Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-akd-3_14-cv-00093/USCOURTS-akd-3_14-cv-00093-0/pdf.json

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

---

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ALASKA

ROGERS MAJOR,

Plaintiff,

v.

CAROLYN W. COLVIN, Commissioner

of Social Security,

Defendant.

Case No. 3:14-cv-00093- RRB

ORDER REMANDING FOR

FURTHER PROCEEDINGS

Docket 18

I. INTRODUCTION

Claimant, Rogers Major, filed an application for Disability Insurance Benefits and Supplemental

Security Income which Defendant, the Commissioner of Social Security, denied.1 Majors has exhausted

his administrative remedies and seeks relieffromthis Court, arguing that the Commissioner’s decisionthat

he is not disabled within the meaning of the Social Security Act is not supported by substantial evidence

1 This matter was originallydecided byALJ decisiondated February7, 2011. On April 27, 2012,

the Appeals Council remanded the matterto the ALJforfurther evaluationofthe treating and non-treating

source opinions in the record, and to, “if necessary, obtain evidence from a medical expert to clarify the

nature and severity of the claimant’s impairment.” Tr. 135. A second and final decision was issued

November 16, 2012. Tr. 30. This appeal considers the November 16, 2012, decision. 

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and applies an erroneous standard of law. Majors seeks a sentence four remand for a rehearing to allow

the ALJ to remedy harmful defects in the decision.

2

Majors has filed an opening brief on the merits, construed bythis Court as a motion for summary

judgment. Defendant opposes, arguing the denial ofbenefitsissupported bysubstantialevidence and free

of legal error. Majors has replied.3 For the reasons set forth below, Claimant’s Motion for Summary

Judgment at Docket 18 is GRANTED and this matter is REMANDED for further consideration.

II. STANDARD OF REVIEW

The findings of the Administrative Law Judge (“ALJ”) or Commissioner of Social Security

regardinganyfactshallbe conclusive ifsupported bysubstantialevidence.

4 A decisionto denybenefits will

not be overturned unless it either is not supported by substantial evidence or is based upon legal error.

5

“Substantial evidence” has been defined by the United States Supreme Court as “such relevant evidence

as a reasonable mind might accept as adequate to support a conclusion.”6 Such evidence must be “more

than a mere scintilla,” but also “less than a preponderance.”7In making its determination, the Court

considersthe evidence initsentirety, weighingboththe evidence thatsupports and that whichdetractsfrom

2

 Docket 23.

3

 Docket nos. 18, 22 7 23.

4

 See 42 U.S.C. § 405(g)(2010).

5Matney ex rel. Matney v. Sullivan, 981 F.2d 1016, 1019 (9th Cir. 1992)(citing Gonzalez v.

Sullivan, 914 F.2d 1197, 1200 (9th Cir. 1990)).

6Richardson v. Perales, 402 U.S. 389, 401 (1971)(quoting Consol. Edison Co. v. NLRB, 305

U.S. 197, 229 (1938)).

7Perales, 402 U.S. at 401; Sorenson v. Weinberger, 514 F.2d 1112, 1119 n.10 (9thCir. 1975).

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the Commissioner’s conclusion.

8

Ifthe evidence issusceptible to more thanone rationalinterpretation, the

ALJ’s conclusion must be upheld.9

III. DETERMINING DISABILITY

The Social Security Act (the “Act”) provides for the payment of disability insurance benefits

(“DIB”) to people who have contributed to the Social Security program and who suffer from a physical

or mental disability.

10

In addition, supplemental security income benefits (“SSI”) may be available to

individuals who are age 65 or over, blind or disabled, but who do not have insured status under the Act.

11

Disability is defined in the Social Security Act as follows:

[I]nability to engage in any substantial gainful activity by reason of any medically

determinable physical or mental impairment which can be expected to result in death or

which has lasted or can be expected to last for a continuous period of not less than 12

months.

12

 The Act further provides:

An individual shall be determined to be under a disability only if his physical or mental

impairments are of such severity that he is not only unable to do his previous work but

cannot, considering his age, education, and work experience, engage in any other kind of

substantialgainful work which exists in the national economy, regardless of whether such

work exists in the immediate area in which he lives, or whether a specific job vacancy

exists for him, or whether he would be hired if he applied for work. For purposes ofthe

preceding sentence (with respect to any individual), “work which exists in the national

8

Jones v. Heckler,760 F.2d 993, 995 (9th Cir. 1985).

9

 Gallant v. Heckler, 753 F.2d 1450, 1452-53 (9th Cir. 1984).

10 42 U.S.C. § 423(a) (2011).

11 42 U.S.C. § 1381 (2011). 

12 42 U.S.C. § 423(d)(1)(A) (2011).

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economy”means work which exists in significant numbers either in the regionwhere such

individual lives or in severalregions of the country.

13

The Commissioner has established a five-step process for determining disability. Claimant bears

the burden of proof at steps one through four.

14

 The burden shifts to the Commissioner atstep five.

15

 The

steps, and the ALJ’s findings in this case, are as follows:

16

Step1. Determinewhetherthe claimant isinvolved in“substantialgainfulactivity. The ALJ found

that the work Claimant engaged in since December 8, 2008, wasan unsuccessful work attempt.

17

Step 2. Determine whether the claimant has a medically severe impairment or combination of

impairments. A severe impairmentsignificantlylimits a claimant’s physicalor mentalabilityto do basicwork

activities, and does not consider age, education, or work experience. The severe impairment or

combination of impairments must satisfythe twelve-monthdurationrequirement. The ALJ found severe

impairments of degenerative disk disease of the cervical spine with left-sided radiculopathy,

degenerative disease of the lumbar spine, and obesity. 

Step3. Determinewhetherthe impairment isthe equivalent ofa number oflisted impairments listed

in20 C.F.R. pt. 404, subpt. P, App. 1 that are so severe as to preclude substantial gainful activity. Ifthe

impairment is the equivalent of one of the listed impairments and meets the duration requirement, the

13

 42 U.S.C. § 423(d)(2)(A) (2011).

14 Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). 

15

Id.

16 Tr. 21-29. TheALJnoted thatMajors met the insured statusrequirements ofthe SocialSecurity

Act through June 30, 2012. Tr. 20. The Appeals Council amended Claimant’s date last insured to

December 31, 2015. Tr. 2. 

17 Thisis not “substantial gainful activity,” despite the ALJ’s mischaracterization of it assuch. This

issue of semantics was harmless error. 

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claimant is conclusively presumed to be disabled. If not, the evaluation goes on to the fourth step. 

According to the ALJ, Claimant’s impairments did not meet or medically equal a listed

impairment, either alone or in combination. 

Residual Functional Capacity. Before proceeding to step four, a claimant’sresidualfunctional

capacity (“RFC”) is assessed. This RFC assessment is used at both step four and step five.

18

In

evaluating his RFC, the ALJ concluded that Claimant retained the RFC to perform light work

with some restrictions. 

Step4. Determine whetherthe impairment preventsthe claimantfromperformingwork performed

inthe past. At this point the analysis considers the claimant’s residual functionalcapacityand pastrelevant

work. If the claimant can still do his or her past relevant work, the claimant is deemed not to be disabled. 

Otherwise, the evaluation process moves to the fifth and final step. The ALJ found that Claimant was

capable of performing past relevant work as a car rustproofer. 

Step 5. Determine whetherthe claimant is able to perform other work in the national economy in

view of his or her age, education, and work experience, and in light of the residualfunctionalcapacity. If

so, the claimant is notdisabled. Ifnot, the claimant is considered disabled. Based on the testimony ofthe

vocational expert, the ALJ found that even ifClaimant could not performhispastrelevantwork,

he could perform other work in the national economy, such as fast food worker, usher, and

tanning salon attendant. 

18

 20 C.F.R. §§ 404.1520(a)(4)(2011); §416.920(a)(4) (2011).

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Claimant bears the burden of proof at steps one through four.

19 The burden shifts to the

Commissioner atstep five.

20

 The Commissioner canmeet this burden“(a) bythe testimonyofa vocational

expert, or(b) byreference to the Medical-VocationalGuidelines at 20 C.F.R. pt. 404, subpt. P, app. 2.”21

Where the grids do not accuratelyreflect the claimant’s limitations, the testimony of a vocational expert is

necessary.

Inorderto be eligible for disabilitybenefits, Claimant mustdemonstrate that he was disabled prior

to December31, 2015, the date he waslast insured forsocialsecuritydisabilitypurposes.

22 The significant

date for disability compensation is the date of onset of the disability, rather than the date of diagnosis.

23

Neither the ALJ nor the claimant is bound by the claimant’s alleged onset date, the date of diagnosis, or

the date a claimant loses herjob. Rather, “the established onset date must be fixed based onthe facts and

can never be inconsistent with the medical evidence or record.”24

IV. DISCUSSION

A. Issues on Appeal

Majors alleges errors at Steps 4 and 5. In response, the Commissioner concedes that the ALJ

erred at Step 4 by finding that Claimant was capable of performing his past relevant work as a car

19 Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). 

20

Id.

21

Id. at 1099. 

22 Tr. 2; Morgan v. Sullivan, 945 F.2d 1079, 1080 (9th Cir. 1991). Claimant’s eligibility for

supplemental security income benefits (SSI) is not dependent upon the date last insured. 

23

Id. at 1081.

24 Goodson v. Bowen, 639 F. Supp 369, 373 (W.D.N.C. 1986) (citing SSR 83-20).

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rustproofer, but arguesthat the ALJ’s alternative findings at Step 5 thatClaimantcould performother work

in the national economy negate the need for a remand. 

Withrespect to the Step 5 findings, Claimant alleges that the ALJ’s determinationofhis RFC was

flawed because the ALJ improperly rejected a treating physician’s prescription for a cane, and because

the ALJ did not obtain the opinionofa physicianabout the functionalimpact ofhis various musculoskeletal

conditions.

25

1. Duty to Develop the Record

Claimant complainsthat the ALJ did not include the need for a cane inthe RFC orthe hypothetical

questionto the vocational expert.

26

 This is true despite Claimant’s testimony that he used a cane 100% of

the time.

27

 Claimant complains that his need for a cane impacts even “sedentary” work, and that although

Dr. Grant prescribed a cane, the ALJ improperly dismissed the need for a cane:

The claimant testified that he began using a cane after his September 2010 surgery. . . In

March 2011, Dr. Grant also noted that the claimant reported he had begun using a cane

afterthatsurgery. However, Dr. Grant’s treatment notes revealno evidence asto whythe

use ofa cane was necessary (exhibit 14F). Nonetheless, Dr. Grant prescribed the use of

a caninMarch 2011 (exhibit 14F). While the evidence supports the claimant’stestimony

that he has been using a cane since September 2010 and his primary care physician has

prescribed the use of a cane, I find nothing in the medical evidence of record that would

support the need for a cane.

28

Claimant argues that Dr. Grant’s prescription was uncontroverted, and therefore the ALJ should have

provided clear and convincing reasons for rejecting it, but instead he inappropriately relied on his own

25

 Docket 18 at 2. 

26 See Tr. 64-65. 

27

 Tr. 52. 

28

 Tr. 26. 

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unsupported and incorrect lay medical knowledge to reject the need for the prescribed cane.

29 Finally,

Claimant complains that the ALJ did not consider the cane in conjunction with his obesity, despite having

determined that his obesity was a severe impairment.

In response, the Commissioner argues that the ALJ did not “reject” Claimant’s use of and

prescription for a cane, but rather he concluded there was “no evidence as to why the use of a cane was

necessary,” and concluded that no medicalsource opined that Plaintiff would be unable to work without

a cane. “Because no medicalevidence demonstrated that Plaintiffwasincapable ofworkingunless he used

a cane, the ALJ appropriately declined to include such a limitation in the residual functional capacity.”30

The Commissioner relies upon an absence of explanation in the medical records to justify the ALJ’s

conclusionthat there was no medical reason for the use ofthe cane, and for omittingthe use ofa cane from

the hypotheticalpresented to the vocational expert. The Commissionerfurtherrationalizesthat “there is no

indication that Dr. Grant connected [Claimant’s] obesity to the prescription for a cane.”31 

Claimant suggests that the Commissioner’s position that a prescribed cane was not necessary in

a work setting because it was not specifically prescribed for work is unreasonable. The Court, too, is

unpersuaded by the Commissioner’s argument that the absence of a specific explanation in the medical

records regarding the need for a cane warrants omission of consideration of the cane entirely. However,

29

 Docket 18 at 11-12. Claimantsuggeststhat the ALJ apparentlylacked anunderstandingof the

fact that abnormalities of the C-5-6 and C6-7 mayaffect the lower extremities, and further complainsthat

the ALJ failed to consider that his physical therapist recommended that he use a cane on a daily basis. 

Docket 18 at 12-13, citing Tr. 739. 

30

 Docket 22 at 5. 

31

 Docket 22 at 6. 

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althoughClaimantsuggeststhat Dr. Grant’s prescription for a cane was akin to an“opinion” thatClaimant

should use a cane, the Court notes that Dr. Grant prescribed a cane several months after the Claimant

started using one on his own. The Court recognizes that the prescriptionmayhave beenwritten merely to

allow for the cost of the cane to be reimbursed. Without more, the record is ambiguous. 

Claimant also argues that the ALJ did not adequately develop the record because he failed to

obtain a medical opinion specifyingwhatClaimant could and could not do, whether from an examining or

non-examining physician, treating or otherwise. 

Medicalsource statements are medicalopinionssubmitted byacceptable medical

sources, includingtreatingsourcesand consultative examiners, aboutwhat anindividualcan

stilldo despite a severe impairment(s), inparticular about anindividual's physicalor mental

abilitiesto performwork-related activities ona sustained basis. Adjudicators are generally

required to request that acceptable medical sources provide these statements with their

medical reports. Medical source statements are to be based on the medical sources'

recordsand examinationofthe individual; i.e., their personalknowledge ofthe individual.

32

Claimant also argues that the record includes “complex medical data” including pre-and post-operative

MRI results, and implies that physician interpretation was necessary. 

The ALJ has a dutyto develop the record “whenthere is ambiguous evidence or when the record

is inadequate to allow for proper evaluation of the evidence.”33 The ALJ bears this duty even when the

claimant is represented by counsel.

34

 Here, the Courtfindsthat the ALJfailed to develop the record with

respect to Claimant’s use ofa cane. Claimant testified that he used the cane 100%ofthe time, and the ALJ

did not challenge this testimony with further questioning. The medical records contain instructions and a

32

 SSR 96-5p. 

33 Mayes v. Massanari, 276 F.3d 453, 459–60 (9th Cir. 2001).

34 Brown v. Heckler, 713 F.2d 441, 443 (9th Cir. 1983). 

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prescription from a physician and a physical therapist to use the cane. In the absence of an explanation

satisfactory to the ALJ’s review, the ALJ had a duty to develop the record further to determine the need

for a cane in this case, rather than to make assumptions. 

In addition, the Court agrees that the ALJ had a duty to seek some medical source opinions to

inform his decision. “Without a personal medical evaluation it is almost impossible to assess the residual

functional capacity of any individual.”

35 This could be obtained most easily through medical source

statements, which are routinely obtained in these matters. 

2. Claimant’s Credibility

The ALJfound thatClaimant’s allegations ofdisablingneck pain, leftarmweaknessand numbness,

right hand numbness, decreased grip strength, and headaches were not consistent with his treatment

providers’observations. TheALJ concluded therefore thatClaimant’sstatements concerningthe intensity,

persistence and limiting effects of his symptoms were not wholly credible. The ALJ also noted that

Claimant’s allegations ofchronic low back painand numbnessfromhis kneesto his feet are not consistent

with the objective evidence, histreatment providers’ observations, orthe nature of treatment. Specifically,

the ALJ found that:

Consideringthe MRIreportsthat the fact that the claimant underwent two surgeries, Ifind

it likely that the claimant did experience severe symptoms related to his cervical spine

impairment. However, Dr. Hadley’s earlier suggestions that the claimant was not giving

anadequate effort during his examinations, the inconsistencies in the physicalexamination

results between treatment providers and examinations, and the apparent success of the

35

 Docket 18 at 15, citing Penny v. Sullivan, 2 F.3d 953, 958 (9th Cir. 1993). 

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claimant’s surgeries leads me to conclude that the claimant’s allegations are not wholly

credible.

36

The ALJfurther noted thatClaimant’stestimonyin2012 regardinghis work historywas not consistent with

histestimonyin2010. The ALJspeculated thatClaimant was attemptingto minimize his work activityafter

the amended onset date.

37

As this matter is being remanded for other reasons, the ALJ’s credibility findings need not be

parsed here. However, inthe absence ofanymedicalsource statementsindicatingwhatClaimant is capable

of, the Court finds that the ALJ’s credibilityfindings regarding Claimant’s testimony cannot be supported

bythe record. There is simply not enough information inthe record regardinghis abilities and limitationsto

determine whether or not his testimony is credible. 

V. ORDER

Based on the foregoing, IT IS HEREBYORDERED that the Claimant’s Motion for Summary

Judgment at Docket 19 is GRANTED and this matter is REMANDED for further proceedings

consistent with this opinion.

IT IS SO ORDERED this 13th day of April, 2015.

S/RALPH R. BEISTLINE

UNITED STATES DISTRICT JUDGE

36

 Tr. 23. 

37Tr. 23-28. The Court notesthat inconsistencyinClaimant’stestimonyregardinghiswork history

between 2010 and 2012 may be attributed to faulty memory, rather than a lack of honesty. 

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