

the following were present: the Veteran experienced, witnessed or was confronted with 

an event that involved actual or threatened death or serious injury, or a threat to the 

physical integrity of self or others. (2) The Veteran’s response involved intense fear, 

helplessness or horror. (Id. at 589)

Criterion B: The traumatic event is persistently re-experienced in 1 or more of the 

following ways: (1) recurrent and distressing recollections of the event including images, 

thoughts or perceptions; (2) recurrent distressing dreams of the event; (3) intense 

psychological distress at exposure to internal or external cues that symbolize or resemble 

an aspect of the traumatic event; (4) Physiological reactivity on exposure to internal or 

external cues that symbolize or resemble an aspect of the traumatic event. (Id. at 589.)

Criterion C: Persistent avoidance of stimuli associated with the trauma and 

numbing of general responsiveness (not present before the trauma), as indicated by three 

or more of the following: (1) Efforts to avoid thoughts, feelings or conversations 

associated with the trauma; (2) Efforts to avoid activities, places or people that arouse 

recollections of the trauma; (3) feeling of detachment or estrangement from others. (Id.

at 589-99.)

Criterion D: Persistent symptoms of increased arousal, not present before the 

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trauma, as indicated by two or more of the following: (1) Difficulty falling or staying 

asleep; (2) hyper vigilance; (3) Exaggerated startle response. (Id. at 599.)

Criterion E: The duration of the symptoms described above in Criteria B, C and D 

is more than 1 month. (Id.) 

Criterion F: The PTSD symptoms described above cause clinically significant 

distress or impairment in social, occupational, or other important areas of functioning. 

(Id.)

Dr. Eggers indicated the following symptoms that applied to Plaintiff’s diagnosis: 

anxiety, chronic sleep impairment, flattened affect, difficulty in establishing and 

maintaining effective work and social relationships, difficulty in adapting to stressful 

circumstances, including work or a work like setting. (Id. at 600.)

Dr. Eggers stated that it was her opinion that Plaintiff’s “PTSD symptoms are at 

least as likely as not incurred in or caused by in-service events.” (Id. at 601.)

3. Dr. Barry J. Broomberg, M.D. 

Dr. Broomberg filled out a Supplemental Certification regarding Plaintiff’s 

disability status on January 2, 2007, which stated that Plaintiff is disabled because of 

anxiety and depression. (Id. at 336.) Dr. Broomberg filled out a similar form on April 2, 

2007 (id. at 333), May 8, 2007 (id. at 335), September 12, 2007 (id. at 342), and October 

12, 2007 each with the same diagnosis. (Id. at 341.)

A Progress Note from Dr. Broomberg’s office from July 22, 2010 states that 

Plaintiff was there to talk about her medication for Depression. (Id. at 327.)

A Progress Note from Dr. Broomberg’s office from December 7, 2011 states that 

Plaintiff was there to talk about her medication for her OCD. (Id. at 326.) Dr. 

Broomberg also filled out a “Claim for Disability Insurance Benefits – Doctor’s 

Certificate” on December 7, 2011. (Id. at 325.) This form states that Plaintiff has been 

incapable of performing her regular or customary work starting on December 2, 2011. 

(Id.) It states an anticipated date to return to work as June 2, 2012. (Id.) Dr. Broomberg 

lists as a diagnosis: Severe OCD, Depression and anxiety. (Id.)

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The record contains what appears to be a prescription form, dated March 20, 2012, 

with letterhead from Barry J. Broomberg, M.D. which states: This patient is unable to 

work any more [illegible] Severe P.T.S.D. Post Traumatic Stress Disorder. (Id. at 323.)

4. Anna M. Franco, State Agency Medical Consultant

State agency medical consultant Anna M. Franco, Psy.D. reviewed Plaintiff’s 

disability application on June 19, 2012. (Id. at 64.) Dr. Franco found that Plaintiff had 

the following medically determinable impairments—anxiety disorders and affective 

disorders. (Id. at 69.) In assessing Plaintiff’s disability determination, Dr. Franco 

considered Listing 12.04 for affective disorders and Listing 12.06 for anxiety disorders. 

(Id. at 70.) Dr. Franco found that Plaintiff’s medically determinable impairments could 

reasonably be expected to produce her pain or other symptoms. (Id.) However, Dr. 

Franco found that Plaintiff’s allegations were “partially credible” because the statements 

were “credible to allegations but not to severity.” (Id. at 71.) Dr. Franco relied on 

Plaintiff’s ADLs (activities of daily living), her medication treatment, and her intact 

recent MSE (mental status examination) in determining that Plaintiff was “partially 

credible.” (Id. at 70-71.)

Dr. Franco determined that Plaintiff did not have the Residual Functional Capacity 

(“RFC”) to perform past relevant work. (Id. at 74.) Based on her RFC, Dr. Franco stated 

that Plaintiff demonstrates the maximum sustained work capability for heavy/very heavy 

work. (Id. at 75.) Dr. Franco stated that Plaintiff had the following limitations: 

understanding and memory, concentration and persistence, social interaction, and 

adaptation. (Id. at 71-73.) Specifically, Dr. Franco determined that Plaintiff was 

moderately limited in the following areas: ability to understand and remember detailed 

instructions, ability to carry out detailed instructions, ability to interact appropriately with 

the general public, ability to respond appropriately to changes in the work setting. (Id. at 

71-73.) Dr. Franco gave controlling weight to the VA MER [medical examiner report], 

and determined that Plaintiff was capable of understanding, remembering, and carrying 

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out simple one to two step (unskilled) tasks. (Id. at 68, 73.) Plaintiff was able to 

maintain concentration, persistence, and pace through a normal workday/workweek as 

related to simple/unskilled tasks. (Id. at 68, 70, 73.) Dr. Franco suggested that Plaintiff 

have limited public contact, but she could otherwise interact and adapt accordingly with 

coworkers and supervisors. (Id. at 70, 73.)

According to Dr. Franco’s evaluation, Plaintiff was limited to unskilled work 

because of her impairments, but Plaintiff was capable of performing work that is less 

demanding. (Id. at 75-76.) Based on the documented findings, Dr. Franco found that 

Plaintiff was not disabled. (Id. at 75.)

5. Peter Bradley, State Agency Medical Consultant

State agency medical consultant Peter Bradley, Ph.D. reviewed Plaintiff’s 

disability application on December 5, 2012 as a reconsideration Mr. Franco’s prior 

review. (Id. at 84.) Dr. Bradley stated that he reviewed the entire file and adopted the 

PRTF (Psychiatric Review Technique Form)/MRFC (Mental Residual Functional 

Capacity) proposed at the initial level. (Id. at 82.) 

IV. JANUARY 13, 2014 HEARING BEFORE THE ALJ3

A. Plaintiff’s Testimony

Plaintiff was born on March 14, 1958. (Id. at 32.) She lives alone. (Id.) Her 

granddaughter lived with her for three years, during which Plaintiff was the primary 

caretaker. (Id.) While Plaintiff was helping to care for her granddaughter, her son and 

daughter-in-law who lived down the street would also help with the child’s care. (Id.) 

Last summer, Plaintiff’s granddaughter injured herself at camp, and Plaintiff took her to 

the emergency room. (Id. at 42-43.) Plaintiff still has guardianship over her 

granddaughter, but does not live with her “on a full time basis.” (Id. at 48.) She spends 

the night with Plaintiff about once a month. (Id. at 49-50.) Plaintiff’s son sustained a 

 

3 Plaintiff also had a hearing before ALJ William K. Mueller on October 21, 2013. (AR at 60.) Before 

any testimony was given, ALJ Mueller recused himself from the case because he knew the Plaintiff. 

(Id.) The hearing was rescheduled before a different ALJ at that time. (Id. at 61.)

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traumatic brain injury and Plaintiff took care of him during his rehabilitation. (Id. at 33.) 

He also lived with Plaintiff during a period of time. (Id.)

Plaintiff takes care of her personal hygiene. (Id. at 34.) She does not shop for 

herself; her sons or her daughter-in-law buy groceries for her. (Id. at 34, 46-47.) Her 

daughter-in-law helps with household chores as well. (Id. at 34.) Plaintiff is not able to 

do the chores because of her depression; she cannot get out of bed. (Id.) Plaintiff has a 

driver’s license, but does not drive. (Id.) If she needs to get around, she has a friend 

drive her. (Id. at 35.) Plaintiff states that on an average day, she does nothing but watch 

television. (Id. at 40.) She does not socialize with people, but has a friend that calls her 

every day. (Id.) Plaintiff likes to read, but has problems with comprehension. (Id. at 

43.) Sometimes she will forget she has read a book before. (Id.) Plaintiff never goes to 

the movies, church, or out to eat. (Id. at 47.) Plaintiff showers maybe once a week. (Id.)

Plaintiff completed “some college” and then joined the Navy where she “went to 

dental school and dental hygiene.” (Id. at 35.) She never worked as a dental hygienist 

because there was no place to take the exam after she got out of the military. (Id.) 

Plaintiff worked as an office manager for a dental office. (Id. at 35-36.) In that position, 

Plaintiff scheduled patients, answered the phone, and did billing. (Id. at 36.) Plaintiff 

stopped working in that job because her boss had a severe drug addiction, and would yell 

and throw things at her. (Id. at 36-37.) She left that job and went on disability for a year 

for depression. (Id. at 38.)

After that, Plaintiff owned a candy shop in La Jolla, California from about 2008 to 

2010. (Id. at 35, 37.) When she owned the candy shop, Plaintiff was responsible for 

hiring staff, and employed nine people. (Id. at 37.) Plaintiff stopped her work at the 

candy shop because “it was too much for [her.]” (Id. at 38.)

Plaintiff does not think anything physical prevents her from work—it is her 

depression, panic attacks and OCD. (Id. at 45.) Plaintiff sees a therapist, Dr. Parry, 

every two weeks, sometimes more. (Id. at 40.) Plaintiff takes medication for anxiety, 

such as panic attacks, and to keep her from “basically being suicidal.” (Id. at 40-41.) 

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The medications have helped, and Plaintiff does not think about suicide anymore. (Id. at 

41.) Without medication, Plaintiff’s mental state is “terrible.” (Id.) She goes through 

manic stages where she does a lot, like repainting a room five times, or she will feel 

exhausted and not get out of bed for days. (Id.) When Plaintiff is medicated, she still has 

episodes where she will feel like she can “conquer the world” and then she goes back to 

bed, but it is not as severe. (Id.) She does not know how often these episodes happen 

now, but she does not think she has had one in three or four months. (Id. at 42.) She was 

in a manic state a couple of months ago, and she was in a depressive state all of last 

week. (Id. at 46.) 

B. Vocational Expert’s Testimony

Gloria Lasoff testified as the Vocational Expert (“VE”). (Id. at 51.) The VE 

classified Plaintiff’s prior job as an office manager as 219.362-010, which is an SVP: 4 

and is light. (Id. at 51-52.) Plaintiff’s job as a retail store manager is 185.167-046, which 

is an SVP: 7 and also light. (Id. at 52.) The ALJ posed the following hypothetical: 

[A]ssume a person of the claimant’s age, education and work experience 

who has no exertional limitations. She does have the following limitations: 

she can understand, remember and carry out job instructions; she can 

maintain attention and concentration to perform simple, routine and 

repetitive tasks; she can occasionally interact with coworkers and 

supervisors; and no direct interaction with the general public; and she can 

work in an environment with occasional changes to the work setting and 

occasional work related decision making. 

(Id.) The VE testified that Plaintiff’s prior work would be “ruled out” with those 

limitations, but other jobs would be available. (Id.) One example would be a hand 

packager, 920.587-018, SVP: 2, medium, of which there are 600,000 jobs in the national 

economy. (Id.) Another example would be cleaner, sweeper, 389.683-010, SVP: 2, 

medium, of which there are 2,000,000 jobs in the national economy. A third example is 

hospital cleaner, 323.687-010, SVP: 2, medium, of which there are 400,000 jobs in the 

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national economy. (Id. at 52-53.)

The ALJ posed the following as a second hypothetical: “assume the same 

limitations of the previous one but now an individual would likely miss four or more days 

of work each month.” (Id. at 53.) With that additional limitation, the VE testified that 

the three previously mentioned jobs would not be available, nor would any other work. 

(Id.) The VE further testified that the typical tolerance level for absenteeism is “at the 

most” one day per month. (Id.)

Plaintiff’s attorney provided for the ALJ and VE a copy of the medical source 

statement from the treating psychotherapist at the VA, Dr. Barbara Parry, which the VE 

reviewed. (Id. at 53-54.) The ALJ asked the VE whether Plaintiff would be capable of 

any of her former work if she were limited to the degree found by Dr. Barbara Parry, to 

which the VE responded that she would not. (Id. at 54.) The VE also stated that Plaintiff 

would not be capable of any of the work identified in response to the ALJ’s first 

hypothetical, nor would she be capable of sustaining gainful activity, at any level, 

competitively in the national environment. (Id.) The VE stated that her testimony was 

consistent with the DOT [Dictionary of Occupational Titles]. (Id. at 55.)

C. ALJ’s Findings

On February 18, 2014, the ALJ issued his decision denying Plaintiff’s application 

for supplemental security income. (Id. at 23.) In reaching his decision, the ALJ applied 

the Commissioner’s five-step sequential disability determination process set forth in 20 

C.F.R. § 404.1520 and described above. (Id. at 13-23.) 

1. Step One

The ALJ found that Plaintiff had not engaged in substantial gainful activity since 

January 25, 2010, the alleged onset date. (Id. at 15.) 

2. Step Two

At step two, the ALJ found that Plaintiff had the following severe impairments: 

posttraumatic stress disorder (PTSD), major depressive disorder, and a history of

obsessive-compulsive disorder (OCD). (Id.)

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3. Step Three

At step three, the ALJ considered Plaintiff’s medically determinable physical 

impairments under all the applicable listings and sections of the Listing of Impairments 

and found that they do not meet or medically equal the criteria of any medical listing, 

singly or in combination. (Id. at 16.) Specifically, the ALJ considered Listings 12.04 and 

12.06. (Id.) The ALJ found that Plaintiff has mild restrictions in her activities of daily 

living. (Id. at 17.) 

In social functioning, the ALJ found Plaintiff has moderate difficulties. (Id.) The 

ALJ noted that certain medical records document Plaintiff’s anxiety around and 

avoidance of men, as well as sleep disturbance, social isolation, and episodes of panic, 

secondary to a history of a sexual assault and domestic violence. (Id.) He also noted her 

ability to participate in an all-female therapy group, be the primary caretaker for her 

granddaughter, and her GAF scores of 60 and 80, all of which support a conclusion that 

her limitations in social functioning are not more than moderate. (Id.)

With respect to concentration, persistence or pace, the ALJ found that Plaintiff has 

moderate difficulties. (Id.) The ALJ noted that Plaintiff asserted she had problems 

concentrating, following instructions, remembering, and occasional difficulty with 

reading comprehension. (Id.) However, the ALJ also noted that she reported being able 

to read for long periods of time without problems, pay bills, and manage her bank 

accounts. (Id.) Furthermore, the ALJ found that the mental status examination findings 

and Plaintiff’s GAF scores support the conclusion that she has no more than moderate 

limitations in this area. (Id.) 

Because the ALJ found that Plaintiff’s mental impairments do not cause at least 

two “marked” limitations or one “marked” limitation and “repeated” episodes of 

decompensation, each of extended duration, he concluded that the “paragraph B” criteria 

were not satisfied. (Id.) The ALJ also found that Plaintiff failed to establish the presence 

of “paragraph C” criteria of Listings 12.04 and 12.06. (Id.)

///

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a. Residual Functional Capacity Determination

Before considering step four of the sequential evaluation process, the ALJ first 

determined Plaintiff’s residual functional capacity. (Id. at 14.) The ALJ found that 

Plaintiff had the residual functional capacity to perform a full range of work at all 

exertional levels, but with the following nonexertional limitations: she can understand, 

remember, and carry out simple job instructions. She can maintain attention and 

concentration to perform simple, routine and repetitive tasks. She can have occasional 

interaction with coworkers and supervisors, and no direct interaction with the general 

public. She can work in an environment with occasional changes to the work setting and 

occasional work-related decision-making. (Id. at 17-18.) In making this finding, the ALJ 

considered all symptoms and the extent to which those symptoms can reasonably be 

accepted as consistent with the objective medical evidence and other evidence, based on 

the requirements of 20 CFR 404.1529 and SSRs 96-4p and 96-7p. The ALJ also 

considered opinion evidence. 

In determining Plaintiff’s residual functional capacity, the ALJ gave no weight to 

multiple statements from Barry J. Broomberg, M.D., who concluded that Plaintiff was 

unable to work due to her mental impairments. (Id.) The ALJ noted that such an opinion 

is reserved for the Commissioner, and such statements are not entitled to controlling 

weight. (Id.) The ALJ also highlighted that Dr. Broomberg’s statements were, for the 

most part, completed to support Plaintiff’s application for State disability benefits, 

“which suggests patient accommodation rather than objective opinion.” (Id.) Moreover, 

none of the statements included supporting objective findings or identified specific 

functional limitations which prevent Plaintiff from working. (Id.)

The ALJ gave no weight to the checkbox-type form completed by Dr. Parry, 

indicating marked limitations in fourteen out of twenty functional areas. (Id.) Although 

the ALJ acknowledged that the opinion of a treating physician is generally given more 

weight, the ALJ found that Dr. Parry’s assessment of Plaintiff was “completely 

inconsistent” with her treatment notes, which document relatively minimal examination 

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findings and GAF scores of 60 and 80. (Id.) The ALJ concluded that such an extreme 

discrepancy “greatly reduces the probative value of Dr. Parry’s opinion.” (Id.)

The ALJ gave significant weight to the assessments by the State agency 

psychological consultants, Anna M. Franco Psy.D., and Peter Bradley, Ph.D., who both 

concluded that Plaintiff was capable of performing simple job tasks and had moderate 

limitations in social functioning and adaptation. (Id.) The ALJ found these 

determinations to be well supported by the objective and clinical evidence, including 

medication efficacy, the mostly unremarkable mental status examination findings, and the 

GAF scores. (Id. at 20-21.) The ALJ noted that these conclusions were also consistent 

with Dr. Eggers’ conclusion that there was “no evidence [the claimant was] 

unemployable due to PTSD symptoms,” which were “mild or transient.” (Id. at 21 citing 

AR 589-90, 592.) The ALJ noted that, although Dr. Eggers’ assessment is based on the 

criteria for VA disability determinations, an ALJ must ordinarily give great weight to a 

VA determination of disability in the Ninth Circuit. (Id. at 21 citing McCartey v. 

Massanari, 298 F.3d 1072 (9th Cir. 2002). 

The ALJ also considered the third party function report completed by Sue Wilson, 

Plaintiff’s friend of twenty years. (Id. at 21.) Ms. Wilson reported talking to Plaintiff on 

the phone daily, and visiting her home three to five times a week. (Id.) The ALJ found 

that Ms. Wilson’s statements as to Plaintiff’s symptoms and functional limitations were 

not fully supported by the objective medical evidence. (Id.) In determining Plaintiff’s 

residual functional capacity, the ALJ considered the diagnoses, symptoms and functional 

limitations Ms. Wilson reported, but noted that, because she is a lay witness, her opinions 

on those issues are less probative than those of medical professionals. (Id.)

b. Credibility Determination

After careful consideration of Plaintiff’s testimony and statements of record, the 

ALJ found that Plaintiff’s medically determinable impairments could reasonably be 

expected to cause some of the alleged symptoms. (Id. at 19.) However, the ALJ found 

Plaintiff’s statements concerning the intensity, persistence and limiting effects of those 

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symptoms were not fully credible. (Id.) In making this determination, the ALJ noted that 

Plaintiff was the primary caretaker of her young granddaughter for approximately three 

years, and still has her granddaughter overnight monthly, and remained the child’s legal 

guardian. (Id.) 

The ALJ also found that inconsistent statements diminished Plaintiff’s credibility. 

(Id.) For example, the ALJ noted that although Plaintiff testified that she relied on family 

to bring her groceries and maintain her household, she stated in her May 2012 functional 

report that she did laundry, cleaned and shopped for food weekly. (Id.) Also, in medical 

records dated June 2013, Plaintiff indicated that her depression was well controlled with 

medication, and her depression screening was negative. (Id.) However, Plaintiff testified 

during her hearing before the ALJ that she spent the entire two weeks prior to the hearing 

in bed due to depression. (Id.) 

Most importantly according to the ALJ, the objective medical evidence did not 

support Plaintiff’s alleged symptom severity and functional limitations. (Id.) The ALJ 

reviewed and considered all of the admitted medical evidence, which included only 

occasional references to mental health symptoms or treatment. (Id.) The ALJ noted that 

Plaintiff began seeing Barbara L. Parry, M.D., a psychiatrist, on January 31, 2012. (Id.) 

Plaintiff saw Dr. Parry approximately every two months through December 2012, “with 

symptom improvement, generally unremarkable mental status examination findings, and 

GAF scores of 60 and 80 noted.” (Id.) The ALJ also noted the evaluation by Cara 

Zuccarelli Eggers, Ph.D., in June 2013, where Plaintiff stated that her depression was 

well controlled with medication, and was diagnosed chronic, mild PTSD and assessed a 

GAF score of 70. (Id.)

4. Step Four

Based on Plaintiff’s documented vocational background, testimony, and earnings 

record, as well as the VE’s pre-hearing analysis and testimony, Plaintiff has past relevant 

work as an office manager, DOT 219.362-010, and as a retail manager, DOT 185.167-

046. The VE testified that as generally performed pursuant to the DOT and as actually 

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performed by Plaintiff, these occupations are semi-skilled and skilled, respectively. (Id.) 

The ALJ concluded that, because Plaintiff is limited to unskilled work, she is unable to 

perform her past relevant work. (Id.)

5. Step Five

Plaintiff was born on March 14, 2958 and was fifty-one years old on the alleged 

disability onset date. (Id. at 22.) Plaintiff has at least a high school education and is able 

to communicate in English. (Id.) The ALJ also found that transferability of job skills is 

not material to the determination of disability because using the Medical-Vocational 

Rules as a framework supports a finding that Plaintiff is not disabled whether or not she 

has transferable job skills. (Id.)

Considering Plaintiff’s age, education, work experience, and residual functional 

capacity, the ALJ determined that there are jobs that exist in significant numbers in the 

national economy that Plaintiff can perform. (Id.) The ALJ noted that Plaintiff’s ability 

to perform work at all exertional levels has been compromised by nonexertional 

limitations. (Id.) To determine the extent to which those limitations erode the 

occupational base of unskilled work at all exertional levels, the ALJ asked the VE 

whether jobs exist in the national economy for an individual with Plaintiff’s age, 

education, work experience and residual functional capacity. (Id.) The VE testified that 

given all of those factors, the individual would be able to perform the requirements of the 

following representative occupations: 

1. Hand packager, DOT 920.587-018, a medium, unskilled (SVP 2) occupation, 

with 600,000 such jobs in the national economy; and

2. Cleaner/sweeper, DOT 389.683-010, a medium, unskilled (SVP 2) occupation, 

with 2,000,000 such jobs in the national economy; and

3. Hospital cleaner, DOT 323.687-010, a medium, unskilled (SVP 2) occupation, 

with 400,000 such jobs in the national economy. 

(Id.) The ALJ determined that the VE’s testimony was consistent with the information 

contained in the Dictionary of Occupational Titles (“DOT”). (Id. at 23.) 

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Based on the testimony of the VE, the ALJ concluded that, considering Plaintiff’s 

age, education, work experience and residual functional capacity, Plaintiff is capable of 

making a successful adjustment to other work that exists in significant numbers in the 

national economy. (Id.) The ALJ, therefore, found Plaintiff not disabled. (Id.)

V. SCOPE OF REVIEW

Section 205(g) of the Social Security Act allows unsuccessful applicants to seek 

judicial review of a final agency decision. 42 U.S.C. § 405(g). The scope of judicial 

review is limited. Id. This Court has jurisdiction to enter a judgment affirming, 

modifying, or reversing the Commissioner’s decision. See id.; 20 C.F.R. § 404.900(a)(5). 

The matter may also be remanded to the Social Security Administration for further 

proceedings. Id.

The Commissioner’s decision must be affirmed upon review if it is: (1) supported 

by “substantial evidence” and (2) based on proper legal standards. Uklov v. Barnhart, 

420 F.3d 1002, 1004 (9th Cir. 2005). If the Court, however, determines that the ALJ’s 

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

may reject the findings and set aside the decision to deny benefits. Aukland v. 

Massanari, 257 F.3d 1033, 1035 (9th Cir. 2001). Substantial evidence is more than a 

scintilla but less than a preponderance. Connett v. Barnhart, 340 F.3d 871, 873 (9th Cir. 

2003). It is “relevant evidence that, considering the entire record, a reasonable person 

might accept as adequate to support a conclusion.” Id.; see also Howard ex rel. Wolff v. 

Barnhart, 341 F.3d 1006, 1012 (9th Cir. 2003) (finding substantial evidence in the record 

despite the ALJ’s failure to discuss every piece of evidence). “Where evidence is 

susceptible to more than one rational interpretation,” the ALJ’s conclusion must be 

upheld. Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005). This includes deferring to 

the ALJ’s credibility determinations and resolutions of evidentiary conflicts. See Lewis v. 

Apfel, 236 F.3d 503, 509 (9th Cir. 2001). This is because the ALJ has a “well-settled role 

as the judge of credibility.” Matthews v. Shalala, 10 F.3d 678, 680 (9th Cir. 1993) 

(quoting Sample v. Schweiker, 694 F.2d 639, 642 (9th Cir. 1982)). Accordingly, the 

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ALJ’s assessment of a claimant’s credibility and pain severity should be given “great 

weight.” Dominguez v. Colvin, 927 F. Supp. 2d 846, 865 (9th Cir. 2003) (citing Nyman 

v. Heckler, 779 F.2d 528, 531 (9th Cir. 1986)). Nevertheless, the Court “must consider 

the entire record as a whole and may not affirm simply by isolating a specific quantum of

supporting evidence.” Robbins v. Soc. Sec. Admin., 466 F.3d 880, 882 (9th Cir. 2006).

VI. ANALYSIS: THE VA DISABILITY APPEAL ISSUE

A. Plaintiff’s Arguments

On April 26, 2016, Plaintiff received a decision of her disagreement from the VA, 

wherein the VA determined that her condition of PTSD was service connected and 

assessed Plaintiff with a 70% disability rating effective March 6, 2012. (ECF No. 16-1 at 

4-5.) The VA also granted Plaintiff a 100% unemployability rating.4 (Id. at 5.) Plaintiff

argues that a Department of Veterans Affairs (VA) disability rating—issued after the 

ALJ’s decision—constitutes new and material evidence requiring a remand for a hearing 

before the ALJ. See Hoa Hong Van v. Barnhart, 483 F.3d 600, 605 (9th Cir. 2007). In 

support of her position, Plaintiff cites to a letter from the Department of Veterans Affairs 

overturning her prior disability determination and awarding her “100% rate due to 

Individual Unmployability[.]” (ECF No. 16-2 at 2.) 

Plaintiff argues that her case should be remanded for further proceedings to review 

the new evidence of her VA disability rating, which was not available at the time of the 

ALJ’s decision. (Id.) In the alternative, Plaintiff argues that she is entitled to summary 

judgment on this basis. (Id.)

B. Defendant’s Arguments

Defendant argues that this case should not be remanded because Plaintiff’s VA 

disability rating was not based on any additional information not previously considered 

 

4 Dr. Eggers completed an evaluation of Plaintiff for VA disability benefits on June 11, 2013, wherein 

she determined that Plaintiff did not qualify for disability benefits. (Id. at 602.) Plaintiff appealed this 

decision. Three years later, on April 26, 2016, Plaintiff received a decision of her appeal from the VA, 

which granted her disability benefits and characterized her as 100% unemployable due to her disability 

status. (See ECF No. 16-2.)

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by the ALJ.5 (ECF No. 21-1 at 5.) According to Defendant, because the VA and the 

ALJ reviewed the same evidence, and reached different conclusions, the fact that the VA 

changed its decision is not sufficient to show that the ALJ would reach a different 

conclusion upon remand, as is required. (Id. at 8.) 

C. Relevant Law

42 U.S.C. § 405(g) states, “[t]he court may, on motion of the Commissioner of 

Social Security made for good cause shown . . . at any time order additional evidence to 

be taken before the Commissioner of Social Security, but only upon a showing that there 

is new evidence which is material and that there is good cause for the failure to 

incorporate such evidence into the record in a prior proceeding.” New evidence is 

material when it “‘bear[s] directly and substantially on the matter in dispute,’ and if there 

is a ‘reasonabl[e] possibility that the new evidence would have changed the outcome of 

the . . . determination.’” Bruton v. Massanari, 268 F.3d 824, 827 (9th Cir. 2001) 

(alterations and omission in original) (quoting Booz v. Sec’y of Health & Human Servs., 

734 F.2d 1378, 1380 (9th Cir. 1984)).

D. Analysis

The letter from the Department of Veterans Affairs that Plaintiff cited references a

Rating Decision, which is said to “provide[] a detailed explanation of [the VA’s] 

decision, the evidence considered, and the reasons for [the VA’s] decision.” (Id.) No 

such Rating Decision is attached to Plaintiff’s exhibit.6 As a result, the Court cannot 

conclude from this letter (ECF No. 16-2) alone whether or not the decision by the VA 

was based on new or different evidence than what was before the ALJ when he issued his 

 

5 The Court notes that the record is not clear whether or not the VA’s decision was based on new 

evidence. 

6 The Court requested supplementation of the record by Plaintiff, specifically requesting this Rating 

Decision. (ECF No. 25.) On August 5, 2016, Plaintiff filed a Supplementation of the Record as Per 

Court Order, attaching the original exhibit in ECF No. 16-2, a declaration from Plaintiff’s attorney, and 

a declaration from Plaintiff. (See ECF No. 26.) This filing did not include the rating decision or any 

information regarding what, if any, new evidence the VA relied on in changing its disability 

determination. 

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decision. 

Defendant’s argument that the VA’s decision is based on the same information 

before the ALJ does not comport with the record. The Court agrees that, if it were known 

that the VA did not review any additional evidence in changing their disability 

determination, the case should not be remanded and Plaintiff’s motion for remand and/or 

summary judgment should be denied. Such was the case in DeOcampo v. Comm’r of 

Soc. Sec., 552 F. App’x 726, 727 (9th Cir. 2014). There, as here, the plaintiff received a 

favorable disability rating by the VA after the ALJ issued his opinion. Id. The Ninth 

Circuit noted that the plaintiff “conceded that the VA’s decision was based on the same 

medical information presented to the ALJ, and he is bound by those concessions.” (Id.

citing Reynoso v. Giurbino, 462 F.3d 1099, 1110 (9th Cir. 2006). Here, however, 

Plaintiff makes no such concession, and the record before the Court is unclear. 

This uncertainty in the record makes this case more akin to the Ninth Circuit 

decision, Luna v. Astrue, 623 F.3d 1032 (9th Cir. 2010). There, the plaintiff received two 

different disability decisions by the social security administration. Id. at 1035. The 

Court stated: 

We cannot conclude based on the record before us whether the decisions 

concerning Luna were reconcilable or inconsistent . . . she may have 

presented different medical evidence to support the two applications, or 

there might be some other reason to explain the change. Given this 

uncertainty, remand for further factual proceedings was an appropriate 

remedy. 

Id. citing Am. Bird Conservacy v. FCC, 545 F.3d 1190, 1195 n. 3 (9th Cir. 2008)(“The 

proper remedy for an inadequate record . . . is to remand to the agency for further 

factfinding.”) 

As in Luna, the record is unclear whether the VA relied on different evidence to 

overturn its decision to award Plaintiff disability benefits, or whether there is another 

explanation for the change. Where the record is inadequate, the Ninth Circuit directs us 

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to remand the case to the agency for further factfinding. As a result, the Court 

RECOMMENDS this case be remanded for further proceedings so the Commissioner 

can determine whether the VA decision was based on new evidence, and if so, whether 

that evidence would influence the ALJ’s disability determination. 

VII. ALJ’S CONSIDERATION OF TREATING SOURCE OPINION

A. Plaintiff’s Argument

Plaintiff argues that the ALJ erred in giving no weight to Dr. Parry, Plaintiff’s 

treating physician. (ECF No. 16-1.) 

B. Defendant’s Argument

Defendant acknowledges that treating physicians are generally afforded greater 

weight when evaluating medical opinion evidence. (ECF No. 21-1 at 8.) However, 

Defendant argues, the opinions of treating physicians are not conclusive, especially if 

they are brief, conclusory and inadequately supported by the clinical evidence. (Id.) 

According to Defendant, the ALJ permissibly gave no weight to the October 2013 checkbox opinion of Dr. Parry because the ALJ found that her opinion was inconsistent with 

her treatment notes reporting unremarkable mental status examinations and mild and 

transient symptoms. (Id. at 9-10.) 

C. Relevant Law

The Ninth Circuit distinguishes 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 (“nonexamining physicians”). Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 

1995). It is undisputed that Dr. Parry is a treating physician. (ECF No. 16-1, at 8.)

Social Security Ruling 96-2p mandates that if a treating source’s medical opinion 

is well-supported and not inconsistent with the other substantial evidence in the case 

record, it must be given controlling weight. Even if the treating source’s opinion is not 

entitled to controlling weight, it is entitled to deference and must be weighed against all 

20 C.F.R. 404.1527 factors. Since opinions of treating doctors are entitled more 

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deference than the opinions of non-treating doctors, an ALJ must provide specific and 

legitimate reasons, supported by substantial evidence in the record, when the treating 

doctor’s opinion will not be given controlling weight. Lester, 81 F.3d at 830. Although 

the treating physician’s opinion is entitled to great deference, it is “not necessarily 

conclusive as to either the physical condition or the ultimate issue of disability.” Morgan

v. Commissioner of Social Sec. Admin., 169 F.3d 595, 600 (9th Cir. 1999). 

The Ninth Circuit requires that an ALJ provide “clear and convincing” reasons to 

reject the opinion of a treating physician when that opinion is uncontradicted. Lester, 81 

F.3d at 830-31. Where the opinion of the claimant’s treating physician is contradicted, 

and the opinion of a non-treating source is based on independent clinical findings that 

differ from those of the treating physician, the opinion of the non-treating source may 

itself be substantial evidence. Andrews v. Shalala, 53 F.3d 1035, 1041 (9th Cir. 1995). 

“When there is conflicting medical evidence, the [Commissioner] must determine 

credibility and resolve the conflict.” Matney v. Sullivan, 981 F.2d 1016, 1019 (9th Cir. 

1992). In addition, the ALJ need not accept the opinion of any physician, including a 

treating physician, if that opinion is brief, conclusory, and inadequately supported by 

clinical findings. Id.

D. Discussion

The ALJ gave Dr. Parry’s “checkbox-style form” no weight, stating that “Dr. 

Parry’s assessment is completely inconsistent with her treatments notes, which . . . 

document relatively minimal examination findings and GAF scores of 60 and 80. (AR at 

20.) The ALJ concluded that “[s]uch an extreme discrepancy greatly reduces the 

probative value of Dr. Parry’s opinion.” (Id.)

In Batson v. Comm’r of Soc. Sec. Admin., the Ninth Circuit upheld an ALJ’s

decision discounting the treating physician’s view because it was in the form of a

checklist, did not have supporting objective evidence, was contradicted by other 

statements and assessments of Plaintiff’s medical condition, and was based on Plaintiff’s 

subjective descriptions of pain. 359 F.3d 1190, 1195 (9th Cir. 2004). Similarly, Dr. 

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Parry opined in checklist format that Plaintiff was seriously limited in nearly every area 

of functioning, yet failed to explain how she reached her conclusions and did not include 

the medical or clinical findings to support her assessment. (AR 441-43.) Instead, Dr. 

Parry writes the following: “Ms. Gilleon suffers from Post-Traumatic Stress Disorder and 

Major Depression as a result of military sexual trauma. Despite her active participation 

in psychological, behavioral and pharmacological treatment, she continues to have 

significant limitations in understanding and memory, in sustained concentration and 

persistence, social interaction and adaptation.”

7

(Id. at 443.) 

Moreover, not only did the ALJ find that Dr. Parry’s opinion was unsupported, he 

also found that it was in contradiction to her own treatment records regarding Plaintiff. 

Specifically, the ALJ noted that Dr. Parry’s treatment notes “document relatively 

minimal examination findings and GAF scores of 60 and 80.” (AR at 20.) Thus, given 

that an ALJ may discredit a treating physician’s opinions that are conclusory, brief, and 

unsupported by the record as a whole, it was not legal error for the ALJ to discount Dr. 

Parry’s opinions in this case since they were in the form of a checklist, and unsupported 

by objective evidence from Dr. Parry herself. See also Tonapetyan v. Halter, 242 F.3d 

1144, 1149 (9th Cir. 2001).

VIII. ALJ’S CONSIDERATION OF NONEXAMINING OPINIONS

Plaintiff argues that the ALJ improperly afforded significant weight to the 

assessments of non-examining state agency physicians. (ECF No. 16-1 at 12.) Plaintiff 

also notes that the state agency examinations took place in 2012, and did not review any 

of the medical evidence submitted after.8 (Id. at 12-13.) 

 

7 The Court notes that the check-the-box form completed by Dr. Parry had four headings: understanding 

and memory, sustained concentration and persistence, social interaction, and adaptation. (AR at 441-

442.) This further supports the Court’s conclusion that Dr. Parry’s analysis was conclusory and lacked 

objective support. 

8 Plaintiff cites case law in support of her insinuation that an ALJ must rely on the most recent medical 

opinion available. However, the cases Plaintiff cites in support of this proposition are inapposite. For 

example, in Stone v. Heckler, the Ninth Circuit did admonish an ALJ for ignoring a more recent medical 

opinion, but only because the Plaintiff suffered from a neuropathic joint disease described as “a 

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Whereas the Defendant argues that the ALJ reasonably gave significant weight to 

the opinions of State agency psychological consultants Anna M. Franco, Psy. D., and 

Peter Bradley, Ph.D. (Id. at 10.)

As mentioned above, the Ninth Circuit distinguishes 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 (“nonexamining physicians”). Lester, 81 F.3d at

830. It is undisputed that Ms. Franco and Dr. Bradley are State agency psychological 

consultants who examined the record, or nonexamining physicians. (ECF No. 16-1 at 12; 

ECF No. 21-1 at 10.) 

The Ninth Circuit has held that the 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. Pitzer v. Sullivan, 908 F.2d 502, 506 n. 4

(9th Cir. 1990); Gallant v. Heckler, 753 F.2d 1450, 1456 (9th Cir. 1984) (emphasis 

added). However, giving the examining physician’s opinion more weight than the 

nonexamining expert’s opinion does not mean that the opinions of nonexamining sources 

and medical advisors are entitled to no weight. Andrews v., 53 F.3d at 1041. Indeed, 

reports of consultative physicians called in by the Secretary may serve as substantial 

evidence supporting the ALJ’s decision. Andrews, 53 F.3d at 1041. 

Importantly, the Court notes that the ALJ did not use the opinions of the state 

agency consultants to discount Dr. Parry’s opinion, as Plaintiff seems to suggest.9 

 

progressive destruction of the weight-bearing joints in the lower extremities.” Stone v. Heckler, 761 

F.2d 530, 532 (9th Cir. 1985). There is no indication from the record, nor does Plaintiff suggest, that 

she has any sort of progressive disease or condition such that Stone is instructive. Moreover, the ALJ 

considered the entirety of the medical record in making his disability determination. See section IV(C)

for a detailed review of the evidence the ALJ considered. 

9 Notably, even if ALJ relied on the opinions of the agency consultants in discounting the opinion of Dr. 

Parry, this would not be error because it was not the only basis of the ALJ’s decision. The opinion of a 

non-examining physician cannot by itself constitute substantial evidence that justifies the rejection of the 

opinion of either an examining physician or a treating physician. Gallant v. Heckler, 753 F.2d 1450, 

1456 (9th Cir. 1984) (emphasis added). In Gallant, the Ninth Circuit held that “the report of [a] nonCase 3:15-cv-02325-BEN-BGS Document 27 Filed 08/05/16 Page 33 of 35
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Instead, the ALJ afforded significant weight to the opinions of the State agency 

consultants in making his overall determination of Plaintiff’s residual functional capacity. 

(See id. at 21.) Specifically, the ALJ noted that “[b]oth concluded the claimant was

capable of performing simple job tasks and had moderate limitations in social functioning 

and adaptation.” (Id.) The ALJ further found that those determinations were “well 

supported by the objective and clinical evidence of record, including the documented 

medication efficacy, the mostly unremarkable mental status examination findings, and the 

GAF scores.” (Id. at 20-21.) The ALJ also noted that these opinions were “consistent 

with Dr. Eggers’ conclusion that there was ‘no evidence [the claimant was] 

unemployable due to PTSD symptoms,’ which were ‘mild or transient.’” (Id. at 21.) 

The ALJ’s use of the nonexamining physician’s opinions was not error because 

these opinions were not the only basis for the ALJ’s determination of Plaintiff’s residual 

functional capacity. The ALJ relied not only on the opinions of the nonexamining 

physicians, but also his consideration of all of Plaintiff’s symptoms, the objective medical 

evidence, and opinion evidence. (Id. at 18.) The ALJ explained his analysis of 

claimant’s testimony, wherein he “considered her statements of record, including those in 

several disability reports and a function report.” (Id.) All of this information relied on by 

the ALJ constitutes substantial evidence that supports his determination of Plaintiff’s 

residual functional capacity. As a result, the ALJ did not err in the weight he afforded to 

Ms. Franco, Psy.D. and Mr. Bradley, Ph.D. 

 

treating, non-examining physician, combined with the ALJ’s own observance of [the] claimant’s 

demeanor at the hearing” did not constitute “substantial evidence” and, therefore, did not support the 

Commissioner’s decision to reject the examining physician’s opinion that the claimant was disabled. 

753 F.2d at 1456. Similarly, in Pitzer, the Ninth Circuit concluded that the nonexamining doctor’s 

opinion “with nothing more” did not constitute substantial evidence. 908 F.2d at 506 n. 4. 

Here, however, the ALJ relied on his review of the objective medical evidence and concluded that Dr. 

Parry’s opinion was “completely inconsistent with her treatments notes, which . . . document relatively 

minimal examination findings and GAF scores of 60 and 80.” (AR at 20.) This inconsistency within 

Dr. Parry’s own medical reports formed the basis for rejecting Dr. Parry’s medical source statement. 

Therefore, even if the ALJ relied on the opinions of the state agency consultants in discounting Dr. 

Parry’s opinion, it did not form the only basis for discounting Dr. Parry’s opinion, and was not error.

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IX. CONCLUSION

Having reviewed the matter, the undersigned Magistrate Judge recommends that 

Plaintiff’s motion for summary judgment be GRANTED in part and DENIED in part

and that Commissioner’s cross-motion for summary judgment be GRANTED in part 

and DENIED in part. The Court recommends a limited remand. On remand to the 

Social Security Administration, the administrative law judge should conduct further 

factfinding on the recent decision by the VA and determine whether or not this decision 

was based on new evidence not previously before the ALJ, and whether or not this 

information changes the disability determination. 

This Report and Recommendation of the undersigned Magistrate Judge is submitted 

to the United States District Judge assigned to this case, pursuant to 28 U.S.C. § 

636(b)(1).

IT IS ORDERED that no later than August 12, 2016, any party to this action may 

file written objections with the Court and serve a copy to all parties. The document 

should be captioned “Objections to Report and Recommendation.”

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

the Court and served on all parties no later than August 19, 2016.

Dated: August 5, 2016

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