Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_10-cv-00120/USCOURTS-azd-4_10-cv-00120-0/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)

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IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Debra M. Rose, 

Plaintiff, 

vs.

Michael J. Astrue, 

Defendant. 

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No. CV 10-120-TUC-FRZ (JCG) 

REPORT & RECOMMENDATION

The plaintiff filed this action for review of the final decision of the Commissioner for

Social Security pursuant to 42 U.S.C. §§ 405(g). The case has been referred to the United

States Magistrate Judge pursuant to the Rules of Practice of this Court. 

Pending before the court is an opening brief filed by Plaintiff on August 3, 2010 (Doc.

No. 13), a response brief filed by Defendant on October 4, 2010 (Doc. No. 16) and a reply

filed by Plaintiff on October 19, 2010. (Doc. 17.) 

The Magistrate Judge recommends that the District Court, after its independent

review, remand for further proceedings consistent with this opinion.

BACKGROUND

1. Procedural History

In July, 1997, Plaintiff filed an application for disability insurance benefits, alleging

a disability that began on July 7, 1997. (AR 192-194; 343.) On October 2, 1997, the Social

Security Administration (“SSA”) found Plaintiff to be disabled as of the alleged onset date;

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the onset date was later amended to May 1, 1997. (AR 73.) In February, 2006, SSA notified

Plaintiff that it had determined that she was no longer disabled as of January, 2006 and that

her disability benefits would be terminated in March, 2006. (AR 106-107.) Plaintiff

requested reconsideration of SSA’s decision. (AR 104.) Following a hearing on Plaintiff’s

request for reconsideration, in May, 2007, the Agency reversed its findings and determined

that Plaintiff continued to be disabled. (AR 100.) Based on Plaintiff’s testimony at the

hearing, however, SSA later determined that Plaintiff had engaged in substantial work

activity and was no longer eligible for benefits. (AR 96.) Plaintiff requested reinstatement

of benefits; that request was denied on April 23, 2008. (AR 93.) Plaintiff requested

reconsideration of the decision to deny her request for reinstatement. (AR 20.) On August

25, 2008, SSA issued notice of its decision to affirm cessation of Plaintiff’s disability

benefits effective February 27, 2008. (AR 20.) Plaintiff requested a hearing. (AR 89.) 

A hearing on Plaintiff’s application was held on February 2, 2009 before

Administrative Law Judge (“ALJ”) Lauren R. Mathon. (AR 26.) Plaintiff testified at the

hearing. (AR 20.) The ALJ also heard testimony from Plaintiff’s mother and brother. (AR

24.) On April 8, 2009, the ALJ issued a decision denying Plaintiff’s application. (AR 20-26)

Plaintiff filed a request for review, which the Appeals Council denied on February 2, 2010.

(AR 4-6.) 

On February 24, 2010, Plaintiff filed a complaint in U.S. District Court, appealing the

Commissioner’s final decision denying his application pursuant to 20 C.F.R. §§ 404.981,

416.1481. (Doc. No. 1.) 

2. Claimant’s Work History

Plaintiff was born on February 19, 1959. (AR 192.) She has a high school education

and training in cosmetology. (AR 342.) Plaintiff has worked as a hairdresser, hostess and

waitress. (AR 342.) The administrative record includes evidence demonstrating that

Plaintiff received wages or income from 1987 through 2007. (AR 114-118.) In 2007,

Plaintiff earned $11,639.92. (AR 118.) 

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Plaintiff worked at Shear Performance from approximately February, 2007 until May,

2007, when she fell at work and was injured. (AR 229.) Beginning in July, 2007, Plaintiff

worked part-time as a hairdresser at Cost Cutters. (AR 229.) In August, 2007, Plaintiff

began working at Regis hair salon; evidence in the record indicates that Plaintiff was

employed there until at least February, 2008. (AR 123-124.)

3. Plaintiff’s Medical History

Plaintiff claims that she suffers from bipolar disorder, back and neck pain, memory

problems, numbness, a recent car accident and benign meningioma. (AR 23.)

On August 28, 2007, Dr. Jennifer Lin examined Plaintiff. Plaintiff reported to Dr. Lin

that she had fallen at work and had received chiropractic treatment. (AR 534.) Plaintiff

reported constant pain in her neck. Dr. Lin observed cervical neck sprain and sacroiliac joint

tenderness bilaterally. (AR 534.) Dr. Lin also noted that Plaintiff suffered from bipolar

disorder and had been taking her medication regularly. 

A September, 2007, MRI of Plaintiff’s lumbar spine showed moderate changes at L4-

5 and degenerative disc disease at L5-S1. (AR 539-40.) The MRI radiologist noted that “a

left neural foraminal spondylotic protrusion ... may mildly affect the exiting left L5 nerve

root” and marked disc desiccation at L4-L5. (AR 540.)

In February, 2008, Dr. Lin noted that Plaintiff suffered from depression. (AR 526.)

Dr. Lin observed abnormalities and tenderness in the lumbosacral spine, sacrum and

iliolumbar region. (AR 525.) 

In April, 2008, Dr. Yost, a consultative physician, examined Plaintiff. (AR 517-519.)

Dr. Yost diagnosed Plaintiff with bipolar affective disorder and alcohol abuse in remission.

(AR 518.) He opined that Plaintiff appeared well-stabilized on her medications and that she

was able to manage benefits on her own behalf. (AR 519.) He also opined that Plaintiff’s

bipolar disorder would not impose any limitations over the next 12 months. (AR 519.)

In April, 2008, a non-examining state-agency physician determined that Plaintiff

could perform a range of “light” work. (AR 495-502.) 

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On May 1, 2008, Plaintiff was treated at the emergency room following a minor traffic

accident in which she was rear-ended. (AR 490.) She was diagnosed with neck and back

sprain, right foot pain and right shoulder pain. The emergency room physician noted

Plaintiff’s history of chronic back pain. X-rays revealed mild degenerative arthritis in the

cervical and thoracic regions of the spine. (AR 492.) 

In May, 2008, Dr. Lin examined Plaintiff and observed some tenderness in her

cervical spine as well as abnormalities in the lumbar/lumbosacral spine. Dr. Lin

recommended ibuprofen and physical therapy.

On June 16, 2008, Dr. Lin treated Plaintiff for low back and neck pain. (AR 392.)

Plaintiff reported that ibuprofen helped her pain “a lot.” Dr. Lin noted that Plaintiff did not

have limb weakness or tingling. Dr. Lin observed abnormalities in Plaintiff’s cervical and

lumbar/lumbosacral spine. Dr. Lin recommended that Plaintiff continue to take ibuprofen

and continue her physical therapy. 

On July 2, 2008, Dr. Lin treated Plaintiff for neck and shoulder pain. (AR 388).

Plaintiff reported that she had been feeling manic in the days preceding the appointment.

Plaintiff also reported some memory loss since her traffic accident. Dr. Lin reviewed x-rays

which demonstrated no significant changes in Plaintiff’s back or neck.

On July 16, 2008, a brain CT scan ordered by Dr. Lin revealed that Plaintiff had a

brain tumor. (AR 398.) 

On July 25, 2008, Dr. Lin reviewed the CT results with Plaintiff and recommended

an MRI and follow-up with a neurosurgeon. Dr. Lin noted that Plaintiff continued to suffer

back pain, depression and cervical strain. (AR 386.) 

On July 29, 2008, Dr. Estes, a state agency physician, evaluated Plaintiff’s mental

condition. He opined that Plaintiff was moderately limited in the ability to understand and

remember details instructions, the ability to carry out detailed instructions, the ability to

maintain attention and concentration for extended periods and the ability to complete a

normal workday without interruption. (AR 430-432.) He found no other significant

limitations in Plaintiff’s abilities. He further opined that Plaintiff retained the ability to

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understand, remember and carry out one- and two- step instructions and that Plaintiff could

meet the basic mental requirements of competitive, remunerative, unskilled work on a

sustained basis. 

On August 8, 2008, Dr. Schroeder, a neurologist, examined Plaintiff and

recommended surgery to remove Plaintiff’s brain tumor. (AR 403.) Plantiff’s brain tumor

was removed in August, 2008. (AR 883.) 

On August 13, 2008, Dr. Lin examined Plaintiff and observed no abnormalities in her

spine and normal affect. (AR 380.)

On September 13, 2008, Dr. Shroeder saw Plaintiff for post-operative follow-up. He

observed that Plaintiff was a little tired and emotional but doing well physically. (AR 887.)

At another post-operative follow-up on September 18, 2008, Dr. Schroeder observed that

Plaintiff was continuing to do well and her fatigue had improved. (AR 886.) 

On December 8, 2008, Dr. Lin examined Plaintiff and observed that Plaintiff was

having headaches and some left arm weakness. (AR 851.) Dr. Lin recommended ibuprofen

and physical therapy.

A follow-up MRI on December 18, 2008 revealed no residual recurrent tumor in

Plaintiff’s brain. (AR 881-882.) 

On January 26, 2009, at her well woman examination of Plaintiff, Dr. Lin observed

that Plaintiff’s judgment, insight and memory were normal and that Plaintiff exhibited a calm

mood and normal affect. (AR 848.) 

On August 13, 2009, Dr. Rohen conducted a psychological evaluation of Plaintiff and

completed a Medical Source Statement on Plaintiff’s behalf. (1033-35.) Plaintiff scored a

27 out of 30 on the mini mental status exam. Dr. Rohen opined that Plaintiff suffered from

moderate to severe bipolar disorder and generalized anxiety disorder. Dr. Rohen also opined

that Plaintiff’s psychiatric conditions would impact her ability to work, that Plaintiff’s

impairment was mild to moderate and that Plaintiff was capable of minor workplace changes.

On November 23, 2009, Plaintiff was again referred to Dr. Rohen as part of SSA’s

disability determination. (AR 893-897.) Plaintiff scored a 27 out of 30 on the mini mental

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status exam. Dr. Rohen opined that Plaintiff suffered from moderate to severe bipolar

disorder and generalized anxiety disorder. Dr. Rohen further opined that Plaintiff would not

have difficulty in basic interactions with supervisors or coworkers and that Plaintiff was

capable of minor workplace changes. (AR 897.)

Between August, 2008 and November 17, 2009, Plaintiff received treatment at

CODAC Behavioral Health Services. (AR 857-882.) Plaintiff was diagnosed with bipolar

disorder, alcohol dependence and nicotine dependence. (AR 864.) CODAC records indicate

Plaintiff was taking Lamictal, a mood stabilizer. Her case manager reported that Plaintiff

was classified as Seriously Mentally Ill due to her bipolar disorder. (AR 844.) 

4. Plaintiff’s Testimony

At her February 2, 2009 hearing, Plaintiff testified that she normally does her own

household cleaning, shopping and driving. (AR 1049-50.) She enjoys art and writing poetry.

(AR 1065.) Plaintiff testified that her bipolar disorder was mostly stabilized by medication

but that she was unable to work full time because of her chronic back pain. (AR 1054.) She

testified that she has episodes of depression or manic episodes that prevent her from working.

(AR 1054-55.) Plaintiff testified that she had recently had a relapse of alcohol abuse but was

currently attending AA meetings. (AR 1056.) Plaintiff opined that she could sit for only a

couple of hours without back pain. (AR 1061.) Plaintiff testified that she had weakness and

pain in her arms as a result of her brain surgery. (AR 1063.) Plaintiff testified that she had

worked part-time as a hairdresser for many years and that she limited the number of hours

that she worked in order to continue to qualify for disability benefits. (AR 1084-1087.)

Plaintiff further testified that she was searching for employment. (AR 1097.)

CLAIM EVALUATION

Continued entitlement to Social Security disability benefits must be reviewed

periodically. See 20 C.F.R. § 404.1594(a). A claimant's disability will be found to have

ended if it is shown that medical improvement related to the claimant's ability to do work has

occurred, and the claimant is currently able to engage in substantial gainful activity. See 20

C.F.R. § 404.1594(a), (b)(3). Medical improvement is any decrease in the medical severity

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1 Residual functional capacity is defined as that which an individual can still do despite her

limitations. 20 C.F.R. § 404.1545.

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of a claimant's impairment(s) which was present at the time of the most recent favorable

medical decision that the claimant was disabled. See 20 C.F.R. § 404.1594(b)(1). A

determination that there has been a decrease in medical severity must be based on changes

(improvement) in the symptoms, signs and/or laboratory findings associated with the

claimant's impairment(s). See id. Medical improvement is related to a claimant's ability to

work if there has been a decrease in the severity as defined in paragraph (b)(1), and an

increase in the claimant's functional capacity to perform basic work activities. See 20 C.F.R.

§ 404.1594(b)(3). 

A continuing disability evaluation consists of eight steps. At step one, the ALJ

evaluates whether a claimant is engaging in substantial gainful activity. § 404.1594(f)(1).

If so, then the claimant is no longer disabled and benefits will be terminated. Id. If the

claimant is not engaged in substantial gainful activity, the ALJ proceeds to step two, which

requires a determination of whether the claimant has an impairment or combination of

impairments which meets or equals the severity of an impairment listed in 20 C.F.R. pt. 404,

subpt. P, app 1, 20 C.F.R. § 404.1594(f)(2). If so, the disability will be found to continue.

If not, the ALJ proceeds to step three of the analysis: whether there has been medical

improvement in the impairment or impairments that were previously disabling. See 20

C.F.R. § 404.1594(f)(3). If the claimant has had medical improvement, the ALJ determines

at step four of the analysis whether the medical improvement is related to the ability to work,

i.e., whether there has been an increase in the residual functional capacity1

 based upon the

impairment(s) present at the time of the most recent favorable medical determination. See

20 C.F.R. § 404.1594(f)(4). If no medical improvement is shown or if medical improvement

is not related to the ability to work, the ALJ proceeds to step five and examines whether

certain exceptions apply. See 20 C.F.R. § 404.1594(f)(5). At step six, if medical

improvement related to the ability to work is shown, the ALJ determines whether all of the

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claimant's current impairments in combination are “severe” such that they significantly limit

the claimant’s physical or mental ability to do basic work activities See 20 C.F.R. §

404.1594(f)(6). If not, the claimant is no longer disabled. If so, claim evaluation proceeds

to the next step. At step seven, the ALJ evaluates whether the claimant is currently able to

perform substantial gainful activity by performing his or her past relevant work in light of

his or her residual functional capacity. See 20 C.F.R. § 404.1594(f)(7). If not, the ALJ

proceeds to step eight, determining whether the claimant is currently able to perform

substantial gainful activity by performing other work in light of his or her residual functional

capacity. See 20 C.F.R. § 404.1594(f)(8).

THE ALJ’S FINDINGS

The ALJ analyzed Plaintiff’s claim of disability according to the eight-step procedure.

At step one of the analysis, the ALJ found that Plaintiff had engaged in periods of substantial

gainful activity between1997 and 2007. (AR 22.) The ALJ noted that Plaintiff had worked

as a hairdresser on a steady basis and had earned $11,639.92 in 2007, an amount exceeding

the presumptive amount for SGA. (AR 22.) The ALJ determined that cessation of Plaintiff’s

benefits could be affirmed at step one of the analysis based on Plaintiff’s work history, but

went on to consider Plaintiff’s medical records as well. At step two of the analysis, the ALJ

found that Plaintiff’s impairments did not meet or equal the severity of a listed impairment.

(AR 23.) At step three of the analysis, the ALJ concluded that medical improvements had

occurred. (AR 23.) At step four, the ALJ concluded that the medical improvements were

related to Plaintiff’s ability to work. The ALJ then concluded at step seven that Plaintiff had

the residual functional capacity to perform light work, including her past relevant work as

a hairdresser.

STANDARD OF REVIEW

An individual is entitled to SSI disability benefits if he or she demonstrates, through

medically acceptable clinical or laboratory standards, an inability to engage in substantial

gainful activity due to a physical or mental impairment that can be expected to last for a

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continuous period of at least twelve months. 42 U.S.C. § 1382c(a)(3)(A). “A claimant will

be found disabled only if the impairment is so severe that, considering age, education, and

work experience, that person cannot engage in any other kind of substantial gainful work

which exists in the national economy.” Penny v. Sullivan, 2 F.3d 953, 956 (9th Cir. 1993)

(quoting Marcia v. Sullivan, 900 F.2d 172, 174 (9th Cir. 1990)).

To establish a prima facie case of disability, the claimant must demonstrate an

inability to perform his or her former work. Gallant v. Heckler, 753 F.2d 1450, 1452 (9th

Cir. 1984) (citing Maounis v. Heckler, 738 F.2d 1032, 1034 (9th Cir.1984)). Once the

claimant meets that burden, the Commissioner must come forward with substantial evidence

establishing the claimant is not disabled. Fife v. Heckler, 767 F.2d 1427, 1429 (9th Cir.

1985).

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 if it is not supported

by substantial evidence or it is based on legal error.” Matney v. Sullivan, 981 F.2d 1016,

1019 (9th Cir. 1992) (citation omitted). The Commissioner’s determination that a claimant

is not disabled must be upheld if the Commissioner applied the proper legal standards and

the record as a whole contains substantial evidence to support the decision. Clem v. Sullivan,

894 F.2d 328, 330 (9th Cir. 1990) (citations omitted). Substantial evidence is defined as

“such relevant evidence as a reasonable mind might accept as adequate to support a

conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971) (citation omitted); Winans v.

Bowen, 853 F.2d 643, 644 (9th Cir. 1987). The standard is “less than a preponderance” of

the evidence standard. See Matney, 981 F.2d at 1019. 

“[I]f the evidence can support either outcome, the court may not substitute its

judgment for that of the ALJ.” Matney, 981 F.2d at 1019. When applying the substantial

evidence standard, however, the court should not mechanically accept the Commissioner’s

findings but should review the record critically and thoroughly. Day v. Weinberger, 522 F.2d

1154, 1156 (9th Cir. 1975). Reviewing courts must consider the evidence that supports as

well as detracts from the Commissioner’s conclusion. Id. A denial of benefits will be set

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2 The term “physician” includes psychologists and other health professionals who are not

medical doctors. Lester v. Chater, 81 F.3d 821, 830 n.7 (9th Cir. 1995). 

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aside if the Commissioner fails to apply proper legal standards in weighing the evidence even

though the findings may be supported by substantial evidence. Frost v. Barnhart, 314 F.3d

359, 367 (9th Cir. 2002); Benitez v. Califano, 573 F.2d 653, 655 (9th Cir. 1978).

In evaluating evidence to determine whether a claimant is disabled, the opinion of a

treating physician2

 is entitled to great weight. Ramirez v. Shalala, 8 F.3d 1449, 1453-54 (9th

Cir. 1993) (citations omitted). The Commissioner may reject a treating physician’s

uncontradicted opinion only if he sets forth clear and convincing reasons for doing so. Lester

v. Chater, 81 F.3d 821, 830 (9th Cir. 1995) (citing Baxter v. Sullivan, 923 F.2d 1391, 1396

(9th Cir.1991)); Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989). If the treating

physician’s opinion is contradicted by another doctor, the Commissioner may reject that

opinion only if he provides specific and legitimate reasons supported by substantial evidence

in the record. Lester, 81 F.3d at 830 (citing Murray v. Heckler, 722 F.2d 499, 502 (9th

Cir.1983)). No distinction is drawn “between a medical opinion as to a physical condition

and a medical opinion on the ultimate issue of disability.” Rodriguez v. Bowen, 876 F.2d

759, 761 n.7 (9th Cir. 1989). 

When medical reports are inconclusive, questions of credibility and resolution of

conflicts in the testimony are functions solely of the Commissioner. Magallanes, 881 F.2d

at 751 (citations omitted). The Commissioner’s finding that a claimant is less than credible,

however, must have some support in the record. See Light v. Soc. Sec. Admin., 119 F.3d 789,

792-93 (9th Cir. 1997).

DISCUSSION

Plaintiff challenges the ALJ’s decision on six grounds: (1) Substantial evidence does

not support the ALJ’s finding that Plaintiff engaged in substantial gainful activity; (2) the

ALJ did not follow the prescribed method in determining whether Plaintiff’s mental

impairment met or equaled a listed impairment; (3) the ALJ’s finding that Plaintiff could

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3 A trial work period is a period in which a claimant is permitted to attempt to return to work

without losing his/her disability benefits. See 20 C.F.R. § 404.1592.

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perform her past relevant work as a hairdresser was not supported by substantial evidence;

(4) the ALJ failed to properly evaluate Dr. Estes’ July 2008 opinion; (5) the August, 2009

report of Dr. Rohen, submitted to the Appeals Council, demonstrates that the ALJ's decision

is not supported by substantial evidence, and (6) the ALJ mischaracterized Plaintiff’s MRI.

1. Substantial evidence does not support the ALJ’s finding that Plaintiff engaged

in substantial gainful activity

At step one of the analysis, the ALJ found that Plaintiff had engaged in periods of

substantial gainful activity between1997 and 2007, and therefore the cessation of Plaintiff’s

benefits could be affirmed on the ground that Plaintiff had completed a trial work period3

 and

was able to work. See 20 C.F.R. § 404.1594(f)(1). Plaintiff contends that the ALJ erred in

making this finding because it was not supported by an adequately developed record. The

Magistrate agrees. 

At step one of the analysis, the ALJ may affirm cessation of benefits upon a showing

that the claimant is “currently engaging in substantial gainful activity.” See C.F.R. §

40.1594(d)(5). The ALJ did not make any factual findings regarding work being performed

by Plaintiff as of her February 27, 2008 cessation date. Instead, the ALJ noted that Plaintiff

had “worked every year from 1997 through 2007 . . . worked as a hairdresser on a steady

basis ... did not always have earnings at the SGA level . . . [and] earned $11,639.92 in 2007.”

(AR 22.) The ALJ did not make any findings with respect to Plaintiff’s “current” ability to

work. If the ALJ intended to presume Plaintiff’s ability to work based on her earnings, the

ALJ was required to evaluate Plaintiff’s earnings over her period of work. See 20

C.F.R. §404.1574(b) (requiring ALJ to divide a claimant’s earnings over the months worked

and determine whether the average exceeds the amount set by regulation). The ALJ also

failed to consider evidence suggesting that Plaintiff’s 2007 earnings were the result of an

“unsuccessful work attempt,” ie. work lasting for a period of 6 months or less before the

claimant’s impairment forced him/her to stop working or to reduce the amount of work

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he/she performed such that his/her earnings from such work fall below the substantial gainful

activity earnings level.

2. The ALJ did not follow the prescribed method in determining whether Plaintiff’s

mental impairment met or equaled a listed impairment

When a claimant has a medically determinable mental impairment, the ALJ is required

to rate the degree of the claimant’s functional limitation by assessing four broad functional

areas: activities of daily living; social functioning; concentration, persistence, or pace; and

episodes of decompensation (“the B-criteria”). See 20 C.F.R. § 404.1520a(c)(3). The ALJ

is required to rate the degree of limitation in the first three functional areas (activities of daily

living; social functioning; and concentration, persistence, or pace), using a five-point scale:

none, mild, moderate, marked, and extreme. See 20 C.F.R. § 404.1520a(c)(4). The ALJ is

required to rate the degree of limitation in the fourth functional area (episodes of

decompensation), using a four-point scale: none, one or two, three, four or more. Id. The

last point on each scale represents a degree of limitation that is incompatible with the ability

to do any gainful activity. Id. The ALJ is also required to complete a standard document to

record how the ALJ applied the technique. See 20 C.F.R. § 404.1520a(e). 

At step two of the analysis, the ALJ found that Plaintiff’s bipolar disorder was a

medically determinable mental impairment, but that Plaintiff’s mental impairment did not

meet or equal the severity of a listed impairment. (AR 23.) However, the ALJ did not

engage in any of the analysis required by 20 C.F.R. § 404.1520a. With respect to Plaintiff’s

bipolar disorder, the ALJ noted only that:

. . . claimant underwent another consultative psychological evaluation in

which she was found to be stable on her medications; have no limitations

expected to last 12 months; and have a GAD in the 71-80 range, which is

consistent with an individual with no more than slight impairment in any area

of psychological functioning ... CODAC notes August 2008 through January

2009 reflect stability in claimant’s mental condition on her medication regimen

with a GAF of 65, indicative of mild symptoms.

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The ALJ then concluded “the claimant’s impairments as of February 27, 2008, did not meet

or medically equal a listing.” The ALJ did not rate the degree of the claimant’s functional

limitation and does not appear to have completed the standard document required by 20

C.F.R. § 404.1520a(e). 

3. The ALJ’s finding that Plaintiff could perform her past relevant work as a

hairdresser was not supported by substantial evidence

“The decision as to whether the claimant retains the functional capacity to perform

past work which has current relevance has far-reaching implications and must be developed

and explained fully in the disability decision. Since this is an important and, in some

instances, a controlling issue, every effort must be made to secure evidence that resolves the

issue as clearly and explicitly as circumstances permit.” SSR 82-62; see Pinto v. Massanari,

249 F.3d 840, 844 n.3 (9th Cir. 2001) (Social Security Rulings and Acquiescence Rulings are

binding on all components of the Social Security Administration). The ALJ must evaluate

either: (1) the actual functional demands and job duties of a particular past relevant job; or

(2) the functional demands and job duties of the occupation as generally required by

employers throughout the national economy. See SSR 82-61. This requires specific findings

as to the claimant's residual functional capacity, the physical and mental demands of the past

relevant work, and the relation of the residual functional capacity to the past work. See SSR

82-62.

In the present case, the ALJ concluded, based on the medical records provided by

Plaintiff’s treating and examining physicians, that Plaintiff had the residual functional

capacity to perform light work. (AR 24-25.) However, the ALJ failed to make any specific

findings regarding the physical and mental demands of Plaintiff’s past relevant work as a

hairdresser, either as actually performed or as generally required. Generally, an ALJ looks

to either the Dictionary of Occupational Titles (“DOT”) or vocational-expert testimony for

evidence of those demands. See SSR 00-4p; SSR 82-62; SSR 82-61. The ALJ did not cite

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4 Defendant suggests that the ALJ implicitly relied on the DOT at step seven of the analysis.

(Doc. 16, pgs. 33-34.) There is nothing in the ALJ’s decision to support this assumption. 

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either the DOT or a vocational expert.4

 In addition, pursuant to 20 C.F.R. § 404.1565, when

evaluating a claimant’s ability to perform past relevant work, the ALJ is required to ask the

claimant about “the dates you worked, all of the duties you did, and any tools, machinery,

and equipment you used . . . the amount of walking, standing, sitting, lifting and carrying you

did during the work day, as well as any other physical or mental duties of your job.” Review

of the transcript indicates that the ALJ did not gather any information from Plaintiff during

the hearing regarding Plaintiff’s past relevant work as a hairdresser. (AR 1044-1074.)

The Magistrate further notes that the ALJ failed to comply with SSR 82-62's

requirement that the ALJ make specific factual findings regarding the relation of the residual

functional capacity to the past work.

4. The ALJ failed to properly evaluate Dr. Estes’ July 2008 opinion

As part of her analysis at step seven, the ALJ concluded that Plaintiff had the residual

functional capacity to perform light work. The ALJ’s conclusion was supported by

Plaintiff’s testimony, which the ALJ found not fully credible, the April, 2008 opinion of a

non-examining state-agency physician (AR 495-502) and the opinions of treating and

examining psychologists. (AR 25.) Plaintiff contends that the ALJ erred in failing to

consider the July, 2008 opinion of Dr. Estes, a state agency physician who opined that

Plaintiff retained the ability to understand, remember and carry out one- and two- step

instructions and that Plaintiff could meet the basic mental requirements of competitive,

remunerative, unskilled work on a sustained basis. The Magistrate agrees.

Although an ALJ is not bound by findings made by State agency or other program

physicians and psychologists, an ALJ may not ignore these opinions and must explain the

weight given to the opinions in their decisions. See SSR 96-6p. The ALJ made no mention

of Dr. Estes’ conclusion that Plaintiff’s residual functional capacity was limited to unskilled,

rather than light work. Thus, the ALJ did not satisfy the regulatory requirement that she

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5 Plaintiff also argued that the Appeals Council failed to consider the November, 2009 report

of Dr. Rohen. However, it does not appear that the November, 2009 report was ever submitted to

the Appeals Council. (AR 7 (listing the additional evidence received by the Appeals Council)). See

Brown v. Astrue, 2009 WL 2998938, *6 (D. Ariz. 2009) (district court may only consider evidence

which was submitted to the Appeals Council). 

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acknowledge the medical evidence and opinions of state agency physicians and explain the

weight given to them.

5. The ALJ should consider the August, 2009 report of Dr. Rohen, submitted to the

Appeals Council, on remand5

Plaintiff contends that the August, 2009 report of Dr. Rohen, which was submitted to

the Appeals Council, confirms that substantial evidence does not support the ALJ’s residual

functional capacity assessment. Dr. Rohen opined that Plaintiff was capable of adapting to

minor workplace changes; Plaintiff contends that this opinion demonstrates that Plaintiff does

not have the residual functional capacity to perform light work. The Appeals Council

considered Dr. Rohen’s report and concluded that it did not provide a basis for changing the

ALJ’s decision. 

Where the Appeals Council considered evidence not previously presented to the ALJ,

the Court may consider such evidence on review. See Lingenfelter v. Astrue, 504 F.3d 1028,

1030 n. 2 (9th Cir.2007) (considering on appeal both the ALJ's decision and the additional

material submitted to the Appeals Council); Harman v. Apfel, 211 F.3d 1172, 1180 (9th

Cir.2000) (recognizing that “[w]e properly may consider the additional materials because the

Appeals Council addressed them in the context of denying Appellant's request for review”

and remanding for further proceedings); Ramirez v. Shalala, 8 F.3d 1449, 1452 (9th Cir.

1449, 1452 (“we consider on appeal both the ALJ's decision and the additional material

submitted to the Appeals Council.”). However, the Court should decline to consider

Plaintiff’s argument that evidence submitted to the Appeals Council demonstrates that the

ALJ’s decision was not supported by substantial evidence. As stated in Harman v. Apfel, 211

F.3d at 1180:

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While we properly may consider the additional evidence presented to the

Appeals Council in determining whether the Commissioner's denial of benefits

is supported by substantial evidence, it is another matter to hold on the basis

of evidence that the ALJ has had no opportunity to evaluate that Appellant is

entitled to benefits as a matter of law. The appropriate remedy in this situation

is to remand this case to the ALJ; the ALJ may then consider, the

Commissioner then may seek to rebut and the VE may answer questions with

respect to the additional evidence.

This Report and Recommendation concludes that this case should be remanded to the ALJ

for further findings consistent with this opinion. On remand, the ALJ should also be

instructed to consider the August, 2009 report of Dr. Rohen. 

6. The ALJ did not mischaracterize Plaintiff’s MRI.

At step seven, in assessing Plaintiff’s residual functional capacity, the ALJ concluded

that Plaintiff’s testimony regarding the severity her back and neck pain was in conflict with

the medical evidence because “claimant’s treating and examining physicians consistently

characterized the impairments as ‘minimal,’ ‘mild,’ ‘slight,’ ‘normal’ and ‘unremarkable’

with reference to the clinical and laboratory findings.” (AR 25.) Plaintiff contends that this

conclusion was not supported by substantial evidence because Plaintiff’s September, 2007,

MRI showed moderate changes at L4-5 and marked disc desiccation at L4-L5. (AR 539-40.)

The court may overturn the decision to deny benefits “only if it is not supported by

substantial evidence or it is based on legal error.” Matney, 981 F.2d at 1019. Although

Plaintiff’s MRI suggested moderate/marked abnormalities in Plaintiff’s spine, there was

substantial evidence to support the ALJ’s findings that Plaintiff’s back and neck pain was not

as severe as she reported. Dr. Lin prescribed only ibuprofen for Plaintiff’s back pain, and

Plaintiff reported to Dr. Lin that ibuprofen helped “a lot.” (AR 392.) In July, 2007, medical

records document that Plaintiff’s neck and back were “non-tender.” (AR 551.) Dr. Lin

observed that Plaintiff had a straight back with no costoverterbral angle tenderness on

December 3, 2007. (AR 529.) A May 1, 2008 x-ray of Plaintiff’s spine showed only “mild”

degenerative arthritis in both the cervical and lumbar regions. (AR 492-93.) Plaintiff had

no lumbar tenderness during a May, 2008 examination by Dr. Lin. (AR 395.) Dr. Lin also

observed that Plaintiff’s cervical spine was non-tender at examinations between June and

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December, 2008. (AR 392, 385, 381, 854, 850.) Because there is adequate evidence to

support the ALJ’s conclusion that Plaintiff’s neck/back pain was mild, the Court cannot

overturn the ALJ’s decision on this ground.

RECOMMENDATION

For the foregoing reasons, the Magistrate Judge recommends that the District Court,

after its independent review, enter an order REMANDING for further proceedings consistent

with this report. 

Pursuant to 28 U.S.C. § 636(b), any party may file and serve written objections within

fourteen (14) days after being served with a copy of this Report and Recommendation. If

objections are not timely filed, the party’s right to de novo review may be waived. See

United States v. Reyna-Tapia, 328 F.3d 1114, 1121 (9th Cir.2003) (en banc), cert. denied, 540

U.S. 900 (2003). If objections are filed, the parties should direct them to the District Court

by using the following case number: CV 10-120-TUC-FRZ.

The Clerk of the Court is directed to send a copy of this Report and Recommendation

to all parties.

DATED this 4th day of November, 2010.

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