Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_19-cv-00086/USCOURTS-azd-4_19-cv-00086-0/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)

---

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

WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Kelly Ann King-McDonald,

Plaintiff,

v. 

Commissioner of Social Security 

Administration,

Defendant.

No. CV-19-00086-TUC-EJM

ORDER 

Plaintiff Kelly Ann King-McDonald brought this action pursuant to 42 U.S.C. § 

405(g) seeking judicial review of a final decision by the Commissioner of Social Security 

(“Commissioner”). Plaintiff raises four issues on appeal: 1) the Administrative Law Judge 

(“ALJ”) failed to give legally sufficient reasons to reject Dr. Hassman’s examining 

physician opinion that Plaintiff needed to frequently change positions; 2) the ALJ failed to 

give legally sufficient reasons to reject Plaintiff’s subjective symptom testimony that she 

could not sit for long periods; 3) the ALJ failed to properly evaluate the lay witness

statements of Plaintiff’s daughter; and 4) the ALJ applied an incorrect, stricter definition 

of disability in finding Plaintiff not disabled. (Doc. 19). 

Before the Court are Plaintiff’s Opening Brief, Defendant’s Response, and 

Plaintiff’s Reply. (Docs. 19, 20, & 21). The United States Magistrate Judge has received 

the written consent of both parties and presides over this case pursuant to 28 U.S.C. § 

636(c) and Rule 73, Federal Rules of Civil Procedure. For the reasons stated below, the 

Court finds that this matter should be remanded for further administrative proceedings.

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 1 of 28
- 2 -

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

I. Procedural History

Plaintiff filed an application for social security disability benefits on December 3, 

2014. (Administrative Record (“AR”) 71). Plaintiff alleged disability beginning on July 2, 

2014 based on diabetes, neuropathy, bulging discs, severe back and neck pain, severe 

migraines, optical migraines, severe TMJ, vertigo, asthma, bronchitis, lung problems, 

aortic valve replacement with minor aortic, mitral, and tricuspid leaks, severe sleep apnea, 

seizures, extreme fatigue, and anxiety. Id. Plaintiff’s application was denied upon initial 

review (AR 70) and on reconsideration (AR 86). A hearing was held on September 11, 

2017 (AR 40), after which ALJ Charles Davis found, at Step Four, that Plaintiff was not 

disabled because she could perform her past relevant work as an administrative assistant 

as generally performed. (AR 33–34). On December 17, 2018 the Appeals Council denied 

Plaintiff’s request to review the ALJ’s decision. (AR 2).

Plaintiff’s date last insured (“DLI”) for DIB purposes is December 31, 2019. (AR 

26).1 Thus, to be eligible for benefits, Plaintiff must prove that she was disabled during the 

time period of her AOD of July 2, 2014 and her DLI of December 31, 2019. 

II. Factual History2

Plaintiff was born on July 31, 1965, making her 48 years old at AOD of her 

disability. (AR 71). She completed college in 2008. (AR 192). In the past 15 years she has 

worked as an executive administrative assistant in IT and finance, an IT administrative 

assistant, and a marketing administrative assistant. (AR 193). 

A. Treating Physicians

A March 2, 2013 echocardiogram showed mechanical aortic valve replacement 

without significant change in gradient compared to prior echo in 2012, preserved left 

ventricular ejection fraction, and no significant other valvular abnormalities. (AR 452). 

On April 2, 2013 Plaintiff was seen for pulmonary hypertension and reported 

 

1 The disability determination explanations at the initial and reconsideration levels state 

that Plaintiff’s DLI is December 31, 2017; however, the ALJ stated that Plaintiff’s DLI is 

December 31, 2019. (AR 26, 71, 87)

2 While the undersigned has reviewed the entirety of the record in this matter, the following 

summary includes only the information most pertinent to the Court’s decision on Plaintiff’s 

claims on appeal. 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 2 of 28
- 3 -

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

episodes of respiratory distress and increased daytime sleepiness. (AR 405). 

On June 3, 2013 Plaintiff reported she was breathing better with no shortness of 

breath and minimal cough, but had daytime sleepiness. (AR 396). A pulmonary function 

test was mostly normal. (AR 399). 

On August 13, 2013 Plaintiff reported a severe headache with aura and vertigo. (AR 

371). 

On November 15, 2013 Plaintiff stated she was sleeping well with her CPAP 

machine. (AR 394). Her asthma was stable. (AR 395). 

On December 10, 2013 Plaintiff reported she hurt her back bending down and had 

left ankle pain and weakness. (AR 326). On exam she had decreased back range of motion 

due to pain, point tenderness at the paraspinal muscles of the lumbar spine, and left ankle 

pain with range of motion. (AR 328). X-rays of the left ankle showed hypertrophic and 

posttraumatic irregularities from old trauma and no acute abnormalities. (AR 329). 

On February 27, 2014 Plaintiff reported a severe headache with double vision and 

gait imbalance, different from her typical migraines, and was referred to the ER for 

evaluation. (AR 322, 324). 

On May 19, 2014 Plaintiff was seen for a psychiatric evaluation because her 

neurologist was concerned about her anxiety. (AR 659). Plaintiff denied feeling depressed 

and said anxiety, poor concentration, and bad energy were related to her medical problems 

and being forced out of her job. Plaintiff reported she had been on Celexa since 2006 for 

depression after her heart valve surgery. Review of systems was negative except for back 

pain and headaches, and the mental evaluation was generally normal. (AR 662). The 

assessment was generalized anxiety disorder and major depressive disorder, recurrent, in 

remission, and Celexa was increased to address anxiety. (AR 662–663). At a follow-up on 

June 11, 2014 Plaintiff reported she was doing ok overall and the medication increase was 

helpful. (AR 664–665). Plaintiff had another follow-up on July 30, 2014 and reported 

Celexa was working well. (AR 668–669). 

On May 21, 2014 Plaintiff reported severe headaches that began in her 30s, a dull 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 3 of 28
- 4 -

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

headache every day, and various types of headaches including a “brain freeze” headache, 

headache in the crown with pain behind the eyes, and vertigo. (AR 363). The impression 

was migraine, suspected anxiety related trigger; and spells/vertigo, needs continuous EEG 

to help clarify. (AR 364). 

On September 10, 2014 Plaintiff was seen for follow-up of headaches and spells and 

reported constant headaches, worse with exertion. (AR 376). On exam her head and neck 

were tender to palpation, and straight leg test positive on the right. (AR 377). Plaintiff was 

prescribed a new migraine medication and referred for an MRI for her lower extremity 

pain. 

On January 12, 2015 Plaintiff was seen for a cardiology follow-up. (AR 348). Since 

her last appointment in 2013, she had recurrent dizziness and vertigo, thought to be 

secondary to anxiety. A January 28, 2015 echocardiogram showed impaired relaxation, left 

atrium mildly dilated, normally functioning prosthetic valve with no significant change of 

gradient, trace mitral regurgitation, and mild tricuspid regurgitation. (AR 441). 

On May 5, 2015 Plaintiff was seen for back pain and shortness of breath. (AR 475). 

A chest x-ray was unremarkable and a CT of the aorta and for pulmonary embolism showed 

no acute abnormalities. (AR 434, 439, 478). 

An August 13, 2015 x-ray of the lumbar spine showed mild degenerative endplate 

spurring. (AR 462). 

On January 27, 2016 Plaintiff reported recurrent episodes of palpitations and 

windedness with exertional activities, and said she had to stop several times walking from 

the parking lot to the doctor’s office. (AR 487). An echocardiogram on February 23, 2016 

showed left ventricular size, thickness, and systolic function normal, impaired relaxation, 

normally functioning mechanical prosthetic valve, and mild mitral regurgitation. (AR 511). 

On March 6, 2016 Plaintiff was seen for right flank pain and persistent cough. (AR 

946). On exam she was tender to palpation in the right paraspinal lumbar and thoracic 

regions. (AR 949). A CT showed a 6 mm nonobstructing calculus in the right kidney, 

diverticulosis in the sigmoid colon, and mural fat deposition in the terminal ileum. (AR 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 4 of 28
- 5 -

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

950). 

On September 8, 2016 x-rays of the left foot and ankle showed arthritic changes and 

no acute findings. (AR 840). 

On October 4, 2016 Plaintiff reported some dizziness with her optical migraines and 

was taking Topiramate, was taking Citalopram for depression, had right lower abdominal 

pain and thought she might have Crohn’s, and complained of chronic back pain and said 

no one had ever done anything about it. (AR 818). Plaintiff appeared to be in pain and had 

limited range of motion in her back secondary to pain, and was referred to pain 

management for evaluation and treatment. (AR 818–820). 

On October 14, 2016 Plaintiff was seen for a follow-up after going to the ER with 

flank pain. (AR 815). A CT showed diffuse fatty infiltration of the liver, stone in the left 

uterus, and right ovarian cyst. Plaintiff appeared to be in pain, was feeling depressed, and 

was under a lot of stress caring for her grandkids. 

On November 10, 2016 Plaintiff was seen for a pain evaluation and reported chronic 

cervical and lumbar pain since 2006. (AR 852). Her pain was throbbing, numbing, tingling, 

sharp, dull, aching, electric, pressure, and shooting; worse with lifting, walking, sitting, 

standing, stress, activity, movement, cold weather, and bending; and relieved by 

medication, relaxation, lying down, changing positions, and stretching. She also had pain 

and symptoms in her stomach, hips, knees, arms, feet, shoulders, back, and legs. Plaintiff 

reported her pain was severe without medication but moderate with pain medications and 

she was able to function; she did not want narcotics. (AR 852–853). Findings on 

examination were:

Musculoskeletal system: 

Shoulder:

General/bilateral: ○ Shoulder joints have full range of motion.

Cervical Spine:

General/bilateral: ● Cervical spine showed tenderness on 

palpation of the spinous process. ○ Occipital protuberance 

(inion) was not tender on palpation. ○ Cervical spine showed 

full range of motion. ○ A foraminal compression test of the 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 5 of 28
- 6 -

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

cervical spine was not performed.

Thoracic Spine:

General/bilateral: ○ Thoracic spine exhibited no tenderness on 

palpation.

Thoracolumbar Spine (Motion):

General/bilateral: ○ Thoracolumbar spine demonstrated full 

range of motion.

Lumbar / Lumbosacral Spine:

General/bilateral: ● Lumbosacral spine exhibited tenderness 

on palpation. ● Lumbosacral spine did not demonstrate full 

range of motion. ● A straight-leg raising test was positive.

Pelvis:

General/bilateral: ○ Both sacroiliac joints did not show 

tenderness on palpation.

Knee:

Right Knee: ● Examined. ○ Medial aspect was not tender on 

palpation. ○ Lateral aspect was not tender on palpation.

Left Knee: ● Examined. ○ Medial aspect was not tender on 

palpation. ○ Lateral aspect was not tender on palpation.

Neurological:

○ Oriented to time, place, and person.

Gait And Stance: ○ Normal.

Reflexes: ○ Deep tendon reflexes were normal. ○ Biceps reflex

was normal +2/4. ○ Brachioradialis reflex was normal +2/4. ○

Triceps reflex was normal +2/4.

(AR 854–855). The impression was lumbar radiculopathy and Plaintiff was referred for 

physical therapy and an MRI. (AR 855). 

On February 12, 2017 Plaintiff was seen for chest pain, nausea, and shortness of 

breath. (AR 878). A chest x-ray showed no acute cardiopulmonary abnormality and EKG 

was normal. (AR 879; 883). The diagnosis was acute pleurisy and acute bronchitis. (AR 

880). 

On March 27, 2017 Plaintiff reported she had stopped using her CPAP for several 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 6 of 28
- 7 -

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

months and was having excessive daytime sleepiness, shortness of breath, and dyspnea on 

exertion, and a sleep study and 6-minute walk test were recommended. (AR 507). A chest 

x-ray the same date showed no evidence of pneumonia or congestive heart failure. (AR 

650). Plaintiff had low back pain after the walk test (AR 614). A sleep study was done on 

April 24, 2017 and the impression was obstructive sleep apnea-hypopnea syndrome, 

moderately severe, and good response to CPAP. (AR 932–933). 

On April 11, 2017 Plaintiff was seen for bilateral foot pain and swelling in the left 

foot. (AR 813). X-rays of both feet showed no acute bony abnormalities and calcaneal 

spurs. (AR 499). 

An April 12, 2017 echocardiogram showed overall left ventricular systolic function 

normal, normally functioning mechanical prosthetic valve, mild mitral regurgitation, and 

mild tricuspid regurgitation. (AR 504).

An April 17, 2017 pulmonary function test was mostly normal with a hint of RLD 

and gas exchange limitation, probably normal. (AR 611). 

On June 29, 2017 x-rays of the left foot showed a soft tissue defect at the plantar 

aspect of the distal left third toe without radiographic evidence of osteomyelitis. (AR 831–

832). 

On July 24, 2017 Plaintiff was concerned about swelling in her left calf. (AR 1110). 

A venous duplex was negative for deep vein thrombosis. (AR 1098). 

On August 11, 2017 Plaintiff reported she was still having problems breathing and 

got shortness of breath easily; she was awaiting the start of CPAP. (AR 914). 

On August 30, 2017 Plaintiff was seen for a pain evaluation at Pima Pain Center. 

(AR 1091). She reported cervical, thoracic, and lumbar pain with intermittent bilateral 

radiculopathy and neuropathy. (AR 1092). Standing, bending, and holding her 

grandchildren made her pain worse, and PT made it worse. Plaintiff did not have any 

prescribed pain medications and only wanted to use opioids as a last resort. Findings on 

exam included:

. . .

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 7 of 28
- 8 -

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

Musculoskeletal

o Cervical Spine :

▪ Inspection/Palpation : trigger point noted at 

anterior aspect of the interspaces between the 

transverse processes of C5-C7 (bilateral)

▪ Axial load testing : moderate pain with axial 

loading

▪ Range of Motion : ROM limited in all directions 

– moderate

▪ Tests/Signs : Spurling’s test positive

o Thoracic Spine :

▪ Inspection/Palpation : mild diffuse spasm noted 

throughout the mid to upper thoracic spine

o Lumbosacral Spine

▪ Inspection/Palpation : moderate spasm noted

▪ Stability : mild to moderate pain with 

extension/axial loading

▪ Range of Motion : range of motion limited due to 

axial loading

▪ Tests/ Signs : Spurling Positive Bilateral, Slump 

Positive Bilaterally

(AR 1094). Plaintiff was also noted to be comfortable sitting without excessive changes in 

position, had normal gait and was able to stand without difficulty, and had reduced 

sensation in the distal extremities. (AR 1094–1095). The assessment was chronic pain 

syndrome, spinal enthesopathy, cervicalgia, pain in thoracic spine, lumbago, cervical 

spondylosis without myelopathy, thoracic spondylosis without myelopathy, displacement 

of cervical intervertebral disc without myelopathy, bulge of thoracic disc without 

myelopathy, and bulging lumbar disc. (AR 1095). The doctor thought Plaintiff had a 

component of neuropathy secondary to diabetes and wanted to ensure her diabetes 

continued to be controlled. (AR 1096). He also recommended Plaintiff start the Diet of 

Hope, schedule PT, get x-rays of the thoracic and lumbar spine, and follow-up in one 

month. 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 8 of 28
- 9 -

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

A May 7, 2018 note from Pima Pain Management states that Plaintiff is unable to 

work due to severe full spine pain. (AR 9). 

B. Examining Physicians

On June 22, 2015 Plaintiff saw Dr. Fred Wiggins for a psychiatric consultative 

examination. (AR 456). Plaintiff reported health problems including heart disease, 

neuropathy, diabetes, sleep apnea, optical seizures, and migraines, and a past history of 

depression due to an abusive relationship. She had difficulty sleeping due to sleep apnea 

and medications, was able to manage her basic activities of daily living, and did cooking 

and light housekeeping based on her physical limitations. (AR 457). Plaintiff stated her 

current depression was related to her medical issues, and reported moderate anxiety on a 

daily basis. Plaintiff was not currently in therapy but was prescribed Citalopram. Her 

examination was normal and the diagnosis was adjustment disorder with mixed anxiety 

and depressed mood related to her chronic medical issues. (AR 458). 

Dr. Wiggins completed a Medical Source Statement and opined that Plaintiff’s 

mental impairments would impose limitations for 12 months and that she had no 

deficiencies in understanding and memory or adaptation, but that her psychiatric disorder 

may limit her ability to maintain regular attendance and her motivation for social 

interaction. (AR 459).

On August 13, 2015 Plaintiff saw Dr. Jeri Hassman for a physical medicine 

consultative examination. (AR 463). Plaintiff reported that she suffered heart damage from 

taking a weight loss medication in the 1990s and had an aortic valve replacement in 2006. 

She has had diabetes since 2007 and frequent tingling of her fingers and toes. She always 

has a headache, but gets several kinds of headaches including optical seizures/migraines, 

which are down from daily to 2–3 times a week with Topamax. Plaintiff described her 

optical migraines as seeing wavy lines come into her visual field and traveling to the middle 

and then she can’t see anything; these were a significant problem when she was at work 

but only last 2–3 minutes. (AR 463–464). Plaintiff reported falling asleep during the day, 

sometime while sitting, standing, or in the middle of a conversation, and uses a CPAP but 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 9 of 28
- 10 -

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

the mask causes pain around her eyes. (AR 464). She has frequent neck, upper back, and 

lower back pain, occasional chest pain and shortness of breath, visual problems associated 

with her optical migraines/seizures, occasional dizziness, decreased memory, and constant 

tingling in her fingertips and toes. 

On exam Plaintiff had normal ambulation without limp or complaints of pain, 

normal balance and gross motor coordination, was able to stand and walk on her toes and 

heels, normal balance for tandem walking, hop on either foot without complaint, bend 

down and pick something up off the floor, kneel down without complaints or pain, and was 

independent in dressing/undressing, getting on/off the exam table, and getting in/out of the 

chair. (AR 465). Plaintiff also had full range of motion of the cervical spine without pain 

and no tenderness, no respiratory distress, full range of motion of upper and lower 

extremities without pain, normal coordination and dexterity in the hands with no tremor, 

no evidence of muscle spasm or hypertonicity of the paraspinal muscles, full range of 

motion of the lumbar spine without pain, negative straight leg raise test bilaterally, and

complained of mild low back pain at the end rank of trunk flexion and some sternal pain 

during trunk flexion. Plaintiff had normal motor strength, sensation, and reflexes in the 

lower extremities, subjective tingling of her fingertips and toes, and a systolic murmur. 

(AR 466). 

Dr. Hassman diagnosed:

History of diabetes mellitus, hypertension, hyperlipidemia, and 

diabetic peripheral neuropathy with very mild tingling of the 

fingertips and toes. She has normal manual dexterity and 

normal grip strength bilaterally and has no limitation in 

activities with her hands.

Allegation of bulging disks and severe back and neck pain. 

Unremarkable physical examination of the cervical spine and 

lumbar spine and normal gait.

History of severe migraines and optical migraines/optical 

seizures; these are described in the report and the optical 

migraines occur 2-3 times per week, but last for only 2 minutes.

Allegation of temporomandibular joint problems. She has 

palpable clunking/subluxation of bilateral temporomandibular 

joints with opening and closing her mouth.

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 10 of 28
- 11 -

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

Allegation of vertigo. The claimant had normal balance and a 

negative Romberg sign on physical examination.

Status post aortic valve replacement and also a history of

leaking of her mitral and tricuspid valves. The claimant did 

have a holosystolic murmur on physical examination.

History of obstructive sleep apnea and complaints of severe 

fatigue during the day. The claimant was awake and alert on 

physical examination and did not appear fatigued or drowsy.

(AR 466). Dr. Hassman also completed a Medical Source Statement and opined that 

Plaintiff’s conditions would impose limitations for 12 continuous months. (AR 467). Dr. 

Hassman opined that Plaintiff could occasionally lift/carry 20 pounds, frequently lift/carry 

10 pounds, stand/walk 6–8 hours, sit 6–8 hours, and had limitations on seeing because 

although she had normal vision, she had a history of optical migraines/seizures. (AR 468–

469). Dr. Hassman further opined that Plaintiff could never climb ladders, ropes, or 

scaffolds; occasionally climb ramps and stairs; occasionally crouch, crawl, and reach; and 

frequently stoop and feel. (AR 469). Plaintiff also had environmental restrictions for 

heights, moving machinery, extremes in temperature, chemicals, dust/fumes, and gases. 

Dr. Hassman noted several times on the form that Plaintiff needed frequent change of 

position. (AR 468–470). 

C. State Agency Reviewing Physicians

At the initial disability determination level, Dr. David Coffman opined that Plaintiff 

could occasionally lift 20 pounds, frequently lift 10 pounds, stand/walk about 6 hours in 

an 8-hour workday, sit for about 6 hours, occasionally climb ramps/stairs, never climb 

ladders/ropes/scaffolds, frequently stoop, and occasionally kneel, crouch, and crawl. (AR 

80–81). He also recommended that Plaintiff avoid concentrated exposure to extreme 

temperatures, fumes, odors, dusts, gases, poor ventilation, and hazards, and noted Plaintiff 

should avoid working around unprotected heights and moving machinery due to her history 

of vertigo. (AR 81). 

On reconsideration, Dr. Charles Fina assessed the same limitations. (AR 102). 

. . .

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 11 of 28
- 12 -

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

D. Plaintiff’s Testimony

On a Function Report dated April 31, 2015, Plaintiff reported that her migraines, 

TMJ, optical migraines/seizures, vertigo, and sleep apnea interrupted her concentration and 

her day. (AR 222). Because of her neuropathy and bulging discs, she can’t sit or stand for 

any length of time without severe pain, and she has pain and tingling in her hands and arms 

and they go numb from typing or writing. On a typical day she wakes up and stretches, 

babysits her grandson, naps, picks up the other grandkids from the bus, makes dinner, and 

goes to bed. (AR 223). She takes care of her grandchildren and her dog, and gets help from 

her daughter. She can no longer work on computers, lift heavy objects, focus, remember 

things, or drive, and cannot stay awake because of sleep apnea and medication side effects. 

She has a hard time dressing because of back pain; it hurts to bend over and she gets dizzy 

and falls. Plaintiff prepares her own meals and does chores, but has to take breaks because 

it feels like her back and ribs are breaking and like she’s walking on nails. (AR 224). Her 

family helps her with chores. She goes out 3–4 days a week, can drive, and shops for 

groceries. (AR 225). Her hobbies are watching tv, doing puzzles, watching grandkids, 

spending time with family, and napping. (AR 226). She can’t exercise because of 

migraines, optical seizures, and vertigo, and doesn’t see her family a lot because she is 

always sick. Plaintiff reported that her conditions affected her ability to lift, squat, bend, 

stand, walk, sit, kneel, climb stairs, see, remember, complete tasks, concentrate, 

understand, and use her hands. (AR 227). She can only stand and sit for a little bit, and can 

only walk for a block or less then needs to rest for a minute. Plaintiff can only pay attention 

for a short period because her mind wanders, can follow written instructions pretty good 

but has to go back over them many times, and for spoken instructions she will forget them 

right away unless she writes them down. 

On a Disability Report dated March 11, 2015, Plaintiff reported that she stopped 

working because her vertigo, migraines, and optical migraines were getting worse, and her 

optical migraines interfered with her vision for 30–45 minutes. (AR 192). She was also 

falling asleep at work because of her sleep apnea. She was given new job responsibilities 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 12 of 28
- 13 -

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

that she couldn’t do because of her medical problems and medications, she couldn’t 

remember simple things, and she was diagnosed with anxiety. 

At the reconsideration level, Plaintiff reported that she had more frequent shooting 

pains in her back and up her spine and it hurt when driving. (AR 88). She also reported 

sharp pains in her legs, behind her knees, and her left hip, and more pain in her feet. 

On a Disability Report dated May 5, 2016, Plaintiff reported that she had severe 

pain in her right side and back when walking, sitting, standing, and sometimes lying down. 

(AR 252). She can’t stand long enough to do dishes, load the dishwasher, or clean the 

floors, had to take breaks to sit when cooking, and sit to get dressed. 

At the hearing before the ALJ, Plaintiff testified that she was let go of her last job 

because of her health. (AR 44). She had heart surgery in 2006 and has had breathing and 

heart problems ever since. She has memory problems and forgets things; she wasn’t fast 

enough at work; she would fall asleep at work because of her medications and sleep apnea; 

and she was out a lot because of medical appointments. She also gets headaches from 

computers and lights, and gets little seizures called optical migraines. She would get severe 

migraines at work and have to lay her head on her desk for 45 minutes to an hour. (AR 46). 

Plaintiff has bulging discs in her back and had an adjustable sit-stand desk at work because 

of her back pain, and she can’t sit or stand for long periods of time. (AR 46). Plaintiff was 

depressed when she lost her job and unsuccessfully tried to apply for other jobs, then got 

more depressed and more sick and stopped applying. (AR 45). 

Plaintiff has pulmonary aortic hypertension and has a hard time breathing; she is 

always short of breath and has chest pain, like someone is stabbing her in the chest. (AR 

45; 62). She had a mask for her sleep apnea but it was causing her face to swell and she got 

migraines so she stopped using it, but recently got another one. (AR 45). She has a 

continuous headache all the time, and also gets migraines when she goes outside, is on the 

computer, or there is bright flashing light on the tv. (AR 64). She is seeing a pain doctor 

for her back and her neck and waiting for them to do tests, and has a bone at the base of 

her neck that has hurt for years. 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 13 of 28
- 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

Plaintiff is fostering her three grandchildren (ages 9, 4, and 2 at the time of the 

hearing) and plans to adopt them. (AR 47–48). The children are in 

school/preschool/daycare full-time, and Plaintiff is able to care for them with help from 

her adult children and DCS respite care. (AR 49). Plaintiff admitted that she certified that 

she was physically, mentally, and emotionally able to care for the children when she 

became their foster parent. (AR 50). Although she takes care of them, she does not believe 

she could go back to work because of her back pain, and she cannot sit, stand, focus, type, 

work on a computer, lift things, or bend over, and has problems with dizziness and

migraines. (AR 51). When she gets a migraine, her children come over to help her with the 

grandchildren. (AR 61). 

Plaintiff is always tired and can fall asleep anywhere. (AR 63). She takes naps while 

the children are at school so she is awake when they’re home, and props herself up on 

pillows while they play games or watch movies. 

Plaintiff is primarily responsible for household chores and grocery shopping. (AR 

54). Her daughter drives her places because she doesn’t like to drive due to her medications. 

It takes Plaintiff 3 hours to wash dishes because she has to take so many breaks. (AR 63). 

The children help her with folding laundry, dishes, and sweeping the floor, and her older 

daughter comes over to help with chores. (AR 63–64). 

Plaintiff stated she could lift her 25-pound grandson but that it hurt to pick him up 

and she could only hold him for a few minutes because it hurt her back. (AR 58). She can 

stand for 5 to 10 minutes and then needs to rest, and sit for 10 to 15 minutes. (AR 58–59). 

Her legs go numb when she sits so she has to constantly move them and get up and readjust 

herself; she is “always on the move.” (AR 58). Her hands go numb and she has neuropathy 

from her arm to her elbow and her feet to her knees. (AR 59). 

E. Lay Testimony

Selena McDonald, Plaintiff’s daughter, completed a third-party function report on 

May 7, 2015. (AR 202). She reported that she spent 3–4 days a week with Plaintiff running 

errands and watching tv. Selena stated that Plaintiff had optical seizures and migraines that 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 14 of 28
- 15 -

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

affected her vision and concentration and could cause nausea, vertigo causing balance 

issues, and sleep apnea and fell asleep often during the day. Selena stated Plaintiff cared 

for her grandchildren and dog and got help from her children when she wasn’t feeling well, 

and spent her days napping, watching tv, and spending time with the grandchildren. (AR 

203). Plaintiff prepared simple meals like sandwiches and frozen dinners because her 

neuropathy pain made it difficult to stand for long periods to cook. (AR 204). Plaintiff did 

chores but was always fatigued or in pain and needed help. Selena reported that Plaintiff’s 

conditions affected her bending, standing, sitting, stair climbing, memory, completing 

tasks, and concentration. (AR 207). She could follow written directions well but not spoken 

directions and would forget what she had been told. Selena further reported that she had 

seen Plaintiff have multiple seizures within the past month where she would lose focus, her 

vision would blur, and she would grab onto something and stare straight ahead like she was 

in a daydream. (AR 210). Each seizure lasts about 3 minutes and Plaintiff’s migraine 

medication was increased to help with them. 

F. Vocational Testimony

At the hearing before the ALJ, Robin Generaux testified as a vocational expert. (AR 

65). She classified Plaintiff’s past work as an administrative assistant as sedentary, but 

Plaintiff stated that she lifted up to 100 pounds. (AR 65–66).

The ALJ asked Generaux to assume an individual who could perform a range of 

light work with the following limitations: occasionally climb ramps and stairs; no ladders, 

ropes, or scaffolds; frequent stooping; occasional kneeling, crouching, and crawling; 

frequent bilateral fingering; occasional exposure to extreme cold or heat; occasional 

exposure to pulmonary irritants; and frequent near acuity. (AR 66). Generaux testified that 

such a person could perform the work of an administrative assistant as generally performed. 

If the ALJ added a limitation to semi-skilled work, such a person could not do the job. (AR 

66–67). However, Plaintiff would have readily transferrable skills to semi-skilled work for 

jobs such as receptionist. (AR 67). Generaux further testified that if someone had problems 

maintaining regular attendance, the most absences an employer would tolerate at the highly 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 15 of 28
- 16 -

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

skilled level would be 3 days a month, but 2 days a month at the lower skilled level would 

not be tolerable. (AR 68). 

G. ALJ’s Findings

The ALJ found that Plaintiff had the severe impairments of status post aortic valve 

replacement, degenerative disc disease, diabetes, and diabetic neuropathy. (AR 28). The 

ALJ found that Plaintiff’s swelling in her left foot and bilateral foot cramping did not cause 

more than minimal limitation and were nonsevere, and that Plaintiff’s sleep apnea was well 

controlled when she was compliant with treatment and thus nonsevere. (AR 28, 30). The 

ALJ also found that that Plaintiff’s migraines were controlled with medication and were 

nonsevere, and that to the extent that Plaintiff had some intermittent vision problems 

related to her migraines, they were nonsevere. (AR 29). Finally, the ALJ considered the 

paragraph B criteria for evaluating mental disorders and found that Plaintiff had no more 

than mild limitations in understanding, remembering, and applying information; in social 

interaction with others; in ability to concentrate, persist, or maintain pace; and in ability to 

adapt and manage oneself. (AR 29). The ALJ therefore found that Plaintiff’s mental 

impairment was nonsevere. (AR 30). 

The ALJ found that Plaintiff’s statements concerning the intensity, persistence, and 

limiting effects of her symptoms were not entirely consistent with the medical and other 

evidence of record. (AR 32).

The ALJ gave reduced weight to the state agency medical consultant opinions. (AR 

33). The ALJ found that their opinion that Plaintiff could perform a wide range of light 

work activity with no mental limitations was consistent with the record; however, the ALJ 

found that Plaintiff did not suffer from any conditions that would limit her exposure to 

workplace hazards. 

The ALJ also gave reduced weight to the consultative examiner opinion because the 

limitations Dr. Hassman assessed for visual acuity and exposure to workplace hazards were

based strictly on Plaintiff’s remote history of an optical migraine. (AR 33). 

The ALJ gave some weight to the third-party statement of Plaintiff’s daughter 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 16 of 28
- 17 -

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

because she observed Plaintiff daily and could attest to her functioning; however, she was 

not a medical professional and thus her observations were of limited value. (AR 33). 

 The ALJ found that Plaintiff had the RFC to perform light work with the following 

limitations: never climb ladders, ropes, or scaffolds; occasionally climb ramps and stairs, 

kneel, crouch, and crawl; frequently stoop and bilateral finger; and occasional exposure to 

temperature extremes and pulmonary irritants. (AR 31). The ALJ found that Plaintiff was 

unable to perform her past relevant work as an administrative assistant as actually 

performed at the heavy exertional level, but that she could perform the work as generally 

performed at the sedentary level. (AR 33–34). The ALJ therefore concluded Plaintiff was 

not disabled. (AR 34).

III. Standard of Review

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

claims. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4); 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) the 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, she does not 

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

The findings of the Commissioner are meant to be conclusive. 42 U.S.C. §§ 405(g), 

1383(c)(3). 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). As set forth in 

42 U.S.C. § 405(g), “[t]he findings of the Secretary as to any fact, if supported by 

substantial evidence, shall be conclusive.” Substantial evidence “means such relevant 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 17 of 28
- 18 -

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

evidence as a reasonable mind might accept as adequate to support a conclusion,” 

Valentine, 574 F.3d at 690 (internal quotations and citations omitted), and is “more than a 

mere scintilla, but less than a preponderance.” Aukland, 257 F.3d at 1035. 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) 

(citations omitted). “Rather, a court must consider the record as a whole, weighing both 

evidence that supports and evidence that detracts from the Secretary’s conclusion.” 

Aukland, 257 F.3d at 1035 (internal quotations and citations omitted). 

The ALJ is responsible for resolving conflicts in testimony, determining credibility, 

and resolving ambiguities. Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995). “When 

the evidence before the ALJ is subject to more than one rational interpretation, [the court] 

must defer to the ALJ’s conclusion.” Batson v. Comm’r Soc. Sec. Admin., 359 F.3d 1190, 

1198 (9th Cir. 2004). This is so because “[t]he [ALJ] and not the reviewing court must 

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

not substitute its judgment for that of the ALJ.” Matney v. Sullivan, 981 F.2d 1016, 1019 

(9th Cir. 1992). 

Additionally, “[a] decision of the ALJ will not be reversed for errors that are 

harmless.” Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005). The claimant bears the 

burden to prove any error is harmful. McLeod v. Astrue, 640 F.3d 881, 888 (9th Cir. 2011) 

(citing Shinseki v. Sanders, 556 U.S. 396 (2009)). An error is harmless where it is 

“inconsequential to the ultimate nondisability determination.” Molina v. Astrue, 674 F.3d 

1104, 1115 (9th Cir. 2012); see also Stout v. Comm’r Soc. Sec. Admin., 454 F.3d 1050, 

1055 (9th Cir. 2006). “[I]n each case [the court] look[s] at the record as a whole to 

determine whether the error alters the outcome of the case.” Molina, 674 F.3d at 1115. In 

other words, “an error is harmless so long as there remains substantial evidence supporting 

the ALJ’s decision and the error does not negate the validity of the ALJ’s ultimate 

conclusion.” Id. (internal quotations and citations omitted). Finally, “[a] claimant is not 

entitled to benefits under the statute unless the claimant is, in fact, disabled, no matter how 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 18 of 28
- 19 -

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

egregious the ALJ’s errors may be.” Strauss v. Comm’r Soc. Sec. Admin., 635 F.3d 1135, 

1138 (9th Cir. 2011).

IV. Discussion

Plaintiff argues that the ALJ failed to explicitly address Dr. Hassman’s opinion that 

she needed to change positions frequently and that this error was harmful because the ALJ 

did not include this limitation in the RFC or hypothetical posed to the VE. Plaintiff further

argues that the ALJ failed to provide clear and convincing reasons to reject her testimony 

that she could not sit for long periods of time and had to adjust herself constantly. Finally, 

Plaintiff argues that the ALJ failed to provide a legally sufficient reason to discount the lay 

witness statement, and that the ALJ applied an incorrect definition of disability because he 

found that her symptoms were not so severe as to prohibit all basic work activities. 

The Commissioner argues that the ALJ properly evaluated Dr. Hassman’s opinion 

in assessing Plaintiff’s RFC, properly evaluated Plaintiff’s subjective allegations, and 

properly considered the lay witness statement. While the Commissioner offers several post 

hoc rationalizations to support the ALJ’s decision on these issues, this Court reviews only 

the reasons provided by ALJ in the disability determination and may not affirm the ALJ on 

a ground upon which he did not rely. Garrison, 759 F.3d at 1010; see also Brown-Hunter 

v. Colvin, 806 F.3d 487, 494 (9th Cir. 2015) (“As we have long held, ‘[W]e are constrained 

to review the reasons the ALJ asserts.’” quoting Connett v. Barnhart, 340 F.3d 871, 874 

(9th Cir.2003)). Finally, the Commissioner contends that the ALJ applied the correct 

definition of disability and referred to “basic work activities” in assessing the RFC, not in 

making the final disability determination at Step Four. 

The Court finds that the ALJ failed to provide legally sufficient reasons to discount 

Plaintiff’s subjective symptom testimony and Dr. Hassman’s opinion. These errors

impacted the ALJ’s RFC assessment and the hypotheticals posed to the VE. Consequently, 

the errors were not harmless because they ultimately impacted the ALJ’s Step Four

nondisability finding. Because questions remain regarding whether in fact Plaintiff was 

disabled within the meaning of the SSA during the relevant time period, and because 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 19 of 28
- 20 -

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

Plaintiff’s subjective symptom testimony is best reassessed in light of the record as a whole, 

the Court finds that remand for further administrative proceedings is appropriate.3 

A. Medical Testimony

In weighing medical source opinions in Social Security cases, the Ninth Circuit 

distinguishes among three types of physicians: (1) treating physicians, who actually treat 

the claimant; (2) examining physicians, who examine but do not treat the claimant; and (3) 

non-examining physicians, who neither treat nor examine the claimant. Lester v. Chater, 

81 F.3d 821, 830 (9th Cir. 1995). “As a general rule, more weight should be given to the 

opinion of a treating source than to the opinion of doctors who do not treat the claimant.” 

Garrison v. Colvin, 759 F.3d 995, 1012 (9th Cir. 2014) (quoting Lester, 81 F.3d at 830). 

“Courts afford the medical opinions of treating physicians superior weight because these 

physicians are in a better position to know plaintiffs as individuals, and because the 

continuity of their treatment improves their ability to understand and assess an individual’s 

medical concerns.” Potter v. Colvin, 2015 WL 1966715, at *13 (N.D. Cal. Apr. 29, 2015). 

“While the opinion of a treating physician is thus entitled to greater weight than that of an 

examining physician, the opinion of an examining physician is entitled to greater weight 

than that of a non-examining physician.” Garrison, 759 F.3d at 1012.

Where a treating physician’s opinion is not contradicted by another physician, it 

may be rejected only for “clear and convincing” reasons. Lester, 81 F.3d at 830. “If a 

treating or examining doctor’s opinion is contradicted by another doctor’s opinion, an ALJ 

may only reject it by providing specific and legitimate reasons that are supported by 

substantial evidence. This is so because, even when contradicted, a treating or examining 

physician’s opinion is still owed deference and will often be entitled to the greatest weight 

. . . even if it does not meet the test for controlling weight.” Garrison, 759 F.3d at 1012 

(internal quotations and citations omitted). Specific, legitimate reasons for rejecting a 

physician’s opinion may include its reliance on a claimant’s discredited subjective 

complaints, inconsistency with the medical records, inconsistency with a claimant’s 

 

3 Because the Court will remand this matter for further administrative proceedings on an 

open record, the Court declines to address the other issues raised by Plaintiff in her appeal. 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 20 of 28
- 21 -

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

testimony, or inconsistency with a claimant’s ADL. Tommassetti v. Astrue, 533 F.3d 1035, 

1041 (9th Cir. 2008). “An ALJ can satisfy the substantial evidence requirement by setting 

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

his interpretation thereof, and making findings. The ALJ must do more than state 

conclusions. He must set forth his own interpretations and explain why they, rather than 

the doctors’, are correct.” Id. However, “when evaluating conflicting medical opinions, an 

ALJ need not accept the opinion of a doctor if that opinion is brief, conclusory, and 

inadequately supported by clinical findings.” Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th 

Cir. 2005). Finally, if the ALJ determines that the plaintiff’s subjective complaints are not 

credible, this is a sufficient reason for discounting a physician’s opinion that is based on 

those subjective complaints. Bray v. Comm’r Soc. Sec. Admin., 554 F.3d 1219, 1228 (9th 

Cir. 2009).

Here, the ALJ gave reduced weight to Dr. Hassman’s opinion because, “[b]ased on 

Dr. Hassman’s narrative, limitations on the claimant’s visual acuity and exposure to 

workplace hazards was based strictly on the claimant’s remote history of an optical 

migraine.” (AR 33). The Court finds that this was not a legally sufficient reason to discount

the entirety of Dr. Hassman’s opinion. The ALJ failed to cite to any other specific reason 

to assign the opinion reduced weight, nor did the ALJ cite to any specific record that 

contradicted Dr. Hassman’s opinion. The only reason given by the ALJ was Dr. Hassman’s 

reliance on Plaintiff’s remote history of optical migraines, which could not possibly 

logically apply to the other limitations that Dr. Hassman assessed on lifting, sitting, 

standing, etc. The Court cannot meaningfully review the ALJ’s decision when the ALJ fails 

to set forth his reasoning. While the Commissioner is not required to “discuss all evidence” 

the Commissioner is required to “make fairly detailed findings in support of administrative 

decisions to permit courts to review those decisions intelligently” and “must explain why 

significant probative evidence has been rejected.” Vincent on Behalf of Vincent v. Heckler, 

739 F.2d 1393, 1394 (9th Cir. 1984) (emphasis in original) (internal quotations and citation 

omitted); Garrison, 759 F.3d at 1012–1013 (“When an ALJ does not explicitly reject a 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 21 of 28
- 22 -

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

medical opinion or set forth specific legitimate reasons for crediting one medical opinion 

over another, he errs. In other words, an ALJ errs when he rejects a medical opinion or 

assigns it little weight while doing nothing more than ignoring it, asserting without 

explanation that another medical opinion is more persuasive, or criticizing it with 

boilerplate language that fails to offer a substantive basis for his conclusion.”). 

Further, the ALJ must evaluate any medical opinion according to the requirements 

set out in 20 C.F.R. § 404.1527(c). Thus, in determining what weight to afford Dr. 

Hassman’s opinion, the ALJ was required to consider (1) the frequency of examination and 

the length, nature, and extent of the treatment relationship; (2) the evidence in support of 

Dr. Hassman’s opinion; (3) the consistency of the opinion and the record as a whole; (4) 

whether Dr. Hassman is a specialist; and (5) other factors that would support or contradict 

Hassman’s opinion. The ALJ wholly failed to address these factors here. See, e.g., Revels

v. Berryhill, 874 F.3d 648, 666–67 (9th Cir. 2017) (ALJ erred by failing to state germane 

reasons to reject physical therapist’s opinion in part where although physical therapist only 

examined claimant once, he did so for 3 1⁄2 hours, extensively reviewed medical records 

from other doctors, and produced a 9-page report). 

In sum, the Court finds that the ALJ erred by failing to provide clear and convincing 

or specific and legitimate reasons supported by substantial evidence to assign reduced 

weight to Dr. Hassman’s opinion that Plaintiff needed to frequently change positions. 

Particularly in a case such as this where there are no opinions from Plaintiff’s treating 

physicians recommending specific limitations on her ability to work, Dr. Hassman’s 

opinion may provide the best estimation of Plaintiff’s physical capabilities and workplace 

limitations. This error is not harmless because it affected the ALJ’s discounting of 

Plaintiff’s subjective symptom testimony, the RFC assessment, and the hypotheticals posed 

to the VE, and thus the ultimate nondisability finding at Step Four. See Marsh v. Colvin, 

792 F.3d 1170, 1172–74 (9th Cir. 2015) (“a reviewing court cannot consider an error 

harmless unless it can confidently conclude that no reasonable ALJ, when fully crediting 

the testimony, could have reached a different disability determination.”). Accordingly, the 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 22 of 28
- 23 -

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

Court finds that this matter should be remanded for further administrative proceedings to 

reassess Dr. Hassman’s opinion and continue the five-step sequential evaluation process. 

B. Plaintiff’s Testimony

“An ALJ’s assessment of symptom severity and claimant credibility is entitled to 

great weight.” Honaker v. Colvin, 2015 WL 262972, *3 (C.D. Cal. Jan. 21, 2015) (internal 

quotations and citations omitted).4 This is because “an ALJ cannot be required to believe 

every allegation of disabling pain, or else disability benefits would be available for the 

asking, a result plainly contrary to 42 U.S.C. § 423(d)(5)(A).” Treicherler v. Comm’r. Soc. 

Sec. Admin., 775 F.3d 1090, 1106 (9th Cir. 2014). “If the ALJ’s credibility finding is 

supported by substantial evidence in the record, the reviewing court may not engage in 

second-guessing.” Honaker, 2015 WL 262972 at * 3 (internal quotations and citation 

omitted).

While questions of credibility are functions solely for the ALJ, this Court “cannot 

affirm such a determination unless it is supported by specific findings and reasoning.” 

Robbins v. Comm’r Soc. Sec. Admin. 466 F.3d 880, 885 (9th Cir. 2006). “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). “First, the ALJ must determine whether the claimant has presented objective 

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

 

4 SSR 16-3p went into effect on March 16, 2016 and supersedes SSR 96-7p, the previous 

policy governing the evaluation of symptoms. SSR 16-3p, 2016 WL 1119029, *1. The 

ruling indicates that “we are eliminating the use of the term ‘credibility’ from our subregulatory policy, as our regulations do not use this term.” Id. Moreover, “[i]n doing so, 

we clarify that subjective symptom evaluation is not an examination of an individual’s 

character[;] [i]nstead, we will more closely follow our regulatory language regarding 

symptom evaluation.” Id. This ruling is consistent with the previous policy and clarifies 

rather than changes existing law. Under either ruling, the ALJ is required to consider the 

claimant’s report of her symptoms against the record—in SSR 96-7p, this resulted in a 

“credibility” analysis; in SSR 16-3, this allows the adjudicator to evaluate “consistency.” 

Compare SSR 16-3p with SSR 96-7p (both rely on two step process followed by an 

evaluation of claimant’s testimony and contain the same factors for consideration).

“The change in wording is meant to clarify that administrative law judges aren’t in 

the business of impeaching claimants’ character,” but “obviously administrative law judges 

will continue to assess the credibility of pain assertions by applicants, especially as such 

assertions often cannot be either credited or rejected on the basis of medical evidence.” 

Cole v. Colvin, 831 F.3d 411, 412 (7th Cir. 2016).

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 23 of 28
- 24 -

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

produce the pain or other symptoms alleged.’” Id. at 1036 (quoting Bunnell v. Sullivan, 947 

F. 2d 341, 344 (9th Cir. 1991)). “Second, if the claimant meets this first test and there is no 

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

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

Lingenfelter, 504 F.3d at 1036 (quoting Smolen v. Chater, 80 F.3d 1273, 1282 (9th Cir. 

1996)). “This is not an easy requirement to meet: The clear and convincing standard is the 

most demanding required in Social Security cases.” Garrison, 759 F.3d at 1015. Further, 

“[t]he ALJ must specifically identify what testimony is credible and what testimony 

undermines the claimant’s complaints.” Morgan v. Comm’r of Soc. Sec. Admin., 169 F.3d 

595, 599 (9th Cir. 1999).

While it is permissible for an ALJ to look to the objective medical evidence as one 

factor in determining credibility, the ALJ’s adverse credibility finding must be supported 

by other permissible evidence in the record. Bunnell, 947 F.2d at 346–47 (“adjudicator may 

not discredit a claimant’s testimony of pain and deny disability benefits solely because the 

degree of pain alleged by the claimant is not supported by objective medical evidence”). 

However, “an ALJ may reject a claimant’s statements about the severity of his symptoms 

and how they affect him if those statements are inconsistent with or contradicted by the 

objective medical evidence.” Robbins, 466 F.3d at 887 (emphasis in original). “Factors that 

an ALJ may consider in weighing a claimant’s credibility include reputation for 

truthfulness, inconsistencies in testimony or between testimony and conduct, daily 

activities, and unexplained, or inadequately explained, failure to seek treatment or follow 

a prescribed course of treatment.” Orn v. Astrue, 495 F.3d 625, 636 (9th Cir. 2007) (internal 

quotations and citations omitted).

Here, the ALJ did not make a finding that Plaintiff was malingering; therefore, to 

support his discounting of Plaintiff’s assertions regarding the severity of her symptoms, 

the ALJ had to provide clear and convincing, specific reasons. The ALJ stated that 

Plaintiff’s statements concerning the intensity, persistence, and limiting effects of her 

symptoms were not entirely consistent with the medical and other evidence of record. (AR 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 24 of 28
- 25 -

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

32). However, the ALJ failed to point to any specific statements that he found not credible, 

nor did he identify any alleged inconsistencies between Plaintiff’s testimony and the 

medical record. See Morgan, 169 F.3d at 599; Smolen, 80 F.3d at 1284 (“The ALJ must 

state specifically what symptom testimony is not credible and what facts in the record lead 

to that conclusion”); A.B. v. Saul, 2019 WL 6139163, at *7 (C.D. Cal. July 23, 2019) (ALJ 

made the identical conclusory statement as here and “at no point thereafter in the decision 

did the ALJ link specific parts of Plaintiff’s testimony ‘to the particular parts of the record’ 

to support his rejection of Plaintiff’s testimony.”). Specific to the issue raised by Plaintiff

here, although the ALJ summarized Plaintiff’s testimony and noted Plaintiff’s statements 

that she could not sit or stand for very long and had to adjust her position after sitting for 

about 10–15 minutes, the ALJ did not specifically state whether he found those statements 

to be credible or inconsistent with the record. Further, in assessing Plaintiff’s RFC and 

posing hypotheticals to the VE, the ALJ did not include any limitations based on Plaintiff’s 

testimony that she could not sit or stand for very long and had to adjust her position. 

In sum, the undersigned finds that the ALJ failed to articulate clear and convincing 

reasons for rejecting Plaintiff’s subjective symptom testimony—indeed, the ALJ failed to 

provide any reasons at all, save for the standard boilerplate language that Plaintiff’s 

statements were “not entirely consistent” with the record. The Court further finds that this 

error was not harmless. See Brown-Hunter, 806 F.3d at 494 (“Because the ALJ failed to 

identify the testimony she found not credible, she did not link that testimony to the 

particular parts of the record supporting her non-credibility determination. This was legal 

error.”). Had the ALJ properly considered Plaintiff’s testimony regarding her symptoms 

and limitations, it would have also impacted the ALJ’s RFC finding and the hypothetical 

posed to the VE. See Embrey v. Bowen, 849 F.2d 418, 423 (9th Cir. 1988) (finding VE 

opinion could not be relied on where ALJ failed to provide clear and convincing reasons 

to reject claimant’s testimony and did not include claimant’s subjective limitations in the 

RFC). Thus, this error was harmful because it affected the ultimate nondisability 

determination. See Molina, 674 F.3d at 1115; Brown-Hunter, 806 F.3d at 494 (“[H]ere, we 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 25 of 28
- 26 -

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

cannot discern the agency’s path because the ALJ made only a general credibility finding 

without providing any reviewable reasons why she found [plaintiff’s] testimony to be not 

credible.”).

V. Remedy

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

U.S.C. § 405(g). Absent legal error or a lack of substantial evidence supporting the ALJ’s 

findings, this Court is required to affirm the ALJ’s decision. After considering the record 

as a whole, this Court simply determines whether there is substantial evidence for a 

reasonable trier of fact to accept as adequate to support the ALJ’s decision. Valentine, 574 

F.3d at 690.

“‘[T]he decision whether to remand the case for additional evidence or simply to 

award benefits is within the discretion of the court.’” Rodriguez v. Bowen, 876 F.2d 759, 

763 (9th Cir. 1989) (quoting Stone v. Heckler, 761 F.2d 530, 533 (9th Cir. 1985)). “Remand 

for further administrative proceedings is appropriate if enhancement of the record would 

be useful.” Benecke v. Barnhart, 379 F.3d 587, 593 (9th Cir. 2004). Conversely, remand 

for an award of benefits is appropriate where:

(1) the record has been fully developed and further 

administrative proceedings would serve no useful purpose; (2) 

the ALJ has failed to provide legally sufficient reasons for 

rejecting evidence, whether claimant testimony or medical 

opinion; and (3) if the improperly discredited evidence were 

credited as true, the ALJ would be required to find the claimant 

disabled on remand. 

Garrison v. Colvin, 759 F.3d 995, 1020 (9th Cir. 2014). “Even if those requirements are 

met, though, we retain ‘flexibility’ in determining the appropriate remedy.” Burrell v. 

Colvin, 775 F.3d 1133, 1141 (9th Cir. 2014) (quoting Garrison, 759 F.3d at 1021). 

“[T]he required analysis centers on what the record evidence shows about the 

existence or non-existence of a disability.” Strauss v. Comm’r Soc. Sec. Admin., 635 F.3d 

1135, 1138 (9th Cir. 2011). “Administrative proceedings are generally useful where the 

record has not been fully developed, there is a need to resolve conflicts and ambiguities, or 

the presentation of further evidence may well prove enlightening in light of the passage of 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 26 of 28
- 27 -

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

time.” Treichler v. Comm’r Soc. Sec. Admin., 775 F.3d 1090, 1101 (9th Cir. 2014) (internal 

quotations and citations omitted). “Where there is conflicting evidence, and not all essential 

factual issues have been resolved, a remand for an award of benefits is inappropriate.” Id. 

“In evaluating [whether further administrative proceedings would be useful, the Court 

considers] whether the record as a whole is free from conflicts, ambiguities, or gaps, 

whether all factual issues have been resolved, and whether the claimant’s entitlement to 

benefits is clear under the applicable legal rules.” Id. at 1103–04. “This requirement will 

not be satisfied if ‘the record raises crucial questions as to the extent of [a claimant’s] 

impairment given inconsistencies between his testimony and the medical evidence in the 

record,’ because ‘[t]hese are exactly the sort of issues that should be remanded to the 

agency for further proceedings.’” Brown-Hunter, 806 F.3d at 495 (quoting Treichler, 775 

F.3d at 1105).

Here, the Court finds remand for further administrative proceedings is appropriate. 

The ALJ erred by failing to address Dr. Hassman’s opinion that Plaintiff needed to change 

positions frequently, and the ALJ’s comment regarding Plaintiff’s remote history of optical 

migraines cannot be a legally sufficient reason to assign reduced weight to this portion of 

Dr. Hassman’s opinion. The ALJ also erred by failing to provide clear and convincing 

reasons to discount Plaintiff’s subjective symptom testimony, and specifically failed to 

address why Plaintiff’s statements that she could only sit and stand for short periods of 

time were inconsistent with the record. Because of these errors, the ALJ did not include

any limitations on sitting/standing or the need to change positions in the RFC assessment 

or the hypotheticals posed to the VE. It is thus unclear whether Plaintiff would be able to 

perform any light or sedentary work with a sit/stand option. Consequently, issues remain 

regarding Plaintiff’s RFC and her ability to perform work existing in significant numbers 

in the national economy during the relevant time period. See Hill v. Astrue, 698 F.3d 1153, 

1162–63 (9th Cir. 2012).

This Court offers no opinion as to whether Plaintiff is disabled within the meaning 

of the Act. “The touchstone for an award of benefits is the existence of a disability, not the 

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 27 of 28
- 28 -

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

agency’s legal error.” Brown-Hunter, 806 F.3d at 495. Plaintiff’s RFC and subjective 

symptom testimony are best reassessed in consideration of the entire record, and on remand 

the ALJ shall give further consideration to all of the previously submitted medical 

testimony and lay testimony and continue the sequential evaluation process to determine 

whether Plaintiff is in fact disabled. Additionally, the ALJ is required to consider all of 

Plaintiff’s alleged impairments, whether severe or not, in the assessment on remand. SSR 

86–8p, 1996 WL 374184, at *5 (“In assessing RFC, the adjudicator must consider 

limitations imposed by all of an individual’s impairments, even those that are not 

‘severe.’”). “Viewing the record as a whole [this Court] conclude[s] that Claimant may be 

disabled. But, because the record also contains cause for serious doubt, [the Court] 

remand[s] . . . to the ALJ for further proceedings on an open record.” Burrell, 775 F.3d at 

1142. The Court expresses no view as to the appropriate result on remand.

VI. Conclusion

In light of the foregoing, IT IS HEREBY ORDERED that the Commissioner’s 

decision is remanded back to an ALJ on an open record with instructions to issue a new 

decision regarding Plaintiff’s eligibility for disability insurance benefits. The Clerk of 

Court shall enter judgment accordingly and close its file on this matter.

Dated this 28th day of May, 2020.

Case 4:19-cv-00086-EJM Document 22 Filed 05/29/20 Page 28 of 28