Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_04-cv-02379/USCOURTS-cand-3_04-cv-02379-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (DIWW)

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United States District Court

For the Northern District of California

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

CLAIRE RANKINS,

 Plaintiff,

v.

JO ANNE B BARNHART, Commissioner

of Social Security 

 Defendant.

________________________________/

No C 04-02379 VRW 

ORDER

Plaintiff Claire Rankins, acting pro se, appeals from

the Social Security Administration (“SSA”) decision to deny her

social security disability benefits. The court now considers cross

motions for summary judgment. Pl Mot (Doc #12), Def Mot (Doc #15). 

Based upon a review of the administrative record, the court finds

that the Administrative Law Judge (“ALJ”) did not provide

sufficient justification for rejecting plaintiff’s subjective

complaints of pain. The court therefore GRANTS in part and DENIES

in part plaintiff’s motion and DENIES defendant’s motion for

summary judgment.

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I

A

Plaintiff is forty-nine years old and has an eleventh

grade education. Administrative Record (“AR”) (Doc #7) at 879. 

She worked as an office assistant for the California State Public

Utilities Commission from 1980 until April 30, 1997, the onset date

of her alleged disability. AR at 879, 121. She has not held

employment since that date. AR at 158, 879. She claims to be

physically disabled from carpal tunnel syndrome and pain in her

neck, lower back, hips, knee and hands. AR at 18, 158-63. She has

also produced evidence that she suffers from depression. AR at

419, 868. Plaintiff traces her neck, back and hip pain to a

collision with a file cabinet at work in December 1996. AR at 880-

82. 

The medical records regarding plaintiff’s alleged

impairments are voluminous and often conflicting. Many of the

records addressing plaintiff’s physical condition come from Dr

Borina Dramov, a neurologist who treated plaintiff regularly from

April 1995 until at least June 2003. AR at 847. According to Dr

Dramov’s most recent report, a Multiple Impairments Questionnaire

dated June 17, 2003, plaintiff suffers from a herniated lumbar

disc, lumbar radiculopathy and bilateral carpal tunnel syndrome. 

AR at 848. Dr Dramov has also listed plaintiff as having bilateral

tenosynovitis, a cervical disc protrusion and degeneration in both

knees. AR at 781. Many of Dr Dramov’s reports document

plaintiff’s severe pain from these impairments, including lower

back pain that radiates into her legs, neck pain and pain in her

wrists and hands. See, for example, AR at 782-83, 848-49. From
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January 2000 to June 2003, Dr Dramov repeatedly described plaintiff

as permanently disabled. See, for example, AR at 774, 809, 852. 

Plaintiff also visited a chiropractor regularly. 

Plaintiff’s treating chiropractor, Alireza Bagherian, reported that

plaintiff suffered from cervical myofascitis, cervical segmental

dysfunction, carpal tunnel syndrome, thoracic segmental

dysfunction, paresthesia/numbness or tingling, sacral segmental

dysfunction, hip pain and knee pain. AR at 835. 

Other physicians who have examined plaintiff since the

onset date of her alleged disability have come to inconsistent

conclusions. In October 1997, Dr William Ross, an orthopedic

surgeon, diagnosed plaintiff with a chronic low back strain with

radiculopathy into lower extremities and chronic bilateral hand

tendinitis. AR at 414. According to Dr Ross, plaintiff had no

significant limitations and could engage in “any and all work

activities that are commensurate with age, training, and

experience.” Id. In February 1998, Dr Arthur Auerbach, an

orthopedic surgeon, diagnosed plaintiff with residuals of a mild

chronic low back strain and left hip bilateral trochanteric

bursitis. AR at 663. Dr Auerbach found that plaintiff was able to

perform her regular workload. AR at 664. In May 2001, Dr Brian

Andrews, a neurosurgeon, found that plaintiff’s gait was normal,

that she was not a surgical candidate and that it was hard to

understand physiologically why she would have radiating pain into

either leg. AR at 797. 

A June 1996 MRI of plaintiff’s right wrist showed

findings consistent with carpal tunnel syndrome. AR at 513. An

August 1997 MRI of both wrists showed no evidence of carpal tunnel
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pathology. AR at 674. A March 1999 MRI showed that plaintiff’s

hips were normal. AR at 768. A February 1998 MRI of the left knee

showed a lesion of the medial meniscus. AR at 655. A December

1999 MRI of the lumbar spine showed a six millimeter protrusion of

the L5-S1 disc. AR at 810. A March 1999 MRI of the cervical spine

showed a two millimeter protrusion of the C5-6 disc. AR at 770. 

July 2001 nerve conduction studies revealed no evidence of

radiculopathy, plexopathy or neuropathy in either lower limb. AR

at 865.

In addition to this evidence of plaintiff’s physical

condition, the record includes the reports of several mental health

professionals. In March 1996, Dr Andrew Whyman performed a

psychiatric examination and found no evidence of anxiety or

depression. AR at 247. In August 1997, however, plaintiff sought

treatment after a suicide attempt and doctors prescribed Paxil. AR

at 403, 408. Although the Paxil helped plaintiff’s symptoms,

plaintiff stopped taking it in 1997 or 1998. AR at 396, 887. In

October 1997, Dr Michael Zizmor examined plaintiff and diagnosed

her with chronic major depression, moderate, in partial remission. 

AR at 419. But in an October 1997 psychiatric review technique, Dr

Robert E Lee found that plaintiff had no work restrictions, in part

because she had responded favorably to antidepressant drugs. AR at

432. In July 2003, plaintiff visited Carol Mills, a licensed

clinical social worker. AR at 868. Mills diagnosed plaintiff with

depressive disorder and generalized anxiety disorder and

recommended antidepressant medication. Id. 

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B

In August 1997, plaintiff filed applications for

Disability Insurance Benefits and Supplemental Security Income

payments. AR at 121-23, 713-14. The SSA denied plaintiff’s

applications initially and on reconsideration. AR at 46, 52. 

After a hearing, the ALJ concluded in August 1999 that plaintiff

was not disabled. AR at 83-84. Plaintiff appealed the decision to

the SSA Appeals Council (“Appeals Council”). The Appeals Council

granted review, vacated the decision and remanded the case with

instructions to the ALJ to give further consideration to

plaintiff’s maximum residual functional capacity and to obtain

supplemental evidence from a vocational expert. AR at 97-99.

A second ALJ held a hearing on July 29, 2003, at which

plaintiff was represented by counsel. AR at 876. Plaintiff

testified to numerous ambiguous pains and symptoms that she stated

prevented her from being able to work. She described a sharp

pinching pain in her neck. AR at 882. She also described severe

pain in her lower back. AR at 882-83. Plaintiff testified that

she could walk for an hour without too much pain, but she could

only sit for one hour or stand for half an hour before it became

too uncomfortable to continue. AR at 884-85. Plaintiff stated

that she could not work as a parking lot attendant because she is

sure that “a pain in [her] left leg” would “come over [her]”. AR

at 886. Finally, she claimed that due to carpal tunnel syndrome

she had numbness, tingling and weakness in her hands that caused

her to drop things. AR at 892.

Dr Louis Lesko, orthopedic surgeon, appeared as a medical

expert at the hearing. Dr Lesko testified that plaintiff had
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anomalous bones in her wrists as a result of a congenital condition

but that it was “questionable that [plaintiff] ever had carpal

tunnel syndrome”. AR at 903-4. He testified that she had a

degenerative and modestly protruding L5-S1 disc in her lower back. 

AR at 904-5. He also testified that plaintiff had a degenerative

tear of the posterior horn of the medial meniscus of the right

knee, but that this condition is commonly found in people “who are

asymptomatic and generally not much is required to be done about

it” unless the person is an athlete. AR at 911. 

Dr Lesko found that plaintiff had a medium level residual

functional capacity and her only limitation was that she could only

perform keyboard work for two-thirds of the day because of the

anomalous bones in her hands. AR at 913. Based on this

conclusion, the vocational expert, Sidney Johnson, testified that

plaintiff could perform her past relevant work as an office

assistant. AR at 923.

On November 28, 2003, the ALJ issued a decision

concluding that plaintiff was not disabled. AR at 22-23. The ALJ

applied the five-step evaluation prescribed by the social security

regulations: (1) whether the claimant is currently engaged in

substantial gainful activity; (2) whether the claimant has a severe

impairment or combination of impairments; (3) if the claimant has a

severe impairment, whether the claimant has a condition which meets

or equals a condition appearing in the Listing of Impairments, 20

CFR § 404, Pt 404, Subpt P, App 1; (4) if the claimant does not

have such a condition, whether the claimant is capable of

performing her past work; and (5) whether the claimant has the 

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residual functional capacity to perform any other work. 20 CFR §

404.1520.

The ALJ specifically found that: (1) plaintiff had not

engaged in substantial gainful activity since the alleged onset of

disability; (2) plaintiff had an impairment or combination of

impairments considered severe; (3) these impairments did not meet

or equal any of the listed impairments; (4) plaintiff’s allegations

regarding her limitations were “not totally credible”; (5) careful

consideration was given to the medical opinions in the record

concerning the severity of plaintiff’s impairments; (6) plaintiff

retained the residual functional capacity to perform the exertional

demands of medium work with inability to lift over twenty-five

pounds frequently. Due to carpal tunnel syndrome, plaintiff can

only perform keyboard tasks two-thirds of the day, but not

continuously; (7) plaintiff had past relevant work as an office

assistant; (8) plaintiff’s impairments did not prevent her from

performing her past relevant work as an office assistant; (9)

plaintiff was not under a “disability” as defined in the Act at any

time through the date of decision. AR at 22-23. 

The Appeals Council denied plaintiff’s request for

review. AR at 10. Plaintiff began this action on June 16, 2004. 

Complaint (Doc #1).

II

The court must uphold the SSA’s decision to deny benefits

if it is supported by substantial evidence and is not based on

legal error. Andrews v Shalala, 53 F3d 1035, 1039 (9th Cir 1995). 

Substantial evidence is “more than a mere scintilla but less than a
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preponderance; it is such relevant evidence as a reasonable mind

might accept as adequate to support a conclusion.” Id. The ALJ is

responsible for determining credibility, resolving conflicts in

medical testimony and resolving ambiguities. Andrews, 53 F3d at

1039.

III

A

To receive benefits plaintiff must be under a disability. 

42 USC § 423(a)(1)(d). Disability is defined as the “inability to

do any substantial gainful activity by reason of any medically

determinable physical or mental impairment which can be expected to

result in death or which has lasted for a continuous period of not

less than 12 months.” 42 USC § 423(d)(1)(A). The impairment must

be of such severity that the individual “is not only unable to do

[her] previous work but cannot, considering [her] age, education,

and work experience, engage in any other substantial gainful work

which exists in the national economy.” 42 USC § 423(d)(2)(A).

B

The ALJ found that plaintiff was not disabled because her

depression did not rise to the level of a severe mental impairment

and because her “severe” physical impairments did not preclude her

from performing her past relevant work. Plaintiff, who is acting

pro se, has not pointed to any specific ALJ errors that warrant

reversal of the SSA’s decision. Pl Mot (Doc #12). Upon its own

review, the court finds that the ALJ’s conclusion that plaintiff

does not have a severe mental impairment is supported by the 

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record, but the ALJ erred in failing to give legally sufficient

reasons for rejecting plaintiff’s subjective complaints of pain.

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An impairment is not severe if it does not significantly

limit the claimant’s ability to do basic work activities. 20 CFR §

404.1521. In this case, medical reports from Dr Whyman and Dr Lee

indicate that plaintiff’s mental condition did not limit her

ability to work. AR at 247, 432. In addition, it appears that

medication helped any symptoms that plaintiff may have had. AR at

396. The ALJ noted that plaintiff stopped this treatment in 1997

or 1998. AR at 19. Finally, the ALJ provided specific reasons for

rejecting Carol Mills’ report, which diagnosed plaintiff with

disabling depression. The ALJ rejected the report because it did

not come from an acceptable medical source, because it was

suspicious in its timing and because Mills had not seen plaintiff

for long enough to form a conclusive opinion. AR at 19.

2

To find that plaintiff could perform her past relevant

work the ALJ adopted the opinion of the medical expert, Dr Lesko,

who testified that plaintiff’s only limitation was that she could

only perform keyboard work for two-thirds of the day. The ALJ

found that the reports of plaintiff’s treating physician, Dr

Dramov, and plaintiff’s own testimony about her pain lacked

credibility. 

Although the opinion of a treating physician generally

deserves more weight than the conflicting opinion of a non-treating

physician, the ALJ may give more weight to the opinion of the non-
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treating physician so long as the ALJ gives specific reasons that

are supported by the record. 20 CFR § 404.1527(d)(2); Lester v

Chater, 81 F3d 821, 830 (9th Cir 1996). In this case, the ALJ

provided a specific and legitimate reason for questioning the

credibility of Dr Dramov’s medical reports: the Medical Board of

California had placed her medical license on probation, after

initially revoking it, for incompetence and repeated negligence. 

AR at 20-21, 214. This was documented in a published Medical Board

Action Report that Dr Lesko presented to the ALJ at the hearing. 

AR at 214, 905-8.

The ALJ did not, however, provide legally sufficient

reasons for rejecting plaintiff’s subjective complaints of pain. 

Once a claimant has produced objective medical evidence of an

impairment that could reasonably be expected to produce the pain

complained of, the ALJ must consider the complaints in determining

disability. 20 CFR § 404.1529; Smolen v Chater, 80 F3d 1273, 1282

(9th Cir 1996). In evaluating the credibility of the complaints

the ALJ must consider: (1) the nature, location, onset, duration,

frequency, radiation and intensity of any pain; (2) precipitating

and aggravating factors; (3) the type, dosage, effectiveness, and

adverse side effects of any pain medication; (4) treatment, other

than medication, for relief of pain; (5) functional restrictions;

and (6) the claimant’s daily activities. SSR 88-13; Smolen, 80 F3d

at 1284. If the ALJ ultimately rejects the complaints as lacking

in credibility, the ALJ must make specific findings stating clear

and convincing reasons for doing so. Smolen, 80 F3d at 1284.

The ALJ may not reject the complaints “based solely on a

lack of objective medical evidence to fully corroborate the alleged
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severity of the pain.” Bunnell v Sullivan, 947 F2d 341, 345 (9th

Cir 1991). In Bunnell, an en banc opinion, the Ninth Circuit

reviewed two cases in which ALJs had rejected claimants’ subjective

complaints of pain. Id at 342. In the first case, ALJs found that

the claimant had a severe impairment but rejected his allegations

of disabling pain because they were “not consistent with the

medical signs and findings” and were “not justified after thorough

and repeated medical evaluations.” Id at 342-43. In the second

case, the ALJ rejected the claimant’s allegations of pain because

they were not “supported by the medical evidence of record.” Id at

343. The court found that the ALJs in both cases had erred by

rejecting the claimants’ complaints solely because the medical

evidence failed to corroborate the severity of the pain alleged. 

Id at 348. 

At the hearing in this case, Dr Lesko did not mention any

of plaintiff’s subjective complaints in his testimony on

plaintiff’s residual functional capacity. AR at 903-22. According

to Dr Lesko, plaintiff did not have any limitations other than the

anomalous bones in her wrists that prevent her from typing

continuously. AR at 913. The vocational expert based his

conclusion that plaintiff could perform her past relevant work

entirely on Dr Lesko’s assessment. AR at 922-23. Nothing in the

vocational expert’s testimony indicates that he considered any of

plaintiff’s pain testimony.

The ALJ found that plaintiff had several severe

impairments, which necessarily includes a finding that plaintiff

presented objective medical evidence of these impairments. See 20

CFR § 404.1508 (in order to prove an impairment the plaintiff must
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present objective medical evidence). The ALJ then adopted the

findings of Dr Lesko and the vocational expert as to plaintiff’s

residual functional capacity. The ALJ’s only reference to

plaintiff’s pain testimony is a paragraph in which the ALJ refers

to plaintiff’s statements as “not completely credible, considering

the differences between the statements and the information

contained in medical reports.” AR at 20. In support of this

statement the ALJ points to several of these reports. AR at 20. 

First, the ALJ cites an August 1997 MRI of both wrists that showed

no evidence of carpal tunnel pathology and a 1991 MRI of the hip

that was negative. Id. Second, the ALJ cites Dr Andrews’ surgical

consultation in May 2001, which found that plaintiff’s gait was

normal, that she was not a surgical candidate and that it was hard

to understand physiologically why she would have radiating pain

into either leg. Id. Finally, the ALJ points to July 2001 nerve

conduction studies that revealed no evidence for radiculopathy,

plexopathy or neuropathy in either lower limb. Id.

In sum, there is no indication that the ALJ considered

any of the factors set out in SSR 88-13 in evaluating plaintiff’s

testimony. Nor is there evidence that the medical expert or

vocational expert included the testimony in their findings. The

only reference to plaintiff’s complaints is the ALJ’s cursory

finding that they were not credible because the objective medical

evidence failed to support them. In effect, the ALJ’s statement

that plaintiff’s complaints were “not completely credible,

considering the differences between the statements and the

information contained in medical reports” is strikingly similar to 

specific statements the Ninth Circuit found to be inadequate in
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Bunnell. AR at 20. According to Bunnell, this is not a legally

sufficient reason for rejecting the testimony. 

C

The final remaining issue is whether, given the ALJ’s

error, the court must remand for an immediate award of benefits. 

The district court should credit improperly rejected

evidence and remand for an immediate award of benefits if (1) the

ALJ failed to provide legally sufficient reasons for rejecting the

evidence; (2) there are no outstanding issues that must be resolved

before a determination of disability can be made; and (3) it is

clear from the record that the ALJ would be required to find the

claimant disabled were such evidence credited. Benecke v Barnhart,

379 F3d 587, 593 (9th Cir 2004). On the other hand, the court

should remand for further administrative proceedings if after

crediting the improperly rejected evidence the record is still

unclear as to whether the plaintiff is disabled. See Harman v

Apfel, 211 F3d 1172, 1179-80 (9th Cir 2000)(upholding remand for

further proceedings where crediting improperly rejected opinion of

claimant’s treating physician did not establish disability as a

matter of law).

In this case, remand for further administrative

proceedings is appropriate because it is not clear that plaintiff

would be disabled even if her testimony were credited as true. In

the first place, the vocational expert did not consider any of

plaintiff’s pain testimony or her stated limitations in his

assessment. This is not a valid reason for further administrative

proceedings if the discredited testimony clearly shows an inability
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to perform any substantial gainful work. Benecke, 379 F3d at 595.

But such clarity is not present here because plaintiff’s testimony

regarding her limitations is ambiguous and incomplete. For

example, plaintiff testified that pain prevents her from standing

for more than half an hour or sitting for more than an hour, but

she did not describe the nature, severity or location of the pain

that causes these limitations. AR at 883-85. She stated that she

could not work as a parking lot attendant, a job in which she could

move around, because she is sure that she would have “a pain in

[her] left leg”. AR at 886. When asked what she would do if she

was sitting and got the pain, she stated that she would change her

sitting position, massage the leg and take her medication. AR at

887. She stated that her pain medications, Vicodin and Naprosyn,

do not help her. AR at 898-900. But she also testified that she

takes the medications often and that they alleviate her pain. Id. 

This testimony is insufficient for the court to conclude that

plaintiff cannot perform any substantial gainful work. Thus,

further consideration of the extent of plaintiff’s pain and whether

this pain renders her disabled is necessary.

IV

For the foregoing reasons, the court DENIES defendant’s

motion for summary judgment (Doc #15) and GRANTS in part and DENIES

in part plaintiff’s motion for summary judgment (Doc #12). The

ALJ’s determination is vacated and the action remanded for further

proceedings consistent with this order.

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The clerk is directed to close the file and terminate all

pending motions.

IT IS SO ORDERED.

 

VAUGHN R WALKER

United States District Judge