Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_06-cv-01496/USCOURTS-azd-2_06-cv-01496-1/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:205 Denial Social Security Benefits

---

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

1

Under Rule 25 (d)(1) of the Federal Rules of Civil Procedure, since Michael J. Astrue

became the Commissioner of Social Security on February 12, 2007 he is properly substituted

for Commissioner Jo Anne B. Barnhart as the defendant. 

2

The decision of the ALJ cites the alleged onset date as May 1, 2002 rather than the

May 1, 2003 date alleged by Plaintiff (AR at 31, 64). It is unclear if this distinction is a

WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Sonja L. Lewis, 

Plaintiff, 

vs.

Michael J. Astrue, Commissioner, Social

Security Administration,

Defendant. _________________________________

)

)

)

)

)

)

)

)

)

)

)

)

CIV-06-1496-PHX-SMM

MEMORANDUM OF DECISION 

AND ORDER

Pending before the Court are Plaintiff Sonja Lewis' Motion for Summary Judgment

(Doc. 11) and Defendant Michael J. Astrue1

, Commissioner of the Social Security

Administration's, Cross-Motion for Summary Judgment (Doc. 15). After consideration of the

arguments advanced by the parties, the Court finds the following.

BACKGROUND

Plaintiff filed an application for disability insurance benefits with the Social Security

Administration (the "SSA") on July 3, 2003, alleging that her disability commenced on May

1, 20032

 due to a back condition. (Administrative Record ("AR") at 64). Plaintiff's application

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 1 of 14
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

mistake. 

3

Claims of disability are evaluated under a five-step procedure under 20 C.F.R.

§404.1520. This case was resolved at step four where the Secretary must determine whether

the Plaintiff retains sufficient residual capacity to perform her past work. The five-step

process is provided in the ALJ's decision. (AR at 32.)

4

"Residual functional capacity" is defined as the maximum individual can do while

considering the effects of physical and/or mental limitations that affect the ability to perform

work-related tasks. 20 C.F.R. §404.1545. In making this determination, the Plaintiff's

symptoms, objective medical evidence, and medical opinions are considered. This

determination also takes into account anything provided under 20 C.F.R. §404.1527 and 20

C.F.R. §404.1529 that is applicable to the determination. 

5

Although the Appeals Council "declined to review" the ALJ's decision, it reached its

decision after considering the case on the merits; examining the entire record, including the

additional material; and concluding that the ALJ's decision was proper. The Appeals Council

cited that the additional material was repetitive and failed to "provide a basis for changing

the hearing decision." (AR at 6.)

- 2 -

was initially denied on October 1, 2003, at which time she moved for reconsideration. (AR

at 41- 44.) Thereafter, the Agency affirmed its denial. (AR at 47- 49.) Subsequently, Plaintiff

requested a hearing before an Administrative Law Judge (the "ALJ"), which was held on

June 20, 2005. (AR at 269.) On July 25, 2005, the ALJ, Michael J. Cianci, Jr., ruled that

Plaintiff was not disabled under the law, and therefore not entitled to receive disability

insurance benefits3

. (AR at 37.) In so finding, the ALJ determined that although Plaintiff's

"back disorder, high blood pressure, [and] mild obesity are considered severe, based on the

requirements in Regulations 20 CFR § 404.1520(c), the [P]laintiff [retains] the residual

functional capacity4

 (RFC) to perform light work". (AR at 33.) The ALJ also found that

Plaintiff was not precluded from performing her past relevant work as a health coordinator,

phlebotomist, and medical secretary. (AR at 36.) On July 25, 2005, Plaintiff requested

agency review of the ALJ's decision. (AR at 5.) On April 6, 2006, the Appeals Council

denied Plaintiff's request for review of the ALJ's determination, rendering the ALJ’s decision

the Commissioner's final determination5

. (AR at 5.) Plaintiff now seeks judicial review of the

ALJ's determination pursuant to 42 U.S.C. § 405 (g). 

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 2 of 14
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

6

20 C.F.R. §404.1572 defines substantial work activity as work that involves doing

significant physical or mental activities. Work can be substantial even if done on a part time

basis or if performed for less money or less work responsibility than that of previous

employment. Gainful work activity is the kind of work usually done for pay or profit,

whether or not a profit is realized. (AR at 32.)

- 3 -

Background Regarding ALJ's Determination

Plaintiff is a fifty-seven year old individual with a high school education. Plaintiff's

past work experience includes employment as a health coordinator, phlebotomist, and

medical secretary. Under 20 CFR § 404.1520, the ALJ determined that Plaintiff's earnings

from her medical secretary work in mid 2003 did not demonstrate the performance of

substantial gainful activity6

. The ALJ also found that the medical evidence of Plaintiff's

impairments were severe within the meaning of the regulations, but not severe enough to

meet or medically equal, singly or in combination, one of the impairments listed in Appendix

1, Subpart P, Regulations No. 4. 

In determining Plaintiff's RFC, the ALJ considered the following evidence: Plaintiff

was treated for back pain from May to June of 2003, with the indication of improvement in

June. (AR at 33.) In July of 2003, Raul Romero, M.D. concluded that Plaintiff could lift

and/or carry less than ten pounds, stand and/or walk less than two hours in a workday, and

could sit for only twenty minutes in an eight hour day. This assessment was for a period from

July 27, 2003 to January 27, 2004. Dr. Romero indicated that he had not seen Plaintiff since

June of 2003. 

In September of 2003, Plaintiff was examined by Malcolm McPhee, M.D. The results

of the examination found a normal gait and the ability to tandem walk. Dr. McPhee

concluded that Plaintiff could lift fifty pounds occasionally, twenty-five pounds frequently,

sit for six hours in an eight hour work day, and stand or walk six hours each. He further

opined that Plaintiff could occasionally climb, balance, stoop, kneel, crouch or crawl, and

was unlimited in use of her upper extremities. A radiological exam of the lumbosacral spine

was normal. 

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 3 of 14
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

- 4 -

In September 2003, a Disability Determination Services' (DDS) RFC evaluation

indicated that Plaintiff had low back pain, however, Plaintiff maintained the ability to lift

and/or carry fifty pounds. The evaluation also indicated that Plaintiff could stand and/or walk

for six hours and sit for six hours, but that she had occasional postural limitations. 

In December of 2003, another DDS assessment had similar results, but indicated no

postural limitations. In July 2003, Plaintiff was treated by Vincent Salazar-Calderon, M.D.

for intermittent low back pain. There was no focal weakness, numbness, or tingling in any

extremity. There was normal range of motion of the neck and a normal sensory examination.

Her gait was normal, she could tiptoe, tandem walk, squat, and hop on either leg. Dr.

Salazar-Calderon saw Plaintiff again in September 2003, and October 2003. Plaintiff then

had physical therapy, and an October MRI of the lumbar spine was normal. Dr.

Salazar-Calderon saw Plaintiff again in January 2004 when Plaintiff requested epidural

injections because of reported chronic intermittent pain. In March 2004, Plaintiff was given

medication, and in May 2004, Plaintiff said she could not stand or sit for long periods of

time, claiming the pain radiated down her thigh. Plaintiff's physical examination was

unchanged. 

Notes on rehabilitation at NovaCare Rehabilitation from September 2003 to December

2003 were for low back pain and degenerative disc disease. In October 2003, Plaintiff's

sensation was considered to be intact, she was obese, but her prognosis was fair to good.

Plaintiff did not express any significant increase in pain, and in December of 2003, Plaintiff

was discharged from NovaCare Rehabilitation after seven visits and three cancellations.

In May 2004, Plaintiff saw Pattabi Kalyanam, M.D. Plaintiff reported low back pain,

and on a scale of one to ten, Plaintiff reported her pain at a nine. An MRI of the lumbar spine

was again normal. Dr. Kalyanam advised Plaintiff to lose weight and provided Caudal

epidural injections in June and July of 2004. The RFC evaluation provided by Dr. Kalyanam

revealed that Plaintiff could lift and carry less than ten pounds in a workday and stand and/or

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 4 of 14
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

7

The ALJ mischaracterizes the report from Dr. Kalyanam by saying that the Plaintiff

can stand and/or walk two hours in an eight hour workday. In actuality, the report, in the

form of a checked box, actually indicates that Plaintiff can stand and/or walk less than two

hours in an eight-hour workday. (AR at 237). 

- 5 -

walk two hours7

, with no limit on sitting other than the requirement to alternate between

sitting and standing with occasional kneeling. From the foregoing evidence, the ALJ found

that Plaintiff retains the RFC to lift and/or carry ten pounds frequently and twenty pounds

occasionally, to sit for six hours in an eight hour workday, and to stand and/or walk eight

hours each. Plaintiff was unable to climb ladders, ropes or scaffolds; however, she was able

to occasionally climb stairs/ramps, and occasionally bend, crouch, crawl, and kneel. 

STANDARD OF REVIEW 

In deciding a Social Security appeal, the decision of the Commissioner to deny

disability benefits, must be affirmed if it is supported by substantial evidence and if the

Commissioner applied the correct legal standards. See Batson v. Commissioner of Soc. Sec.

Admin., 359 F.3d 1190, 1193 (9th Cir. 2004); Benton v. Barnhart, 331 F.3d 1030, 1035 (9th

Cir. 2003). When reviewing factual determinations by the Commissioner, acting through the

ALJ, this Court affirms if substantial evidence supports the determination. See Celaya v.

Halter, 332 F.3d 1177, 1180 (9th Cir. 2003); Saelee v. Chater, 94 F.3d 520, 521 (9th Cir.

1996). Substantial evidence is more than a mere scintilla, but less than a preponderance. See

Howard ex rel. Wolff v. Barnhart, 341 F.3d 1006, 1011 (9th Cir. 2003); Mayes v. Massanari,

276 F.3d 453, 459 (9th Cir. 2001). Substantial evidence is relevant evidence which a

reasonable person might accept as adequate to support a conclusion when considering the

entire record. Howard, 341 F.3d at 1011; Morgan v. Commissioner of Soc. Sec. Admin., 169

F.3d 595, 599 (9th Cir. 1999). If the evidence can reasonably support either affirming or

reversing the Commissioner's conclusion, the Court may not substitute its judgment for that

of the Commissioner. See Batson, 359 F.3d at 1193; McCartey v. Massanari, 298 F.3d at

1072, 1075 (9th Cir. 2002). The ALJ is responsible for determining credibility, resolving

conflicts in medical testimony, and for resolving ambiguities. See Benton, 331 F.3d at 1040;

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 5 of 14
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

- 6 -

Edlund v. Massanari, 253 F.3d 1152, 1156 (9th Cir. 2001). The ALJ's determinations of law

are reviewed de novo, although deference is owed to a reasonable construction of the

applicable statutes. See Edlund, 253 F.3d at 1156; McNatt v. Apfel, 201 F.3d 1084, 1087 (9th

Cir. 2000). Where the evidence is susceptible to more than one rational interpretation, it is

the ALJ's conclusion that must be upheld. Morgan, 169 F.3d at 599.

DISCUSSION

Plaintiff raises three arguments pertaining to why the ALJ wrongly denied disability

benefits to Plaintiff. First, she contends that the ALJ erred in failing to base the decision on

substantial record evidence, claiming that relevant evidence was ignored and/or not

developed. Next, Plaintiff argues that the ALJ erred by failing to properly and fully evaluate

Plaintiff's credibility. Finally, Plaintiff asserts that the ALJ erred in presenting an incomplete

hypothetical to the vocational expert (VE). 

I. Plaintiff's Credibility

There is substantial evidence to support the ALJ's finding that Plaintiff's allegations

regarding her limitations are not totally credible. When assessing the credibility of a plaintiff,

if the ALJ finds the testimony pertaining to the severity of pain and impairments to be

unreliable, the ALJ must make a credibility determination with findings sufficiently specific

to permit the court to conclude that the ALJ did not arbitrarily discredit claimant's testimony.

Social 42 U.S.C.A. § 423(d)(1)(A). Bunnell v. Sullivan, 947 F.2d 341, 345-46 (9th Cir.1991).

The ALJ may consider inconsistencies either in claimant's testimony or between her

testimony and her conduct, her daily activities, her work record, testimony from physicians

and third parties concerning the nature, severity, and effect of the symptoms of which

claimant complains. Thomas, 278 F.3d at 959, 42 U.S.C.A. § 423 (d)(1)(A).

The ALJ found Plaintiff's complaints and alleged limitations inconsistent with the

treatment she receives for her impairments. Furthermore, the ALJ found that Plaintiff's daily

activities are incongruent with her allegations of impairment. Plaintiff alleges an inability to

perform even sedentary unskilled work and many activities of daily living (AR at 35.)

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 6 of 14
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

8

"If there is medical evidence establishing an objective basis for some degree of pain

and related symptoms, and no evidence affirmatively suggesting that the claimant was

malingering, the Secretary's reason for rejecting the claimant's testimony must be "clear and

convincing" and supported by specific findings" Dodrill v. Shalala, 12 F.3d 915, 918 (9th

Cir. 1993).

9

Although Plaintiff contends that the ALJ improperly sites the alleged onset date as

May 1, 2002, if in error, it does not leave the ALJ without substantial evidence as to the

credibility determination of Plaintiff. Batson, 359 F.3d at 1197(error by the ALJ was

harmless to the validity of the ALJ's ultimate conclusion); Burch, 400 F.3d at 679("A

decision of the ALJ will not be reversed for errors that are harmless." (citing Curry v.

Sullivan, 925 F.2d 1127, 1131 (9th Cir.1990)). 

10The ALJ has properly considered the conflicts between the medical evidence and the

Plaintiff's subjective complaints of disability. See Section I. above.

- 7 -

However, the ALJ cites clear and convincing evidence8 to support his conclusion finding

otherwise. For example, Plaintiff does not use an ambulatory device, she exercises, walks,

stretches, and is able to sit for approximately one hour. Furthermore, “an ability to perform

such activities may be seen as inconsistent with the presence of a condition which would

preclude all work activity." See Curry v. Sullivan, 925 F.2d 1127, 1130 (9th Cir. 1990)

(substantial evidence supported finding that Plaintiff was capable of performing light work

where she had the ability to take care of personal needs, do light housework, and shop).

Plaintiff drives, goes shopping, attends church, socializes with her family, and visits her

mother in law. (AR at 35.) In addition to Plaintiff's daily activities, the ALJ cites the

conservative treatments received by Plaintiff, including pain medication and several

epidermal injections as objective evidence against Plaintiff's testimony. (AR at 34.) 

If the ALJ's interpretation of Plaintiff's contentions is reasonable and supported by

substantial evidence, even where a contrary finding may also be reasonable, it is not the

Court's role to second-guess. Rollins v. Massanari, 261 F.3d 853, 857 (9th Cir. 2001). The

Court finds that the evidence in the record refutes Plaintiff's claims of disability9

, and further,

that the ALJ properly advanced its reasons for discounting Plaintiff's subjective complaints10.

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 7 of 14
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

- 8 -

Accordingly, the Court finds that the ALJ's decision is supported by substantial evidence.

Benton, 331 F.3d at 1035. 

II. Substantial Record Evidence

Plaintiff contends that relevant evidence was ignored and/or not developed by the

ALJ. This Court finds that the ALJ failed to properly consider relevant medical evidence

only in regards to Plaintiff's migraine headaches. 

Relevant Medical Evidence

Plaintiff contends that the ALJ did not properly credit her treating physicians. "The

opinion[s] of treating physician[s] [are] not necessarily conclusive as to either the physical

condition or the ultimate issue of disability." Morgan, 169 F.3d at 600. Although the treating

physician's opinion is given deference, the ALJ may reject the opinion of a treating physician

in favor of a conflicting opinion, of an examining physician, if the ALJ makes "findings,

setting forth specific, legitimate reasons for doing so that are based on substantial evidence

in the record." Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir.1989). The ALJ can "meet

this burden by setting out a detailed and thorough summary of the facts and conflicting

clinical evidence, stating his interpretation thereof, and making findings." Thomas v.

Barnhart, 278 F.3d 947, 957 (9th Cir. 2002). The ALJ has provided substantial evidence and

a thorough summary of the facts, demonstrating a conflicting medical record in support of

his determination. For example, the ALJ points out that Plaintiff's treating physician Dr.

Romero made treatment notes that Plaintiff could not sit for long periods of time and was

limited in walking. However, Dr. Romero also noted that Plaintiff's back pain had improved.

(AR at 33). Dr. Romero made a determination that Plaintiff could lift and/or carry less than

ten pounds, stand/walk less than two hours in a workday, and sit only twenty minutes in an

eight hour day (AR at 33). These restrictions were for a period of six months, not within the

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 8 of 14
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

11Disability is defined as the inability to engage in any substantial gainful activity by

reason of any medically determinable physical or mental impairment that can be expected

to result in death or that has lasted or can be expected to last for a continuous period of not

less than 12 months. (AR 31.)

12The ALJ misstates the RFC evaluation of Dr. Kalyanam. In the ALJ's decision it is

stated that Plaintiff could stand and/or walk two hours but Dr. Kalyanam actually marked a

box indicating that Plaintiff could stand and/or walk less than two hours. (AR at 237.) This

error does not make a difference in the evaluation of the ALJ's substantial evidence because

Plaintiff is reduced to light work which allows for alternating between sitting, standing and

occasionally kneeling. 

- 9 -

meaning of a disability11. Furthermore, the diagnosis was made one month after Dr. Romero

had last seen Plaintiff. 

The ALJ further notes that Dr. Salazar-Calderon treated Plaintiff for low back pain

but contemporaneously found no focal weakness, no numbness or tingling in any extremity,

and a normal range of motion of the spine. (AR at 34.) Further, the record indicates that a

2003 MRI of the lumbar spine was unchanged. Plaintiff then received epidural injections

from Dr. Salazar-Calderon. One year later, Plaintiff stated that she could not stand or sit for

a period of time and that she had pain radiating down her thigh, however, her physical

examination was unchanged. (AR at 34.) 

Despite an MRI of the lumbar spine showing normal results, Dr. Kalyanam treated

the patient for low back pain after Plaintiff claimed a pain level of a nine out of ten.(AR at

34.) Dr. Kalyanam provided epidural injections and concluded that her RFC restricted her

to lifting and carrying less than ten pounds in a workday and standing and/or walking less12

than two hours, however Plaintiff could sit if she periodically alternated between sitting and

standing, with the occasional kneeling. (AR at 238.)

In September of 2003 Dr. Malcolm McPhee conducted a consultative evaluation,

which was corroborated by two DDS RFC evaluations.(AR at 33-34.) Although Dr. McPhee

is not a treating physician, the record supports his conclusion. The evaluations by Dr.

McPhee and the two DDS employees revealed that Plaintiff could lift fifty pounds

occasionally, twenty-five pounds frequently, sit for six hours in an eight hour work day, and

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 9 of 14
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

- 10 -

stand or walk six hours each. Plaintiff was able to occasionally climb, balance, stoop, kneel,

crouch or crawl, and was unlimited in her use of her upper extremities. Furthermore, a

radiological exam of her spine was normal. This determination, supported by the record,

substantially supports the ALJ's decision. 

As Defendant properly concedes, Dr. Romero's August 2005 form opinions were not

specifically addressed. (AR at 243-251.) The reports were issued after the Commissioner's

decision, therefore they are less persuasive. Marci v. Chater, 93 F.3d 540, 544 (9th Cir.

1996). Morever, the ALJ permissibly rejected Dr. Romero's form opinions because they were

check-off reports which did not contain any explanation for the bases of their conclusions

and were brief, conclusory, and inadequately supported by narrative explanation of clinical

signs and diagnostic findings. Thomas, 278 F.3d at 957. Where the evidence is susceptible

to more than one rational interpretation, one of which is in support of the ALJ's decision, the

ALJ's conclusion must be upheld. Consequently, in regards to Plaintiff's back pain, the ALJ's

RFC determination is upheld. Id. at 947.

Plaintiff's Obesity

The Court concludes that the ALJ did in fact consider Plaintiff's obesity in his

determination that neither of the listed "severe" impairments were severe enough to meet or

medically equal, either singly or in combination, one of the impairments listed in Appendix

1, Subpart P, Regulations No. 4. (AR at 33.) Agency ruling SSR 96-8p provides that [i]n

assessing the RFC, the adjudicator must consider limitations and restrictions imposed by all

of an individual's impairments, even those that are not "severe." While a "not severe"

impairment may not significantly limit an individual's ability to do basic work activities, it

may, when considered with limitations or restrictions due to other impairments, be critical

to the outcome of a claim. Id. As obesity is not a separately listed impairment, a plaintiff will

be deemed to meet the requirements if "there is an impairment that, in combination with

obesity, meets the requirements of a listing." Burch v. Barnhart, 400 F.3d 676 at 682. (citing

SSR 02-01p (2002)). 

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 10 of 14
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

- 11 -

An ALJ will not make assumptions about the severity or functional effects of obesity

combined with other impairments but will evaluate each case based on the information in the

case record. Burch, 400 F.3d at 682. Here, the record does not indicate that Plaintiff's obesity

exacerbated her other impairments. Id. There was no evidence before the ALJ, or in the

record, which states that Plaintiff’s obesity limits her functioning. Neither treatment notes

nor any diagnoses addressed Plaintiff's limitations due to obesity. The medical record is silent

as to whether and how Plaintiff's obesity might have exacerbated her condition. Moreover,

Plaintiff did not present any testimony or other evidence at her hearing that her obesity

impaired her ability to work. Even on appeal, Plaintiff has not pointed to any evidence of

functional limitations due to obesity which would have impacted the ALJ's analysis. In fact,

the only evidence in the record relating to her obesity are notes from doctors who observed

weight gain, indicated that Plaintiff is obese, and recommended that she lose weight. Id. 

The ALJ fully and fairly develops the record in regards to Plaintiff's obesity. The ALJ

assumes Plaintiff's obesity without Plaintiff presenting evidence of such an impairment. The

ALJ notes Plaintiff's obesity four times within his decision and tracks Plaintiff's weight. (AR

at 33-35.) The ALJ discredits the effects and severity of Plaintiff's obesity with substantial

evidence, explaining that obesity is a mild condition and is not supported by significant

findings. (AR at 35.) The Court finds that Plaintiff's obesity was properly considered and

accounted for in assessing the Plaintiff's RFC. 

Migraine Headaches

In contrast to the ALJ's consideration of Plaintiff's obesity, the ALJ did not properly

consider Plaintiff's migraine headaches. In Social Security cases, when a disability benefits

claimant is not represented by counsel, it is incumbent upon the ALJ to scrupulously and

conscientiously probe into, inquire of, and explore all of the relevant facts, proceeding in a

manner that is especially diligent in insuring that favorable as well as unfavorable facts and

circumstances are elicited. Cox v. Califano, 587 F.2d 988, 991 (9th Cir. 1978). For example,

Plaintiff did not testify as to her obesity, however, the ALJ nonetheless considered it and

referenced it. Despite the fact that the record reflects notes from three different treating

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 11 of 14
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

13The ALJ was to address Plaintiff's migraine headaches at step two of the five step

disability analysis. Webb v. Barnhart, 433 F.3d 683, 687 (9th Cir. 2005). Step two is "a de

minimis screening device [used] to dispose of groundless claims," and an ALJ may find that

a claimant lacks a medically severe impairment or combination of impairments only when

his conclusion is "clearly established by medical evidence." S.S.R. 85-28. Thus, applying the

normal standard of review to the requirements of step two, we must determine whether the

ALJ had substantial evidence to find that the medical evidence clearly established that

Plaintiff did not have a medically severe impairment or combination of impairments, when

considering Plaintiff's migraines. Webb, 433 F.3d at 687. The record includes evidence of

problems caused by Plaintiff's migraine headaches sufficient to pass the de minimis threshold

of step two.

- 12 -

physicians pertaining to migraines, the ALJ, fails to address in his opinion migraines or the

possible effects migraines may have on other impairments. 

More specifically, Dr. Romero states that Plaintiff has blurred tunnel vision and is

unable to work during migraine episodes. (AR at 154 and 137). Dr. Salazar-Calderon made

an assessment of migraine headaches on two different occasions and prescribed Darvocet and

Ativan for treatment.(AR at 259, 263.) Dr. Kalyanam, also a treating physician, cites

Plaintiff's migraine headaches as a secondary diagnosis in 2004. (AR at 232, 241.) Plaintiff

herself acknowledges the severity of her migraine headaches and makes note of how they

have gotten worse with age. (AR at 104, 105, 214.) 

The ALJ need not accept the opinion of a treating physician if that opinion is brief,

conclusory, and inadequately supported by clinical findings. Thomas, 278 F.3d at 957. The

opinion of three treating physicians, speaking to Plaintiff's migraine headaches, should have

been considered, and if not considered, the ALJ must present clear and convincing reasons

for rejecting the uncontroverted opinion of a claimant's physician. Thomas, 278 F.3d at 957.

At a minimum the ALJ must provide a specific, legitimate reason, supported by substantial

evidence, as to why he rejected the opinions of the treating physicians. Magallanes, 881

F.2d at 751. Therefore, because the ALJ failed address Plaintiff's migraine headaches this

case will be remanded for further consideration.13 

The Lay Witness Testimony

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 12 of 14
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

- 13 -

Plaintiff contends that the ALJ erred by failing to assist with the development of her

daughter's testimony and for failing to provide reasons for rejecting said testimony. The

Court finds that despite the fact that the ALJ may have failed to develop such testimony,

rejecting the testimony was not in error.

Lay testimony as to a claimant's symptoms is competent evidence that the ALJ must

take into account unless he expressly decides to disregard such testimony and gives reasons

germane to each witness for doing so. Lewis v. Apfel, 236 F.3d 503, 511 (9th Cir. 2001).

Inconsistency with medical evidence is considered a valid reason to disregard lay testimony.

Lewis, 236 F.3d at 511. In finding that the medical record is inconsistent as to Plaintiff's back

pain, the lay witness's testimony, speaking only to Plaintiff's back pain, is inconsistent with

the medical record. By properly discounting the credibility of Plaintiff, the ALJ can properly

reject the lay witness testimony that purported to bolster that credibility. See Bayliss v.

Barnhart, 427 F.3d 1211, 1218 (9th Cir. 2005) (permitting ALJ to reject lay witness

testimony that conflicts with other evidence). The testimony of Plaintiff's daughter merely

bolstered Plaintiff's subjective complaints of back pain and the severity thereof (AR 286-

287), which conflicted with the record and the ALJ's determination of Plaintiff's credibility

based on the record. Therefore, the ALJ properly disregarded the lay testimony. 

III. Hypothetical Presentation

The hypothetical(s) posed to the vocational expert (VE) properly included all of

Plaintiff's impairments. For the testimony of a VE to be considered reliable in a Social

Security proceeding, the hypothetical posed must include all of the claimant's functional

limitations, both physical and mental, that are supported by the record. Thomas, 278 F.3d

947. In the present case the hypotheticals presented to the VE included an individual of the

same age, education, work experience, and same physical limitations as Plaintiff. Five

hypotheticals were posed which provided scenarios that included Plaintiff's impairments as

determined by DDS, impairments that would limit activity to sedentary activity, and

impairments that would prevent Plaintiff from performing work in an eight hour day for more

than four days per month. The hypotheticals included all of Plaintiff's alleged impairments

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 13 of 14
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

14It is noted that because the ALJ found that none of Plaintiff's impairments were

severe the testimony of a VE was not needed. Mathews v. Shalala, 10 F.3d 678, 681 (9th Cir.

1993). 

- 14 -

which would have affected the VE's testimony. Therefore, because the hypotheticals posed

raised all of Plaintiff's impairments, the hypothetical questions were proper14. Therefore, the

Motions for Summary Judgment are denied. 

CONCLUSION

Accordingly,

IT IS HEREBY ORDERED that Plaintiff's Motion for Summary Judgment (Doc.

11) is DENIED. 

IT IS HEREBY ORDERED that Defendant's Motion for Summary Judgment (Doc.

15) is DENIED.

IT IS FURTHER ORDERED that the case be REMANDED for further review.

DATED this 10th day of July, 2007.

Case 2:06-cv-01496-SMM Document 20 Filed 07/11/07 Page 14 of 14