Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_19-cv-00090/USCOURTS-azd-4_19-cv-00090-0/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 

Gerardo Romero Trinidad, 

Plaintiff, 

v. 

Andrew Saul, 

Defendant. 

No. CV-19-00090-TUC-LCK

ORDER 

 

 Plaintiff Gerardo Trinidad filed this action pursuant to 42 U.S.C. § 405(g) seeking 

judicial review of a final decision by the Commissioner of Social Security (Commissioner). 

(Doc. 1.) Before the Court are Plaintiff’s Opening Brief, Defendant’s Responsive Brief, 

and Plaintiff’s Reply. (Docs. 22, 25, 26.) The parties have consented to Magistrate Judge 

jurisdiction. (Doc. 15.) Based on the pleadings and the administrative record, the decision 

of the Commissioner is affirmed. 

PROCEDURAL AND FACTUAL HISTORY 

 Trinidad was born in November 1963 and was almost 50 years of age at the onset 

date of his alleged disability. (AR 341.) He had past relevant work experience as an air 

conditioning technician. (AR 388.) Trinidad filed an application for Disability Insurance 

Benefits (DIB) and Supplemental Security Income (SSI) in February 2013. (Administrative 

Record (AR) 341, 345.) That month, he underwent a total left shoulder replacement. (AR 

517.) He alleged disability from April 30, 2012 (AR 341), which he amended subsequently 

to October 1, 2013 (AR 57, 466, 487). Trinidad’s application was denied upon initial 

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review (AR 141-58) and on reconsideration (AR 159-80). A hearing was held on July 29, 

2015. (AR 51-111.) The ALJ then found Trinidad was not disabled. (AR 184-99.) The 

Appeals Council remanded the case for a supplemental hearing and directed the ALJ to 

assess whether Trinidad engaged in substantial gainful activity in 2014 and evaluate the 

expanded record. (AR 208-09.) A second hearing was held in front of a different ALJ on 

September 11, 2017. (AR 112-33.) Subsequently, the ALJ found that Trinidad was not 

disabled. (AR 29-38.) The Appeals Council denied Trinidad’s request for review. (AR 13.) 

The ALJ found that Trinidad had three severe impairments: osteoarthritis of the left 

shoulder status post total arthroplasty, carpal tunnel syndrome of the left upper extremity, 

and mild degenerative changes of the spine. (AR 27.) The ALJ determined Trinidad had 

the Residual Functional Capacity (RFC) to perform light work limited to frequent handling 

with the left hand; occasional reaching overhead on the left and climbing of ramps/stairs; 

and, no climbing of ladders/ropes/scaffolds. (AR 31.) The ALJ concluded at Step Five, 

based on the testimony of a vocational expert, that Trinidad could perform work available 

in the national economy such as usher and ticket taker. (AR 36.) 

STANDARD OF REVIEW 

 The Commissioner employs a five-step sequential process to evaluate SSI and DIB 

claims. 20 C.F.R. §§ 404.1520; 416.920; see also Heckler v. Campbell, 461 U.S. 458, 460-

462 (1983). To establish disability the claimant bears the burden of showing he (1) is not 

working; (2) has a severe physical or mental impairment; (3) the impairment meets or 

equals the requirements of a listed impairment; and (4) claimant’s RFC precludes him from 

performing his past work. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). At Step Five, the 

burden shifts to the Commissioner to show that the claimant has the RFC to perform other 

work that exists in substantial numbers in the national economy. Hoopai v. Astrue, 499 

F.3d 1071, 1074 (9th Cir. 2007). If the Commissioner conclusively finds the claimant 

“disabled” or “not disabled” at any point in the five-step process, he does not proceed to 

the next step. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). 

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 “The ALJ is responsible for determining credibility, resolving conflicts in medical 

testimony, and for resolving ambiguities.” Andrews v. Shalala, 53 F.3d 1035, 1039 (9th 

Cir. 1995) (citing Magallanes v. Bowen, 881 F.2d 747, 750 (9th Cir. 1989)). The findings 

of the Commissioner are meant to be conclusive if supported by substantial evidence. 42 

U.S.C. § 405(g). Substantial evidence is “more than a mere scintilla but less than a 

preponderance.” Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999) (quoting Matney v. 

Sullivan, 981 F.2d 1016, 1018 (9th Cir. 1992)). The court may overturn the decision to 

deny benefits only “when the ALJ’s findings are based on legal error or are not supported 

by substantial evidence in the record as a whole.” Aukland v. Massanari, 257 F.3d 1033, 

1035 (9th Cir. 2001). This is so because the ALJ “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, 981 F.2d at 1019 (quoting Richardson 

v. Perales, 402 U.S. 389, 400 (1971)); Batson v. Comm’r of Soc. Sec. Admin., 359 F.3d 

1190, 1198 (9th Cir. 2004). The Commissioner’s decision, however, “cannot be affirmed 

simply by isolating a specific quantum of supporting evidence.” Sousa v. Callahan, 143 

F.3d 1240, 1243 (9th Cir. 1998) (citing Hammock v. Bowen, 879 F.2d 498, 501 (9th Cir. 

1989)). Reviewing courts must consider the evidence that supports as well as detracts from 

the Commissioner’s conclusion. Day v. Weinberger, 522 F.2d 1154, 1156 (9th Cir. 1975). 

DISCUSSION 

 Trinidad argues the ALJ committed two errors: (1) he failed to provide clear and 

convincing reasons for rejecting Trinidad’s symptom testimony; and (2) he failed to 

properly weigh the opinion of treating physician Dr. Patricia Soliz. 

Trinidad’s Symptom Testimony 

 Trinidad argues the ALJ failed to provide clear and convincing reasons to reject his 

symptom testimony. In general, “questions of credibility and resolution of conflicts in the 

testimony are functions solely” for the ALJ. Parra v. Astrue, 481 F.3d 742, 750 (9th Cir. 

2007) (quoting Sample v. Schweiker, 694 F.2d 639, 642 (9th Cir. 1982)). However, 

“[w]hile an ALJ may certainly find testimony not credible and disregard it . . . [the court] 

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cannot affirm such a determination unless it is supported by specific findings and 

reasoning.” Robbins v. Soc. Sec. Admin., 466 F.3d 880, 884-85 (9th Cir. 2006); Bunnell v. 

Sullivan, 947 F.2d 341, 345-346 (9th Cir. 1995) (requiring specificity to ensure a reviewing 

court the ALJ did not arbitrarily reject a claimant’s subjective testimony); SSR 96-7p. “To 

determine whether a claimant’s testimony regarding subjective pain or symptoms is 

credible, an ALJ must engage in a two-step analysis.” Lingenfelter v. Astrue, 504 F.3d 

1028, 1035-36 (9th Cir. 2007). 

 Initially, “the ALJ must determine whether the claimant has presented objective 

medical evidence of an underlying impairment ‘which could reasonably be expected to 

produce the pain or other symptoms alleged.’” Id. at 1036 (quoting Bunnell, 947 F.2d at 

344). The ALJ found Trinidad had satisfied part one of the test by proving an impairment(s) 

that could produce the symptoms alleged. (AR 32.) Next, if “there is no affirmative 

evidence of malingering, the ALJ can reject the claimant’s testimony about the severity of 

her symptoms only by offering specific, clear and convincing reasons for doing so.” 

Tommasetti v. Astrue, 533 F.3d 1035, 1039 (9th Cir. 2008) (quoting Smolen v. Chater, 80 

F.3d 1273, 1281, 1283-84 (9th Cir. 1996)). Here, the ALJ did not make a finding of 

malingering. Therefore, to support his discounting of Trinidad’s assertions regarding the 

severity of his symptoms, the ALJ had to provide clear and convincing, specific reasons. 

See Garrison v. Colvin, 759 F.3d 995, 1014-15 (9th Cir. 2014); Vasquez v. Astrue, 572 

F.3d 586, 591 (9th Cir. 2008) (quoting Lingenfelter, 504 F.3d at 1036). 

 In April 2013 (two months after a left shoulder replacement), Trinidad completed a 

Function Report, in which he stated that he was unable to lift more than fifteen pounds with 

his left arm and could not rotate or fully extend that arm. (AR 405, 406.) He was able to 

drive his son to school, perform light household chores, care for his dog, and perform 

personal care with his right arm. (AR 406.) He went shopping two to four times a month, 

watched television, read books, attended sporting events for his son and grandchildren, and 

socialized with family and friends monthly. (AR 409.) He stated that he took oxycodone 

and Ibuprofen for his impairments. (AR 412.) 

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In June 2013, Trinidad reported that he had lost almost all mobility in his left arm, 

and that over-use of his right hand was causing pain and cramping. (AR 417.) He stated his 

pain was severe and would interrupt his sleep, and that he would lose his balance while 

walking or become dizzy if he moved quickly. (Id.) 

In an October 2013 Function Report, Trinidad reported a worsening of function in 

his left arm that precluded extending it past his shoulder or reaching to grab objects. (AR 

421.) He stated that if he used his left arm while standing, it triggered severe back pain. 

(Id.) Trinidad indicated he was not doing any household chores due to lack of strength in 

his left arm. (AR 423-24.) He stated that he watched television, attended church and 

sporting events, and occasionally went to the movies. (AR 425.) Trinidad listed 

substantially greater limitations at this time, including pain on squatting or bending, and 

lack of balance on standing. (AR 426.) He also noted that shoulder pain inhibited his ability 

to pay attention. (Id.) 

 At the 2015 hearing, Trinidad testified that he could no longer perform his past 

work, not even by compensating with his right hand, had developed anxiety and depression, 

and had been diagnosed with diabetes. (AR 63.) During the day, Trinidad stated that he 

helped monitor his grandkids (with his wife), watched television, and read magazines or 

mail. (AR 77-79.) He did not do yardwork but would assist his wife with dishes. (AR 79.) 

He reported driving up to four times a week to run errands. (AR 69.) Trinidad stated that 

he was diagnosed with depression in late 2013, and his primary care doctor prescribed 

medication. (AR 80.) He had become forgetful, anxious, and moody. (AR 82-83.) He also 

reported low back pain, restless legs, stiffness in his right shoulder, and numbness in his 

left fingers. (AR 88-90.) He described needing to shift around frequently or alternate with 

standing when sitting for more than fifteen minutes; he opined that he could stand for 

approximately an hour. (AR 91-92.) 

He stated that he was limited to lifting forty pounds with his right arm and ten 

pounds with his left, but also stated that he could not lift an eight-pound gallon of milk 

with his left arm. (AR 64, 65.) He tried not to use his left arm because he would suffer 

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afterwards. (AR 64.) He reported that two to four times per day, he experienced shoulder 

pain at an eight out of ten while taking ibuprofen. (AR 66, 70-71.) Trinidad stated that he 

could not extend his left shoulder forward, overhead, or laterally. (AR 67.) Trinidad noted 

that he was to schedule carpal tunnel surgery soon for his left arm. (AR 68, 73-74.) He 

identified left wrist pain at the level of a ten or eleven, and he was wearing a brace on it 

most of the time. (AR 75-76.) 

At the 2017 hearing, Trinidad testified that he stopped working because he could 

not lift with his left hand. (AR 118.) He spent his days driving his wife to and from work 

and doing small jobs for his dad. (AR 124.) He indicated he was having surgery on both 

eyes due to limited peripheral vision and, also, would have carpal tunnel surgery in the next 

year or two (due to episodic finger numbness and a ganglion cyst). (AR 125.) Trinidad 

testified that his inability to work had become very depressing and it would overwhelm 

him, but he had not sought any treatment. (AR 118, 125, 130.) 

The ALJ discounted Trinidad’s symptom testimony because medical records 

indicated he continued to work, he was receiving only conservative treatment for his 

shoulder, he was taking no medication for his mental impairment, and his testimony was 

inconsistent with his activities of daily living and the objective medical evidence. (AR 32.) 

First, the ALJ noted that Trinidad was continuing to work despite testifying that he 

had been unable to work since his alleged onset date of October 2013. Trinidad’s earnings 

records reveal that he earned approximately $20,000 in 2013 and $16,000 in 2014. (AR 

368.) In the disability report submitted with his application, Trinidad stated that he stopped 

working in November 2012. (AR 387.) He testified, in 2017, that he stopped working in 

October 2012, prior to his surgery (AR 118, 122), but, at the 2015 hearing, he had testified 

that he stopped working in October 2013 (AR 61). In 2017, he explained that he was selfemployed from 2011 until October 2012 but, after that date, he continued to receive 

payments for prior jobs and commissions from giving work to a friend. (AR 120-22.) 

The ALJ found Trinidad’s testimony about his 2013 and 2014 earnings to be “vague 

and evasive.” (AR 27.) He thought it unlikely that small jobs or prior commissions would 

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add up to $16,000 in 2014, or that Trinidad would receive commission payments a long 

time after work was completed. (Id.) Based on medical records that stated Trinidad was 

working in 2017, the ALJ believed he likely was working. (Id.) However, he concluded 

there was not reliable evidence of substantial gainful activity (SGA). (Id.) 

In reviewing the medical records, the ALJ noted that, in November 2014, Trinidad 

cut his finger with a power saw working in his “plumbing business.” (AR 641, 661.) In 

June 2017, Trinidad was discharged from physical therapy because he was too busy with 

his HVAC business to attend regularly. (AR 876.) The ALJ also relied upon medical 

records from 2017, which documented that Trinidad’s shoulder was fatigued from working 

40 or more hours per week, and that he was doing full-time work in his own HVAC 

business. (AR 869, 875.) 

Trinidad argues that the ALJ offered no reason not to believe his testimony that he 

had not been working. To the contrary, the ALJ referenced numerous medical records that 

indicated Trinidad was working. And, there are several additional records documenting 

Trinidad’s work. (AR 781 (April 2015); AR 790 (September 2015); AR 865 (February 

2017); AR 877 (August 2017).) Trinidad further argues that the ALJ could not discount his 

symptom testimony based on engaging in work because the ALJ concluded Trinidad had 

not engaged in SGA since October 2013. A claimant could remain below the threshold for 

SGA and still earn more than $12,000 per year in 2013, and up to $14,000 in 2017. See

https://www.ssa.gov/oact/cola/sga.html. The ALJ’s Step One finding established only a 

lack of earnings above the SGA level for work after October 2013. That finding does not 

undermine the ALJ’s determination that Trinidad’s testimony – that he had not worked 

since October 2012 and was unable to perform any work – was inconsistent with the 

numerous records documenting his work activity in subsequent years. Turner v. Comm’r 

of Soc. Sec., 613 F.3d 1217, 1224 n.3 (9th Cir. 2010) (holding that ALJ may rely upon 

“ordinary techniques of credibility evaluation” such as inconsistencies with the claimant’s 

testimony or “testimony by the claimant that appears less than candid”) (quoting Smolen, 

80 F.3d at 1284. The ALJ’s reliance on Trinidad’s continued work was a clear and 

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convincing reason, supported by substantial evidence, to discount his testimony that his 

symptoms prevented his performance of work. 

Second, the ALJ cited the fact that Trinidad received only conservative treatment 

for his shoulder.1

 If a claimant obtains only conservative treatment and does not seek more 

aggressive treatment, that can provide a clear and convincing reason to discount his 

symptom testimony. Tommasetti, 533 F.3d at 1039-40; SSR 16-3p (“if the frequency or 

extent of the treatment sought by an individual is not comparable with the degree of the 

individual’s subjective complaints, or if the individual fails to follow prescribed treatment 

that might improve symptoms, we may find the alleged intensity and persistence of an 

individual’s symptoms are inconsistent with the overall evidence of record.”). 

Trinidad had his left shoulder replaced in February 2013 and began physical therapy 

that month. (AR 517, 567.) The record documents seven appointments running into April 

2013. (AR 574, 571, 577, 579, 581, 584.) Two days after the last physical therapy record, 

his surgeon, Dr. Sheppard, noted that Trinidad had excellent pain relief but continued 

stiffness, and he prescribed an escalation in therapy. (AR 591.) However, there are no 

further physical therapy records until 2017. In May 2013, a primary care doctor noted that 

Trinidad was “performing usual activities.” (AR 598.) In April 2014, Dr. Sheppard again 

documented satisfactory pain relief but referred Trinidad for formal strength therapy. (AR 

635.) Again, there is no documentation of therapy at that time. At his January 2015 

appointment with Dr. Sheppard, Trinidad reported excellent pain relief and significant 

function improvement. (AR 662.) In April 2016, Trinidad reported only intermittent 

performance of exercises, and Dr. Sheppard noted he had obtained no recent shoulder 

treatment. (AR 794.) The surgeon found the shoulder stable but noted Trinidad’s report of 

functional diminishment and directed him to resume at-home exercises. (AR 794-95.) In 

January 2017, an orthopedist discussed Trinidad’s symptoms with him and offered the 

possibility of a second surgery. (AR 803.) At Trinidad’s request, the doctor referred him to 

1

 The record summary in Plaintiff’s brief included, from Trinidad’s testimony, only information about his left-arm impairment and inability to lift with that arm. (Doc. 22 at 6-

7.) Thus, the Court believes the ALJ’s discounting of Trinidad’s symptom testimony regarding his left arm is central to the Court’s review of this claim. 

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physical therapy, noting that Trinidad did not believe his symptoms warranted surgery. 

(Id.) After attending six sessions, the physical therapist discharged him because his work 

schedule precluded him from attending regularly. (AR 876.) The therapist noted that 

Trinidad’s strength was improved, and he had met his goals other than getting his pain 

level consistently below a two out of ten. (AR 875-76.) 

Trinidad argues that the ALJ did not demonstrate that more aggressive treatment 

was available or that Trinidad failed to participate in available treatment. Actually, the ALJ 

noted that when a doctor offered the possibility of further shoulder surgery, Trinidad did 

not believe his symptoms warranted that level of treatment. (AR 33 (citing AR 803).) When 

Trinidad chose physical therapy rather than exploring surgery, the ALJ noted that Trinidad 

was discharged after a few sessions because he could not make time to attend. (Id. (citing 

AR 876).) Further, the record indicates that Dr. Sheppard recommended an escalation of 

physical therapy in 2013 (AR 591) and strength training in 2014 (AR 635), but no records 

indicate Trinidad engaged in that therapy. Also, in 2016, Trinidad reported diminished 

functioning and acknowledged he was intermittent with performing his home strengthening 

and stretching exercises. (AR 794.) The record shows that physical therapy in 2013 and 

2017 was beneficial to decreasing pain and improving Trinidad’s stiffness and range of 

motion. (AR 577, 581, 871, 873, 875-76.) 

Trinidad provides no reason he did not actively engage in physical therapy or home 

exercise or consider surgery if his shoulder impairment precluded all work. See Johnson v. 

Comm’r of Soc. Sec. Admin., No. CV-18-01230-PHX-DGC, 2019 WL 429887, at *7 (D. 

Ariz. Feb. 4, 2019) (holding that an ALJ “must consider ‘any explanations that the 

individual may provide, or other information in the case record, that may explain’ the 

claimant’s failure to follow a treatment plan.”) (quoting Orn v. Astrue, 495 F.3d 625, 638 

(9th Cir. 2007)). Nor did Trinidad point to any record evidence that explained his failure 

to seek or pursue more aggressive treatment, which would have triggered the ALJ to 

consider and address the evidence. See Carmickle v. Comm., Soc. Sec. Admin., 533 F.3d 

1155, 1162 (9th Cir. 2008); SSR 16-3p; Sperry v. Comm’r of Soc. Sec. Admin., No. CVCase 4:19-cv-00090-LCK Document 27 Filed 03/30/20 Page 9 of 16
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18-01484-PHX-JAT, 2019 WL 1513203, at *7 (D. Ariz. Apr. 8, 2019) (“SSR 16-3p does 

not explicitly require the ALJ to ask the claimant at the hearing why he or she has failed to 

continue treatment. Rather, an ALJ may permissibly discount a claimant’s testimony if a 

review of the record suggests that “[a]n individual’s symptoms [were] not [ ] severe enough 

to prompt him or her to seek treatment[.]”).The Court found no record evidence of an 

explanation for Trinidad’s failure to pursue treatment for his shoulder, such as a financial 

limitation or absence of effective treatment. See Orn, 495 F.3d at 638 (finding if claimant 

has an inability to pay or treatment is unlikely to provide relief then ALJ should not 

discount symptom testimony for lack of treatment) (citing Fair v. Bowen, 885 F.2d 597, 

603 (9th Cir. 1989)). Trinidad’s failure to pursue more substantial treatment for his 

shoulder was a clear and convincing reason supported by substantial evidence to discount 

his symptom testimony that his shoulder impairment precluded all work. 

Third, the ALJ relied on the fact that Trinidad was not taking any medication for his 

depression and anxiety. (AR 29, 35.) Trinidad’s primary care doctor prescribed medication 

for depression beginning in April 2014. (AR 609-10.) The dose was increased in July 2016. 

(AR 799.) In October of that year, Trinidad reported stopping the medication and feeling 

the same, not depressed; his affect and mood were normal at the appointment. (AR 800-

02.) As he acknowledged at the 2017 hearing, Trinidad did not seek treatment for his 

mental health. In evaluating his symptom testimony, the ALJ properly considered that 

Trinidad never sought mental health treatment, beyond his primary care physician, and 

stopped taking his medication without explanation. See Molina v. Astrue, 674 F.3d 1104, 

1112 (9th Cir. 2012) (noting that an ALJ may discount symptom testimony based on 

“unexplained or inadequately explained failure to seek treatment or to follow a prescribed 

course of treatment”) (quoting Tommasetti, 533 F.3d at 1039); SSR 16-3p (allowing an 

ALJ to consider failure to seek or follow treatment when there is no evidence to explain 

the claimant’s actions). 

 Fourth, the ALJ also relied upon inconsistencies between Trinidad’s testimony and 

the objective medical evidence. The primary basis Trinidad consistently alleged for his 

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inability to work was his left shoulder impairment. See supra note 1. The ALJ documented 

a left total shoulder arthroplasty in February 2013. (AR 517.) In all subsequent exams, his 

shoulder was stable with no hardware complications. (AR 524, 587, 590, 664, 669, 795, 

817.) From surgery into 2016, Trinidad repeatedly noted significant pain relief. (AR 524, 

579, 581, 584, 591, 635, 662, 794.) In January 2017, Trinidad reported his pain had been 

increasing. (AR 803.) It subsequently improved with physical therapy, although full relief 

was not achieved prior to the treatment ending due to Trinidad’s inability to attend. (AR 

868, 871, 873, 876.) Several records documented improved range of motion and function. 

(AR 508, 584, 635, 662, 876.) 

With respect to carpal tunnel syndrome, the ALJ cited testing showing it was mild, 

or at most moderate. (AR 33 (citing AR 646, 796).) Although Trinidad testified that he 

would be having surgery for this condition, as the ALJ noted, the record does not document 

surgery as a recommended treatment at any time. With respect to Trinidad’s lower back 

pain, the ALJ cited evidence showing normal cervical and thoracic spine with no 

tenderness (December 2011); degenerative disc disease without high-grade central stenosis 

or cord compression, and no cervical radiculopathy (March 2012); and mild degenerative 

changes of thoracic spine seen on x-ray performed to evaluate coughing (April 2014). (AR 

33 (citing AR 502-03, 541, 675).) The Court identified only two medical records related to 

Trinidad’s lower back. (AR 718 (pain on palpation), AR 799 (increased low back pain in 

the morning).) With respect to his vision, the ALJ found it would not pose more than a 

minimal limitation for greater than twelve months. (AR 28.) The records reveal blurry 

vision “at times” in late November 2016 (AR 800); and, subsequent treatment for droopy 

eyelids culminating in a November 2017 corrective surgery. (AR 830, 843, 848, 851.) 

The Court finds that, overall, there is substantial evidence to support the ALJ’s 

conclusion that the objective medical evidence was inconsistent with Trinidad’s symptom 

testimony. Although there are records documenting functional limitations, “the key 

question is not whether there is substantial evidence that could support a finding of 

disability, but whether there is substantial evidence to support the Commissioner’s actual 

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finding that claimant is not disabled.” Jamerson v. Chater, 112 F.3d 1064, 1067 (9th Cir. 

1997). There is substantial record evidence to support the ALJ’s finding that the objective 

medical evidence did not support Trinidad’s testimony of disabling symptoms. See 

Valentine v. Comm’r Social Sec. Admin., 574 F.3d 685, 690 (9th Cir. 2009) (defining 

substantial evidence as “such relevant evidence as a reasonable mind might accept as 

adequate to support a conclusion.”); Burch v. Barnhart, 400 F.3d 676, 680–81 (9th Cir. 

2005) (quoting Magallanes, 881 F.2d at 750) (“[w]e must uphold the ALJ’s decision where 

the evidence is susceptible to more than one rational interpretation.”); Batson, 359 F.3d at 

1196 (“When evidence reasonably supports either confirming or reversing the ALJ’s 

decision, we may not substitute our judgment for that of the ALJ.”). Further, Plaintiff did 

not contest the ALJ’s conclusion regarding objective findings. (See Doc. 22 at 15-19.) 

Trinidad is correct that the Court cannot reject symptom testimony solely on the basis of 

objective medical evidence. Lingenfelter, 504 F.3d at 1036 (quoting Smolen, 80 F.3d at 

1282). However, the Court may consider inconsistencies with the medical evidence as one 

basis to discount a claimant’s symptom testimony. Id. at 1040. 

Finally, Trinidad argues that the ALJ’s findings regarding his symptom testimony 

were inadequate because he relied on boilerplate language that the testimony was not 

“entirely consistent” with the record evidence; and, he did not link the medical evidence to 

specific symptom testimony. The ALJ’s decision is not a model of clarity and he did 

employ meaningless boilerplate. However, he also laid out a discussion of the medical 

evidence as to Trinidad’s non-severe impairments (AR 28-29), as well as severe 

impairments of left shoulder osteoarthritis, carpal tunnel, and disc disease (AR 32-33). 

And, as discussed above, the ALJ cited specific records to support his discounting of 

Trinidad’s testimony based on evidence that he was working and sought and obtained only 

episodic conservative treatment for his shoulder. Therefore, the errors cited by Trinidad 

are, at most, harmless. See Petty v. Colvin, No. CV-12-02289-PHX-BSB, 2014 WL 

1116992, at *8–9 (D. Ariz. Mar. 17, 2014). 

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The Court identified four valid grounds cited by the ALJ to find Trinidad’s symptom 

testimony not fully credible. The Court finds they are supported by substantial evidence 

and satisfy the clear and convincing standard. 

Medical Opinion of Dr. Patricia Soliz 

Trinidad argues the ALJ erred in giving very little weight to treating physician Dr. 

Soliz, but giving some weight to examining physician Dr. Rothbaum, and non-examining 

physicians Drs. Holly and LMW. In July 2015, Dr. Soliz opined that symptoms would 

constantly interfere with Trinidad’s concentration, he could sit and stand for only two hours 

each in a work day with shifting positions at will, needed two 30-minute breaks per hour, 

could only occasionally lift ten pounds, could grasp, manipulate, or reach only twenty 

percent of the time with his left arm, and would be absent from work for three days per 

month. (AR 718-22.) 

The opinion of a treating physician is generally afforded more weight than a nonexamining or reviewing physician’s opinion. Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 

1995), as amended (Apr. 9, 1996). The opinion of Dr. Soliz was contradicted by that of 

examining physician Dr. Rothbaum, who found Trinidad could perform medium-exertion 

work with some limitations related to his left arm (AR 739-43), and reviewing physicians 

Drs. Holly and LMW, who found Trinidad could perform light-exertion work limited to 

occasional overhead reaching on the left. (AR 146-48, 166-68.) When there are 

contradictory medical opinions, to reject a treating physician’s opinion, the ALJ must 

provide “specific and legitimate reasons that are supported by substantial evidence.” 

Lester, 81 F.3d at 830-31; Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th Cir. 2005). 

The ALJ stated that he gave little weight to Dr. Soliz’s opinion because the day she 

completed the form was the only day she treated him, she acknowledged that her opinion 

as to the expected longevity of Trinidad’s functional restrictions was based on his report, 

she stated in her exam records that she completed the paperwork based on Trinidad’s 

subjective report to each question, and she spent her exam time on completing disability 

paperwork. (AR 34.) 

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First, Trinidad argues that Dr. Soliz’s opinion was not limited to one visit because 

she reviewed his history “with another treating physician” and her opinion was based on 

“a holistic view of Trinidad’s condition.” (Doc. 22 at 11.) Although Trinidad had a multiyear history of treatment within the same medical system (Banner), neither Dr. Soliz’s 

opinion nor her appointment notes indicate she reviewed those records. In her exam notes, 

Dr. Soliz acknowledged reviewing only Dr. Ricker’s records, but she noted that Dr. Ricker, 

too, had only seen Trinidad one time. (AR 723.) Dr. Ricker saw Trinidad on November 5, 

2014 (AR 636), and Dr. Soliz used that as the date on which Trinidad’s limitations began 

(AR 718, 722). This fact further supports the Court’s conclusion that Dr. Soliz reviewed 

only that singular record. Although Dr. Soliz’s notation that she reviewed Trinidad with 

another doctor is not without ambiguity, it does not appear she actually discussed 

Trinidad’s impairments or limitations with another physician. She stated that the review 

she conducted occurred on November 5, 2014 (Trinidad’s appointment date with Dr. 

Ricker). If she had consulted with Dr. Ricker personally that would have occurred on July 

22, 2015, because she received and completed the paperwork that day. (AR 723-24 (noting 

Trinidad needed paperwork urgently and it was completed during appointment).) 

The November 5, 2014 examination notes upon which Dr. Soliz relied were from 

an appointment with Dr. Ricker to discuss ENT concerns and erectile dysfunction. (AR 

635.) The physical exam was normal, with the exception of the ENT findings, which are 

not at issue in Trinidad’s disability claim. (AR 636-37.) At that time, Trinidad did not raise 

any concerns about his shoulder, spine, carpal tunnel, depression, vision, or pain in any 

location other than his throat. (AR 635.) And, Dr. Ricker did not examine him relative to 

those issues nor document any impairments or treatment for those issues. (AR 635-37.) 

Thus, it appears that Dr. Soliz’s opinion was not based on a longitudinal history but on her 

single visit and Trinidad’s input. The Holohan case upon which Trinidad relies is 

inapposite. In that case, the doctor that offered a functional opinion noted she had reviewed 

the claimant’s “file” from her prior doctor of two years, and the court agreed that the prior 

doctor’s records supported the medical opinion offered. Holohan v. Massanari, 246 F.3d 

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1195, 1207 & n.10 (9th Cir. 2001). Here, Dr. Soliz did not review a lengthy medical file, 

and the singular medical record reviewed did not document limitations at the level included 

in Dr. Soliz’s opinion. 

Further, the ALJ noted that Dr. Soliz performed a short examination, which was 

normal other than Trinidad’s shoulder abduction being limited to 160 degrees. (AR 723.) 

Dr. Soliz offered no treatment for any medical issues because the entire appointment was 

spent completing the disability paperwork. (Id.) The fact that Dr. Soliz did not review any 

records of relevance, her exam results were normal, she had no history of treating Trinidad, 

and she provided no medical treatment that day are specific, legitimate reasons to discount 

Dr. Soliz’s opinion. See Lester, 81 F.3d at 833 (noting that the reason treating physician’s 

opinions are of particular weight is because they have a continuing relationship with their 

patients and are uniquely positioned to synthesize input from other examining professionals 

to evaluate the patient’s limitations and treatment); Magallanes, 881 F.2d at 751 

(upholding an ALJ’s rejection of a treating physician’s opinion because only minimal 

clinical findings supported it) (quoting Young v. Heckler, 803 F.2d 963, 968 (9th Cir. 

1986)).

Second, the ALJ discounted Dr. Soliz’s opinion because it was based on Trinidad’s 

subjective input. In her medical opinion, Dr. Soliz did not state as to each question that it 

was based on Trinidad’s subjective reports. (AR 718-22.) However, she had only seen him 

one time and her exam was abbreviated; therefore, her highly restrictive opinion must have 

been based on Trinidad’s reporting. The two objective findings she sighted were “pain on 

palpation to lower back,” and “limited range of motion of left shoulder.” (AR 718.) Her 

exam notes do not document a finding of back tenderness; limited shoulder abduction was 

noted, although 160 is close to full abduction of 180 degrees and considered within normal 

limits. (AR 723.) Regardless, in her examination record, she explicitly stated “form was 

filled out based on the patient’s subjective report to each question.” (AR 723.) Therefore, 

it was legitimate for the ALJ to find that Trinidad’s input was the basis for the doctor’s 

opinion. In light of the ALJ’s legitimate discounting of Trinidad’s symptom testimony, it 

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was a specific, legitimate reason to reject Dr. Soliz’s opinion because it was premised on 

Trinidad’s characterization of his symptoms. See Tonapetyan v. Halter, 242 F.3d 1144, 

1149 (9th Cir. 2001) (citing Fair, 885 F.2d at 605). 

The ALJ’s discounting of Dr. Soliz’s opinion was supported by specific, legitimate 

reasons supported by substantial record evidence. 

CONCLUSION 

A federal court may affirm, modify, reverse, or remand a social security case. 42 

U.S.C. § 405(g). The Court concludes the ALJ did not err as to the claims raised by 

Plaintiff. Therefore, Plaintiff is not entitled to relief and the appeal is denied. 

Accordingly, IT IS ORDERED that Plaintiff’s case is DISMISSED and the Clerk 

of Court shall enter judgment. 

Dated this 30th day of March, 2020. 

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