Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_15-cv-00269/USCOURTS-azd-2_15-cv-00269-0/pdf.json

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

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WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Russell Lee Frigon, 

Plaintiff, 

v. 

Carolyn W. Colvin, 

Defendant.

No. CV-15-00269-PHX-DGC

ORDER 

Plaintiff Russell Lee Figon seeks review under 42 U.S.C. § 405(g) of the final 

decision of the Commissioner of Social Security, which denied him disability insurance 

benefits and supplemental security income under sections 216(i), 223(d), and 

1614(a)(3)(A) of the Social Security Act. Because the decision of the Administrative 

Law Judge (“ALJ”) is generally supported by substantial evidence and not based on legal 

error, the decision will be generally affirmed. Because the ALJ entirely failed to address 

one issue, however, the Court will remand for further proceedings on that issue. 

I. Background. 

Plaintiff is a 52 year old male who previously worked as a hair stylist and retail 

store manager. A.R. 29. On September 21, 2011, Plaintiff applied for disability 

insurance benefits and supplemental security income, alleging disability beginning 

May 15, 2011. A.R. 18. On October 1, 2013, he appeared with his attorney and testified 

at a hearing before an ALJ. Id. A vocational expert also testified. Id. On October 31, 

2013, the ALJ issued a decision that Plaintiff was not disabled within the meaning of the 

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Social Security Act. A.R. 18. The Appeals Council denied Plaintiff’s request for review 

of the hearing decision, making the ALJ’s decision the Commissioner’s final decision. 

See A.R. 1. 

II. Legal Standard. 

The district court reviews only those issues raised by the party challenging the 

ALJ’s decision. See Lewis v. Apfel, 236 F.3d 503, 517 n.13 (9th Cir. 2001). The court 

may set aside the Commissioner’s disability determination only if the determination is 

not supported by substantial evidence or is based on legal error. Orn v. Astrue, 495 F.3d 

625, 630 (9th Cir. 2007). Substantial evidence is more than a scintilla, less than a 

preponderance, and relevant evidence that a reasonable person might accept as adequate 

to support a conclusion considering the record as a whole. Id. In determining whether 

substantial evidence supports a decision, the court must consider the record as a whole 

and may not affirm simply by isolating a “specific quantum of supporting evidence. Id. 

As a general rule, “[w]here the evidence is susceptible to more than one rational 

interpretation, one of which supports the ALJ’s decision, the ALJ’s conclusion must be 

upheld.” Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002) (citations omitted). 

Harmless error principles apply in the Social Security Act context. Molina v. 

Astrue, 674 F.3d 1104, 1115 (9th Cir. 2012). An error is harmless if there remains 

substantial evidence supporting the ALJ’s decision and the error does not affect the 

ultimate nondisability determination. Id. The claimant usually bears the burden of 

showing that an error is harmful. Id. at 1111. 

III. The ALJ’s Five-Step Evaluation Process. 

To determine whether a claimant is disabled for purposes of the Social Security 

Act, the ALJ follows a five-step process. 20 C.F.R. § 404.1520(a). The claimant bears 

the burden of proof on the first four steps, but the burden shifts to the Commissioner at 

step five. Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). 

At the first step, the ALJ determines whether the claimant is engaging in 

substantial gainful activity. 20 C.F.R. § 404.1520(a)(4)(i). If so, the claimant is not 

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disabled and the inquiry ends. Id. At step two, the ALJ determines whether the claimant 

has a “severe” medically determinable physical or mental impairment. 

§ 404.1520(a)(4)(ii). If not, the claimant is not disabled and the inquiry ends. Id. At step 

three, the ALJ considers whether the claimant’s impairment or combination of 

impairments meets or medically equals an impairment listed in Appendix 1 to Subpart P 

of 20 C.F.R. Pt. 404. § 404.1520(a)(4)(iii). If so, the claimant is automatically found to 

be disabled. Id. If not, the ALJ proceeds to step four. At step four, the ALJ assesses the 

claimant’s residual functional capacity and determines whether the claimant is still 

capable of performing past relevant work. § 404.1520(a)(4)(iv). If so, the claimant is not 

disabled and the inquiry ends. Id. If not, the ALJ proceeds to the fifth and final step, 

where he determines whether the claimant can perform any other work based on the 

claimant’s residual functional capacity, age, education, and work experience. 

§ 404.1520(a)(4)(v). If so, the claimant is not disabled. Id. If not, the claimant is 

disabled. Id. 

At step one, the ALJ found that Plaintiff met the insured status requirements of the 

Social Security Act through December 31, 2012, and that he had not engaged in 

substantial gainful activity during the period from his alleged onset date through his date 

last insured. A.R. 20. At step two, the ALJ found that Plaintiff had the following severe 

impairments: Human Immunodeficiency Virus (“HIV”), degenerative disc disease of the 

cervical spine, and arthritis. Id. At step three, the ALJ determined that Plaintiff did not 

have an impairment or combination of impairments that met or medically equaled an 

impairment listed in Appendix 1 to Subpart P of 20 C.F.R. Pt. 404. A.R. 23. At step 

four, the ALJ found that Plaintiff had the residual functional capacity to perform the full 

range of light work (as defined in 20 C.F.R. § 404.1567(b)), including his past relevant 

work as a hair stylist or store manager. A.R. 23, 29. The ALJ did not reach step five. 

IV. Analysis. 

Plaintiff argues the ALJ’s disability determination was defective for two reasons: 

(1) the ALJ improperly rejected the medical opinions of Plaintiff’s medical sources, and 

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(2) the ALJ erred in failing to consider Reiter’s Syndrome as a severe impairment. The 

Court will address each argument below. 

A. Weighing of Medical Source Evidence. 

Plaintiff argues that the ALJ improperly discounted the medical opinions of Dr. 

Drew A. Kovach, Dr. Thanes Vanig, and Dr. Brent B. Geary. 

1. Legal Standard. 

The Commissioner is responsible for determining whether a claimant meets the 

statutory definition of disability, and need not credit a physician’s conclusion that the 

claimant is “disabled” or “unable to work.” 20 C.F.R. § 416.927(d). But the 

Commissioner generally must defer to a physician’s medical opinion, such as statements 

concerning the nature or severity of the claimant’s impairments, what the claimant can do 

despite the impairments, and the claimant’s physical or mental restrictions. 

§ 416.927(a)(2). 

In determining how much deference to give a physician’s medical opinion, the 

Ninth Circuit distinguishes between the opinions of treating physicians, examining 

physicians, and non-examining physicians. See Lester v. Chater, 81 F.3d 821, 830 (9th 

Cir. 1995). Generally, an ALJ should give the greatest weight to a treating physician’s 

opinion and more weight to the opinion of an examining physician than to one of a nonexamining physician. See Andrews v. Shalala, 53 F.3d 1035, 1040-41 (9th Cir. 1995); 

see also 20 C.F.R. § 404.1527(c)(2)-(6) (listing factors to be considered when evaluating 

opinion evidence, including length of examining or treating relationship, frequency of 

examination, consistency with the record, and support from objective evidence). 

If a treating or examining physician’s medical opinion is not contradicted by 

another doctor, the opinion can be rejected only for “clear and convincing” reasons. 

Lester, 81 F.3d at 830 (citation omitted). Under this standard, the ALJ may reject a 

treating or examining physician’s opinion if it is “conclusory, brief, and unsupported by 

the record as a whole[] or by objective medical findings,” Batson v. Commissioner, 359 

F.3d 1190, 1195 (9th Cir. 2004), or if there are significant discrepancies between the 

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physician’s opinion and her clinical records. See Bayliss v. Barnhart, 427 F.3d 1211, 

1216 (9th Cir. 2005). 

When a treating or examining physician’s opinion is contradicted by another 

doctor, it can be rejected “for specific and legitimate reasons that are supported by 

substantial evidence in the record.” Lester, 81 F.3d at 830-31 (citation omitted). This 

standard requires the ALJ to set out “a detailed and thorough summary of the facts and 

conflicting clinical evidence, stating his interpretation thereof, and making findings.” 

Cotton v. Bowen, 799 F.2d 1403, 1408 (9th Cir. 1986). Under either standard, “[t]he 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.” Embrey v. Bowen, 849 F.2d 418, 

421-22 (9th Cir. 1988). 

2. Drew A. Kovach, M.D. 

Dr. Kovach has treated Plaintiff for HIV since June 2003, consulting with Plaintiff 

every three to four months. A.R. 895. On November 3, 2011, Dr. Kovach completed 

two medical evaluations. In the first, Dr. Kovach indicated that Plaintiff suffered from 

Acquired Immune Deficiency Syndrome (AIDS), diarrhea, fatigue, depression, and 

anxiety, and that these conditions produced symptoms including physical weakness, 

decreased muscle strength, and decreased sensation in his hands. A.R. 895-96. Dr. 

Kovach stated that Plaintiff was limited to walking one city block at a time, sitting for 

thirty minutes at one time, standing for forty-five minutes at a time, sitting for a total of 

less than two hours in an eight hour day, standing and walking for less than two hours in 

an eight hour day, and reaching, handling, and fingering less than ten percent of the day. 

A.R. 896-97. Dr. Kovach further opined that Plaintiff would need a job that permitted 

him to walk around every ninety minutes for at least fifteen minutes, to elevate his feet 

above the heart with prolonged sitting, to shift positions at will, to use a cane to stand and 

walk, and to take four unscheduled breaks during the day. A.R. 897. 

/ / / 

/ / / 

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In his second evaluation, Dr. Kovach reported that Plaintiff suffered from several 

additional conditions, including HIV Wasting Syndrome,1

 diarrhea lasting for over one 

month,2

 and HIV Encephalopathy characterized by cognitive dysfunction. A.R. 901. Dr. 

Kovach opined that Plaintiff suffered marked limitations of daily living, marked 

difficulties in maintaining social functioning, and marked difficulties in completing tasks 

in a timely manner due to deficiencies in concentration, persistence, or pace. A.R. 902. 

The ALJ concluded that Dr. Kovach’s evaluations were entitled to “no weight.” 

A.R. 27. The ALJ found the evaluations to be “wildly exaggerated” and “inconsisten[t] 

with the last three years of the claimant’s treatment and the claimant’s report of daily 

activities.” A.R. 28. The ALJ stated that the evaluations were inconsistent with 

Plaintiff’s unremarkable blood work, stable viral load, and report of daily activities. Id. 

The ALJ also found discrepancies between the evaluations and Dr. Kovach’s clinical 

records, including notes for Plaintiff’s October 27, 2011 consultation stating that Plaintiff 

had “no complaints” and “no health concerns at the present time,” id. (citing A.R. 349), 

and notes from Plaintiff’s May, 16, 2011 consultation stating that Plaintiff had no 

complaints, no abdominal pain, and no change in bowel habits or consistency, A.R. 24 

(citing A.R. 352). Finally, the ALJ found that Dr. Kovach’s opinion was contradicted by 

two medical consultants for the Arizona Office of Disability Determination Services 

(“DDS”) – Dr. Mikhail Bargan, a non-examining physician, and Dr. Galluci, a nonexamining psychologist. See A.R. 28, 27; see also A.R. 119 (opinion of Dr. Gargan), 

A.R. 101-02 (opinion of Dr. Galluci). 

 

1

 The evaluation defined this condition as “characterized by involuntary weight loss of ten percent or more of baseline (or other significant involuntary weight loss) and, in the absence of a concurrent illness that could explain the findings, involving: chronic diarrhea with two or more loose stools daily lasting for one month or longer; or chronic weakness and documented fever greater than 38°C (100.4°F) for the majority of one month or longer.” A.R. 901. 

2

 The evaluation defined this condition as “[d]iarrhea, lasting for one month or longer, resistant to treatment, and requiring intravenous hydration, intravenous alimentation, or tube feeding.” A.R. 901. 

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Because Dr. Kovach’s medical opinion was contradicted by another doctor, the 

Court must determine whether the ALJ offered “specific and legitimate” reasons for 

rejecting Dr. Kovach’s medical opinion.3

 Under this standard, the ALJ can reject a 

treating or examining physician’s opinion if there are significant discrepancies between 

the physician’s opinion and his or her clinical records. See Bayliss v. Barnhart, 427 F.3d 

1211, 1216 (9th Cir. 2005). The ALJ reasonably concluded that such discrepancies are 

present here. For example, although Dr. Kovach indicated in his second evaluation that 

Plaintiff suffered from HIV Wasting Syndrome, diarrhea lasting for over one month, and 

HIV Encephalopathy characterized by cognitive dysfunction, Dr. Kovach’s clinical notes 

contain no mention of these conditions. See A.R. 349 (Oct. 27, 2011) (listing Plaintiff’s 

diagnoses as AIDS and depression); A.R. 351 (May 16, 2011) (listing Plaintiff’s 

diagnoses as AIDS and alopecia). Instead, these notes indicate that Plaintiff’s most 

recent physical exam was “generally normal,” A.R. 352, and that Plaintiff had “no health 

concerns” other than “depressive symptoms” as of October 27, 2011, less than a week 

before Dr. Kovach completed his medical opinions. A.R. 349. See also A.R. 352 

(reporting no change in weight, no abdominal pain or change in bowel habits or 

consistency, and “no health concerns” as of May 2011). Because the ALJ identified 

significant discrepancies between Dr. Kovach’s medical opinion and his clinical records, 

the ALJ had specific and legitimate reasons for rejecting that opinion. 

3. Thanes Vanig, M.D. 

Dr. Vanig has treated Plaintiff since August 2011. A.R. 874. On July 17, 2012, 

Dr. Vanig completed a medical evaluation. A.R. 966-68. Dr. Vanig’s findings were 

almost identical to those included in Dr. Kovach’s second evaluation. Like Dr. Kovach, 

Dr. Vanig found that Plaintiff suffered from HIV Wasting Syndrome, diarrhea lasting for 

over one month, and HIV Encephalopathy characterized by cognitive dysfunction. A.R. 

967. Dr. Vanig also reported that Plaintiff suffered marked limitations of daily living, 

 

3

 Plaintiff does not dispute that the “specific and legitimate reasons” test applies to Dr. Kovach’s opinion. See Doc. 12 at 10. 

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marked difficulties in maintaining social functioning, and marked difficulties in 

completing tasks in a timely manner due to deficiencies in concentration, persistence, or 

pace. A.R. 968. Finally, Dr. Vanig indicated that Plaintiff suffered severe diarrhea that 

affected Plaintiff on a daily basis over the course of a year, and severe fatigue that 

affected Plaintiff on a daily basis over the course of a year. Id. 

 The ALJ concluded that Dr. Vanig’s evaluation was entitled to “no weight.” 

A.R. 27. The ALJ provided the following explanation for discounting Dr. Vanig’s 

opinion: 

Dr. Vanig’s indication that the claimant has severe diarrhea daily is inconsistent with Dr. Vanig’s own treatment notes, as Dr. Vanig noted the claimant as “negative for abdominal pain, abdominal bleeding, diarrhea, heartburn, nausea, and vomiting” in January, February, and June of 2012 . . . In fact, Dr. Vanig provided in August 20, 2011, that the claimant was asymptomatic at the time of his diagnosis with HIV, “has never had any opportunistic infections,” sustained an undetectable viral load,” and was 

also “negative for abdominal pain, abdominal bleeding, diarrhea, heartburn, nausea and vomiting” . . . Therefore, this opinion appears to reflect a sympathetic treatment provider, and is clearly not an objective assessment of claimant’s functional capacity. 

A.R. 28 (citations omitted). 

 Neither the ALJ nor the Commissioner contends that Dr. Vanig’s medical opinion 

is contradicted by another examining or treating physician. Therefore, the Court must 

determine whether the ALJ offered “clear and convincing” reasons for rejecting Dr. 

Vanig’s opinion. 

Significant discrepancies between the physician’s opinion and his or her clinical 

records constitute a clear and convincing reason to reject the physician’s opinion. See 

Bayliss, 427 F.3d at 1216. The ALJ reasonably determined that such discrepancies were 

present here. Dr. Vanig’s clinical records indicate that Plaintiff was negative for 

abdominal pain and diarrhea as of his consultations on August 30, 2011, and on January 

24, January 27, and April 17, 2012. See A.R. 874, 972, 977, 975. Dr. Vanig’s report for 

Plaintiff’s July 16, 2012 consultation does list chronic diarrhea as among Plaintiff’s 

conditions. See A.R. 988. Even so, the ALJ reasonably concluded that Dr. Vanig’s 

negative finding for diarrhea in the four prior consultations undermined his conclusion 

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that Plaintiff was likely to experience severe diarrhea on a “daily” basis over the course 

of a one-year period.4

 In light of the discrepancy between Dr. Vanig’s opinion and his 

clinical records on Plaintiff’s diarrhea, the ALJ had clear and convincing reasons for 

rejecting that aspect of Dr. Vanig’s opinion. 

 The ALJ failed, however, to provide any reason for rejecting Dr. Vanig’s medical 

opinion concerning the severity of Plaintiff’s fatigue. Although the ALJ stated that 

“[Plaintiff’s] fatigue . . . is not supported anywhere in the record,” A.R. 27, Dr. Vanig 

diagnosed Plaintiff with this condition on at least four occasions. See A.R. 972 (Jan. 24, 

2012), A.R. 977 (Jan. 27, 2012), A.R. 975 (Apr. 17, 2012), A.R. 988 (July 16, 2012, 

describing Plaintiff’s fatigue as “severe”).5

 Because the ALJ overlooked this evidence, 

he entirely failed to address it in discussing Dr. Vanig’s opinion. That fact precludes the 

Court from affirming the ALJ’s decision to reject Dr. Vanig’s opinion entirely. 

Even if Dr. Vanig’s opinion regarding Plaintiff’s fatigue is credited as true, it is 

unclear from the administrative record that Plaintiff is disabled. Plaintiff did not 

specifically ask about the limiting effect of fatigue in his cross-examination of the Social 

Security Administration’s vocational expert, see A.R. 70-80, and the Court therefore is 

unable to determine from the record whether there is some work Plaintiff could perform 

despite his fatigue. In addition, the Court is unable to determine whether Plaintiff’s battle 

with methamphetamine addiction during the period relevant to this case contributed to his 

fatigue. If it did, Plaintiff might be ineligible for disability insurance despite suffering 

debilitating symptoms. See 20 C.F.R. § 404.1535. In light of these sources of 

uncertainty, the Court will remand for further proceedings to address Plaintiff’s fatigue. 

 

4

 Furthermore, Dr. Vanig’s clinical records fail to support his conclusion that Plaintiff’s diarrhea was “resistant to treatment” and requiring of “intravenous hydration, intravenous alimentation, or tube feeding.” A.R. 968. 

5

 Dr. Vanig’s clinical records from 2013 indicate that Plaintiff continued to suffer 

severe fatigue after the expiration of his coverage. See A.R. 1001 (Jan. 16, 2013), A.R. 

1004 (May 6, 2013), A.R. 1007 (May 22, 2013). 

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4. Brent B. Geary, Ph.D. 

On March 9, 2012, Dr. Geary conducted a psychological evaluation of Plaintiff 

and diagnosed him with moderate, chronic adjustment disorder with depressed mood. 

A.R. 910-14. Shortly thereafter, Dr. Geary completed a medical source statement based 

on the evaluation. A.R. 915. The statement indicated that Plaintiff’s psychological 

condition imposed limitations that could be expected to last twelve continuous months 

from the date of the exam. Id. According to the statement, Plaintiff’s conditions 

significantly limited his mental energy and stamina. Id. As a result, Plaintiff “would 

require frequent breaks” and “would tend to fall behind in execution of duties.” Id. 

The ALJ concluded that Dr. Geary’s medical opinion was entitled to “[l]ittle 

weight.” A.R. 27. The ALJ explained that Dr. Geary was unable to accurately assess 

Plaintiff’s psychological condition because Plaintiff misrepresented his history of 

substance abuse. Id. The administrative record indicates that Plaintiff commenced 

inpatient treatment for methamphetamine dependence in September 2011, at which time 

he indicated that he was unable to control his use, that he had started using eight years 

prior, and that his last use was “yesterday.” A.R. 882-83. Although Plaintiff had been 

discharged from inpatient treatment the previous month, he failed to mention this 

treatment in his consultation with Dr. Geary, reporting instead that his last use of 

methamphetamine was “quite a while ago.” A.R. 912. 

 Neither the ALJ nor the Commissioner contends that Dr. Geary’s medical opinion 

is contradicted by another examining or treating psychologist. Therefore, the Court must 

determine whether the ALJ offered “clear and convincing” reasons for rejecting Dr. 

Kovach’s opinion. 

 In determining how much weight to accord a medical source opinion, the ALJ may 

consider “the extent to which [the] medical source is familiar with the other information 

in [the claimant’s] record.” 20 C.F.R. § 404.1527(c)(6). Because Dr. Geary was 

unaware of information that was plainly relevant to the question upon which he opined, 

the ALJ provided a clear and convincing reason for according his opinion little weight. 

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B. Determination of Plaintiff’s Severe Impairments. 

Plaintiff’s final contention is that the ALJ erred by failing to list Reiter’s 

Syndrome as a severe impairment.6

 Plaintiff argues that this error was harmful because 

the “ALJ use[d] the absence of findings and treatment for traditional arthritis in order to 

make a negative and misguided finding of [Plaintiff’s] symptoms.” Doc. 17 at 6 (citing 

A.R. 26). In particular, Plaintiff asserts that the ALJ’s misunderstanding caused the ALJ 

to draw improper inferences from Plaintiff’s failure to meet with a specialist for pain or 

obtain injections for pain. Id.

The Commissioner notes that the ALJ did list “arthritis” as a severe impairment. 

Doc. 16 at 15 (citing A.R. 20). She contends that this listing necessarily encompassed 

Reiter’s Syndrome and other forms of reactive arthritis. Id. The Commissioner further 

argues that any error was harmless, as Plaintiff has not identified any specific limitations 

that were excluded from the residual functional capacity finding as a result of the ALJ’s 

failure to specifically address Plaintiff’s Reiter’s Syndrome. Id. 

The Commissioner has the better of the argument. Plaintiff has the burden of 

showing that the ALJ’s alleged error was harmful – that it affected the ultimate disability 

determination. See Molina, 674 F.3d at 1111. Plaintiff has not borne this burden. Even 

assuming that the ALJ drew improper inferences from Plaintiff’s failure to seek certain 

treatment for pain, these inferences were not central to the ALJ’s reasoning. The ALJ 

relied most heavily on evidence indicating that Plaintiff’s joint pain and swelling were 

not severe enough to be considered debilitating. See A.R. 25-26 (explaining that 

Plaintiff’s x-ray results “reveal no fractures and no erosions or evidence of inflammatory 

arthropathy in his bilateral hands”); A.R. 26 (“objective scans of [Plaintiff’s] hands, feet, 

knees, and spine reveal largely no remarkable findings other than mild to moderate 

degeneration in his lumbar spine”); id. (explaining that examining physician reported 

 

6

 Reiter’s Syndrome is a type of reactive arthritis characterized by inflammation that typically affects the eyes and urethra, as well as the joints. See Mayo Clinic, http://www.mayoclinic.org/diseases-conditions/reactive-arthritis/basics/definition/con20020872 (last visited October 1, 2015). Reactive arthritis is characterized by joint pain and swelling triggered by an infection elsewhere in the body. Id. 

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“full function 5/5 grip strength, normal gait, [and] normal range of motion in his lower 

and upper extremities bilaterally”). Because Plaintiff has not shown that the ALJ’s 

central findings were undermined by the ALJ’s failure to specifically address Plaintiff’s 

Reiter’s Syndrome, Plaintiff has not demonstrated that the ALJ committed harmful error. 

IT IS ORDERED that the final decision of the Commissioner of Social Security 

is remanded for further proceedings consistent with this opinion. The Clerk shall enter 

judgment accordingly and terminate this case. 

Dated this 16th day of October, 2015. 

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