Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_09-cv-01871/USCOURTS-azd-2_09-cv-01871-0/pdf.json

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

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WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Mary A. Miller, 

Plaintiff, 

vs.

MichaelJ. Astrue, Commissioner of Social

Security, 

Defendant. 

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No. CV 09-01871-PHX-JAT

ORDER

Pending before the Court is Plaintiff Mary A. Miller’s appeal from the Administrative

Law Judge’s (“ALJ”) denial of Plaintiff’s application for Social Security disability benefits.

For the reasons that follow, the Court remands this matter to the ALJ for further

consideration.

I. PROCEDURAL HISTORY

On December 29, 2004, Plaintiff filed an Application for Disability Insurance

Benefits, alleging a disability onset date of July 22, 2004. Record Transcript (“TR”) 69.

Plaintiff asserts that she is disabled due to migraine headaches, a back disorder, and a thyroid

disorder. TR 18. Plaintiff’s claim was initially denied on September 1, 2005, and Plaintiff

timely requested a hearing, which was held on August 28, 2007. TR 18. The Social Security

Administration (“SSA”) denied Plaintiff’s application, and found that Plaintiff was capable

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of performing her past work as a credit collector. TR 15, 25. After Plaintiff’s request for

review by the SSA Appeals Counsel was denied on July 10, 2009, Plaintiff commenced an

action before the District Court. (Doc. # 25 at p. 15; Doc. # 26 at p. 2.)

Plaintiff filed a second application for disability benefits with the SSA (Doc. # 21 at

p. 2), and was found disabled as of October 24, 2007, due to migraine headaches and chronic

neck and back pain with bilateral upper extremity weakness (Doc. # 27 at p. 1). By reason

of the SSA’s subsequent decision that Plaintiff was disabled as of October 24, 2007, the

period in dispute in this appeal is limited to July 22, 2004 through October 23, 2007. (Doc.

# 21.) On November 15, 2010, the Court granted Plaintiff’s motion to amend her complaint

to reflect that the period of Plaintiff’s alleged onset date of disability as July 22, 2004

through October 23, 2007. (Doc. # 22.) The Court also set a new briefing schedule for the

parties. (Id.) Plaintiff subsequently moved for submission of the briefs on file (Doc. # 24);

however, the Court did not address this motion prior to the briefing deadlines, and the parties

filed their briefs according the Court’s revised briefing schedule.

II. FACTUAL BACKGROUND

A. Plaintiff’s Disability Claim

Plaintiff has not performed substantial gainful activity since July 22, 2004. (Doc. #

25 at p. 16.) Plaintiff alleges that she is disabled due to the following severe impairments

considered by the ALJ: amblyopia of the right eye with vision loss, migraine headaches,

hyperthyroidism (status: post thyroidectomy), degenerative dis disease (status: post remote

surgery in 1969), left hydronephrosis with impaired kidney function, a history of carpal

tunnel syndrome, and hypertension. (Id. at p. 17.)

B. Plaintiff’s Background

Plaintiff was born on August 17, 1952, stands at 5 feet, 8 inches tall, and weighs 160

pounds. TR 80, 89. She lives alone in an efficiency apartment next door to her son. TR

406–07. Plaintiff does not have a college degree or post-secondary certification; however,

she did complete some college courses. TR 108, 404. Before applying for disability

benefits, Plaintiff worked as a credit collector on and off from 1988 to July 22, 2004. TR

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108. Plaintiff smokes cigarettes, and testified that she has tried to quit. She also testified that

she cannot smoke when she has a bad headache. TR 409.

On May 22, 2007, Plaintiff, representing herself, appeared before the ALJ for a

hearing. TR 394. Plaintiff brought additional documentation of her conditions, which the

ALJ added to the record. TR 394–95. The ALJ stated that he “might have to send [Plaintiff]

out for a consultative examination in light of all this new evidence.” TR 395. Based on the

receipt of new evidence, the ALJ continued the hearing. TR 396.

A second hearing before the ALJ was conducted on August 28, 2007, at which time

Plaintiff, representing herself, testified about her alleged disability. TR 399–416. Plaintiff

testified that she takes prescription drugs for her headaches and for the side effects of her

headaches, including Fluoxetine (generic Prozac), Premarin, Vicodin, Zomig, and

Propranolol. TR 407. Plaintiff testified that she also takes Flexeril for pain in her back. TR

408. Plaintiff testified that in 1998, her vision and headaches got worse, and she started

taking leave from her employment under the Family Medical Leave Act. TR 404. Plaintiff

testified that she has headaches every day, all day with varying severity. TR 408.

Sometimes her headaches are so severe that she vomits and must administer her medicine

through a nasal spray. TR 405. Plaintiff testified that she was born with a lazy eye, and that

despite initial accommodations by her employer, her decreasing eyesight in her “good eye”

could no longer be accommodated. TR 405. Plaintiff testified that she had a “bad back”

since she was 15 years old, but that over the years it was getting worse. TR 406, 408.

Plaintiff testified that she has been treated for depression for the past two years, and that

Prozac helps. TR 408.

Additionally, Plaintiff testified that she has constant pain from her head down her

back, arthritis in her left hip, sciatica down her right leg, neuropathy in her arms and legs,

numbness and tingling in her hands and fingers, sore feet, carpal tunnel in both arms, flank

pain, a bladder disorder, severe hydronephrosis, and the need to have her left kidney

removed. TR 409–10. Plaintiff testified that even though she is in pain every day, she varies

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her medications and does not take pain medication every day to avoid potential

ineffectiveness. TR 411.

According to Plaintiff, she cannot lift things due to a herniated disc in her thoracic

spine and bulging discs in her mid-back. TR 408. Plaintiff testified that she has difficulty

walking and difficulty sleeping. TR 408, 409. Plaintiff testified that she has a driver’s

license and drove herself to the hearing. TR 406. Plaintiff testified that she was an avid

reader, but no longer reads unless required, and that she no longer sews or uses a computer.

TR 410. Finally, Plaintiff testified that when she goes grocery shopping, she must lean on

the grocery cart, and when she washes dishes, she leans “like an old woman,” because she

cannot stand up straight. TR 415.

C. Record Evidence

1. Plaintiff’s Impairments

Plaintiff alleges that she became disabled on July 22, 2004, due to severe migraine

headaches with vision problems, dizziness, a bad back, back surgery, and thyroid surgery.

TR 80–81. The medical records indicate that Plaintiff has a history of headaches, TR 133,

a history of sinus infections causing frontal sinus pain, TR 132, 147, right amblyopia and left

presbyopia, TR 133, and chronic back pain following surgery in 1969, TR 133, 169.

On March 25, 2003, Dr. Jeffrey L. Shy of Neurological Physicians of Arizona, Inc.,

examined Plaintiff for complaints of “lifetime headaches” that had been particularly

problematic over the prior five years. TR 133. Plaintiff claimed that, at least two times per

week, she had a diffuse severe throbbing headache with nausea, vomiting, light and sound

sensitivity, exertional increase, and problematic dizziness and blurry vision. TR 133.

Plaintiff informed Dr. Shy that during her headaches, she was often incapacitated and unable

to work or function. TR 133. The results of Dr. Shy’s neurological examination were

normal. TR 134. The impression was intractable chronic daily headache with intermittent

migraine without aura. TR 134. Plaintiff was prescribed Topamax, Imitrex, and Tramadol,

instructed to keep a headache diary, and asked to follow-up in eight weeks. TR 134. There

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are no records indicating that Plaintiff returned for an eight-week follow-up examination or

kept the headache diary.

On October 9, 2003, over seven months after the initial consultation, Plaintiff returned

to Dr. Shy for a follow-up visit. TR 132. Plaintiff complained of chronic daily headaches

with a “full-blown migraine episode” occurring one to two times per week. TR 132.

Plaintiff admitted that she had ceased taking prescription Topamax before its effectiveness

could be measured, even though her headaches were persistent and unchanged. TR 132.

Plaintiff reported that oral triptans provided some relief from headaches, but she had

problems vomiting up her medications. TR 132. Dr. Shy restarted Plaintiff’s Topamax

prescription and prescribed Imitrex. TR 132.

Between April and June 2004, Plaintiff was treated at Mesa Family Medical Center

for sinusitis and headaches affecting her vision and causing dizziness and nausea. TR

140–44. X-rays of Plaintiff’s hip and lumbar spine were normal. TR 142–43. A CT of

Plaintiff’s sinuses revealed no significant paranasal sinus disease. TR 139.

On June 12, 2004, Plaintiff was treated at the Southwestern Eye Center for her

amblyopia, migraine headaches, and visual disturbances. Clinical notes indicate that Plaintiff

was instructed to see a neurologist. TR 153.

On June 24, 2004, Plaintiff was treated at the Valley Lutheran Medical Center

emergency room with a chief complaint of cephalgia with sinus pain and hypertension. TR

147–50. CT scan was negative. TR 147, 150. It was noted that Plaintiff had a chronic

headache and chronic cephalgia. TR 148. Plaintiff responded to intravenous labetalol for

her high blood pressure, and improved with narcotics for her cephalgia. TR 148. Plaintiff

was discharged with instructions to follow-up with her regular care provider the next week.

TR 148.

On July 14, 2004, Dr. Gilbert J. Toffol at Desert Neurocare, LLP, saw Plaintiff for a

neurological consultation regarding her severe headaches. TR 206–10. Plaintiff reported

that in the last three months her headaches were becoming more frequent, lasted longer, and

were more severe. TR 206. She reported that she experienced dizziness, nausea, vomiting,

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and blurred vision with her headaches, which generally lasted several days and resolved on

their own. TR 206. Plaintiff stated that she is rarely pain free, and complained of balance

difficulties, lack of coordination, and forgetfulness when she is in pain. TR 207. The

impression was transformed migraines with and without aura, with further diagnostic studies

necessary. TR 209. Plaintiff was diagnosed and treated for depression secondary to her

chronic pain. TR 209.

On August 17, 2004, Plaintiff was seen by Dr. Toffol to review the results of her

diagnostic exams. TR 203–05. Plaintiff reported that she had minimal improvement of her

migraine headaches over the past month, and that she had been off work lately and not

exposed to reading on the computer. TR 203. Plaintiff reported taking the hormonal

replacements and nutritional supplements recommended by Dr. Toffol. TR 203. An MRI

of Plaintiff’s brain revealed minimal, nonspecific white matter hyperintensity, which occurs

in individuals with migraines. TR 204. An MRA of the Circle of Willis was normal. TR

204. An MRI of Plaintiff’s spine revealed some degenerative disc disease at C3-C4 with

anterior osteophyte formation and anterior disc bulging, but no focal disc herniation, spinal

canal stenosis or neural forminal narrowing. TR 204. An ultrasound revealed an enlarged

left thyroid lobe with a dominant 3.7 centimeter nodule and a nodule on the right thyroid

lobe. Plaintiff was referred to an endocrinologist for follow-up. TR 204. An EMG with

nerve conduction studies was normal. TR 204. Laboratory studies were within normal

range. TR 204. Dr. Toffol prescribed Topamax, as an additional medication for prophylactic

treatment of Plaintiff’s migraine headaches, and instructed Plaintiff to continue with Zomig

and Vicodin for abortive treatment. TR 205. Finally, Plaintiff was referred to an

ophthalmologist for her persistent blurred vision, and instructed to return for a follow-up in

four weeks. TR 205.

Plaintiff returned to Dr. Toffol on September 21, 2004, and reported that her

migraines were essentially unchanged in frequency or intensity. TR 201–02. Plaintiff

reported that her mood was more relaxed, and that with her prescription for Lexapro, she was

less anxious. TR 201. Dr. Toffol increased Plaintiff’s prescription for Topamax in hopes

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that it would be more efficacious in preventing migraine headaches. TR 202. On October

19, 2004, Plaintiff returned for a follow-up exam, and reported that she continues to have

migraine headaches. TR 200. Plaintiff reported that her severe migraine headaches occurred

several times per week, and her severe low-grade headaches occurred daily. TR 200. Dr.

Toffol increased Plaintiff’s prescriptions of Lexapro and Topamax. TR 200.

On November 23, 2004, Plaintiff returned to Desert Neurocare, and complained of a

very severe migraine headache that occurred twice the prior week, which included nausea

and vomiting. TR 199. Plaintiff reported that her thyroid nodule would be removed after her

ophthalmology evaluation. TR 199. Plaintiff also reported significant blood pressure

fluctuations trending more towards the high side, regardless of the headache pain. TR 199.

Plaintiff was seen by an ophthalmologist in December 2004. TR 197. According to

ophthalmologist, Plaintiff’s blurred vision was not due to any major eye pathology, but likely

due to Plaintiff’s migraine headaches. TR 197.

On January 27, 2005, Plaintiff had a total thyroidectomy, due to a thyroid gland cyst.

TR 164–80. During a follow-up appointment on February 22, 2005, Dr. Thomas J. Ketterer

noted that Plaintiff failed to keep multiple post-operative appointments, but that overall, she

was doing “extremely well” and on thyroid replacement. TR 181.

On March 22, 2005, Plaintiff reported to Dr. Toffol that she still experienced severe

recurrent headaches. TR 195. Dr. Toffol noted that Plaintiff’s next appointment with the

endocrinologist was scheduled to occur in two weeks, and that he would like to re-evaluate

her after that post-thyroidectomy evaluation. TR 195. Dr. Toffol stated that in the meantime,

Plaintiff “should not return back to work since her headaches are still very incapacitating.”

TR 195. Two weeks later, Plaintiff reported to Dr. Toffol that she was “around 50%

improved on Topamax 100 mg once daily.” TR 192. Dr. Toffol increased Plaintiff’s

Topamax prescription and ordered monthly evaluations of Plaintiff. TR 192. On May 15,

2005, Dr. Toffol stated that he was “happy to report that [Plaintiff] is perhaps more than 50%

improved while on Topamax,” and that Plaintiff was “doing very well at this point in time.”

TR 191. Plaintiff reported that she was relocating to Missouri. TR 191.

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On July 27, 2005, Plaintiff was evaluated by Dr. Michael E. Somers in Kansas City,

Missouri. TR 237. Dr. Somers performed an eye examination, and informed Plaintiff that

a neurologist would be trained to determine which medications would be most beneficial for

her migraine headaches. TR 237.

On or about August 31, 2005, a “Physical Residual Functional Capacity Assessment”

of Plaintiff was performed by the State Agency Medical Consultants. TR 238–45. The

primary diagnosis listed was “vision loss” with “bad back, thyroid” listed as other alleged

impairments. TR 238. According to the report, no exertional, manipulative or

communicative limitations were established. TR 239, 241, 242. Postural limitations

included climbing ramp/stairs (occasionally) and ladders/ropes/scaffolds (never). TR 240.

Visual limitations included depth perception and field of vision, with limited accommodation

necessary. TR 241. Environmental limitations included concentrated exposure to hazards,

such as machinery and heights. TR 242. With respect to Plaintiff’s symptoms, it was

reported that Plaintiff “does have some headaches,” but that she was “doing very well.” TR

243.

On September 13, 2005, Plaintiff was seen by Dr. John H. Amick for a new patient

evaluation. TR 276–77. Dr. Amick’s review of symptoms included severe chronic

migraines, hypertension, and depression. TR 276.

A November 2005 MRI of Plaintiff’s thoracic spine showed central/left paracentral

disc herniation with cord deviation and compression, and minimal annular disc bulge. TR

279. Electrodiagnostic testing of Plaintiff in November 2005 showed moderate bilateral

carpal tunnel syndrome and early bilateral ulnar neuropathy at the elbow, but no evidence

of radiculopathy, peripheral neuropathy or other entrapment syndrome. TR 280. A physical

examination of Plaintiff was negative for Hoffman’s, Froment’s and Tinel’s signs, and

Phalen’s maneuver. TR 280. A January 18, 2006 CT of Plaintiff’s spine showed very mild

rounded kyphosis, and scattered areas of degenerative change, including a large calcified

anterolateral extradural defect extending into the neural canal consistent with a calcified disc

fragment. TR 281.

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In February 2006, Plaintiff was treated at Kansas City Urology Care for

hydronephrosis, and instructed to return in one year for an evaluation. TR 283–86.

On May 8, 2006 and June 6, 2006, Plaintiff was examined by Dr. Gail Francis at the

Minneapolis Clinic of Neurology, Ltd., for migraine headaches and chronic pain issues. TR

342–47. Plaintiff reported being incapacitated and in bed for two to three days at a time due

to headache symptoms. TR 344. Dr. Francis’s assessment was intractable headaches,

probably vascular in nature. TR 347. Dr. Francis administered an occipital nerve block, but

Plaintiff did not respond, and was referred to a headache specialist. TR 342–43.

In June and July 2006, Plaintiff was treated for left-sided hydronephrosis at the

Northeast Urology Clinic, P.A. TR 348–49, 358–62, 379–82, 387–88. It was determined

that Plaintiff had a non-functioning left kidney, and removal of the kidney was discussed.

TR 348.

2. Recent Medical Assessments

During the initial hearing before the ALJ on May 22, 2007, the ALJ indicated that in

light of the additional medical records presented by Plaintiff at the hearing, the ALJ “might

have to send [Plaintiff] out for a consultative examination.” TR 395. The ALJ stated that

he would continue the hearing, review the new evidence, and determine whether it would be

necessary to obtain a consultative examination. TR 396. A consultative examination was

not obtained.

Prior to the second hearing before the SSA, on August 18, 2007, Plaintiff’s treating

physician Dr. Jennifer Auge completed a medical opinion form, in which she diagnosed

Plaintiff with the following conditions: back pain, a kidney disorder, migraines, depression,

and vision problems. TR 391. Dr. Auge opined that Plaintiff’s conditions would last more

than 30 days, and that Plaintiff was following the prescribed treatment plan. TR 391. Dr.

Auge indicated that Plaintiff “will not be able to perform any employment in the foreseeable

future,” and stated that Plaintiff has been unable to work since 2004. TR 391. Finally, Dr.

Auge indicated that Plaintiff suffered from mental illness. TR 391.

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3. Vocational Expert

During the August 28, 2007 hearing before the SSA, the Vocational Expert (“VE”)

testified to Plaintiff’s past work history and potential for future employment. TR 412–15.

The VE testified that he had reviewed Plaintiff’s vocational history. TR 412.

The ALJ’s first hypothetical concerned a woman of Plaintiff’s educational and

vocational background. TR 412. This hypothetical person suffered from ophthalmic

migraine headaches, amblyopia of the right eye with vision loss, a history of amblyopia of

the left eye, hyperthyroidism status post-thyroidectomy, depression, bilateral carpal tunnel

syndrome, and left-sided hydronephrosis with impaired kidney functioning. TR 412. This

hypothetical person also had degenerative disc disease of the lumbosacral spine. TR 412.

This hypothetical person was receiving treatment for a tempomandibular joint disorder or

dysfunction. TR 412. This hypothetical person had a history of degenerative disc disease

with surgery, neuropathy of the hands and feet, and degenerative joint disease of the hip. TR

412–13. The ALJ asked if this combination of impairments would limit the hypothetical

person to light work, which included occasionally lifting of 20 pounds and frequently lifting

10 pounds or less. TR 413. The hypothetical person would spend six hours during the eight

hour day on her feet, occasionally climbing stairs or ramps, and occasionally stooping,

kneeling, crouching or crawling. TR 413. The hypothetical person would not climb ladders,

ropes or scaffolds, and would not be exposed to unprotected heights or dangerous moving

machinery. TR 413.

The VE found that this hypothetical person could perform Plaintiff’s past work as a

credit collector. TR 413. The VE reminded the ALJ that Plaintiff’s past work as a credit

collector was at the sedentary level. TR 413. The VE seemed to state that the hypothetical

person described above would be performing light work, not sedentary work. TR 413. The

ALJ then asked the VE if the hypothetical person was limited to sedentary work, whether she

could perform Plaintiff’s past work as a credit collector. TR 413. The VE stated she could

perform that work. TR 413.

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1

 Based on the hearing transcript, it appears that Plaintiff neither understood the VE’s

testimony, nor her right to present additional hypothetical questions to the VE:

ALJ: And, Ms. Miller, well, did you have any questions about Mr. Ogren’s

testimony?

Plaintiff: Yeah. What did all that mean?

ALJ: Well, like I said —

Plaintiff: Because at first it sounded like, you know, yes and a no. . . . Because

I understand the second part of it because no, you couldn’t go get hired at a job

and basically pick your own schedule. . . . So the first part of it I didn’t

understand about she is able to do the sedentary meaning?

ALJ: Oh, well, sedentary work means lifting only 10 pounds, only up to 10

pounds occasionally and frequent lifting of less than 10 pounds, and sitting six

out of eight hours.

Plaintiff: Oh, no. I would not be, I have to change positions all the time.

ALJ: Okay.

TR 414–15.

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The ALJ then posed a second hypothetical to the VE in which the hypothetical person

needed the ability to leave the workplace or be absent from the workplace for four or more

days [each month] without scheduling the absences in advance. TR 413. The hypothetical

person also needed the ability to take additional unscheduled breaks for unspecified durations

of time due to headaches. TR 413. The VE testified that the hypothetical person would not

be able to perform Plaintiff’s past work, or any other jobs in the national economy. TR 413.

Plaintiff was then given the opportunity to question the VE. TR 414. Plaintiff

expressed some confusion as to the meaning of the VE’s testimony.1

 TR 414, 415. The ALJ

explained sedentary work as lifting only 10 pounds occasionally, lifting less than 10 pounds

frequently, and sitting six out of eight hours during the work day. TR 415. Plaintiff stated

that she could not perform sedentary work, because she needed to change positions all the

time. TR 415.

III. LEGAL STANDARD

To qualify for disability benefits under the Social Security Act, a claimant must show,

among other things, that the claimant is “under a disability.” 42 U.S.C. § 423(a)(1)(E). The

Social Security Act defines “disability” as the “inability to engage in any substantial gainful

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2

 Here, Plaintiff does not challenge the ALJ’s finding that Plaintiff did not engage in

substantial gainful activity during the period of July 22, 2004 through October 23, 2007. TR

20; Doc. # 25 at p. 16.

3

 Here, Plaintiff does not challenge the ALJ’s finding that Plaintiff suffers from the

following severe impairments: amblyopia of the right eye with vision loss, migraine

headaches, hyperthyroidism (status: post thyroidectomy), degenerative disc disease (status:

post remote back surgery in 1969), left hydronephrosis with impaired kidney function, a

history of carpal tunnel syndrome, and hypertension. TR 20, Doc. # 25 at p. 17.

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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.” Id. § 423(d)(1)(A). A person is “under a disability only

if his physical or mental impairment or 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 substantial gainful work which exists in the national

economy.” Id. § 423(d)(2)(A). The Social Security regulations set forth a five-step

sequential process for evaluating disability claims. 20 C.F.R. § 404.1520; see Reddick v.

Chater, 157 F.3d 715, 721 (9th Cir. 1998) (describing the sequential process). A finding of

“not disabled” at any step in the sequential process will end the ALJ’s inquiry. 20 C.F.R. §

404.1520(a)(4). The claimant bears the burden of proof at the first four steps, but the burden

shifts to the ALJ at the final step. Reddick, 157 F.3d at 721. The five steps are as follows:

1. First, the ALJ determines whether the claimant is “doing substantial gainful

activity.” 20 C.F.R. § 404.1520(a)(4)(i). If so, the claimant is not disabled.2

2. If the claimant is not gainfully employed, the ALJ next determines whether the

claimant has a “severe medically determinable physical or mental impairment.” 20 C.F.R.

§ 404.1520(a)(4)(ii). The “step-two inquiry is a de minimis screening device to dispose of

groundless claims.” Smolen v. Chater, 80 F.3d 1273, 1290 (9th Cir. 1996). If the claimant

does not have a severe impairment, the claimant is not disabled.3

3. Having found a severe impairment or impairments, the ALJ next determines

whether the impairment “meets or equals” one of the impairments listed in the regulations.

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20 C.F.R. § 404.1520(a)(4)(iii). If so, the claimant is found disabled without considering the

claimant’s age, education, and work experience. Id. § 404.1520(d). If the impairment or

impairments do not meet or equal a listed impairment, before proceeding to the next step, the

ALJ will make a finding regarding the claimant’s “residual functional capacity based on all

the relevant medical and other evidence in [the] record.” Id. § 404.1520(e). A claimant’s

“residual functional capacity” is the most the claimant can do despite all her impairments,

including those that are not severe, and any related symptoms. Id. § 404.1545(a)(1–2).

4. At step four, the ALJ determines whether, despite the impairments, the

claimant can still perform “past relevant work.” Id. § 404.1520(a)(4)(iv). To make this

determination, the ALJ compares its “residual functional capacity assessment . . . with the

physical and mental demands of [the claimant’s] past relevant work.” Id. § 404.1520(f). If

the claimant can still perform the kind of work she previously did, the claimant is not

disabled. Otherwise, the ALJ proceeds to the final step.

5. At the final step, the ALJ determines whether the claimant “can make an

adjustment to other work” that exists in the national economy. Id. § 404.1520(a)(4)(v). In

making this determination, the ALJ considers the claimant’s residual functional capacity,

together with vocational factors (age, education, and work experience). Id. § 404.1520(g)(1).

If the claimant can make an adjustment to other work, then she is not disabled. If the

claimant cannot perform other work, she will be found disabled. As previously noted, the

Commissioner has the burden of proving the claimant can perform other substantial gainful

work that exists in the national economy. Reddick, 157 F.3d at 721.

IV. THE ALJ’S DECISION

The ALJ evaluated Plaintiff’s alleged disability according to the five-step evaluation

process set forth above. TR 15–26. As an initial matter, the ALJ determined that Plaintiff

has not engaged in substantial gainful activity since the alleged onset of her disability, July

22, 2004. TR 20. Next, the ALJ found Plaintiff suffered from the following severe

impairments: amblyopia of the right eye with vision loss, migraine headaches,

hyperthyroidism (status: post thyroidectomy), degenerative disc disease (status: post remote

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back surgery in 1969), left hydronephrosis with impaired kidney function, a history of carpal

tunnel syndrome, and hypertension. TR 20. However, the ALJ concluded that Plaintiff’s

impairments failed to meet the criteria of the third step. TR 21.

The third step requires the ALJ to determine whether a claimant’s impairment or

combination of impairments “meets or equals one of the SSA’s listings in appendix 1 to

subpart P of part 404 of this chapter and meets the duration requirement.” 20 C.F.R. §

416.920(a)(4)(iii); see id. § 404.1520(d). The ALJ reviewed Plaintiff’s severe impairments

under Sections 1.00 (Musculoskeletal System), 2.00 (Special Senses), 6.00 (Genitourinary

Impairments), and 9.00 (Endocrine System). TR 21 The ALJ found that Plaintiff “does not

have an impairment or combination of impairments that meets or medically equals one of the

listed impairments in 20 C.F.R. 404, Subpart P, Appendix 1, Regulations No. 4.” TR 21.

Next, as part of step four, the ALJ found that Plaintiff had the residual functional

capacity (“RFC”) to perform light exertional level tasks. TR 21. The RFC is defined as “the

most [Plaintiff] can still do despite [her] limitations.” 20 C.F.R. § 416.945(a)(1). The ALJ

reduced Plaintiff’s RFC to allow for a credible degree of pain, but found that the objective

medical records did not support a finding that Plaintiff’s pain or functional limitations were

so severe as to keep her from working. TR 25. The ALJ stated that the wide range of

Plaintiff’s daily activities were inconsistent with disability, but within the realm of the RFC

for light work. TR 25. According to the ALJ, the objective medical evidence, the lack of

treatment, and the lack of significant pain medications, as well as other factors, failed to

support Plaintiff’s allegations of her inability to work. TR 25.

The ALJ did not reduce Plaintiff’s RFC due to her hyperthyroidism, because she was

stable following the thyroidectomy and did not suffer complications. TR 22. The ALJ found

that because Plaintiff suffered from chronic back pain since 1969, but still sustained

substantial gainful activity, this strongly suggested that Plaintiff’s back pain currently would

not prevent work. TR 23. The ALJ also found that the RFC did not need to be reduced due

to Plaintiff’s degenerative disc disease, because Plaintiff did not have neurological deficits,

mobility limitations, sensory deficits, or strength losses related to this impairment. TR 24.

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According to the ALJ, the RFC of light exertional tasks accommodated Plaintiff’s pain

complaints and symptoms of degenerative disc disease. TR 24. The ALJ found Plaintiff’s

alleged significant vision problems to be inconsistent with her ability to drive, her

ophthalmologist’s report, and the fact that Plaintiff’s right eye amblyopia did not prevent her

from working prior to July 22, 2004. TR 24. According to the ALJ, this strongly suggested

that Plaintiff’s vision impairments would not prevent her from working currently. TR 24.

However, the ALJ’s RFC limits work around heights or dangerous moving machinery in

order to accommodate Plaintiff’s vision loss in her right eye and her episodic complaints of

dizziness. TR 24. With respect to Plaintiff’s diagnosis of left hydronephrosis with impaired

kidney function, the ALJ did not reduce the RFC, because Plaintiff denied urinary problems

on July 11, 2006, and her right kidney and bladder were functioning normally. TR 24.

Finally, the ALJ did not reduce the RFC to accommodate Plaintiff’s hypertension, because

it had been successfully treated. TR 24.

Before determining the RFC, the ALJ found Plaintiff’s statements concerning the

intensity, duration and limiting effects of her medically determinable impairments were “not

entirely credible.” TR 22. Plaintiff testified that she was unable to smoke cigarettes when

she had a bad headache. The ALJ found the fact that Plaintiff continued to smoke despite

her numerous complaints, diminished her credibility. TR 23. Further, the ALJ stated that

because Plaintiff did not take any steps to obtain different medication, then it could be

reasonably inferred that Plaintiff was satisfied with the effects of her present medications.

TR 25.

The ALJ gave little weight to the opinions of the State Agency Medical Consultants,

who found Plaintiff was capable of performing work at all levels of exertional activity,

because these non-examining, non-treating physicians did not review Plaintiff’s most recent

medical evidence or hear her testimony. TR 24. The ALJ also gave little weight to the

opinion evidence of Dr. Jennifer Auge, because Dr. Auge’s conclusion that Plaintiff would

be unable to perform any employment in the foreseeable future was supported only by the

conclusory comment that “patient has been unable to work since 2004.” Further, Dr. Auge

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did not set forth specific functional limitations, and, according to the ALJ, her opinion was

“clearly inconsistent with other more persuasive and substantive evidence of record.” TR

24. The ALJ gave substantial weight to the “objective medical evidence,” including

Plaintiff’s x-ray, EMG with nerve conduction studies, laboratory studies, CT scan, MRIs, and

direct motor testing. TR 22–23.

The ALJ concluded his decision at step four of the sequential process, and found that

Plaintiff was not disabled. Based on the RFC and the testimony of the VE, the ALJ found

that Plaintiff was capable of performing her past work as a credit collector, as such work was

actually and generally performed. TR 25. Accordingly, the ALJ held that Plaintiff was not

disabled under sections 216(i) and 223(d) of the Social Security Act. TR 26.

V. STANDARD OF REVIEW

A district court

may set aside a denial of disability benefits only if it is not supported

by substantial evidence or if it is based on legal error. Substantial

evidence means more than a mere scintilla but less than a

preponderance. Substantial evidence is relevant evidence which,

considering the record as a whole, a reasonable person might accept as

adequate to support a conclusion. Where the evidence is susceptible to

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

decision, the ALJ’s decision must be upheld.

Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002) (internal citation and quotation

omitted). This standard of review exists, because “[t]he trier of fact and not the reviewing

court must resolve conflicts in the evidence, and if the evidence can support either outcome,

the court may not substitute its judgment for that of the ALJ.” Matney ex rel. Matney v.

Sullivan, 981 F.2d 1016, 1019 (9th Cir. 1992). Also under this standard, the Court will

uphold the ALJ’s findings “if supported by inferences reasonably drawn from the record.”

Batson v. Soc. Sec. Admin., 359 F.3d 1190, 1193 (9th Cir. 2004). However, the Court must

consider the entire record as a whole and “may not affirm simply by isolating a ‘specific

quantum of supporting evidence.’” Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007) (quoting

Robbings v. Soc. Sec. Admin., 466 F.3d 880, 882 (9th Cir. 2006)).

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VI. ANALYSIS

On appeal, Plaintiff argues that the ALJ committed legal errors in his assessment at

steps three and four of the sequential process, and that this matter should be remanded either

for further proceedings or a determination of benefits. Asserting the SSA’s final decision is

supported by substantial evidence and free of harmful legal error, the Commissioner asks the

Court to affirm the decision of the ALJ.

Plaintiff first argues that the ALJ erred at step three of the sequential process by not

considering Listing 11.03 (Epilepsy), 20 C.F.R. pt. 404, Subpt. P, App’x 1, in connection

with Plaintiff’s migraine headaches and history. Plaintiff also argues that the ALJ erred at

step four of the sequential process by not setting forth a function-by-function assessment of

Plaintiff’s impairments and restrictions in determining Plaintiff had the RFC to perform a

range of light work. Plaintiff further objects to the ALJ’s failure to consider the effect of

Plaintiff’s migraines on the RFC. Plaintiff finally argues that the ALJ erred in not properly

considering Plaintiff’s subjective complaints and the opinions of Plaintiff’s treating

physicians. Plaintiff argues, and the Court agrees, that the ALJ did not fully develop the

record prior to denying Plaintiff’s application for disability benefits.

A. Consideration of Listing 11.03 in Step 3 Analysis

In order for a claimant’s impairment or combination of impairments to meet the

requirements of a listed impairment, all of the criteria of that listing and the duration

requirement must be satisfied. See 20 C.F.R. §§ 404.1525(c)(1–3), 416.925(c)(1–3).

Medical equivalence will be found “if the medical findings are at least equal in severity and

duration to the listed findings.” 20 C.F.R. § 404.1526(a); see Marcia v. Sullivan, 900 F.2d

172, 175 (9th Cir. 1990). “Marcia simply requires an ALJ to discuss and evaluate the

evidence that supports his or her conclusion.” Lewis v. Apfel, 236 F.3d 503, 513 (9th Cir.

2001). A claimant must offer a plausible theory of how her combination of impairments

equals a listing before the failure to consider the issue will be error. Id. at 514; see Burch v.

Barnhart, 400 F.3d 676, 683 (9th Cir. 2005) (“An ALJ is not required to discuss the

combined effects of a claimant’s impairments or compare them to any listing in an

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 Listing 11.03 of the SSA’s Listing of Impairments provides, in full:

Epilepsy - nonconvulsive epilepsy (petit mal, psychomotor, or focal),

documented by detailed description of a typical seizure pattern, including all

associated phenomena; occurring more frequently than once weekly in spite

of at least 3 months of prescribed treatment. With alteration of awareness or

loss of consciousness and transient postictal manifestations of unconventional

behavior or significant interference with activity during the day.

20 C.F.R. Pt. 404, Subpt. P, App’x 1.

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equivalency determination, unless the claimant presents evidence in an effort to establish

equivalence.”).

Plaintiff argues that the ALJ’s failure to evaluate her severe impairments under Listing

11.03 constitutes legal error. According to the ALJ’s decision, the ALJ considered and

rejected Plaintiff’s impairments under Sections 1.00, 2.00, 5.00 and 9.00 of the Listing of

Impairments. TR 21. The ALJ did not consider Listing 11.03. Plaintiff argues that her

migraine headaches meet or equal Listing 11.03, and, therefore, she is disabled. See 20

C.F.R. § 404.1520(d).

The Commissioner refers to the SSA’s Question and Answer (“Q&A”) 09-036, which

is attached to Plaintiff’s reply brief, as the SSA’s current guidance for determining whether

migraine headaches are a medically determinable impairment. (Doc. # 27-1, App’x 4.)

According to the SSA, Listing 11.03 (Epilepsy - nonconvulsive epilepsy)4

 “is still the most

analogous listing for considering medical equivalence [of migraine headaches].” Q&A 09-

036. The Q&A describes the essential components of Listing 11.03, as those components

apply to migraine headaches: typical headache event pattern that is documented by detailed

descriptions, including all associated phenomena (e.g., premonitory symptoms, aura,

duration, intensity, treatment), that occurs more frequently than once weekly with alteration

of awareness or an effect that significantly interferes with activity during the day (e.g., need

for a darkened quiet room, lying down without moving, or sleep disturbance that impacts

daytime activities). Id.

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The Commissioner argues that Plaintiff has not met her burden to present medical

findings satisfying all the criteria of Listing 11.03 over 12 months. (Doc. # 26 at p.10.)

Plaintiff disagrees, and refers the Court to the record, wherein Plaintiff’s long history of

migraine headaches is discussed. (Doc. # 27 at p. 2–3.) The record contains sufficient

evidence that Plaintiff’s migraine headaches may be analogous to the listing for epilepsy.

For instance, Plaintiff cites to medical evidence describing Plaintiff’s typical headache

pattern, including associated phenomena, TR 199, 206–10, frequency of her migraine

headaches, TR 132, 200, 203–05, interference with daily activity caused by her migraine

headaches, TR 197–98, 237, 344–47, and existence of her migraine headaches for a period

of at least 12 months, TR 133–34, 195, 370–72. The credibility of this medical evidence,

which is largely anecdotal, must be determined by the ALJ upon remand.

The Court will not go so far as to determine whether Plaintiff meets Listing 11.03, but

finds that there is sufficient evidence in the record for the ALJ to evaluate Plaintiff’s

migraine headaches under Listing 11.03. Accordingly, it was error for the ALJ not to

consider Listing 11.03 in evaluating whether Plaintiff is disabled at step three of the

sequential process. For this, and the additional reasons set forth below, the Court will

remand this matter to the ALJ for further determination.

B. Residual Functional Capacity Determination in Step Four Analysis

Plaintiff argues that the ALJ’s failure to set forth a function-by-function assessment

of Plaintiff’s residual functional capacity or RFC makes the ALJ’s decision legally deficient.

The Court agrees, and remands this matter to the ALJ for a thorough RFC assessment,

provided that the ALJ’s inquiry on remand reaches step four of the sequential process.

As described above, at step four of the sequential process the ALJ determines whether,

despite Plaintiff’s impairments, Plaintiff can still perform her “past relevant work.” 20

C.F.R. § 420.1520(a)(4)(iv). This determination is made by comparing the RFC assessment

with the physical and mental demands of Plaintiff’s past relevant work. Id. § 404.1520(f).

The RFC is determined by the relevant medical and other evidence in a claimant’s case

record, and is considered to be the most the claimant is able to do despite her limitations. Id.

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 Social Security Rulings constitute the SSA’s interpretations of the statutes it

administers and of its own regulations. Chavez v. Dep’t of Health & Human Servs., 103 F.3d

849, 851 (9th Cir.1996). Although Social Security Rulings do not have the force of law, id.,

once published, these rulings are binding upon ALJs and the Commissioner, Holohan v.

Massanari, 246 F.3d 1195, 1202–03 n.1 (9th Cir.2001); Gatliff v. Comm’r of Soc. Sec.

Admin., 172 F.3d 690, 692 n.2 (9th Cir.1999).

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§ 404.1545(a)(1). Before making an RFC assessment, the ALJ is responsible for developing

a claimant’s complete medical history, including arranging for consultative examinations,

if necessary. Id. § 404.1545(a)(3).

A relevant Social Security Ruling5

 provides that “[t]he RFC assessment must first

identify the individual’s functional limitations or restrictions and assess his or her workrelated abilities on a function by function basis.” Soc. Sec. Rul. 96-8p, 1996 WL 374184,

at *1 (July 2, 1996); see Reed v. Massanari, 270 F.3d 838, 843 n.2 (9th Cir. 2001) (“Notably

absent from the record before the ALJ was any assessment of Reed’s RFC on a function-byfunction basis . . . . A Social Security Administration ruling specifically warns against this

practice of determining a claimant’s ability to perform past work on the sole basis of a

categorical RFC assessment.”). Accordingly,

At step 4 of the sequential evaluation process, the RFC must not be expressed

initially in terms of the exertional categories of ‘sedentary,’ ‘light,’ ‘medium,’

‘heavy,’ and ‘very heavy’ work because the first consideration at this step is

whether the individual can do past relevant work as he or she actually

performed it.

Soc. Sec. Rul. 96-8p, at *3. The Social Security Ruling states that “without the initial

function-by-function assessment of the individual’s physical and mental capacities, it may

not be possible to determine whether the individual is able to do past relevant work as it is

generally performed in the national economy.” Id. The Social Security Ruling further

recognized that the “[i]nitial failure to consider an individual’s ability to perform the specific

work-related functions could be critical to the outcome of a case.” Id.; see Pinto v.

Massanari, 249 F.3d 840, 845 (9th Cir. 2001) (stating that the ALJ has the “burden to make

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the appropriate findings to insure that the claimant really can perform his or her past relevant

work”).

Here, the ALJ failed to set forth a function-by-function assessment of Plaintiff’s

physical and mental capabilities. The ALJ stated that Plaintiff had the RFC for “light

exertional level tasks with occasional climbing of stairs and ramps; occasional stooping,

crawling and kneeling; and, no work around heights or dangerous moving machinery.” TR

21. The ALJ further defined “light work” by its generic definition as “work lifting 20 pounds

occasionally and frequent lifting or carrying of objects weighing 10 pounds, standing and/or

walking 6 of 8 hours, or sitting most of the time with some pushing and pulling arm or leg

controls.” TR 21. In reaching the conclusion that Plaintiff’s RFC is for “light work,” the

ALJ did not make findings as to the functions that Plaintiff could perform in consideration

of her impairments, and the functions Plaintiff performed or was expected to perform on a

day to day basis as a credit collector. It is unclear how the ALJ came to the conclusion that

Plaintiff is suited for “light work” despite her impairments, because the ALJ did not make

any findings as to Plaintiff’s functional limitations or restrictions.

Even though the ALJ reported that Plaintiff’s RFC would not preclude work in the

credit collection field, because it is a skilled sedentary occupation, TR 26, the ALJ failed to

make any specific findings as to the duration and frequency of the specific functions that

Plaintiff could perform. The ALJ states that “[i]n comparing the claimant’s residual

functional capacity with the physical and mental demands of this work, the [ALJ] finds that

the claimant is able to perform this past work as actually and generally performed.” TR 26.

However, the ALJ did not provide a function-by-function assessment before reaching this

conclusion. Further, the ALJ did not describe of the functions of a credit collector.

Plaintiff further argues that the ALJ did not properly consider the effect of Plaintiff’s

migraine headaches on her RFC. Specifically, Plaintiff argues that, “[a]t a minimum, the

ALJ was required to identify the frequency, duration and severity of migraine headaches as

Defendant’s vocational expert affirmed that migraine headaches causing unscheduled

absences or missed work at a rate of 4 or more per month is work precluding.” (Doc. # 25

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 RFC is an individual’s maximum remaining ability to do sustained work activities

in an ordinary work setting on a regular and continuing basis, where “regular and continuing

basis” means eight hours a day for five days a week. Soc. Sec. Rul. 96-8p, at *2.

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at pp. 21–22.) While there is no authority requiring the ALJ to make a specific frequency,

duration and severity finding, the Court agrees that an assessment of Plaintiff’s RFC

invariably should include an assessment of Plaintiff’s ability to attend work on a regular and

continuous basis.6

 The ALJ’s decision does not appear to take into account the effect of

Plaintiff’s unscheduled absences on her ability to engage in substantial gainful activity. The

ALJ states that the RFC “accommodates the claimant’s pain complaints and symptoms of

degenerative disc disease,” TR 24; however, the RFC does not account for unscheduled

absences of any duration or frequency. On remand, and assuming the ALJ reaches step four

of the sequential process, the ALJ must address the VE’s testimony that four or more days

of unscheduled absences and the need to take unscheduled breaks for unspecified durations

would not permit a person to perform any jobs that exist in the national economy. TR 413.

As cautioned by the Social Security Ruling, without an initial function-by-function

assessment of the claimant’s physical and mental capacities, it may not be possible to

determine whether the claimant is able to do past relevant work as it is generally performed

in the national economy. See Soc. Sec. Rul. 96-8p, at *3. The ALJ’s conclusory statement

of Plaintiff’s RFC and recitation of the generic definition of “light work” is not the

equivalent of this assessment. On remand, and assuming the ALJ reaches step four of the

sequential process, the ALJ must identify Plaintiff’s functional limitations or restrictions, and

assess her work-related abilities on a function-by-function basis.

C. Consideration of Plaintiff’s Subjective Complaints

With respect to Plaintiff’s subjective complaints, the ALJ concluded “the claimant’s

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

entirely credible.” TR 22. Plaintiff argues that the ALJ failed to properly consider her

subjective complaints.

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If a claimant produces objective medical evidence of an underlying impairment, as

Plaintiff did here, then the ALJ cannot reject the claimant’s subjective complaints based

solely on a lack of objective medical support for the alleged severity of the pain. Rollins v.

Massanari, 261 F.3d 853, 856 (9th Cir. 2001). When the ALJ finds the claimant’s subjective

pain testimony not credible, the ALJ must make findings sufficiently specific to allow the

reviewing court to conclude that the ALJ rejected the testimony on permissible grounds and

did not arbitrarily discredit the claimant’s testimony. Id. at 856–57. If no affirmative

evidence of malingering exists, then the ALJ must provide clear and convincing reasons for

rejecting the claimant’s testimony about the severity of her symptoms. Id. at 857.

The Court concludes that the ALJ provided clear and convincing reasons supported

by substantial evidence for not fully crediting Plaintiff’s testimony. The ALJ found

Plaintiff’s treatment was conservative and consisted primarily of medication with minimal

side-effects, which the ALJ considered was persuasive evidence that Plaintiff was not totally

disabled. TR 25. The ALJ also found that the battery of tests performed were all negative

and/or normal, which was objective evidence that Plaintiff’s impairments were not as severe

as Plaintiff claimed. TR 22–23. The ALJ stated that the fact that Plaintiff continued “to

smoke [cigarettes] despite her numerous complaints diminished her credibility,” because it

“is well known that smoking is a contradiction for good health.” TR 23. The ALJ also noted

that Plaintiff suffered from chronic back pain since 1969, and yet the record reflects

Plaintiff’s ability to sustain substantial gainful activity despite this pain. TR 23 (“The fact

that the chronic pain did not prevent the claimant from working prior to the onset date

strongly suggests that it would not currently prevent work.”). The ALJ also pointed out that

Plaintiff’s alleged vision problems were undermined by her ability to drive herself to the

hearing. TR 24. While the ALJ stated that he recognized Plaintiff was suffering pain, the

wide range of Plaintiff’s daily activities was inconsistent with disability. TR 24 (“The

claimant is self-sufficient in her activities of daily living. She is able to manager her self-care

and household chores and living arrangements independently.”). The ALJ considered

Plaintiff’s anticipation of the receipt of disability benefits, employer-based benefits, and

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proceeds from the sale of her house to be economic disincentives to return to work. TR 25.

The ALJ concluded his analysis of the credibility of Plaintiff’s subjective complaints by

stating that “[t]he objective medical evidence, the lack of treatment and/or need for

significant pain medications, the claimant’s daily activities and other factors all fail to

support the claimant’s allegations of inability to work.” TR 25.

Contrary to Plaintiff’s briefs, the ALJ gave “little weight” to the opinions of the State

Agency Medical Consultants, because these non-examining, non-treating physicians did not

review Plaintiff’s recent medical records or hear Plaintiff’s testimony, which the ALJ stated

supported a reduction of Plaintiff’s RFC. TR 24.

Despite Plaintiff’s testimony concerning the severity of her impairments, the ALJ’s

interpretation is reasonable and supported by substantial evidence. It is not the Court’s role

to second guess the ALJ’s fact findings. See Rollings, 261 F.3d at 857. Consequently, the

Court rejects Plaintiff’s argument that the ALJ improperly discredited her subject complaints.

The ALJ gave clear and convincing reasons for discounting the severity and effect of her

impairments based on Plaintiff’s subjective complaints, and those reasons were supported

by substantial evidence.

D. Consideration of Treating Physician Opinions

“The ALJ is responsible for resolving conflicts in the medical record.” Carmickle v.

Soc. Sec. Admin., 533 F.3d 1155, 1164 (9th Cir. 2008). Generally, “more weight should be

given to the opinion of a treating source than to the opinion of doctors who do not treat the

claimant.” Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995) (citing Winans v. Bowen, 853

F.2d 643, 647 (9th Cir. 1987)). However, where an opinion is contradicted, the ALJ may

reject it for “specific and legitimate reasons that are supported by substantial evidence in the

record.” Carmickle, 533 F.3d at 1164 (quoting Lester, 81 F.3d at 830–31).

Plaintiff argues that the ALJ improperly ignored the opinions of Plaintiff’s treating

physicians concerning the severity of Plaintiff’s headaches. Specifically, Plaintiff contends

the ALJ’s decision failed to address the opinion of Dr. Toffol that Plaintiff should not return

to work during a two week period due to incapacitating headaches, TR 195, the opinion of

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 Plaintiff also cites the medical opinion prepared by Dr. Jennifer Auge, which states

that Plaintiff could not perform work in the foreseeable future, TR 391, as an improperly

ignored medical source opinion. (Doc. # 25 at p. 29.) However, the ALJ did review this

opinion and concluded that Dr. Auge’s opinion “is quite conclusory, providing very little

explanation of the evidence relied on in forming that opinion.” TR 24–25. The ALJ goes

on to state that this opinion “contrasts sharply with the other contemporaneous evidence of

record.” TR 25. On remand, the ALJ is instructed to set for the “other contemporaneous

evidence of record” he is referring to, because the Court, based on its review of the record,

does not find contemporaneous records to contrast sharply with Dr. Auge’s opinion.

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Dr. Michael Somers that Plaintiff “has disabling ophthalmic migraine headaches,” TR 237,

and the opinion of Dr. Gail Francis that Plaintiff did not respond to a nerve block and has

intractable headaches, TR 342–47.7

 While the ALJ does not have to accept a treating

physician’s opinion as true, the ALJ is required to provide specific and legitimate reasons for

rejecting a contradicted opinion. Based on the ALJ’s decision, it appears that the ALJ

ignored or summarily dismissed these opinions. The Court does not quarrel with the

Commissioner’s argument that the Social Security Act has a very specific standard for

determining disability, and that a doctor’s use of the word “disabled” or a finding of

disability by another agency does not carry significant weight. However, the opinions of

treating physicians do carry at least some weight, and the ALJ must set forth legitimate and

specific reasons for discounting these opinions.

A treating physician’s opinion can be discounted based on the results and findings of

an independent consultative examination. Batson, 359 F.3d at 1194–95. On remand, if the

ALJ finds it necessary to obtain a consultative examination, which was not previously

obtained, the ALJ can potentially and reasonably discount the opinions of Plaintiff’s treating

physicians. However, the ALJ is required to compare the records and reports prepared by

various treating and consulting physicians, before concluding that the evidence, as a whole,

supports a finding that Plaintiff had the ability to perform light work during the relevant time

period. If the ALJ finds an opinion to be contradicted by other parts of the record, then the

ALJ must set for the specific and legitimate reasons for rejecting the medical opinion.

Lester, 81 F.3d at 830–31; see 20 C.F.R. § 404.1527(d)(2) (“We [the ALJ] will always give

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good reasons in our notice of determination or decision for the weight we give your treating

source’s opinion.”). Accordingly, on remand, the ALJ is required to consider and weigh the

opinions of Plaintiff’s treating physicians.

E. ALJ’s Duty to Fully Develop the Record

“The ALJ in a social security case has an independent ‘duty to fully and fairly develop

the record and to assure that the claimant’s interests are considered.’” Tonapetyan v. Halter,

242 F.3d 1144, 1150 (9th Cir. 2001) (quoting Smolen, 80 F.3d at 1288). When a claimant

is not represented “the ALJ must be especially diligent,” id., and “scrupulously and

conscientiously probe into, inquire of, and explore all the relevant facts,” Cox v. Califano,

587 F.2d 988, 991 (9th Cir. 1978) (quoting Gold v. Sec’y of Health, Educ. & Welfare, 463

F.2d 38, 43 (2d Cir. 1972)). When “the heavy burden imposed by Cox” is not met, and the

claimant may have been prejudiced, “the interests of justice demand that the case be

remanded.” Vidal v. Harris, 637 F.2d 710, 714–15 (9th Cir. 1981).

In Celaya v. Halter, the Ninth Circuit outlined the ALJ’s heightened duty to fully

develop the record when the claimant is not represented by counsel. 332 F.3d 1177 (9th Cir.

2003). There, the ALJ found that the claimant was not disabled because she could perform

light work, including her past work as a presser for a dry cleaners, despite her impairments.

Id. at 1180. The Ninth Circuit required the ALJ to “probe into, inquire of, and explore for

all the relevant facts.” Id. at 1183 (citing Higbee v. Sullivan, 975 F.2d 558, 561 (9th Cir.

1992)). The Court of Appeals remanded the case for development of the record on the

claimant’s obesity. Id. at 1184.

Plaintiff argues that the ALJ failed to fully develop the record when the ALJ failed

to obtain a consultative examination. Plaintiff misreads the record. During the May 22, 2007

hearing, the ALJ stated that he “might have to send [Plaintiff] out for a consultative

examination in light of all this new evidence.” TR 395. The ALJ then continued the hearing

to August 28, 2007, TR 399, but did not obtain a consultative examination.

Based on the reasoning throughout this Order, the Court finds that the ALJ has not

met his burden of “assur[ing] that the claimant’s interests are considered.” Tonapetyan, 242

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F.3d at 1150. Specifically, the Court finds that the ALJ failed to fully develop the record

with regard to the consideration of Plaintiff’s migraine headaches under Listing 11.03,

Plaintiff’s functional limitations and restrictions in connection with determining Plaintiff’s

RFC, and the weight of her treating physician’s opinions. On remand, the ALJ also may find

it necessary to obtain a consultative examination.

VII. CONCLUSION

Because the Court finds that there are outstanding issues that must be resolved before

a proper disability determination can be made, and because the ALJ has not fully and fairly

developed the record in the manner described above, this matter must be remanded for a new

determination regarding Plaintiff’s entitlement to disability benefits.

Accordingly,

IT IS ORDERED that the decision of the ALJ is vacated and the case is remanded

for further proceedings.

IT IS FURTHER ORDERED that Plaintiff’s Motion fo Submission on Briefs Filed

is DENIED as moot.

DATED this 17th day of February, 2011.

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