Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_18-cv-01059/USCOURTS-caed-1_18-cv-01059-6/pdf.json

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

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UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

Martha Franco asserts she is entitled to supplemental security income under Title XVI of the 

Social Security Act. Plaintiff seeks judicial review of the decision to deny benefits, arguing the 

administrative law judge erred in evaluating the medical record. Because the ALJ erred in evaluating 

the record related to Plaintiff’s mental impairments, the matter is REMANDED for further proceedings 

pursuant to sentence four of 42 U.S.C. § 405(g).

BACKGROUND

In May 2014, Plaintiff filed her application for benefits, alleging disability due to her mental 

condition, diabetes, high blood pressure, arthritis, gastritis, left breast pain, incontinence, and a heart 

murmur. (Doc. 10-7 at 4; Doc. 10-8 at 6) The Social Security Administration denied the application at 

the initial level and upon reconsideration. (See generally Doc. 10-4) Plaintiff requested a hearing and 

testified before an ALJ on April 4, 2017. (See Doc. 10-3 at 11, 30) The ALJ determined Plaintiff was 

not disabled under the Social Security Act and issued an order denying benefits on August 1, 2017. (Id.

MARTHA FRANCO,

 Plaintiff,

v.

COMMISSIONER OF SOCIAL SECURITY,

Defendant.

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Case No.: 1:18-cv-1059 - JLT

ORDER REMANDING THE ACTION PURSUANT 

TO SENTENCE FOUR OF 42 U.S.C. § 405(g)

ORDER DIRECTING ENTRY OF JUDGMENT IN 

FAVOR OF MARTHA FRANCO AND AGAINST 

DEFENDANT, THE COMMISSIONER OF 

SOCIAL SECURITY

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at 11-22) Plaintiff filed a request for review of the decision with the Appeals Council, which denied her

request on June 6, 2018. (Id. at 2-4) Therefore, the ALJ’s determination became the final decision of 

the Commissioner of Social Security. 

STANDARD OF REVIEW

District courts have a limited scope of judicial review for disability claims after a decision by 

the Commissioner to deny benefits under the Social Security Act. When reviewing findings of fact, 

such as whether a claimant was disabled, the Court must determine whether the Commissioner’s 

decision is supported by substantial evidence or is based on legal error. 42 U.S.C. § 405(g). The 

ALJ’s determination that the claimant is not disabled must be upheld by the Court if the proper legal 

standards were applied and the findings are supported by substantial evidence. See Sanchez v. Sec’y of 

Health & Human Serv., 812 F.2d 509, 510 (9th Cir. 1987).

Substantial evidence is “more than a mere scintilla. It means such relevant evidence as a 

reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 

389, 401 (1971) (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197 (1938)). The record as a whole 

must be considered, because “[t]he court must consider both evidence that supports and evidence that 

detracts from the ALJ’s conclusion.” Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). 

DISABILITY BENEFITS

To qualify for benefits under the Social Security Act, Plaintiff must establish she is unable to 

engage in substantial gainful activity due to a medically determinable physical or mental impairment 

that has lasted or can be expected to last for a continuous period of not less than 12 months. 42 U.S.C. 

§ 1382c(a)(3)(A). An individual shall be considered to have a disability only if:

his physical or mental impairment or impairments are of such severity that he is not only 

unable to do his previous work, but cannot, considering his age, education, and work 

experience, engage in any other kind of substantial gainful work which exists in the 

national economy, regardless of whether such work exists in the immediate area in 

which he lives, or whether a specific job vacancy exists for him, or whether he would be 

hired if he applied for work. 

42 U.S.C. § 1382c(a)(3)(B). The burden of proof is on a claimant to establish disability. Terry v. 

Sullivan, 903 F.2d 1273, 1275 (9th Cir. 1990). If a claimant establishes a prima facie case of disability, 

the burden shifts to the Commissioner to prove the claimant is able to engage in other substantial 

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gainful employment. Maounis v. Heckler, 738 F.2d 1032, 1034 (9th Cir. 1984).

ADMINISTRATIVE DETERMINATION

To achieve uniform decisions, the Commissioner established a sequential five-step process for 

evaluating a claimant’s alleged disability. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The process 

requires the ALJ to determine whether Plaintiff (1) is engaged substantial gainful activity, (2) had 

medically determinable severe impairments (3) that met or equaled one of the listed impairments set 

forth in 20 C.F.R. § 404, Subpart P, Appendix 1; and whether Plaintiff (4) had the residual functional 

capacity to perform to past relevant work or (5) the ability to perform other work existing in significant 

numbers at the state and national level. Id. The ALJ must consider testimonial and objective medical 

evidence. 20 C.F.R. §§ 404.1527, 416.927. 

Pursuant to this five-step process, the ALJ determined Plaintiff had not engaged in substantial 

gainful activity since her application date of May 19, 2014. (Doc. 10-3 at 13) Second, the ALJ found 

Plaintiff’s severe impairments included: “major depression with psychotic features, adjustment disorder 

with depressed mood, anxiety disorder, antisocial personality disorder, and posttraumatic stress 

disorder.” (Id.) The ALJ noted Plaintiff also alleged physical impairments, but found they were not 

severe. (Id. at 13-14) 

At step three, the ALJ determined Plaintiff’s impairments did not meet or medically equal a 

Listing. (Doc. 10-3 at 15) Next, the ALJ found:

[T]he claimant has the residual functional capacity to perform a full range of work 

at all exertional levels but with the following nonexertional limitations: limited to 

simple and routine tasks and needs a cane to ambulate for more than 30 minutes.

(Id. at 16) At step four, Plaintiff did not have past relevant work for the ALJ to evaluate with this 

residual functional capacity. (See id. at 21) However, at step five the ALJ found “there are jobs that 

exist in significant numbers in national economy that the claimant can perform.” (Id.) Thus, the ALJ 

concluded Plaintiff was not disabled as defined by the Social Security Act from May 19, 2014, through 

the date of the decision. (Id. at 22)

DISCUSSION AND ANALYSIS

Plaintiff argues the ALJ erred at step two by finding her physical impairments were not severe. 

(Doc. 16 at 14-15) In addition, Plaintiff asserts the ALJ erred in reviewing the opinions related to her 

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mental limitations and rejecting the limitations identified by her treating physician. (Id. at 10-14) The 

Commissioner argues the ALJ properly evaluated the medical evidence and requests that the Court 

affirm the decision. (See generally Doc. 23 at 4-13)

A. Plaintiff’s Physical Impairments and the Step Two Findings

The inquiry at step two is a de minimus screening “to dispose of groundless claims.” Smolen v. 

Chater, 80 F.3d 1273, 1290 (9th Cir. 1996), citing Bowen v. Yucket, 482 U.S. 137, 153-54 (1987)). The 

purpose is to identify claimants whose medical impairment makes it unlikely they would be disabled 

even if age, education, and experience are considered. Bowen, 482 U.S. at 153. A claimant must make 

a “threshold showing” (1) she has a medically determinable impairment or combination of impairments 

and (2) the impairment or combination of impairments is severe. Id. at 146-47; see also 20 C.F.R. § 

416.920(c). Thus, the burden of proof is on the claimant to establish a medically determinable severe 

impairment that significantly limits her physical or mental ability to do basic work activities, or the 

“abilities and aptitudes necessary to do most jobs.” 20 C.F.R. § 416.921(a). 

Plaintiff argues the ALJ erred by finding her “leg length discrepancy, plantar fasciitis, and 

lumbar spine pain [were] non-severe.” (Doc. 16 at 14) Plaintiff asserts:

Dr. Tobigo-On and Dr. Herr both opined that Plaintiff is limited to less than a full 

range of sedentary work with a limitation to a maximum sitting of less than six hours, 

maximum lifting of ten pounds, and two hours combined standing and walking. Ar. 

429, 522.

The ALJ rejected these assessments as inconsistent with normal examination findings 

noted by these physicians. Ar. 13. 

(Doc. 16 at 15) According to Plaintiff, “the ALJ’s conclusion is not supported by substantial record 

evidence, because he merely picked and chose through only the normal findings which support his 

assessment, while ignoring significantly more evidence of abnormal findings that are consistent with 

the physicians’ assessments.” (Id.) Specifically, Plaintiff asserts, “the ALJ ignored X-Ray, MRI, and 

range of motion testing evidence that shows significant abnormalities.” (Id., citing AR 481, 637, 691, 

and 698 [Doc. 10-10 at 90; Doc. 10-12 at 56, 110; Doc. 10-13 at 4])

The Commissioner argues the ALJ properly determined Plaintiff’s physical impairments were 

not severe at step two. (Doc. 23 at 10-11) The Commissioner observes that Plaintiff did not identify 

leg length discrepancy, plantar fasciitis, or lumbar spine pain as impairments in her application, yet “the 

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ALJ still considered Plaintiff’s physical impairments and noted she used a cane during the hearing.” 

(Id. at 11) In addition, the Commissioner asserts that, contrary to Plaintiff’s assertion, “The ALJ 

discussed imaging evidence regarding Plaintiff’s leg length discrepancy in that her right leg is shorter 

than the left leg, mild to moderate face joint degeneration in the lower lumbar spine and mild tendinosis 

in the right hip.” (Id. citing AR 13, 481, 483, 691 [Doc. 10-3 at 14; Doc. 10-10 at 90, 92; Doc. 10-12 at 

110]) According to the Commissioner, “As the ALJ noted, there was very little objective support based 

on the physical examinations during the relevant period, including full muscle strength and normal 

sensation that supported their assessments.” (Id. at 12) 

1. Evidence considered by the ALJ

As an initial matter, the Court notes that AR 637—which Plaintiff asserts includes imagining or 

range of motion testing (Doc. 16 at 15)— does not include any objective signs or clinical findings. 

Instead, the exhibit includes only a list of Plaintiff’s medication history as of June 25, 2015. (See Doc. 

10-12 at 54) Thus, this exhibit does not support Plaintiff’s assertion that “[t]he ALJ ignored X-Ray, 

MRI, and range of motion testing evidence...” In addition, the exhibits identified by Plaintiff do not 

include any range of motion testing that the ALJ failed to address. (See Doc. 10-10 at 90; Doc. 10-12 at 

56, 110; Doc. 10-13 at 4)

Moreover, contrary to Plaintiff’s assertion, the ALJ clearly addressed the imagining stating: 

“[D]iagnostic imaging revealed a leg length discrepancy, with the right leg shorter than the left leg, as 

well as mild to moderate facet joint degeneration in the lower lumbar spine and mild tendinosis in the 

right hip.” (Doc. 10-3 at 14) Despite these findings, the ALJ noted that Plaintiff’s “examinations 

revealed only an abnormal gait and paralumbar tenderness throughout the relevant period.” (Id.) Thus, 

Plaintiff fails to show the ALJ ignored probative evidence related to her physical impairments at step 

two of the evaluation.

2. Rejection of the opinions of Drs. Tabigo-On and Herr

Plaintiff contends the ALJ erred in rejecting the opinions of Drs. Tobigo-On and Herr, who 

“opined that Plaintiff is limited to less than a full range of sedentary work with a limitation to a 

maximum sitting of less than six hours, maximum lifting of ten pounds, and two hours combined 

standing and walking.” (Doc. 16 at 15) 

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Notably, a physician’s opinion is not binding upon the ALJ, and may be discounted whether it is 

contradicted by another physician. Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989). An ALJ 

may reject an uncontradicted opinion of a treating or examining medical professional only by 

identifying a “clear and convincing” reason. Lester v. Chater, 81 F.3d 821, 831 (9th Cir. 1996). In 

contrast, a contradicted opinion of a treating or examining professional may be rejected for “specific 

and legitimate reasons that are supported by substantial evidence in the record.” Id., 81 F.3d at 830. 

When there is conflicting medical evidence, “it is the ALJ’s role to determine credibility and to resolve 

the conflict.” Allen v. Heckler, 749 F.2d 577, 579 (9th Cir. 1984). Here, the opinions of Drs. TobigoOn and Herr conflicted with the opinions of Drs. Sachdeva, De la Rosa, and Bobba. (See Doc. 10-3 at 

14) Thus, the ALJ was required to set forth specific and legitimate reasons for rejecting the limitations, 

supported by substantial evidence in the record. 

The ALJ indicated he gave “little weight” to the opinions of Drs. Tabigo-On and Herr “because 

they are inconsistent with the examination findings as noted by both [physicians]...” (Doc. 10-3 at 14)

Importantly, an ALJ may reject the limitations identified by a physician where they are inconsistent 

with the record, including the physician’s own findings. See Connett v. Barnhart, 340 F.3d 871, 875 

(9th Cir. 2003) (opinion properly rejected where physician’s own findings do not support the opinion); 

see also Khounesavatdy v. Astrue, 549 F. Supp. 2d 1218, 1229 (E.D. Cal. 2008) (“it is appropriate for 

an ALJ to consider... the inconsistency of conclusions with the physician’s own findings, in rejecting a 

physician’s opinion”). The ALJ found “although the claimant presented with an abnormal gait and 

paralumbar tenderness throughout the relevant period, she exhibited otherwise normal findings, 

including full muscle strength and normal sensation.” (Doc. 10-3 at 14) Because the ALJ identified

clinical findings that were inconsistent with the limitations identified by Drs. Herr and Tabiago, the 

ALJ identified a legally sufficient reason to reject their conclusions.

3. Substantial evidence supports the ALJ’s determination

Plaintiff contends the ALJ’s reported error in reviewing the evidence at step two resulted in a 

physical residual functional capacity that is “not supported by substantial record evidence.” (Doc. 16 at 

15) The Commissioner maintains there was “no ALJ error in the RFC regarding her physical 

limitations.” (Doc. 23 at 13)

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The term “substantial evidence” “describes a quality of evidence ... intended to indicate that the 

evidence that is inconsistent with the opinion need not prove by a preponderance that the opinion is 

wrong.” SSR 96-2p, 1996 SSR LEXIS 9 at *8. “It need only be such relevant evidence as a reasonable 

mind would accept as adequate to support a conclusion that is contrary to the conclusion expressed in 

the medical opinion.” Id. Previously, this Court explained: “The role of this Court is not to second 

guess the ALJ and reevaluate the evidence, but rather it must determine whether the decision is 

supported by substantial evidence and free of legal error.” Gallardo v. Astrue, 2008 WL 4183985 at 

*11 (E.D. Cal. Sept. 10, 2008); see also German v. Comm’r of Soc. Sec., 2011 WL 924737 at *3 (E.D. 

Cal. Mar. 14, 2011) (explaining “[i]t is not for this court to reevaluate the evidence”).

The ALJ indicated he gave “great weight” to the opinion of Dr. Mickey Sachdeva, who 

performed a consultative examination in December 2016. (See Doc. 10-3 at 14) Dr. Sachdeva found 

Plaintiff did not exhibit any muscle spasms and had “no tenderness to palpation in the midline or 

paraspinal areas” in her back. (Doc. 10-10 at 24) In addition, he found Plaintiff had a negative straight 

leg test, and her range of motion in her spine was within normal limits. (Id.) Dr. Sachdeva determined 

Plaintiff had a reduced range of motion in her hips with forward flexion, abduction, and adduction; but 

a normal range in her hips with backward extension, internal rotation, and external rotation. (Id.) He 

opined Plaintiff had “good active motion” and her motor strength was “5/5 in all extremities.” (Id. at 

25) Dr. Sachdeva noted Plaintiff’s senses were grossly intact and Plaintiff had normal reflexes. (Id.) 

Further, he observed that Plaintiff’s gait was “[w]ithin normal limits.” (Id.) Dr. Sachdeva concluded 

Plaintiff could lift and carry 50-100 pounds occasionally and up to 50 pounds frequently; ambulate 

without a cane or other assistive device; continuously balance and stoop; and frequently climb, kneel, 

crouch, and crawl.” (Id. at 26) Dr. Sachdeva also opined, “In a total eight hour work day she can sit for 

eight hours, stand for six hours and walk for six hours due to right hip pain.” (Id.) Notably, these 

limitations were based upon Dr. Sachdeva’s own “objective clinical findings” (id. at 25), and findings 

from an examining physician that “rest[] on independent examination” constitute substantial evidence); 

Orn v. Astrue, 495 F.3d 625, 632 (9th Cir. 2007) (when an examining physician provides independent 

clinical findings, such findings are substantial evidence).

Likewise, the ALJ’s physical RFC is supported by the opinions of Drs. De la Rosa and Bobba, 

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non-examining physicians who reviewed the record and determined Plaintiff “does not have a severe 

physical impairment.” (Doc. 10-3 at 14, citing Exh. 1A, p.9; Exh. 3A, p. 7 [Doc. 10-4 at 10, 22]) The 

ALJ gave these opinions “great weight.” (Id.) Because these opinions are consistent with the 

conclusions of Dr. Sachdeva—who did not identify any functional limitations with sitting, standing, or 

walking— these opinions are also substantial evidence to support of the RFC identified by the ALJ. 

See Tonapetyan, 242 F.3d 1149 (the opinions of non-examining physicians “may constitute substantial 

evidence when ... consistent with other independent evidence in the record”). 

Consequently, substantial evidence supports the ALJ’s determination at step two that Plaintiff’s 

physical impairments are not severe, as well as the corresponding physical RFC, which included a 

limitation for a cane to give Plaintiff the benefit of the doubt, despite the fact that “none of the available 

medical evidence indicates that the claimant requires a cane for ambulation.” (See Doc. 10-3 at 13)

B. Evaluation of Dr. Morales’ Opinion and Plaintiff’s Mental Impairments

Plaintiff asserts that “[t]he ALJ erred in weighing the medical opinion evidence concerning 

Plaintiff’s mental limitations.” (Doc. 16 at 10) Plaintiff asserts “the ALJ improperly rejected the 

opinions of Plaintiff’s treating provider, Dr. Morales.” (Id. at 11) Because the limitations identified by 

Dr. Morales were contradicted by the findings of other physicians, the ALJ was required to identify 

specific and legitimate reasons to support his findings. Lester, 81 F.3d at 830.

In addressing the medical evidence related to Plaintiff’s mental impairments and the opinions 

from Dr. Morales, the ALJ observed:

The record reflects a history of major depressive disorder (Ex.3F). In late April 2014, the 

claimant presented to Jean Luckman, a clinical social worker, and Ramon Garcia, M.D., 

with the California Department of Corrections and Rehabilitation, for an initial evaluation 

after her release from prison (Exs.5F/7, 8; 13F/4, 5). She indicated that she had been

taking Zoloft and reported symptoms of poor sleep, crying all the time, and feelings of 

desperation; Dr. Garcia continued the claimant’s use of Zoloft and started her on 

buspirone and trazodone for treatment of her major depression (Ex.5F/8). The claimant 

followed up with Ms. Luckman in late May 2014 and asserted she took her medications 

with good results (Ex.5F/6). Ms. Luckman noted that the claimant presented as stable, 

oriented, and alert (Ex.5F/6).

Several weeks later, in mid-June 2014, the claimant met with Eduardo R. Morales, M.D., 

with California Department of Corrections and Rehabilitation and stated that she was 

unable to sleep with her current medication combination (Ex.13F/l). She described her 

mood as “very sad and crying,” endorsed auditory hallucinations in the form of an 

intelligible voice calling her name, and stated that she experienced recurrent distressing 

memories related to her time in prison with intense psychological reactions, persistent 

avoidance of stimuli, and recurrent distressing dreams (Ex.13F/1, 2). The claimant 

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further reported symptoms of increased irritability, anhedonia, high anxiety level, and 

normal energy level (Ex.13F/l ). A mental status examination revealed normal 

psychomotor activity; full orientation; full affect; sad, tearful, and anxious demeanor; 

impaired concentration; normal speech; hypervigilance; generally goal directed thought 

processes; racing thoughts; paranoid delusions; no preoccupations, and impaired insight 

and judgment (Ex.13F/l, 2). Dr. Morales diagnosed the claimant with major depression 

with psychotic features as well as PTSD, and he increased the doses of Zoloft and 

trazodone (Ex.13F/l).

The claimant continued to meet with Dr. Morales from July 2014 through February 2017, 

during which time her complaints included difficulty sleeping, depression, tearfulness, 

irritability, easily angered, anxiety, paranoia, and feeling sedated (Exs.13F/6-48; 23F). 

Based on these complaints, Dr. Morales adjusted the claimant's medication regimen at 

almost every visit; she asserted that an adjustment had improved her symptoms but would 

then complain at the next visit that her symptoms had again worsened. Mental status 

examinations conducted between July 2014 and February 2017 revealed findings nearly 

identical to those noted by Dr. Morales during the June 2014 visit, with the only major 

changes being the claimant’s lack of reported hallucinations as of July 2014 and her 

reported mood, which varied between depressed, improved, and happy.

...

Dr. Morales opined from June 2014 to May 2016 that the claimant could not seek 

employment and could not work full time or with a modified schedule (Exs.13F; 23F/l7). Between June 2016 and February 2017, Dr. Morales did not specifically opine that the 

claimant could not work; however, he consistently opined that her anxiety level was so 

high that task completion was impaired, her mood was so unstable that any attempt at 

supervision could lead to emotion decompensation, and her concentration was very 

impaired (Ex.23F/8-22). In November 2014 and December 2016, Dr. Morales opined 

that the claimant had moderate to marked limitation in nearly all areas of understanding 

and memory, sustained concentration and persistence, social interaction, and adaptation 

(Exs. l7F, 21).

(Doc. 10-3 at 18-19) 

The ALJ indicated he gave “little weight to all of Dr. Morales’s opinions because none of them 

is consistent with his treatment notes, which reflect only conservative mental health treatment with 

medication and improvement of symptoms with medication.” (Doc. 10-3 at 19, citing Exhs. 13F and 

23F) In addition, the ALJ found “that Dr. Morales’s opinions are highly inconsistent with the findings 

and opinions of Dr. Cohn, who examined the claimant only several months after she began treatment 

with Dr. Morales, as well as with those of Dr. Michiel, who examined the claimant only one month 

prior to Dr. Morales’s most recent examination in February 2017.” (Id., citing Exhs. 8F, 11F)

1. Treatment provided

This Court and others have determined treatment such as Plaintiff received—including 

continual adjustments to her medication, as acknowledged by the ALJ—may not be characterized as

conservative mental health treatment. See, e.g., Williams v. Berryhill, 2018 WL 4204798 at *4 (E.D. 

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Cal. Aug. 31, 2018) (finding it “not apparent that mental health treatment that includes psychotropic 

medications and treatment from a psychiatrist is conservative”); Gentry v. Colvin, 2013 2013 WL 

6185170 at *12 (E.D. Cal. Nov. 26, 2013) (observing that prescription mental health treatment “is not 

conservative in the same manner as over the counter [medication]” and finding no evidence that the 

claimant’s prescription medication was conservative); Wyatt v. Colvin, 2016 WL 6102335 at *6 (C.D. 

Cal. Oct. 19, 2016) (“a mental health medication regimen, involving numerous variations of 

medications and treatment and spanning multiple years is not fairly characterized as ‘conservative 

care.’”). As the ALJ acknowledged, Plaintiff was prescribed various medications, including Zoloft, 

buspirone, and trazodone; and Dr. Morales “adjusted the claimant’s medication regimen at almost every 

visit” from July 2014 through February 2017. (See Doc. 10-3 at 19) Thus, it is not clear the treatment 

Plaintiff received was conservative, and the treatment provided did not support the ALJ’s decision to 

give less weight to the opinions of Dr. Morales.

2. Effectiveness of treatment

The ALJ indicates that he gave less weight to the opinion of Dr. Morales in part because 

Plaintiff showed “improvement of symptoms with medication.” (Doc. 10-3 at 19, citing Exhs. 13F and 

23F) Thus, the ALJ implies that the opinions of Dr. Morales are inconsistent with his own treatment 

notes. However, the ALJ failed to cite specific evidence supporting the conclusion that Plaintiff’s 

symptoms improved. Instead, the ALJ cited broadly to approximately 70 pages of treatment notes, 

without identifying any clinical findings or observations from Dr. Morales regarding Plaintiff’s mental 

status. (See Doc. 10-10 at 42-89 [Exh. 13F]; Doc. 10-13 at 13-22 [Exh. 23F]) This is inadequate to 

satisfy the ALJ’s burden to “set[] out a detailed and thorough summary of the facts and conflicting 

clinical evidence, stating his interpretation thereof, and making findings.” See Cotton v. Bowen, 799 

F.2d 1403, 1408 (9th Cir. 1986). 

The ALJ’s own summary of the record indicates that Plaintiff’s improvements waxed and 

waned, as Plaintiff “asserted that an adjustment had improved her symptoms but would then complain 

at the next visit that her symptoms had again worsened”—and Dr. Morales continued to make 

medication adjustments. (Doc. 10-3 at 18) Thus, the ALJ fails to show the effectiveness of Plaintiff’s 

mental health treatment was specific and legitimate reason to give less weigh to the limitations 

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identified by Dr. Morales.

3. Inconsistency with the record

The ALJ gave less weight to the opinions of Dr. Morales upon finding they were “highly 

inconsistent with the findings and opinions of Dr. Cohn, who examined the claimant only several 

months after she began treatment with Dr. Morales, as well as with those of Dr. Michiel, who examined 

the claimant only one month prior to Dr. Morales’s most recent examination in February 2017.” (Doc. 

10-3 at 19, citing Exhs. 8F, 11F)

Significantly, when an ALJ believes the conclusions of a physician are contradicted by other 

evidence in the record, he has a burden to specifically identify the conflicting evidence. See Cotton v. 

Bowen, 799 F.2d at 1408. The Ninth Circuit explained, (“The ALJ must do more than offer his 

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

are correct.” Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998). For example, an ALJ may also 

discount the opinion of a treating physician by identifying an examining physician’s findings to the 

contrary and identifying the evidence that supports that finding. See, e.g., Creech v. Colvin, 612 F. 

App’x 480, 481 (9th Cir. 2015). 

The ALJ failed meet this burden because he did not identify the specific clinical findings or the 

objective evidence that he believed conflicted with the limitations identified by Dr. Morales. Instead, 

the ALJ merely offered his conclusion that the findings from Drs. Cohn and Morales conflicted with 

those from Plaintiff’s treating psychiatrist. The Court is unable to review the findings of the 

physicians to cure this defect in the ALJ’s analysis. See Ortiz v. Colvin, 2016 WL4992674, at *7 (E.D. 

Cal. Sept. 19, 2016) (“It is not sufficient for the ALJ simply to state that evidence and opinions exist 

that are contrary to the treating doctor’s opinion, leaving it to the court to dig around through the 

record in search of the unidentified evidence and opinions”). Consequently, the purported 

inconsistencies with the opinions of the examining physicians do not support the ALJ’s decision to 

give less weight to the limitations identified by Dr. Morales.

C. Remand is Appropriate

The decision whether to remand a matter pursuant to sentence four of 42 U.S.C. § 405(g) or to 

order immediate payment of benefits is within the discretion of the district court. Harman v. Apfel, 

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211 F.3d 1172, 1178 (9th Cir. 2000). Except in rare instances, when a court reverses an administrative 

agency determination, the proper course is to remand to the agency for additional investigation or 

explanation. Moisa v. Barnhart, 367 F.3d 882, 886 (9th Cir. 2004) (citing INS v. Ventura, 537 U.S. 

12, 16 (2002)). Generally, an award of benefits is directed when:

(1) the ALJ has failed to provide legally sufficient reasons for rejecting such 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. 

Smolen v. Chater, 80 F.3d 1273, 1292 (9th Cir. 1996). In addition, an award of benefits is directed 

where no useful purpose would be served by further administrative proceedings, or where the record is 

fully developed. Varney v. Sec’y of Health & Human Serv., 859 F.2d 1396, 1399 (9th Cir. 1988). 

The ALJ failed to resolve conflicts in the record related to Plaintiff’s mental impairments and 

residual functional capacity. The failure to properly reject limitations by Plaintiff’s treating physician 

was not “inconsequential to the ultimate nondisability determination.” See Molina v. Astrue, 674 F.3d 

1104, 1115 (9th Cir. 2012). Accordingly, the matter should be remanded for the ALJ to re-evaluate the 

medical evidence and determine Plaintiff’s residual functional capacity. See Moisa, 367 F.3d at 886.

CONCLUSION AND ORDER

For the reasons set for above, the Court finds the ALJ erred in evaluating the medical evidence, 

and the administrative decision should not be upheld by the Court. See Sanchez, 812 F.2d at 510.

Accordingly, the Court ORDERS:

1. The matter is REMANDED pursuant to sentence four of 42 U.S.C. § 405(g) for further 

proceedings consistent with this decision; and

2. The Clerk of Court is DIRECTED to enter judgment in favor of Plaintiff Martha Franco, 

and against Defendant, the Commissioner of Social Security.

IT IS SO ORDERED.

Dated: March 20, 2020 /s/ Jennifer L. Thurston 

UNITED STATES MAGISTRATE JUDGE

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