Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_13-cv-00856/USCOURTS-azd-2_13-cv-00856-0/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 (SSID)

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WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Sherri Bergan, 

Plaintiff, 

v. 

Carolyn W. Colvin, Acting Commissioner 

of Social Security, 

Defendant.

No. CV-13-00856-PHX-NVW

ORDER 

Plaintiff Sherri Bergan seeks review under 42 U.S.C. § 405(g) of the final decision 

of the Commissioner of Social Security (“the Commissioner”), which denied her 

disability insurance benefits and supplemental security income under sections 216(i) and 

223(d) of the Social Security Act. Because the decision of the Administrative Law Judge 

(“ALJ”) is supported by substantial evidence and is not based on legal error, the 

Commissioner’s decision will be affirmed. 

I. BACKGROUND 

A. Factual Background 

Plaintiff was born in August 1965. She completed high school and a few years of 

college and worked as a waitress, administrative assistant, and timekeeper. She has low 

back problems. She testified that the main reason she is unable to work is severe pain in 

her leg caused by a back injury in 2007. She does not use an assistive device for walking, 

such as crutches or a cane. 

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B. Procedural History 

On August 5, 2009, Plaintiff applied for disability insurance benefits and 

supplemental security income, alleging disability beginning March 20, 2009. On 

August 3, 2011, she appeared with her attorney and testified at a hearing before the ALJ. 

A vocational expert also testified. 

On August 26, 2011, the ALJ issued a decision that Plaintiff was not disabled 

within the meaning of the Social Security Act. The Appeals Council denied Plaintiff’s 

request for review of the hearing decision, making the ALJ’s decision the 

Commissioner’s final decision. On April 26, 2013, Plaintiff sought review by this Court. 

II. STANDARD OF REVIEW 

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). 

III. FIVE-STEP SEQUENTIAL 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). 

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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 

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 meets the insured status requirements of 

the Social Security Act through December 31, 2011, and that she has not engaged in 

substantial gainful activity since March 20, 2009. At step two, the ALJ found that 

Plaintiff has the following severe impairment: lumbar stenosis with radiculopathy. At 

step three, the ALJ determined that Plaintiff does not have an impairment or combination 

of impairments that meets or medically equals an impairment listed in Appendix 1 to 

Subpart P of 20 C.F.R. Pt. 404. 

At step four, the ALJ found that Plaintiff: 

has the residual functional capacity to perform light work as defined in 

20 CFR 404.1567(b); except for the following limitations: she is capable of 

standing and/or walking only two hours in an eight-hour workday; she is 

capable of frequently pushing and/or pulling with her lower extremities; 

and occasionally climbing ramps or stairs; but is precluded from climbing 

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ladders, ropes or scaffolds. She is capable of occasionally balancing, 

bending, stooping, kneeling, crouching and crawling; but is precluded from 

all exposure to unprotected heights. 

The ALJ further found that Plaintiff is capable of performing past relevant work as a 

timekeeper or administrative assistant. 

IV. ANALYSIS 

A. The ALJ Did Not Err in Weighing Medical Source Evidence. 

1. Legal Standard 

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

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

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

(3) non-examining physicians, who neither treat nor examine the claimant. Lester v. 

Chater, 81 F.3d 821, 830 (9th Cir. 1995). Generally, more weight should be given to the 

opinion of a treating physician than to the opinions of non-treating physicians. Id. 

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

rejected only for “clear and convincing” reasons, and where it is contradicted, it may not 

be rejected without “specific and legitimate reasons” supported by substantial evidence in 

the record. Id. Factors that an ALJ may consider when evaluating any medical opinion 

include “the amount of relevant evidence that supports the opinion and the quality of the 

explanation provided; the consistency of the medical opinion with the record as a whole; 

[and] the specialty of the physician providing the opinion.” Orn, 495 F.3d at 631. 

2. Treating Physician Matthew Duke, D.O. 

Plaintiff saw Dr. Duke of Southwest Family Practice on March 22, 2011, for 

prescription refills. The progress note does not indicate that Dr. Duke examined Plaintiff, 

reviewed any records, took any medical history, or identified any diagnosis. The record 

does not include any evidence of actual treatment by Dr. Duke. 

On July 25, 2011, Dr. Duke completed a Medical Assessment of Ability to Do 

Work Related Physical Activities and a Pain Functional Capacity (RFC) Questionnaire. 

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He indicated a diagnosis of lumbar disc degenerative joint disease although there are no 

records showing how he determined the diagnosis. He opined that the most Plaintiff can 

lift and/or carry is less than 10 pounds, the longest she can stand or walk is less than 2 

hours in an 8-hour work day, and the longest she can sit is less than one hour in an 8-hour 

work day. He opined that she must alternate sitting and standing every 20 minutes and 

can never climb, balance, stoop, kneel, crouch, or crawl. He stated that his finding 

supporting these limitations is “severe pain, not safe for balance.” Also on July 25, 2011, 

Plaintiff was discharged from physical therapy with no limitation on walking and only 

mild limitations on sitting, bending, and recreational exercise. 

Plaintiff contends that the ALJ erred by giving little weight to Dr. Duke’s opinion 

because there is “ample objective evidence in the record to support Dr. Duke’s 

assessments,” Dr. Duke did not discredit Plaintiff’s reported symptoms, and his opinion 

“should be given greater weight based on the nature of the treatment relationship and the 

consistency and supportability of the assessments when compared to the remainder of the 

record.” The record does not show that Dr. Duke had any “treatment relationship” with 

Plaintiff, only that she obtained prescription refills from him. Because the record does 

not include any treatment notes, it is impossible to determine whether Dr. Duke had any 

basis upon which to credit or discredit Plaintiff’s reported symptoms. Moreover, as the 

ALJ found, Dr. Duke’s opinion is the only opinion evidence in the record that imposed 

limitations greater than those included in the ALJ’s residual functional capacity 

assessment. 

3. Non-Examining State Agency Physicians 

Plaintiff further contends that the ALJ erred by giving great weight to the opinions 

of the non-examining state agency physicians, whom she does not identify. Plaintiff 

alludes to the ALJ’s consideration of Alicia Blando, M.D., a state agency medical 

consultant who reviewed the medical evidence of record and provided a residual 

functional capacity assessment in April 2010. The ALJ found Dr. Blando’s opinion to be 

consistent with the objective findings, opinion evidence, and the record as a whole. 

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Plaintiff claims the ALJ erred by not providing independent support from the medical 

evidence of record for this conclusion, but the ALJ did so in great detail, discussing 

findings of physical examinations that were generally normal, successful treatment by 

physical therapy and medication, lumbar spine MRI results, Plaintiff’s reported daily 

activities, and pain management treatment notes. 

Thus, the ALJ provided clear, convincing, specific, and legitimate reasons for 

giving little weight to Dr. Duke’s medical assessment. 

B. The ALJ Did Not Err by Misinterpreting Evidence of the Severity of 

Plaintiff’s Back Problems. 

Plaintiff contends that the ALJ misinterpreted evidence to the detriment of the 

Plaintiff by noting that the physical therapy discharge notes dated July 25, 2011, 

indicated “no limitation” with walking and “mild limitation” with sitting, bending, and 

recreational exercise and not acknowledging that the initial physical therapy evaluation 

on April 27, 2011, showed that Plaintiff reported moderate limitations in sitting and 

walking and severe limitations in bending and recreational exercise before beginning 

physical therapy. Plaintiff does not explain what error the ALJ committed by failing to 

comment on her condition before she began the 8-week therapy she described as 

successful. 

Plaintiff also contends the ALJ misinterpreted the May 29, 2009 MRI report, 

which stated the impression of “Large L5-S1 disc extrusion to the left with S1 nerve root 

displacement,” and erred by concluding that “evidence of record reveals minimal 

objective medical evidence supporting the severity of [Plaintiff’s] allegations.” Plaintiff 

incorrectly equates “large disc extrusion” with the degree of any functional limitation 

imposed by the disc extrusion. 

Finally, Plaintiff improperly asks the Court to find error in the ALJ’s 

determination of the severity of Plaintiff’s back problems by considering the fact that she 

eventually had back surgery, which she testified Dr. Ferguson recommended “in the 

beginning” and she refused. The surgery performed on May 23, 2013, was not in the 

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administrative record closed on August 23, 2011, and therefore not considered in this 

appeal from the administrative determination. 

C. Substantial Evidence Supports the ALJ’s Determination that Plaintiff 

Does Not Have an Impairment or Combination of Impairments That 

Meets or Medically Equals the Severity of One of the Listed 

Impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. 

Plaintiff contends that the ALJ erred by not finding that Plaintiff has an 

impairment or combination of impairments that meets or medically equals Listing 

1.04(A). To meet the requirements of a listing, a claimant must have a medically 

determinable impairment that satisfies all of the criteria in the listing. 20 C.F.R. 

§ 404.1525(d). 

Listing 1.04(A) requires a disorder of the spine, such as degenerative disc disease, 

with evidence of “nerve root compression characterized by neuro-anatomic distribution 

of pain, limitation of motion of the spine, motor loss (atrophy with associated muscle 

weakness or muscle weakness) accompanied by sensory or reflex loss and, if there is 

involvement of the lower back, positive straight-leg raising test (sitting and supine).” 

“[A] report of atrophy is not acceptable as evidence of significant motor loss without 

circumferential measurements of both thighs and lower legs, or both upper and lower 

arms, as appropriate,” and must be accompanied by measure of the strength of the 

muscles in question generally based on a grading system of 0 to 5. 

Listing 1.00(B)(2)(a) defines functional loss as the inability to ambulate 

effectively or perform fine and gross movements effectively on a sustained basis for any 

reason, including pain. Under Listing 1.00(B)(2)(b)(1), “[i]nability to ambulate 

effectively means an extreme limitation of the ability to walk; i.e., an impairment(s) that 

interferes very seriously with the individual’s ability to independently initiate, sustain, or 

complete activities.” Ineffective ambulation generally means the claimant is unable to 

walk without the use of a walker, two crutches, or two canes. The ALJ “particularly 

considered the criteria specified under section 1.00 generally of the Listing of 

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impairments” and concluded that “the medical evidence does not establish limitations of 

Listing level security.” The ALJ elaborated: 

Specifically, physical examinations were largely “normal,” “within normal 

limits,” and “unremarkable.” Findings repeatedly included “good” muscle 

strength, bulk and tone; “normal” gait; “normal” range of motion, flexion 

and extension; “unremarkable” sensory results; and “normal” deep tendon 

reflexes, with normal neurological findings as well (Exhibits 1F; 2F; 3F; 

6F; 22F; 25F; 26F; 27F), despite positive MRI findings with nerve root 

pressure (Exhibit 25F). Additionally, the claimant uses no assistive device 

to ambulate and there has been no surgical intervention for her back 

impairment. Treatment was essentially routine and conservative in nature, 

consisting of physical therapy and epidural injections, with evidenced 

efficacy of the claimant’s physical therapy and medication regimen 

(Exhibits 23F; 25F). 

Plaintiff contends “the record provides sufficient evidence to meet or medically 

equal the requirements of Listing 1.04(A),” but she does not identify any evidence of 

“motor loss (atrophy with associated muscle weakness or muscle weakness).” Plaintiff 

cites to office visit notes showing decreased range of motion of the spine on several dates 

in 2010, but the notes also show Plaintiff denied any muscular weakness or atrophy. 

Similarly, she cites to the physical therapy initial evaluation in April 2011 to show she 

reported low back pain with radicular symptoms down the left leg, but the evaluation also 

states that testing showed minimal to moderate tightness in the lumbar paraspinal 

muscles, negative straight-leg test, and negative quadrant test (L-Spine). Moreover, after 

8 weeks of physical therapy, her gait and posture had returned to normal, her spine had 

100% active range of motion, and her bilateral muscle strength was 5/5. 

Therefore, the ALJ fully considered whether the medical evidence shows that 

Plaintiff has an impairment or combination of impairments that meets or medically equals 

the general requirements for any musculoskeletal listing, and substantial evidence 

establishes that Plaintiff does not have an impairment or combination of impairments that 

meets or medically equals Listing 1.04(A). 

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IT IS THEREFORE ORDERED that the final decision of the Commissioner of 

Social Security is affirmed. The Clerk shall enter judgment accordingly and shall 

terminate this case. 

 Dated this 25th day of April, 2014. 

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