Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_08-cv-01482/USCOURTS-caed-1_08-cv-01482-2/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)

---

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

According to Local Rule 140(a)(1), the child’s name is redacted because his identity is not necessary to the 1

action.

1

IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF CALIFORNIA

D.D.L. M., by and through his guardian ad 

litem, MALLORY WAFER,

Plaintiff, 

vs.

MICHAEL J. ASTRUE,

Commissioner of Social Security,

 

Defendant. 

 

)

)

)

)

)

)

)

)

)

)

)

)

)

)

Case No. 08-cv-1482-JLT 

ORDER DENYING PLAINTIFF’S SOCIAL

SECURITY COMPLAINT (DOC. 1)

ORDER DIRECTING THE ENTRY OF

JUDGMENT FOR DEFENDANT MICHAEL J.

ASTRUE, COMMISSIONER OF SOCIAL

SECURITY, AND AGAINST PLAINTIFF

D.D.L.M.

BACKGROUND

In this action, Plaintiff D.D.L.M. (“Claimant” or “Plaintiff”), is a child who is proceeding 1

through his guardian ad litem Mallory Wafer. Plaintiff seeks judicial review of an administrative

decision of the Commissioner of Social Security (“Commissioner”) denying his claim for child’s

supplemental security income benefits under Title XVI of the Social Security Act (the “Act”). On

October 1, 2008, Plaintiff’s complaint was filed in the United States District Court for the Eastern

District of California. (Doc. 1). Plaintiff filed his opening brief on July 2, 2009. (Doc. 20). The

Commissioner filed his opposition brief on July 23, 2009. (Doc. 21). In October 2008, the parties

Case 1:08-cv-01482-JLT Document 23 Filed 02/12/10 Page 1 of 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

 References to the Administrative Record will be designated as “AR,” followed by the appropriate page

2

number.

2

consented to the jurisdiction of the Magistrate Judge. (Docs. 12, 13)

FACTS AND PRIOR PROCEEDINGS2

On April 20, 2006, Plaintiff filed an application for child’s supplemental security income

benefits under Title XVI of the Act. AR at 85. Plaintiff alleged that he had been under a disability

since his date of birth on May 18, 2005, due to disabling physical problems. Id. After initial denial

of his request for benefits by the Agency, Plaintiff requested a hearing before an Administrative Law

Judge (“ALJ”). Id. at 65. On February 19, 2008, the ALJ held a hearing, and on May 29, 2008,

denied benefits. Id. at 11-24. Specifically, the ALJ found that Plaintiff was not disabled within the

meaning of the Act. Id. at 24. The Appeals Council denied review on July 22, 2008. Id. at 5-7.

Hearing Testimony

The hearing was held on February 19, 2008. AR at 25. Plaintiff, his mother Mallory Wafer,

and his attorney, Melissa Prudian, appeared. Id. 

Plaintiff testified briefly but did not provide any substantive information concerning his

condition. AR at 28-29. Generally, he gave the impression of a happy, healthy child a little less than

three years old. See id. 

Plaintiff’s mother, Mallory Wafer (“Mallory”) was questioned by Plaintiff’s attorney. She

stated that Plaintiff was born prematurely. AR at 30. Plaintiff had surgery when he was two months

old because blood was not flowing properly through his heart valves. Id. at 31. He was also

prescribed medication at that time. Id. 

Ms. Wafer testified that besides a heart murmur he has no other heart problems and is now

receiving checkups only once a year, although previously, he was seen for checkups every 3-6

months. AR at 38. He was last seen by their treating physician, Dr. Walls, in October, 2007. Id. at

41. His next appointment is set for October, 2008. Id. He may have to have additional surgery for

his heart condition when he is about seven years old. Id. at 35. He is not currently taking any

medication. Id. at 34.

Ms. Wafer stated that if Plaintiff “runs around” for more than about 15-20 minutes, he turns

Case 1:08-cv-01482-JLT Document 23 Filed 02/12/10 Page 2 of 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

 Tetralogy of Fallot is heart condition with the following traits: (1) ventricular septal defect (a hole between the 3

ventricles of the heart); (2) obstruction from the right ventricle and the lungs (pulmonary stenosis); (3) the aorta lies

directly over the ventricular septal defect; and (4) the right ventricle develops thickened muscle. See MedicineNet.com,

Definition of Tetralogy of Fallot. The defect causes oxygen-poor blood to be pumped throughout the body but can be

corrected by surgery.

3

bright red and starts sweating and wheezing. AR at 32. This only happens when he is “running

around.” Id. at 33. He also wheezes at night. Id. at 32. He must avoid getting hot because this

makes him sweaty and nauseous. Id. at 33. Besides some breathing trouble, Plaintiff suffers only

“ordinary” ills like cold and flu. Id. at 41.

Ms. Wafer stated that Plaintiff doesn’t usually go to sleep until about 2 a.m., although he is

put to bed usually by about 10 p.m. AR at 37. He consumes more liquids than solid food. Id. at 36. 

He is not currently in preschool because his treating physician, Dr. Walls, recommended that he wait

until his specialist approves it because of the possibility he might pick up germs which could affect

his heart condition. Id. at 33. He likes to watch Happy Feet on television and dances to the music. 

Id. at 38. Ms. Wafer’s mother helps her care for Plaintiff. Id. at 39. Plaintiff’s father lives in the

area and sees him on weekends. Id.

Medical Record

Plaintiff was born on May 18, 2005 and was premature (35 weeks). AR at 188. He had

respiratory distress and required intubation. Id. Doctors determined that he had a heart murmur and

recommended a cardiac consultation. Id.

The same day, Plaintiff was seen by Dr. Kenneth Roillard who determined that the child’s

echocardiograph (“EKG”) revealed a tetralogy of fallot. AR at 189. Plaintiff’s respiratory distress 3

was alleviated with one dose of Surventa. Id. at 185. Dr. Rouillard confirmed his diagnosis of

tetralogy of fallot in a follow-up EKG on June 2, 2005. AR at 177. In light of Plaintiff’s premature

birth, he believed the best course was to delay any corrective surgery for two to three months to

allow Plaintiff to maximize his growth, unless the severity of his pulmonary valve stenosis

worsened. Id. at 175.

On July 26, 2005, cardiologist Dr. Edwin Pedrossian performed corrective surgery on

Plaintiff’s heart. AR at 156-57. Plaintiff tolerated the surgery without complications and Dr.

Case 1:08-cv-01482-JLT Document 23 Filed 02/12/10 Page 3 of 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

4

Rouillard noted in an August 10, 2005 report that his mother stated that he was doing well and was

asymptomatic from a cardiac standpoint. Id. at 136. In his examination, Dr. Rouillard found

Plaintiff to be a healthy, acyanotic infant with no distress, no increased respiratory effort or wheezing

and described his surgical incision as well-healed. Id. at 137. He characterized Plaintiff as

continuing to recover well and was hopeful that his mild residual subvalvar and valvar pulmonary

stenosis would continue to improve. Id.

Notes from a September 27, 2005 examination by Dr. Charlotte Clark-Neitzel of the Sea Mar

Community Health Clinic, recount Plaintiff’s mother describing him as “thriving and feeling well.” 

AR at 200. Dr. Clark-Neitzel noted a smiling, playful baby in no apparent distress. Id.

In a November 17, 2005 follow-up, Dr. Donald Trippel, also with Sea Mar, found no

apparent chronic medical problems and described Plaintiff as “a vigorous-appearing infant” with no

respiratory distress. AR at 198. Although he recounted Plaintiff as having an upper respiratory

infection, he stated that his ventricular function was good with no residual ventricular septal defect,

mild pulmonary valve stenosis and mild to moderate pulmonary insufficiency. Id. at 199. 

Nevertheless he concluded that Plaintiff is “doing well” and believed he would continue to do well

but warned of the possibility for worsening of his stenosis and pulmonary insufficiency, necessitating

a follow-up cardiac exam. Id.

A December 2005, report filed with the Washington State Department of Social Services

(where Plaintiff lived at the time) noted that Plaintiff had a cold with noisy congested breathing but

described his cardiac function and his growth development as normal. AR at 196. A February 2006

report described Plaintiff as “very playful” and noted that he was still “raspy” but had no distress. Id.

at 194. 

In July 2006, consulting expert Dr. De la Rosa, filled out a Childhood Disability Evaluation

Form for the Social Security Administration. Dr. De la Rosa described Plaintiff’s impairment as

“severe” but concluded it did not meet, equal or functionally equal the listings for presumed

disability. AR at 207. Dr. De la Rosa described Plaintiff’s health and physical well-being as “less

than marked” and “s/p surgical repair of acyanotic tetrology of fallot with good growth development

post surgery.” Id. at 210. In January 2007, a “Case Analysis” by another SSA consultant, Dr. M.O.

Case 1:08-cv-01482-JLT Document 23 Filed 02/12/10 Page 4 of 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

5

Nawar, affirmed Dr. De la Rosa’s opinion. Id. at 214, 216.

In June 2006, a report from the Family Care Providers Medical Group, Inc., described

Plaintiff as “well nourished and developed” with no heart murmurs and a regular rhythm and normal

lung function. AR at 229. Follow-up assessment from this organization in September 2006, April

2007 and October 2007, revealed similar findings. See id. at 223, 225 and 227. The April 2007

report noted also that Plaintiff “walks alone fast,” climbs and has a 7-20 word vocabulary. Id. at 225. 

The October 2007 report notes he “runs well,” kicks and throws a ball, plays hide and seek and is

able to put 2-3 words together. Id. at 223.

SCOPE OF REVIEW

Congress has provided a limited scope of judicial review of the Commissioner’s decision to

deny benefits under the Act. In reviewing findings of fact with respect to such determinations, the

Court must determine whether the decision of the Commissioner is supported by substantial

evidence. 42 U.S.C. 405 (g). Substantial evidence means “more than a mere scintilla,” Richardson

v. Perales, 402 U.S. 389, 402 (1971), but less than a preponderance. Sorenson v. Weinberger, 514

F.2d 1112, 1119, n. 10 (9th Cir. 1975). It is “such relevant evidence as a reasonable mind might

accept as adequate to support a conclusion.” Richardson, 402 U.S. at 401. The record as a whole

must be considered, weighing both the evidence that supports and the evidence that detracts from the

Commissioner’s conclusion. Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). In weighing the

evidence and making findings, the Commissioner must apply the proper legal standards. E.g.,

Burkhart v. Bowen, 856 F.2d 1335, 1338 (9th Cir. 1988). This Court must uphold the

Commissioner’s determination that the claimant is not disabled if the Secretary applied the proper

legal standards, and if the Commissioner’s findings are supported by substantial evidence. See

Sanchez v. Sec’y of Health and Human Serv., 812 F.2d 509, 510 (9th Cir. 1987). 

This Court must review the whole record and uphold the Commissioner's determination that

the claimant is not disabled if the Commissioner applied the proper legal standards and if the

Commissioner's findings are supported by substantial evidence. See, Sanchez v. Secretary of Health

and Human Services, 812 F.2d 509, 510 (9th Cir. 1987); Jones v. Heckler, 760 F.2d at 995. If the

Court concludes that the ALJ did not use the proper legal standard, the matter will be remanded to

Case 1:08-cv-01482-JLT Document 23 Filed 02/12/10 Page 5 of 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

A “marked” limitation is one that “interferes seriously with [the child’s] ability to independently initiate,

4

sustain, or complete activities.” 20 CFR 416.926a(e)(2). It means “‘more than moderate’ but ‘less than extreme.”“ Id. On

the other hand, an “extreme” limitations “interferes very seriously with [the child’s] ability to independently initiate,

sustain, or complete activities.” 20 CFR 416.926a(e)(3). It is the rating given to the “worst limitations.” Id.

6

permit application of the appropriate standard. Cooper v. Bowen, 885 F.2d 557, 561 (9 Cir. 1987). th

REVIEW

In determining disability in children with respect to SSI benefits, the SSA will consider

whether the child is performing substantial gainful activity. If not, the SSA must consider whether

an impairment or combination of impairments is severe and if severe, whether the impairments meet,

medically equal, or functionally equal the listings.

Finally, the SSA must determine whether such impairments have lasted, or are expected to

last, for twelve continuous months. 20 C.F.R. §§ 416.923, 416.924(a). If the child’s impairment

meets or functionally equals an impairment in the listings and meets the durational requirement, then

disability is conclusively presumed and benefits are awarded. 20 C.F.R. §§ 416.924(d). If the

impairment does not meet or functionally equal a listed impairment or meet the durational

requirement, then the child is not disabled. 20 C.F.R. § 416.924(d)(2). To determine whether an

impairment or combination of impairments functionally equals any listing, the ALJ was required to

evaluate the child’s ability to acquire and use information, to attend to and complete tasks, to interact

and relate with others, to move about and manipulate objects, to care for himself and the child’s

health and well-being. 20 CFR 416.926a(b)(1)(i)-(vi).. The child must have marked limitations in 4

two of these domains of functioning or an extreme limitation in one domain. Id. 

ALJ Findings

The ALJ evaluated Plaintiff pursuant to the 3-step sequential evaluation for eligibility for

child benefits. After determining that Plaintiff had not engaged in substantial gainful activity (Step

One), he noted at Step Two that Plaintiff’s tetrology of fallot was a“severe” impairment within

Agency regulations. AR at 17. However, at Step Three, he concluded that this impairment did not

meet or equal, or functionally equal the level required under Agency listed impairments. Id. 

In reaching this conclusion, the ALJ addressed Plaintiff’s physical impairment (tetrology of

fallot) under the six domains previously noted. With respect to each of the first five domains, he

Case 1:08-cv-01482-JLT Document 23 Filed 02/12/10 Page 6 of 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

7

concluded that Plaintiff had no limitation resulting from his impairment. AR at 18-23. With respect

to the sixth domain (physical health and well-being), he determined that Plaintiff’s limitation was

“less than marked.” Id. at 23. As a result, he concluded that Plaintiff was not disabled under the

Act. Id. at 24.

DISCUSSION

The ALJ Properly Discounted Mallory Wafer’s Symptom Testimony

Plaintiff, via his guardian ad litem, raises one claim of error on appeal. He contends that the

ALJ improperly discounted the symptom testimony of himself and his mother. (See Doc. 20 at 4-

11). In fact, review of the record shows that Plaintiff, who was not three years old at the time of the

hearing, provided no testimony concerning the degree of his condition or his symptoms. All

testimony in this respect was presented by his mother, Mallory Wafer. A close read of Plaintiff’s

brief shows that it is her symptom testimony that he contends was improperly discounted by the ALJ. 

(See Doc. 20 at 5-11).

Lay witness testimony, such as Mallory Wafer’s, is competent evidence which the

Commissioner must take into account. Dodrill v. Shalala, 12 F.3d 915, 919 (9 Cir. 1993). The ALJ th

may reject the testimony of lay witnesses “only if he gives reasons germane to each witness whose

testimony he rejects.” Id. at 919; see also Smolen v. Chater, 80 F.3d 1273, 1288-89 (9 Cir. 1996). th

Plaintiff does not precisely identify what symptom testimony was rejected by the ALJ. The

ALJ has not specifically identified that testimony either. However, he does state in his decision that

“considering the evidence of record, I find . . . that the statements concerning the intensity,

persistence and limiting effects of the claimant’s symptoms are not entirely credible.” AR at 18. 

The Court notes that at the hearing, Plaintiff’s mother testified that Plaintiff could only run around

for about 15-20 minutes at a time, after which he began to turn red and started to sweat and wheeze. 

Id. at 32. In addition, she stated that she has to keep Plaintiff from getting too hot or he would start

to sweat and become nauseous. Id. at 32-33. Plaintiff contends that in discounting the mother’s

testimony, the ALJ only stated a belief “that the objective medical evidence did not support the level

of limitations Ms. Wafer describes and that the daily activities are inconsistent with disability.” 

(Doc. 20 at 8.) Plaintiff asserts this is an insufficient basis for discounting her testimony.

Case 1:08-cv-01482-JLT Document 23 Filed 02/12/10 Page 7 of 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

8

The Court disagrees. Review of the ALJ’s decision reveals specific, detailed and germane

reasons based on substantial evidence in the record for discounting Ms. Wafer’s symptom testimony

and finding that Plaintiff was not disabled. The ALJ did not merely contend that her symptom

testimony was not supported by objective evidence. He specifically identified evidence to support

this conclusion. 

For instance, the ALJ cited examinations of Plaintiff in 2006 and 2007 indicating that he had

normal growth and development, a 20-word vocabulary, ran well, walked up and down, kicked and

threw a ball and walked alone fast, to support his findings of no limitations with respect to the first

five domains and a “less than marked limitation” with respect to the sixth (physical health and wellbeing). See AR at 223. 225. 227 and 229. Based on his own observation of Plaintiff at the hearing,

he noted that Plaintiff played games such as peek-a-boo and appeared to be a typical two-year old

who was affectionate and interactive and full of life and energy. Id. at 21. He noted that Ms. Wafer

herself indicated that Plaintiff had good mobility and dexterity. He observed also that Plaintiff had

no difficulty walking and jumping up to the bench level at the hearing. Id. at 22. The ALJ further

noted that Plaintiff was able to feed himself and cited Ms. Wafer’s testimony that he was taking no

medications of any kind at the time of the hearing and was not scheduled for another medical

appointment for another eight months, a full year after his last appointment. See id. at 18-19. In

addition, he cited the findings of the two State Agency physicians that Plaintiff had no marked

limitations that would support a finding that his impairment met, equaled or functionally equaled the

listings of impairments. Id. at 19.

Review of the medical evidence supports the ALJ’s findings. In the immediate aftermath of

Plaintiff’s corrective surgery in July, 2005, medical reports indicated that Plaintiff had no

complications, was improving well and that his growth and development were progressing. See AR

at 136-37. Ms. Wafer told a doctor in September 2005, that Plaintiff was “thriving and feeling well.” 

Id. at 200. In follow-up examinations in November and December, 2005, doctors indicated Plaintiff

was a “vigorous appearing infant” who was “doing well” and had no respiratory distress despite his

condition. Id. at 196, 198-99. In February, 2006, a report stated that Plaintiff was “very playful” and

had normal cardiac function with no sign of distress. Id. at 194.

Case 1:08-cv-01482-JLT Document 23 Filed 02/12/10 Page 8 of 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

9

As noted by the ALJ, a July 2006 report prepared for the SSA by a non-examining medical

consultant concluded that Plaintiff’s impairment, although “severe,” did not meet, equal or

functionally equal the listings of impairments required for a finding of disability. AR at 207. 

Another non-examining consultant agreed. Id. at 214, 216. In contrast, Plaintiff has failed to cite any

opinion of a treating, examining or non-examining consulting physician stating that Plaintiff’s

disability was so severe as to compromise his ability to function normally in any of the six domains

analyzed by the ALJ, let alone support the testimony of Ms. Wafer as to his physical limitations. 

Moreover, the fact that Plaintiff takes no medications for his condition, a fact cited by the

ALJ, is supportive of a finding that Ms. Wafer’s symptom testimony is less than credible. See Macri

v. Chater, 93 F.3d 540, 544 (9 Cir. 1996); see also Matthews v. Shalala, 10 F.3d 678, 679-80 (9 th th

Cir. 1993). In fact, the record indicates that Plaintiff’s post-surgery treatment has been conservative

and medical evaluations generally show steady improvement in terms of both growth and

development and a lessening of symptoms. See Parra v. Astrue, 481 F.3d 742, 750-51 (9 Cir 2007) th

(“evidence of ‘conservative treatment’ is sufficient to discount a claimant’s testimony regarding the

severity of an impairment”); Johnson v. Shalala, 60 F.3d 1428, 1434 (9 Cir. 1995) (same): th

Matthews, 10 F.3d at 679 (finding claimant’s symptom testimony incredible in light of the

“conservative” nature of his treatment).

Finally, the Court notes that Ms. Wafer’s testimony is vague and not necessarily inconsistent

with the ALJ’s conclusion that Plaintiff is not disabled. She testified that Plaintiff would become

red-faced, sweaty and wheeze if engaged in strenuous activity for a period of 15-20 minutes and that

if he became hot he would sweat and become nauseous. See AR at 32-33. These rather vague

descriptions, without more, are not necessarily unusual, particularly for a child under age three, nor

are they conclusive of the question of disability. In his brief, Plaintiff fails to identify why these

statements provide evidence supporting a view that his impairment meets or equals the Agency

listings of impairments. Without more, such vague claims are insufficient to overturn the ALJ’s

findings. See Independent Towers of Washington v. Washington, 350 F.3d 925, 929 (9 Cir. 2003) th

(“Beyond its bold assertion, [Plaintiff] provides little if any analysis to assist the court in evaluating

its legal challenge”); Hibbs v. Department of Human Resources, 273 F.3d 844, 873 n. 34 (9 Cir. th

Case 1:08-cv-01482-JLT Document 23 Filed 02/12/10 Page 9 of 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

10

2001) (finding argument too undeveloped to be capable of assessment). 

CONCLUSION

For all these reasons, the Court concludes that the ALJ properly presented germane reasons for

discounting Ms. Wafer’s symptom testimony. Moreover, he has cited substantial evidence in the

record to support his finding that Plaintiff is not disabled under the applicable Agency guidelines. 

Accordingly, the Court DENIES Plaintiff’s appeal from the administrative decision of the

Commissioner of Social Security. The Clerk of Court IS DIRECTED to enter judgment in favor of

Defendant Michael J. Astrue, Commissioner of Social Security and against Plaintiff Dominiq D.L.

Mayberry.

IT IS SO ORDERED.

Dated: February 12, 2010 /s/ Jennifer L. Thurston 

9j7khi UNITED STATES MAGISTRATE JUDGE 

Case 1:08-cv-01482-JLT Document 23 Filed 02/12/10 Page 10 of 10