Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-3_13-cv-08300/USCOURTS-azd-3_13-cv-08300-0/pdf.json

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

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WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Nels Leslie Madsen, 

Plaintiff, 

v. 

Carolyn W. Colvin, 

Defendant.

No. CV-13-08300-PCT-DGC

ORDER 

 Pursuant to 42 U.S.C. § 405(g), Plaintiff Nels Leslie Madsen seeks judicial review 

of the Commissioner’s decision finding him not disabled within the meaning of the 

Social Security Act. Doc. 16. The Court will affirm the decision. 

I. Background. 

Plaintiff applied for disability and supplemental security insurance benefits in 

September 2010, alleging disability beginning in January 2008. Doc. 17 at 1. After a 

hearing on September 25, 2012, an administrative law judge (“ALJ”) issued an opinion 

on November 28, 2012, finding Plaintiff not disabled (A.R. 13-24). Plaintiff’s request for 

review was denied by the Appeals Council and the ALJ’s opinion became the 

Commissioner’s final decision. Doc. 17 at 1. 

II. Legal Standard. 

The district court reviews only those issues raised by the party challenging the 

ALJ’s decision. See Lewis v. Apfel, 236 F.3d 503, 517 n.13 (9th Cir. 2001). The court 

may set aside the Commissioner’s disability determination only if the determination is 

not supported by substantial evidence or is based on legal error. Orn v. Astrue, 495 F.3d 

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625, 630 (9th Cir. 2007). Substantial evidence is more than a scintilla, less than a 

preponderance, and relevant evidence that a reasonable person might accept as adequate 

to support a conclusion considering the record as a whole. Id. In determining whether 

substantial evidence supports a decision, the court must consider the record as a whole 

and may not affirm simply by isolating a “specific quantum of supporting evidence.” Id. 

As a general rule, “[w]here the evidence is susceptible to more than one rational 

interpretation, one of which supports the ALJ’s decision, the ALJ’s conclusion must be 

upheld.” Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002) (citations omitted). 

A. Five-Step Sequential Evaluation. 

To determine whether a claimant is disabled for purposes of the Social Security 

Act, the ALJ follows a five-step process. 20 C.F.R. § 404.1520(a). The claimant bears 

the burden of proof on the first four steps, but at step five the burden shifts to the 

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

At the first step, the ALJ determines whether the claimant is engaging in 

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

disabled and the inquiry ends. Id. At step two, the ALJ determines whether the claimant 

has a “severe” medically determinable physical or mental impairment. § 404.1520(a) 

(4)(ii). If not, the claimant is not disabled and the inquiry ends. Id. At step three, the 

ALJ considers whether the claimant’s impairment or combination of impairments meets 

or medically equals an impairment listed in Appendix 1 to Subpart P of 20 C.F.R. Pt. 

404. § 404.1520(a)(4)(iii). If so, the claimant is automatically found to be disabled. Id. 

If not, the ALJ proceeds to step four. At step four, the ALJ assesses the claimant’s 

residual functional capacity (“RFC”) and determines whether the claimant is still capable 

of performing past relevant work. § 404.1520(a)(4)(iv). If so, the claimant is not 

disabled and the inquiry ends. Id. If not, the ALJ proceeds to the fifth and final step, 

where he determines whether the claimant can perform any other work based on the 

claimant’s RFC, age, education, and work experience. § 404.1520(a)(4)(v). If so, the 

claimant is not disabled. Id. If not, the claimant is disabled. Id. 

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At step one, the ALJ determined that Plaintiff meets the insured status 

requirements of the Social Security Act and that he has not engaged in substantial gainful 

activity since September 15, 2010. At step two, the ALJ found that Plaintiff has the 

following impairments which are severe when considered in combination: “low back pain 

due to degenerative changes; leg pain, status-post a motorcycle accident in January 2012 

resulting in tibial plateau fracture, treated initially with external fixation and later open 

reduction, internal fixation, and status-post another motorcycle accident in August 2012; 

gastroesophageal reflux disease (GERD); mild to moderate degenerative changes of the 

bilateral hips; depression; and drug and alcohol abuse, in questionable remission[.]” 

A.R. 15. At step three, the ALJ found that the Plaintiff does not have an impairment or 

combination of impairments that meets or medically equals an impairment listed in 

Appendix 1 to Subpart P of 20 C.F.R. Pt. 404. At step four, the ALJ found that Plaintiff 

has the RFC to perform light work with restrictions as defined in 20 C.F.R.. § 416.967(b). 

The ALJ found that Plaintiff has postural restrictions and is unable to climb, squat, kneel, 

crouch, or crawl, has lower extremity limitations consisting of no use of the legs or feet 

for pushing or pulling of foot or leg controls; needs a sit/stand option which allows him to 

alternate between sitting and standing while still performing his job duties; and is limited 

to unskilled work. At step five, the ALJ concluded that there are jobs that exist in 

significant numbers in the national economy that Plaintiff can perform. 

III. Analysis.

 Plaintiff argues that the ALJ erred in rejecting the opinions of two treating 

physicians, Drs. Nudelman and Heiner. Doc. 16 at 8. 

A. Legal Standard. 

The Ninth Circuit distinguishes between the opinions of treating physicians, 

examining physicians, and non-examining physicians. See Lester v. Chater, 81 F.3d 821, 

830 (9th Cir. 1995). Generally, an ALJ should give greatest weight to a treating 

physician’s opinion and more weight to the opinion of an examining physician than to 

one of a non-examining physician. See Andrews v. Shalala, 53 F.3d 1035, 1040-41 (9th 

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Cir. 1995); see also 20 C.F.R. § 404.1527(c)(2)-(6) (listing factors to be considered when 

evaluating opinion evidence, including length of examining or treating relationship, 

frequency of examination, consistency with the record, and support from objective 

evidence). If it is not contradicted by another doctor’s opinion, the opinion of a treating 

or examining physician can be rejected only for “clear and convincing” reasons. Lester, 

81 F.3d at 830 (citing Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir. 1988)). A 

contradicted opinion of a treating or examining physician “can only be rejected for 

specific and legitimate reasons that are supported by substantial evidence in the record.” 

Lester, 81 F.3d at 830-31 (citing Andrews, 53 F.3d at 1043). 

An ALJ can meet the “specific and legitimate reasons” standard “by setting out a 

detailed and thorough summary of the facts and conflicting clinical evidence, stating his 

interpretation thereof, and making findings.” Cotton v. Bowen, 799 F.2d 1403, 1408 (9th 

Cir. 1986). But “[t]he ALJ must do more than offer [her] conclusions. [She] must set 

forth [her] own interpretations and explain why they, rather than the doctors’, are 

correct.” Embrey, 849 F.2d at 421-22. 

The Commissioner is responsible for determining whether a claimant meets the 

statutory definition of disability and does not give significance to a statement by a 

medical source that the claimant is “disabled” or “unable to work.” 20 C.F.R. 

§ 416.927(d). 

B. Dr. Nudelman. 

 Dr. Nudelman opined that Plaintiff was limited to a range of sedentary work. 

A.R. 270-72. More specifically, he opined that Plaintiff could never carry or lift more 

than 10 pounds, could never climb, and could only occasionally stoop, squat, or crawl. 

Id. Dr. Nudelman also opined that Plaintiff’s pain and fatigue moderately affected his 

ability to function. Id. at 272. 

The ALJ stated that Dr. Nudelman’s opinion was “contradicted by the opinions of 

other physicians of record” (A.R. 22), but did not specifically identify any contradictory 

opinions. The Court need not determine whether the ALJ identified contradictory 

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evidence elsewhere in his opinion because, in any event, the ALJ provided clear and 

convincing reasons to discount Dr. Nudelman’s opinion. 

 Dr. Nudelman’s assessment form was completed on September 1, 2011. A.R. 

270-72. The ALJ noted that Dr. Nudelman’s treatment notes from the same day 

contained the following statements: “The patient wanted me to fill out a disability form 

for him. I do not have the expertise to do this. Basically I had asked him his opinion 

with regard to the questions and I answered them.” A.R. 22 (citing A.R. 273). The ALJ 

properly discounted this opinion: “The ALJ need not accept the opinion of any physician, 

including a treating physician, if that opinion is brief, conclusory, and inadequately 

supported by clinical findings.” See Thomas, 278 F.3d at 957. 

 The ALJ further noted that Dr. Nudelman’s progress notes do not support his 

opinion. A.R. 22. The Court agrees. Plaintiff identifies no treatment records that 

support the doctor’s opinion, and the treatment records reviewed by the Court do not 

contain any information that would support the limitations stated on the September 2011 

form. See A.R. 258-61, 273-78. The ALJ provided clear and convincing reasons for 

rejecting Dr. Nudelman’s opinion. 

C. Dr. Heiner. 

 Dr. Heiner, Plaintiff’s orthopedic surgeon, opined that Plaintiff was unable to 

perform even sedentary work due to his leg injuries. A.R. 314-16. The actual form 

completed by Dr. Heiner is quite confusing because several items are scribbled out, but it 

appears that he opined that Plaintiff could only occasionally carry up to five pounds. He 

also opined that Plaintiff could sit or stand continuously for only two hours at a time and 

that he could only be on his feet for a total of one hour in an eight hour workday. Dr. 

Heiner further opined that Plaintiff could never stoop, squat, crawl, or climb, and that he 

was totally restricted from working around unprotected heights or moving machinery. 

Dr. Heiner noted that Plaintiff’s pain and fatigue were moderately severe. Id. 

The ALJ gave little weight to Dr. Heiner’s opinion for several reasons. The ALJ 

noted that “no diagnostic or clinical findings” were included to support the opinion. A.R. 

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22. He further noted that Dr. Heiner’s opinion was completed six months after Plaintiff 

was involved in a motorcycle accident and that nothing in the opinion indicated that the 

“opinion would meet the duration requirement of 12 continuous months despite 

treatment.” Id. The ALJ also found that the opinion “appears to rely on the subjective 

complaints of the [Plaintiff]” and noted that Plaintiff was “not entirely credible[.]” Id. 

Additionally, the ALJ observed that Plaintiff was riding his motorcycle “not long after 

[Dr. Heiner] gave his opinion.” Id. Finally, the ALJ stated that Dr. Heiner’s opinion did 

not meet the duration requirement because the “record does not contain any recent 

progress notes from the doctor that would support his opinion continuing to remain 

valid.” Id. 

 The ALJ did not explicitly identify contradictory evidence, nor was the Court able 

to locate a discussion of contradictory evidence at any other point in the opinion. 

Accordingly, the ALJ was required to provide clear and convincing reasons for rejecting 

Dr. Heiner’s opinion. The Court concludes that the ALJ has met this burden. 

 As already noted, the ALJ need not accept the opinion of a treating physician if it 

is brief, conclusory, or inadequately supported by clinical findings. See Thomas, 278 

F.3d at 957. The ALJ concluded that Dr. Heiner’s opinion was not supported by any 

diagnostic or clinical findings. Plaintiff does not identify clinical evidence or treatment 

notes from Dr. Heiner in the record, but the Court was able to locate some treatment 

notes completed by Dr. Heiner. Some of these records deal with the surgery following 

Plaintiff’s first motorcycle accident in January 2012 and his apparent readmission to the 

hospital due to an infection. See A.R. 279-81, 288-304. These notes appear to describe 

surgical procedures conducted by Dr. Heiner and follow-up examinations conducted 

while Plaintiff was hospitalized, and do not appear to contain any information about 

Plaintiff’s long-term restrictions. Another set of notes from Dr. Heiner (A.R. 305-13) are 

from office follow-up visits that occurred between March and June of 2012. These notes 

reveal improvement in Plaintiff’s range of motion and ability to walk at each 

appointment. These treatment notes support the ALJ’s conclusion that limitations 

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assessed by Dr. Heiner would not be expected to last for more than 12 months. 

 The ALJ also noted that Plaintiff was “riding his motorcycle” not long after Dr. 

Heiner’s assessment form was completed and found this to be additional evidence that 

Dr. Heiner’s opinion would not meet the duration requirement. This assertion is 

supported by treatment records from Havasu Regional Medical Center. These records 

show that Plaintiff was seen on August 13, 2012, less than one month after Dr. Heiner’s 

opinion, because Plaintiff had again fallen off his motorcycle. See A.R. 317-21. The fact 

that Plaintiff was again operating a motorcycle suggests that his limitations were not as 

severe as those assessed by Dr. Heiner, that Plaintiff continued to improve from his 

January 2012 motorcycle accident, and that the limitations assessed by Dr. Heiner likely 

would not be expected to last more than 12 months. The fact that no further treatment 

records were submitted also supports these conclusions. The ALJ therefore identified 

clear and convincing reasons for rejecting Dr. Heiner’s opinion. 

IT IS ORDERED: 

1. The Commissioner’s decision is affirmed. 

 2. The Clerk is directed to enter judgment and terminate this action. 

 Dated this 29th day of August, 2014. 

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