Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_15-cv-03599/USCOURTS-cand-3_15-cv-03599-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:205 Denial Social Security Benefits

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ORDER (No. 3:15-cv-3599-LB)

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United States District Court

Northern District of California

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

San Francisco Division

DANIELLE ELIZABETH OSBORN,

Plaintiff,

v.

CAROLYN W. COLVIN,

Defendant.

Case No. 15-cv-03599-LB

ORDER GRANTING IN PART AND 

DENYING IN PART THE PARTIES’ 

CROSS-MOTIONS FOR SUMMARY 

JUDGMENT; REMANDING CASE FOR 

FURTHER PROCEEDINGS

Re: ECF Nos. 14 & 23

INTRODUCTION

The plaintiff, Danielle Elizabeth Osborn, suffers from lumbar degenerative-disc disease, 

depression, anxiety, and obesity.1 Ms. Osborn seeks judicial review of the Social Security 

Administration’s final decision denying her disability benefits.2The Administrative Law Judge 

(“ALJ”) found that Ms. Osborn’s lumbar degenerative-disc disease, exacerbated by obesity, was a

severe impairment but declared Ms. Osborn not disabled and denied Social Security Income 

(“SSI”) benefits.3 Ms. Osborn now moves for summary judgment.4 Carolyn Colvin, the Social 

 

1 Motion for Summary Judgment — ECF No. 14; Administrative Record (“AR”) 84. Record citations 

refer to material in the Electronic Case File (“ECF”); pinpoint citations are to the ECF-generated page 

numbers at the top of documents.

2

Id.

3 AR 24, 26, 32.

4 Motion for Summary Judgment.

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ORDER (No. 3:15-cv-3599-LB) 2

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Security Commissioner (“Commissioner”), opposes the motion and cross-moves for summary 

judgment.5

The court deems the matter submitted for decision without oral argument. N.D. Cal. Civ. L.R.

16-5. All parties have consented to this court’s jurisdiction.6The court grants in part and denies in 

part Ms. Osborn’s motion for summary judgment, and grants in part and denies in part the 

Commissioner’s cross-motion, because the ALJ did not err by giving less weight to Dr. MarionIsabel Zipperle’s consultative examining opinion, but did err by (1) giving less weight to Dr. 

Jackson and Nurse Practitioner Laura McDonald’s co-authored lumbar spine residual-functionalcapacity assessment, and (2) discrediting Ms. Osborn’s testimony.

STATEMENT

1. Procedural History

On June 7, 2011, Ms. Osborn filed an application for Title II Disability Insurance Benefits and 

Title XVI Supplemental Security Income, alleging a disability onset date of December 1, 2006.7

The Social Security Administration (“Administration” or “SSA”) initially denied her applications 

and again upon reconsideration.

8 Ms. Osborn filed a timely “Request for Hearing by 

Administrative Law Judge” on April 22, 2012.9

Administrative Law Judge Amita B. Tracy (the “ALJ”) held an initial hearing on January 17, 

2013, where Ms. Osborn, her non-attorney representative Dan McCaskell, and vocational expert 

Gene Johnson were present.10 At this hearing, the ALJ questioned all parties present; Ms. Osborn 

and Mr. Johnson testified as to her alleged disability.11 The ALJ held a supplemental hearing on 

 

5 Cross-Motion for Summary Judgment — ECF No. 23.

6 Consent Forms — ECF Nos. 6, 9.

7 AR 278-87, 288-94.

8

Id. at 110-35, 138-61. 

9

Id. at 185-86.

10 Id. at 77-109.

11 Id.

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ORDER (No. 3:15-cv-3599-LB) 3

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September 5, 2013, where Ms. Osborn, Mr. McCaskell, and medical expert William Alexander 

Rack were present.12 The ALJ again questioned all parties present; Ms. Osborn and Mr. Rack

testified as to her alleged disability.

13

The ALJ issued an order in December 2013 denying benefits and finding Ms. Osborn not 

disabled.14 She appealed that decision to the Appeals Council the following January.

15 The 

Appeals Council denied that request for review in June 2015.

16

Two months later Ms. Osborn timely sought judicial review of the final decision denying her 

SSI benefits.17 The Commissioner answered the complaint in December, and Ms. Osborn filed her 

motion for summary judgment in January 2016.18 The Commissioner filed an opposition and 

cross-motion for summary judgment in April.

19

2. Summary of Record and Administrative Findings

2.1 Medical Records

This section chronologically summarizes Ms. Osborn’s relevant medical visits during the 

specified time period with health care providers. These visits were for her alleged disabilities

stemming from lumbar degenerative-disc disease, depression, anxiety, and obesity. 

2.1.1 Medical records from 2005

On October 12th, Ms. Osborn had two medical visits. The Healdsburg District Hospital 

emergency department saw Ms. Osborn for pelvic pain, diarrhea, nausea and dizziness.20 Dr. Paris

 

12 Id. at 39-76. 

13 Id.

14 Id. at 20-37. 

15 Id. at 19.

16 Id. at 1-7. 

17 Complaint — ECF No. 1.

18 Answer — ECF No. 12; Motion for Summary Judgment.

19 Cross-Motion for Summary Judgment; Reply — ECF No. 24.

20 AR 479-481.

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ORDER (No. 3:15-cv-3599-LB) 4

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prescribed her Doxycycline, and reported her demeanor as alert, not in distress, and cooperative.21

An unidentified medical provider at Alliance Medical Center (“Alliance”) saw Ms. Osborn that 

same day for a post-emergency room follow-up visit.22 The report reflected that Ms. Osborn was 

suffering from depression symptoms: “tired, [fluctuating] moods, crying, [more] sleeping, 

[fluctuating] appetite.”23 It also revealed that the emergency department prescribed her Vicodin 

and Doxycycline.

24 It concluded with the diagnosis that Ms. Osborn’s physical symptoms

probably stemmed from residual pelvic pain or infection, and it prescribed her Prozac.25

Ms. Osborn had two Alliance medical reports in November. The first showed that Ms. Osborn

missed her appointment on the November 2 for depression and obesity.26 On November 11, an 

unidentified medical provider reported that she had completed her antibiotics from the emergency 

department visit the month prior, had no more stomach pain, and was low on Prozac.

27 Also, when 

Ms. Osborn was asked for a urine analysis, “she took the cup and left the clinic.”28

2.1.2 Medical records from 2007

Ms. Osborn had many medical visits at various hospitals and clinics in 2007. Alexander Valley 

Regional Medical Center physicians treated Ms. Osborn from January 12, 2007 to June 29, 2010 

for a variety of medical issues including pregnancy via Caesarean section, chronic lower-back

pain, bronchitis, depression, anxiety, and obesity.29

A January 2007 progress note reported that Ms. Osborn was “very angry, yelling and blaming 

[the] clinic for not following the on call and OB tests and medications.”30

 

21 Id.

22 AR 451.

23 Id.

24 Id.

25 Id.

26 AR 450.

27 AR 449.

28 Id.

29 AR 415-44.

30 AR 433. 

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The next month, examining physician Dr. David Gorchoff noted that Ms. Osborn had a recent

Caesarean section and gave birth to a healthy newborn male.31 He included that Ms. Osborn 

“moved wrongly” two days ago and somehow wrenched her back, causing her diffuse lower-back

pain.32 He observed Ms. Osborn to be in general mild distress, walking with obvious discomfort, 

and having diffuse tenderness in her lower-back.

33 He assessed her with lower-back strain, 

prescribed Naprosyn, and recommended rest with heat and cold application.

34

In March, treating physician Dr. Dirk van Meurs reported that Ms. Osborn was complaining of 

back and neck pain, and that the Naprosyn was “not cutting it.”

35 Ms. Osborn was “anxious and 

angry at times.”

36 He diagnosed her with bacterial bronchitis, post-partum depression, and neck 

and lower-back pain.

37 He prescribed her Doxycycline, Prozac, baclofen, and tramadol.38

Treating physician Dr. Gary Pace reported in June that Ms. Osborn started having lumbar pain 

during her pregnancy in December, and that she was currently working as a caregiver for a 

quadriplegic woman.39 He wrote that her pain has persisted since delivery, was mainly in the 

lumbar region, and occasionally radiated down her right leg.

40 Ms. Osborn claimed that work 

worsened her pain, and that she had not yet been x-rayed.

41 Ms. Osborn was trying Naprosyn, 

Tylenol, and baclofen.

42 The report said that Ms. Osborn was suffering from depression with some 

improvement, noting that her boyfriend moved out and she no longer used Prozac.43 Dr. Pace’s 

 

31 AR 435. 

32 Id.

33 Id.

34 Id.

35 AR 436.

36 Id. 

37 Id.

38 Id.

39 AR 437-38.

40 Id.

41 Id.

42 Id. 

43 Id. 

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prognosis parallels this: her depression was stable with chronic back pain since December.44 For 

her back pain, Dr. Pace ordered x-rays and referred her to physical therapy.45 Dr. Pace noted that 

“[Ms. Osborn] mainly want[ed] pain medication.”46 He opined that Ms. Osborn may have to 

“reconsider her current job situation, because working with her quadriplegic can be rare [sic] in 

her back.”47 After a long discussion on the downside of opiate usage, Dr. Pace prescribed her 

Vicodin with plans to reevaluate treatment after reviewing the x-rays in a week.48 He further noted

that “she may need to go on disability for a while and see [if] we can really get an aggressive 

rehab program going.”49

Later in June Dr. Pace followed up with Ms. Osborn’s back pain.50 She had been x-rayed and 

off work since the 15th, a period of ten days.

51 She thought her back pain somewhat improved

with unemployment, but “she does have an infant.”

52 Ms. Osborn had two Vicodin left, and was 

interested in physical therapy.53 Her lumbar pain continued to radiate down her right side.

54

Difficult movements caused her to freeze.

55 Dr. Pace noted “patient has a history of drug abuse,” 

her last methamphetamine use was in November 2006, and she was in rehab.56 He reported her

depression was stable, and the x-rays showed degenerative changes.

57 He recommended physical 

therapy and an MRI.58 He noted that Ms. Osborn would start receiving disability benefits on June 

 

44 AR 438.

45 Id.

46 Id. 

47 Id.

48 Id. 

49 Id.

50 AR 439-40.

51 Id. 

52 Id. 

53 Id.

54 Id.

55 Id.

56 Id.

57 Id.

58 Id.

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11th with a return date of September 1st.

59 After discussing pain medication, Dr. Pace suggested 

Ms. Osborn provide a urine toxicology screen.60 She reported that she would rather not take 

opiates.

61 Dr. Pace said that they would need a toxicology screen if any opiates were prescribed.62

He continued her on tramadol, baclofen, and anti-inflammatories.63 Her depression seemed 

stable.64

Ms. Osborn visited Redwood Regional Medical Group in July for a lumbar-spine MRI.

65 Nonexamining physician Dr. David H. Schmidt compared her MRI with her Healdsburg lumbar-spine

x-rays.

66 He reported disc desiccation and mild disc space narrowing of her L3-4 and L4-5; a small 

paracentral disc protrusion at L3-4; a small central protrusion at L4-5; mild thecal sac effacement 

with no demonstrated nerve root impingement; and mild broad-based disc bulging at L5-S1.67

Back at Alexander Valley, Dr. Pace’s August notes showed Ms. Osborn was managing her 

pain through swimming and exercise.68 The pain, however, was disrupting her sleep and barring 

her from grocery shopping.69 The notes also referred to her difficulties with public transportation 

due to her “inability to sit on a bus for an hour and a half.”70 Dr. Pace reviewed and confirmed the 

July MRI findings.71 He recommended she pursue physical therapy and chiropractic and

acupuncture treatment.

72 He noted her stable depression.73 He also commented that Ms. Osborn 

 

59 Id.

60 AR 440.

61 Id.

62 Id.

63 Id.

64 Id.

65 AR 409, 413-14, 491.

66 Id.

67 Id. 

68 AR 440.

69 Id.

70 Id.

71 AR 441.

72 Id.

73 Id.

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was complacent with her state disability benefits, not involved in furthering her recovery through

an active rehabilitation program, failed to pursue therapy, and “needs to get actively trying to 

improve [and] . . . get her work life on track.”74

Ms. Osborn had no significant changes in September.

75 She was using ibuprofen, and her 

lumbar pain continued to radiate down her right leg into the knee.76 She felt that she was unable to 

work because of the pain.77 She was receiving chiropractic and acupuncture care, and had tried 

physical therapy, “but there has been some mix up in the scheduling.”78 The MRI showed some 

minor disc disease, and minor nerve root compression.79 She was caring for her seven-month-old 

baby.80 Dr. Pace observed her to be alert and in good spirits.81 He continued her treatment with

ibuprofen, and referred her to receive lumbar epidural steroid injections.

82 He also declared on a 

renewal-request form for state disability benefits that he was actively treating Ms. Osborn’s

chronic lumbar pain, and he estimated her recovery in three months.83

In October, treating physician Dr. Manuel Fernandez administered a smooth routine lumbar 

epidural steroid injection on Ms. Osborn, noting her “history of chronic low back pain and some 

right-sided buttock and upper thigh radicular pain.”84

2.1.3 Medical records from 2008

Ms. Osborn required a second lumbar epidural steroid injection in February 2008 because the 

October injection’s beneficial effects lasted until January (about four weeks earlier).

85 Dr. 

 

74 Id.

75 AR 443.

76 Id.

77 Id.

78 Id. 

79 Id. 

80 Id.

81 Id.

82 AR 443, 428.

83 AR 429. 

84 AR 477.

85 AR 472.

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Fernandez successfully administered this second injection with a post-procedure diagnosis of L3-4 

and L4-5 degenerative-disc disease.

86

Dr. van Meurs reported in August that despite her continued efforts to lose weight, Ms. 

Osborn’s back pain worsened, and she wanted disability benefits again.87 He observed her ability 

to heel-toe walk, and determined that obesity was exacerbating her lower-back pain.88 He

recommended she increase her weight-loss efforts.

89

By November, Ms. Osborn suffered a “sudden pinching in her right buttock” and could not 

stand up without rolling onto all fours.90 Dr. van Meurs diagnosed an exacerbation of her chronic 

lower-back pain.91 He prescribed Prevacid, Vicodin, and a return to physical therapy.92

2.1.4 Medical records from 2009

In June 2009, Dr. van Meurs saw Ms. Osborn, who complained of lower-back pain and 

numbness in the right leg, and asked for prescription refills.

93 Dr. van Meurs noted that there was 

“no surgery in sight,” and that Ms. Osborn was trying to lose weight.94 He diagnosed her with 

severe exacerbation of her chronic lower-back pain, and he prescribed Percocet.95

Two months later, Dr. van Meurs reported that Ms. Osborn recently returned from Arizona,

and was stressed because “her parents want[ed] her out.”96 He observed her to be alert and anxious 

with easy movement.

97 He diagnosed her with anxiety and depression, in addition to chronic 

 

86 Id.

87 AR 425.

88 Id.

89 Id.

90 AR 424.

91 Id.

92 Id.

93 AR 421.

94 Id.

95 Id.

96 AR 420.

97 Id.

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lower-back pain exacerbated by obesity.98 He prescribed her Percocet and Zoloft and 

recommended weight loss.

99 In October, he further prescribed Percocet and advocated for weight 

loss.100

Ms. Osborn had two medical visits in November. On the 10th, Dr. van Meurs noted that Ms. 

Osborn demanded a Percocet refill appointment notwithstanding her previous two no-show 

appointments, and that “she was very rude.”101 On the 12th, Ms. Osborn had her Percocet 

prescription refilled, was taking it appropriately, and her pain was stable.102 Her depression was 

controlled at this point.

103

2.1.5 Medical records from 2010

In January 2010, Ms. Osborn complained of lower-back pain and numbness down the back of 

her right thigh.104 The Percocet no longer helped her, but “someone gave her a 10mg of oxy

(?codone vs. contin?),” and she slept better.

105 Dr. van Meurs diagnosed progressive lower-back

pain and radicular parethesis down her right leg.106 He prescribed oxycodone, and referred her for 

a lumbo/sacral spine x-ray comparison.

107

The lumbo/sacral spine x-ray was taken in February.

108 Non-examining physician Dr. Scott 

Lomax compared this latest x-ray with her June 22, 2007 x-ray.

109 He reported findings consistent 

with mild L4-5 and L5-S1 disc narrowing with no definitive changes since the previous x-ray.110

 

98 Id.

99 Id.

100 Id.

101 AR 419.

102 Id.

103 Id.

104 AR 418.

105 Id.

106 Id.

107 Id.

108 AR 409, 490.

109 Id.

110 Id.

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In April, Ms. Osborn was upset because her boyfriend suddenly vanished.

111 She reported staying 

in bed a lot, and Dr. van Meurs observed her in an alert, tearful, and depressed state.

112 He 

diagnosed her with chronic back pain, grief, and depression.

113 He prescribed her “oxyco” and

ordered a urine toxicology screen.114

Ms. Osborn’s parents kicked her out in June and she was facing a lot of stress.115 She was 

staying with a friend and doing okay with her boyfriend.

116 Her ex-boyfriend refused to return her 

child even though she claimed she stopped using drugs, but she did admit to drinking alcohol.117

She asked for more pain medication, but her urine toxicology screen tested positive for 

amphetamines, methamphetamines, and MDMA/ecstasy.118 Dr. van Meurs tried to explain to her 

that she should attend Alcoholics Anonymous and return in two weeks to re-test, but she was 

angry and left the clinic very upset when she was not prescribed her pain medication.119 Dr. van 

Meurs diagnosed her with chronic back pain and psychosocial chaos.120

From July to December, Ms. Osborn received multiple ultrasound procedures for her third 

pregnancy.

121 In an Alliance health questionnaire, Ms. Osborn stated she had two Caesarean 

sections in 1997 and 2007, had stopped using drugs or alcohol, smoked five cigarettes a day, and 

was unemployed due to her back injury.122 Nurse practitioner (“NP”) Phillipa stated that Ms. 

Osborn had chronic back pain and was 21 weeks pregnant.123

 

111 AR 417.

112 Id.

113 Id.

114 Id.

115 AR 416.

116 Id.

117 Id.

118 Id.

119 Id.

120 Id.

121 AR 485, 487, 489, 493, 495.

122 AR 448.

123 AR 447.

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2.1.6 Medical records from 2011

Ms. Osborn had a string of emergency department visits from February to April 2011.124 A 

wide range of medical issues were associated with these visits, including hemorrhoids, bronchitis, 

and abdominal pain associated with her third Caesarean section on March 9.

125 In February, she 

was thirty-five weeks pregnant, and had stabbing pain from hemorrhoids.126 Examining physician 

Dr. Edward Wang prescribed her Anusol and suppositories.127 On March 8, Ms. Osborn was 

thirty-eight weeks pregnant, and went in with a two-week cough.128 Treating physician Dr. 

Lawrence Gettler diagnosed her with asthmatic bronchitis, and prescribed amoxicillin and 

albuterol.129

Later in March, Ms. Osborn complained of incisional pain from her Caesarean section the 

week prior.130 She claimed increased activity led to a ripping sensation.

131 Her increased activity 

was due partly to Child Protective Services taking her child after she tested positive for 

methamphetamines.132 The prescribed Vicodin was no longer controlling her pain, and her 

Caesarean doctor, Dr. Kachru, told her to get a pain shot at the emergency department.

133 Upon 

inspection of her Caesarean incision, treating physician Dr. Bruce Deas did not see anything to 

suggest wound infection or any other significant intra-abdominal process.

134 He opined that Ms. 

Osborn may have “overdone things,” and had resulting pain. The pain shots helped, and Dr. Deas 

 

124 AR 453, 456, 459-60, 463, 467.

125 Id.

126 AR 467.

127 Id.

128 AR 463.

129 AR 463-64.

130 AR 459. 

131 Id.

132 Id.

133 Id.

134 AR 460.

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prescribed her Percocet.135 Ms. Osborn admitted to smoking, but denied further alcohol and

methamphetamine use.

136

Dr. Gettler saw Ms. Osborn on March 31 for abdominal pain.137 He recommended an 

ultrasound, but she declined, stating that she did not have time for the scan due to her daughter’s 

dental appointment.138 He prescribed her Vicodin instead.139 In April, he saw Ms. Osborn again 

for abdominal pain.140 She requested and received more Vicodin.141 He diagnosed her with

postoperative abdominal pain of uncertain etiology.142

Nurse Indiana Moreno saw Ms. Osborn the next month because, although Ms. Osborn was on 

oxycontin before her pregnancy, she now wanted Vicodin.

143 Nurse Moreno referred her to urgent 

care, because narcotic pain medication requests were inappropriate for walk-in patients.

144

In May and June, Ms. Osborn received a computed topography (“CT”) scan and a magnetic 

resonance imaging (“MRI”) scan at Redwood Regional Medical Group.

145 Examining physician 

Dr. Frank Modic’s CT scan revealed post-operative changes related to Ms. Osborn’s recent 

Caesarean section.146 He concluded that there was a visible defect in the lower anterior uterine 

wall, and three small postoperative fluid pockets in the vicinity likely to be seroma or 

hematoma.147 The MRI scan of Ms. Osborn’s lumbar spine showed the following: (1) L3-4 small 

central disc protrusion and annular tear; (2) L4-5 broad-based central disc protrusion producing 

 

135 Id.

136 Id. 459.

137 AR 456.

138 AR 57. 

139 Id.

140 AR 453.

141 AR 454.

142 Id.

143 AR 446.

144 Id.

145 AR 483-84, 499.

146 AR 484.

147 Id.

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borderline central spinal stenosis; and (3) L5-S1 advanced degenerative-disc disease and broadbased disc bulging with questionable impingement upon the exiting right L5 nerve root (mild 

degenerative facet changes were also noted).

148

Examining physician Dr. Marion-Isabel Zipperle, Ph.D. (of MDSI Physician Services)

conducted a detailed psychiatric evaluation of Ms. Osborn’s mental health in September 2011.

149

Dr. Zipperle’s report contained the following remarks about Ms. Osborn’s life situation: she drove 

herself to the meeting, and her chief complaints were back problems, bulging discs, sciatic nerves, 

ulcers, stress, depression, and anxiety.150 She had a work injury, but did not receive workers’ 

compensation because she did not think she could obtain it.

151 She has struggled with 

methamphetamine use, culminating with Child Protective Services taking her children.

152 “She 

became very depressed when her children were removed and suffers from depression.”

153 “She is 

depressed every day and the medication does not work. She wants to get better.”

154 She had low 

motivation and energy, had self-esteem and self-confidence issues, and felt worthless, helpless,

and hopeless.155 She had mood swings, racing thoughts, impulsivity, and poor judgment.156 She 

had difficulty getting along with others and being grateful.157 She had lost interest in enjoyable 

activities, and had become isolated, withdrawn, and emotional.158 She was taking omeprazole, 

Celexa, and ibuprofen.159 She mentioned seeing a therapist named “Annette” for depression.

160

 

148 AR 499.

149 AR 502-05.

150 AR 502.

151 Id.

152 Id.

153 Id.

154 Id.

155 Id.

156 Id.

157 Id.

158 AR 502-03.

159 AR 503.

160 Id.

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ORDER (No. 3:15-cv-3599-LB) 15

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Dr. Zipperle included a detailed account of Ms. Osborn’s family, social, and employment 

history: she had a good and supportive childhood from an intact family, and was a good student 

until she associated herself with drug-abusing classmates in the eighth grade.

161 Her work history 

was short due to depression and addiction problems, including eight years of cashier and in-home 

work.162 She experienced a variety of legal troubles from methamphetamine use, grand theft, and 

driving under the influence.

163

An account of Ms. Osborn’s living situation showed her attempts to turn her life around ever 

since Child Protective Services took her children.

164 She had been living in a women’s recovery 

home for three months, went to Narcotics Anonymous meetings, and had a sponsor.165 She was

working on getting her daughter back and had visitation rights.166 She lived with a friend, was able 

to “do self-care,” and complete light housework, but she could not “do heavy stuff like laundry or 

lifting things.”167 She had no hobbies due to her depression.168 She could accomplish tasks, but 

had trouble remembering appointments and bills.169

A series of mental status tests showed Ms. Osborn had no deficits in her concentration, 

memory, abstract thinking, ability to draw comparisons, or judgment.170 She also had good 

grooming, hygiene, manners, and eye contact.171 Her attitude was quiet, agitated, and depressed, 

yet she spoke normally, coherently, and logically.

172 Her thoughts were generally negative due to 

 

161 Id.

162 Id.

163 Id.

164 Id.

165 Id.

166 Id.

167 Id.

168 Id.

169 Id.

170 AR 504.

171 Id.

172 Id.

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ORDER (No. 3:15-cv-3599-LB) 16

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self-criticism and rumination over past mistakes.

173 Her mood was depressed, withdrawn, tearful,

and emotional.174 Dr. Zipperle diagnosed Ms. Osborn with bipolar disorder, polysubstance 

dependence in remission, self-defeating behavior, and mental health problems.175

Dr. Zipperle’s functional assessment and medical source statement claimed Ms. Osborn’s state 

of mind would result in moderate deficits in her ability to interact with others, especially 

coworkers, supervisors, and the general public in cooperative or competitive settings.176 She

further opined that Ms. Osborn “could understand and carry out simple and two[-]part 

instructions,” and could manage complex tasks.177 Dr. Zipperle noted that Ms. Osborn appeared to 

be a person who could learn and carry out simple new tasks in a typical work environment without 

additional or special supervision.178 She may have issues with work-related stress, because “stress 

presses upon her mental health issues, her liability, and depression.”

179 “She may have difficulty 

pacing herself in an eight-hour day as she can dress, and do self-care and some housework, but she 

has difficulty remembering appointments and everyday things.”

180 She “may need the assistance 

of someone to help her with her funds.”

181

On September 18, 2011, examining physician Dr. John Alchemy, also of MDSI Physician 

Services, conducted an internal medicine evaluation of Ms. Osborn’s physical health.182 She had 

been living in a sober transitional facility since August 18.183 He diagnosed her with chronic 

lower-back pain radiating to her right knee caused by a 2006 work injury.184 He reviewed her 

 

173 Id.

174 Id.

175 Id.

176 AR 505.

177 Id.

178 Id.

179 Id.

180 Id.

181 Id.

182 AR 509-13.

183 AR 510.

184 AR 513.

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ORDER (No. 3:15-cv-3599-LB) 17

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MRI, and reported no objective findings of radiculopathy or nerve root compression.

185 His

functional assessment concluded that because she had no postural difficulties, she had no 

condition that would impose limitations for twelve or more continuous months.186

Ms. Osborn visited Sutter Health’s emergency room in October for more Vicodin.187

Examining physician Dr. Edward Hard noted that Dr. Sheppard held off on giving her narcotics

during a similar recent trip to the same emergency department in August.

188 When Dr. Hard asked 

her about this, she responded that she had stopped abusing narcotics, yet still wanted more 

Vicodin.189 Dr. Hard noted that he was cautious about giving her additional narcotics if she really 

was in recovery.190 Ultimately, Ms. Osborn did not receive her requested Vicodin, and was 

prescribed Toradol instead.

191 Dr. Hard advised against further narcotic refills in the emergency 

room.192 He diagnosed her with lower-back strain, right hip sciatica, and moderate obesity at 225 

pounds.193

By October, Ms. Osborn transferred from Alliance to Santa Rosa Community Health Centers, 

which marked the beginning of a lengthy treatment relationship with Nurse Practitioner (“NP”)

Laura McDonald.194 NP McDonald analyzed and summarized her medical history: a lumbar-spine

MRI showing degenerative-disc disease and some disc protrusion, a referral from Alliance for a 

neurosurgery consult, and good pain management with daily Vicodin.195 She noted her history of 

methamphetamine abuse, and time spent at a women’s treatment center in 2011 resulting in 

 

185 Id.

186 Id.

187 AR 551-52.

188 AR 551.

189 Id.

190 AR 552.

191 Id.

192 Id.

193 Id.

194 AR 547-48.

195 AR 547.

Case 3:15-cv-03599-LB Document 25 Filed 10/17/16 Page 17 of 70
ORDER (No. 3:15-cv-3599-LB) 18

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sobriety.

196 Ms. Osborn felt that, unlike oxycodone, Vicodin did not “wake up” her addiction.197

NP McDonald’s screening showed that Ms. Osborn was negative for depression and anxiety.198

NP McDonald assessed lumbar back pain, depression, drug abuse in remission, and tobacco 

abuse.199 She referred Ms. Osborn to physical therapy, and encouraged weight loss and exercise.

200

She also prescribed Vicodin for her lumbar back pain.201

NP McDonald followed up with Ms. Osborn’s back pain twice in November and December.

202

In November, she gave her more Vicodin for her lumbar back pain after a urine drug screen 

showed her negative for everything.203 Ms. Osborn was supposed to continue with exercise and

weight loss.

204 In December, Ms. Osborn had a new complaint of abdominal epigastric pain.205 NP 

McDonald gave her Omeprazole for her abdominal epigastric pain, and more Vicodin for her 

lumbar back pain.

206

2.1.7 Medical records from 2012

A January lumbar-spine MRI revealed that Ms. Osborn was suffering from the following 

conditions: (1) L3-4 dehydrated disc and very mild narrowing, 3 mm right posterolateral 

protrusion with annular fissure and crowding of the right subarticular gutter, and patent neural 

foramina; (2) L4-5 subtle annular fissuring, a 3 mm broad-based protrusion and crowding of the 

left ubarticular gutter, and facet capsular tissue and ligamentum flavum thickening; and (3) L5-S1 

slight anterolisthesis across dehydrated mildly narrowed disc, a broad-based 3 mm protrusion and 

 

196 Id.

197 Id.

198 Id.

199 Id.

200 Id.

201 Id.

202 AR 544-46.

203 AR 545.

204 Id.

205 AR 542-43.

206 AR 543.

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ORDER (No. 3:15-cv-3599-LB) 19

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subtle reactive endplate change suggesting motion segment instability, and moderately severe right 

and moderate left up-down foraminal narrowing.207 Non-examining Dr. Meghan Blake found no 

significant changes when she compared this MRI to Ms. Osborn’s June 22 MRI.

208 Ms. Osborn 

stopped taking Vicodin that same month because it was “waking up” her addiction.209 NP 

McDonald noted that Ms. Osborn would deal with the pain without medication, and continue with 

weight loss.

210 She was negative on a depression screening, and had a pleasant and alert general 

appearance.211

Ms. Osborn had her initial neurosurgical consultation with UCSF treating physician Dr. 

Jeffery Yablon in February.212 He reviewed her diagnostic MRI, and reported degenerative-disc

disease at L3-4, L4-5 and L5-S1, with minimal stenosis at all levels, and a central protrusion 

slightly acentric to the left at L4-5.213 Her cervical and thoracic spines were normal.

214 Lumbar 

examination also revealed unremarkable results: full range of motion with no tenderness or 

spasms.215 He found no evidence of any peripheral compressive neuropathy.216 Neurological 

testing showed a normal mental status, muscle bulk, and sensory function.

217 He observed minimal 

difficulty with her gait and ability to heel-toe walk.218 His overall assessment was that Ms. Osborn 

was symptomatic from her three-level degenerative-disc disease, primarily at L4-5, and obesity.

219

He ultimately opined that it was unwise to operate, and recommended weight loss or gastric

 

207 AR 592-93.

208 AR 592.

209 AR 540-41.

210 AR 540.

211 Id.

212 AR 577-79, 601-04.

213 AR 577, 601. 

214 AR 578, 601-02.

215 AR 578, 602.

216 Id.

217 Id.

218 Id.

219 Id.

Case 3:15-cv-03599-LB Document 25 Filed 10/17/16 Page 19 of 70
ORDER (No. 3:15-cv-3599-LB) 20

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bypass.

220 He informed her that if she lost 50 pounds and still had significant problems, he would 

consider a three-level fusion.221

A few months later, Family Nurse Practitioner (“FNP”) Jeni Cooper saw Ms. Osborn for 

medication refills.222 Ms. Osborn’s pain increased in January and February when she started taking 

care of her young children.223 Ms. Osborn had not started physical therapy yet due to “so much 

going on in life right [then,]” but stated that she could start in July after her classes ended.

224 FNP 

Cooper prescribed Ms. Osborn tramadol for her lumbar back pain, and noted that she needed to be 

involved in treating her pain via physical therapy, ice/heat application, lower-back stretches, and 

anti-inflammatory medications.

225

The tramadol did not help Ms. Osborn’s back pain, and she wanted to stop taking it.

226 She 

still had yet to attend physical therapy, citing difficulty in finding childcare, although her recent

swimming in a friend’s pool had beneficial results.227 She also complained of right shoulder pain 

that began two weeks prior, but said she holds her baby on that side.228 Regarding her obesity, she 

had been dieting and did not want gastric bypass surgery because she “[did not] want to lose too 

much [weight], [she had] seen friends with ‘all that extra skin.’”229 NP McDonald referred her to 

physical therapy for her back and shoulder pain.230

At the next follow-up appointment, Ms. Osborn had a new complaint of restless leg 

syndrome.231 NP McDonald noted Ms. Osborn was signing up for the YMCA at the end of 

 

220 Id.

221 Id.

222 AR 584-85.

223 AR 585.

224 Id.

225 AR 584.

226 AR 582.

227 Id.

228 Id.

229 Id.

230 AR 583.

231 AR 580-81, 659-60.

Case 3:15-cv-03599-LB Document 25 Filed 10/17/16 Page 20 of 70
ORDER (No. 3:15-cv-3599-LB) 21

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October when she could afford it.232 She observed her to be alert and oriented, with normal gait 

and balance.233 She prescribed gabapentin for Ms. Osborn’s restless leg syndrome.234

Ms. Osborn’s weight loss was going well; she lost eleven pounds in November.235 NP 

McDonald refilled her ibuprofen prescription, and started her on acetaminophen.

236 Ms. Osborn 

was still smoking, and the nurse recommended quitting to ease her ulcers and restless leg 

syndrome.237 In December, she was actively trying to lose weight, and had lost two more 

pounds.238 Her walking increased, and she could walk for about 60 minutes.

239 She could not sit 

for more than sixty to ninety minutes before her “back [would] start[] killing her.”

240

In December 2012, examining physician Dr. Jerilyn Jackson and NP McDonald co-signed a 

five-page lumbar spine residual-functional-capacity questionnaire detailing Ms. Osborn’s physical 

limitations.241 They diagnosed her with spinal stenosis of the lumbar region and radiculopathy.

242

They noted the following: the June MRI showed L4-5 spinal stenosis, L5-S1 advanced 

degenerative-disc disease, and impingement on the L5 nerve root.243 Her symptoms included back 

pain radiating down her right leg, which affected her sleep and worsened with prolonged sitting or 

standing, and a reduced range of motion in forward flexion and extension secondary to pain.

244

Emotional factors did not contribute to her pain or limitations.

245 Her impairments were 

 

232 AR 580, 659.

233 Id.

234 AR 581, 660.

235 AR 657.

236 Id.

237 Id.

238 AR 655.

239 Id.

240 Id.

241 AR 595-99.

242 AR 595.

243 AR 595-96.

244 AR 596.

245 Id.

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ORDER (No. 3:15-cv-3599-LB) 22

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reasonably consistent with the symptoms and functional limitations described in the residualfunctional-capacity questionnaire.246 In a typical workday her pain would frequently interfere with 

attention and concentration needed to perform simple work tasks.247 The medical providers opined 

that her impairments lasted or could be expected to last at least twelve months.248

Ms. Osborn could walk two city blocks without rest or severe pain.249 She could sit at one time 

for 30 minutes before needing to get up, stand twenty to thirty minutes before needing to sit or 

walk around, and sit less than two hours total and stand or walk around for about two hours total 

in an eight-hour working day.250 Every thirty minutes she needed three to five-minute periods of 

walking around during an eight-hour working day.251 She required a job that permits shifting

positions at will from sitting, standing or walking, and she would sometimes need to take

unscheduled breaks every hour for five minutes during an eight-hour working day.252 Prolonged 

sitting meant her legs should be elevated thirty degrees for fifty percent of a sedentary eight-hour 

working day.253 She does not need to use a cane or other assistive device with occasional standing 

or walking.254 

In a competitive work situation, Ms. Osborn could lift and carry less than ten pounds 

frequently, ten pounds occasionally, twenty pounds rarely, and never fifty pounds.255 She could 

never twist, crouch or squat, and could rarely stoop (bend) or climb ladders or stairs.256 She did

not have significant limitations with reaching, handling, or fingering.257 Her impairments were

 

246 Id.

247 Id.

248 Id.

249 Id.

250 AR 597.

251 Id.

252 Id.

253 Id.

254 Id.

255 AR 598.

256 Id.

257 Id.

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ORDER (No. 3:15-cv-3599-LB) 23

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likely to produce good days and bad days, and it was unknown if she would be absent from work 

three or more days per month. The functional-capacity questionnaire concluded by listing 2006 as 

the earliest date the described symptoms and limitations applied.258

2.1.8 Medical records from 2013

Ms. Osborn’s other interaction with Dr. Jackson was in February, when she treated her for 

heavy menstrual bleeding.

259 Dr. Jackson assessed her with menorrhagia, and prescribed

Provera.

260 She also assessed her with dysmenorrhea, and prescribed Vicodin.261 Ms. Osborn was 

pleasant, alert, and oriented.262

MDSI Physician Services’ examining physician Dr. Farjallah Khoury conducted a consultative 

neurological evaluation for Ms. Osborn’s chronic back pain in March 2013.

263 He reviewed Ms. 

Osborn’s three lumbosacral MRIs to date: (1) July 2007, showing mild disc space narrowing and 

disc protrusions at L3-4 and L4-5, with mild disc bulge at L5-S1; (2) June 2011, showing small 

disc protrusions at L3-4 and advanced degenerative-disc disease at L5-S1; and (3) January 2012, 

showing no significant changes compared to the previous scans.

264 He summarized her presentillness history: “a 33-year-old former nurse who suffered a work related lifting injury while 

attempting to transfer a patient in 2007, who presents today with continued chronic low back pain, 

right-sided, progressively getting worse, now constant and severe, stabbing in quality [and]

radiating down the right leg to the toes. She has had multiple recent hospitalizations within the last 

several months due to pain in her back status post intravenous opiate medications with relief of 

symptoms. She is currently on oral opiates and anti-inflammatories with mild to moderate overall 

relief, but does not have a home TENS unit. Her last epidural steroid injection course was in 2008 

 

258 Id.

259 AR 650.

260 Id.

261 Id.

262 AR 651.

263 AR 620-24.

264 AR 620.

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ORDER (No. 3:15-cv-3599-LB) 24

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with mild to moderate relief of symptoms for approximately two months.”265 She had no recent 

physical therapy, chiropractic interventions, or acupuncture.266 “She has associated spasms and 

lower limb instability during ambulation.”

267 Her medications were Vicodin, Tylenol, and 

naproxen.268 Her daily living activities included driving, self-caring, and completing light-duty 

house chores.

269 She has needed increased time to perform her daily living activities.270 She could 

move independently into the examination room, and sit down without assistance.271 Dr. Khoury

diagnosed her with right-sided lumbar radiculitis at L5-S1, gait abnormality, and obesity.272

His functional assessment was that Ms. Osborn’s condition would continue to impose mild to 

moderate overall functional and work-related impairments.273 She could stand or walk for a total 

of six hours in a regular workday with frequent breaks for stretching or rest, and could sit for a 

total of six hours in a regular day with frequent rest breaks.274 She could lift or carry twenty

pounds occasionally, and ten pounds frequently, secondary to her chronic pain and lumbar 

radiculitis.

275 Her postural activities were “occasionally climbing, balancing, stooping, kneeling, 

crouching, and/or crawling secondary to her chronic pain and lumbar radiculitis.”276 Her 

manipulative activities had “no relevant functional deficits that would restrict reaching, handling, 

fingering and/or feeling.”277 As to her workplace environmental activities, Ms. Osborn should 

“only occasionally perform tasks associated with unprotected heights, operating heavy machinery, 

 

265 Id.

266 Id.

267 Id.

268 AR 621.

269 Id.

270 Id.

271 Id.

272 AR 623.

273 Id.

274 Id.

275 Id.

276 AR 624.

277 Id.

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ORDER (No. 3:15-cv-3599-LB) 25

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working at extreme temperatures, chemicals, dust/fumes/gases, and around excessive noise.”

278

Dr. Khoury concluded that Ms. Osborn was “at a high fall risk secondary to her gait 

instability/lumbar radiculitis.”279

Later that month, NP McDonald had a follow-up appointment with Ms. Osborn due to a 

snapping sensation in her back.

280 She had gone to the emergency room for evaluation, and asked 

for another MRI.281 She had been taking depression medication for four days; a depression 

screening was administered but was negative.282 NP McDonald diagnosed Ms. Osborn with 

lumbar spinal stenosis, and major depression, single episode.283 For her lumbar spinal stenosis, she 

prescribed her oxycodone-acetaminophen, and ordered a diagnostic MRI.284 She decreased her 

venlafaxine prescription (used for depression) because of drowsiness.

285

Ms. Osborn reported the Percocet’s successful results to examining physician Dr. Anthony 

Lim during her next follow-up on April 29, 2013.

286 It was working better than Norco and 

Vicodin, but her two pills per day allotment were insufficient at times.

287 Dr. Lim increased her 

Percocet allocation from two to three pills a day, and wrote that he would let NP McDonald decide 

if more was needed.288 The next month, examining physician Dr. Parker Duncan increased her 

oxycodone/Percocet prescription from three to four pills a day.

289 In June, Ms. Osborn requested 

an increase of oxycodone from four to five pills a day, with a new complaint of radiating pain into 

 

278 Id.

279 Id.

280 AR 646-47.

281 AR 646.

282 Id.

283 AR 647.

284 Id.

285 AR 646-47.

286 AR 643.

287 Id.

288 AR 644.

289 AR 640-42.

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ORDER (No. 3:15-cv-3599-LB) 26

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her upper back, shoulders, neck, and head.

290 NP McDonald granted this request, and ordered 

diagnostic MRIs for her cervical and thoracic spine.

291

An MRI of Ms. Osborn’s lumbar spine was taken in July, and Dr. Modic compared this with 

her June 2011 MRI.

292 He found the following. L1-2: normal; L2-3: normal; L3-4: degenerativedisc disease with loss of height and signal from intervertebral disc; stable small central disc 

protrusion with associated annular tear; L4-5: moderate degenerative-disc disease; central and 

right paracentral disc protrusion larger than the prior study affecting right lateral recess and 

displacing the traversing right L5 and S1 nerve roots with moderate central canal stenosis; and L5-

S1: advanced degenerative-disc disease with a broad-based disc bulge; this extended into the 

inferior recess of the neural foramina bilaterally with flattening of the exiting right L5 nerve 

root.

293 He concluded that Ms. Osborn had (1) degenerative-disc disease in the lower lumbar 

spine; (2) enlarged disc protrusion at L4-5 with a greater impact on the spinal canal and the 

traversing nerve roots; and (3) significant degenerative-disc disease at L5-S1 with likely 

impingement on the exiting right L5 nerve root in the neural foramen.294

On June 22, 2013, Ms. Osborn had an MRI of her thoracic and cervical spine, both analyzed 

by examining physician Dr. Douglas Munro.295 Regarding her thoracic spine, he saw some mild 

degeneration at the mid-disc, evidenced by loss of disc space height and decreased T2 signal, but 

no central spinal canal or neural foraminal compromise.296 In general, the MRI showed an

unremarkable thoracic spine.

297 Her cervical spine had C5-6 “disc degeneration with a mild disc 

bulge and mild osteophytic ridging,” which “create[d] mild-to-moderate central spinal canal 

stenosis with equivocal cord effacement. Left uncovertebral osteophytosis [was] seen creating a 

 

290 AR 638-39.

291 AR 639.

292 AR 667.

293 Id.

294 Id.

295 AR 668-69.

296 AR 668.

297 Id.

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ORDER (No. 3:15-cv-3599-LB) 27

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small left neural foramen. The right neural foramen [was] patent.”298 She also had C6-7 “disc 

degeneration with a mild broad disc bulge and minimal osteophytic ridging,” which “create[d]

minimal central spinal canal stenosis. The neural foramina [were] patent.”

299 The cervical-spine

report concluded as follows: foramen magnum was widely patent; the cervical cord appeared

unremarkable, the hemopoietic marrow signal was normal, and the bony structures and 

paravertebral soft tissues were felt to be normal. The “Impression” section showed “C5-6 disc 

bulge and osteophytic ridging creating mild-to-moderate central spinal canal stenosis with 

equivocal cord effacement”; and “C6-7 mild disc bulge creating minimal central spinal canal 

stenosis.”

300

By August 14, 2013, NP McDonald noted that Ms. Osborn was in terrible pain due to her 

recent hemorrhoidectomy.301 She had already taken all of her prescribed Percocet and Norco.

302

NP McDonald temporarily increased her Percocet for surgery recovery, but noted that it would be 

reduced back to her usual amount the following month.303 She also referred her to neurosurgery to 

evaluate her recent MRIs.304 Her acute pain from the hemorrhoidectomy, however, continued into 

the next month.305 Ms. Osborn went to the emergency room a few days after this latest 

appointment for back pain and a fever; she was diagnosed with pyelo and given Cipro and 

fluids.306 She asked NP McDonald for something stronger than Norco, and she refilled her 

Percocet prescription at the previously increased amount.

307

 

298 AR 669.

299 Id.

300 Id.

301 AR 689.

302 Id.

303 Id.

304 AR 689-90.

305 AR 687-88.

306 AR 687.

307 Id.

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ORDER (No. 3:15-cv-3599-LB) 28

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After losing the “required 50 pounds,” Ms. Osborn met with Dr. Yablon for a follow-up

neurosurgical consultation on September 16.

308 At the last neurosurgical evaluation, “her chief 

complaint was of low back pain.”309 This time, her chief complaint was “of cervical pain radiating 

down her left arm to all digits of her left hand.”310 He reported that this was “not associated with 

weakness. There are paresthesias. There are no symptoms in the right upper extremity.”

311 There 

was no neck pain at the last evaluation, but Ms. Osborn “state[d] that the neck pain and left upper 

extremity radicular symptoms ha[d] been present for the last 4 months.”312 In addition, she still 

complained of lower-back pain radiating “down her right leg in a typical posterior lateral 

distribution towards the foot. There are paresthesias. There is no weakness.”313 Her symptoms did 

not increase with the Valsalva maneuver.314

Dr. Yablon reviewed her three recent MRIs and found the following. Her cervical MRI scan 

showed bilateral degenerative changes at the uncovertebral joints at C5-6 and C6-7 with foraminal 

stenosis.315 Her thoracic MRI scan was normal.316 Her lumbar MRI scan showed “mild discdegeneration at L3-4 and L5-S1[,] but at L4-5 she had a moderately large herniated disc centrally 

into the right with foraminal and central stenosis.”

317

He conducted a physical examination of Ms. Osborn and found the following: there were 

unremarkable mechanical signs in her cervical, thoracic, and lumbar spines; her mental status was

normal; she had no cranial nerve palsies; her muscle bulk, tone, and strength was normal; “sensory 

testing [was] intact”; her deep tendon reflexes were all to seventy percent use in the left lower 

 

308 AR 691-92.

309 AR 691.

310 Id.

311 Id.

312 Id.

313 Id.

314 Id.

315 Id.

316 Id.

317 Id.

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extremity, but her right knee and ankle jerks were absent; and she had minimally antalgic gait

ambulation.

318

Dr. Yablon’s assessment and plan was as follows. Ms. Osborn was suffering from significant 

pathology in her cervical and lumbar spines, manifested as neck pain, left upper-extremity 

radiculopathy, low-back pain, and right lower-extremity radiculopathy.319 As to her cervical spine, 

he did “not believe she has had adequate conservative therapy,” and he recommended physical 

therapy and cervical epidural steroids.320 If she failed to respond to this treatment, he would then 

consider her a candidate for two-level anterior cervical discectomy and fusion at the C5-6 and C6-

7 levels.

321 “Regarding her thoracic spine, there [was] nothing to do.”322 As for her lumbar spine, 

Dr. Yablon gave her the option of either another set of lumbar epidural steroid injections, or 

surgery in the form of a minimally invasive right L4-5 hemilaminectomy and discectomy.

323

In October, Ms. Osborn’s hemorrhoidectomy pain had resolved, but she was having terrible 

sciatica.324 She also had an epidural “that caused really bad pain,” and she did not want another.

325

NP McDonald noted that she was trying to decide on neurosurgery to get the herniated disk 

repaired.326 She also felt that she did not need Percocet for pain anymore, and instead wanted to

stick with Norco for pain management.

327 Ms. Osborn also would like something for anxiety.328 A 

urine drug screen showed her negative for everything except opiates.329 NP McDonald refilled her

 

318 AR 692.

319 Id.

320 Id.

321 Id.

322 Id.

323 Id.

324 AR 684-85.

325 AR 684.

326 Id.

327 Id.

328 Id.

329 Id.

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Norco prescription, and warned her against utilizing the emergency room for acute pain 

medication and early refill requests.330 She also started her on hydroxyzine for anxiety.331

In November, Ms. Osborn awoke “with suddenly swollen legs,” and went to the emergency 

department “where she had a w/u that apparently didn’t reveal anything.”332 Despite her attempts 

to lose weight, she gained 20 pounds in the few weeks before this emergency visit.

333 Dr. James 

Wu assessed her with acute swelling of an unclear etiology.

334 He prescribed her furosemide for 

the swelling, and five days’ worth of Percocet.

335

2.2 SSA Non-Examining Physicians

2.2.1 Initial claim for disability Drs. Robert C. Scott, M.D. & H. Pham, M.D.

In October 2011, SSA non-examining Drs. Scott and Pham reviewed Ms. Osborn’s medical 

records, including the reports by Drs. Zipperle and Alchemy from MDSI Physician Group.336

Dr. Pham listed Ms. Osborn’s Allegations of Impairments as “back problems/discs/pinched 

sciatic nerve, pinched sciatica nerve, and ulcer/stress.”337 Dr. Scott found that Ms. Osborn suffered 

from an affective disorder, and a substance-addiction disorder, that caused a mild restriction on 

Ms. Osborn’s daily activities, and moderate restrictions on her ability to maintain social function, 

concentration, persistence, and pace.338 Dr. Pham wrote that one or more of Ms. Osborn’s 

medically determinable impairments were reasonably expected to produce her pain or other 

symptoms.339 She also wrote that Ms. Osborn’s statements about the intensity, persistence, and 

functionally limiting effects of the symptoms were not substantiated by the objective medical 

 

330 Id.

331 AR 685.

332 AR 681.

333 Id.

334 AR 682.

335 Id.

336 AR 111-13.

337 AR 115.

338 AR 116.

339 AR 117.

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evidence alone.340 Dr. Pham decided that the “ADLs” were most informative in assessing the 

credibility of Ms. Osborn’s statements.341 Dr. Pham assessed the credibility of Ms. Osborn’s 

statements regarding symptoms considering the total medical and non-medical evidence as 

“partially credible.”

342 She explained this credibility assessment as follows: Ms. Osborn’s 

“abilities for functioning per ADL and functional accounts were not consistent with her alleged 

limitations due to mental impairment.”343 Dr. Pham gave both Drs. Zipperle and Alchemy’s 

opinions “great weight,” and explained this assessment as follows: “no TP opinions in file. CE 

MSS are consistent with other evidence in file.”344

Dr. Pham completed a physical residual-functional-capacity assessment.345 She rated Ms. 

Osborn’s exertional limitations as follows.346 She could occasionally (cumulatively 1/3 or less of 

an eight-hour day) lift and/or carry (including upward pulling) 50 pounds.

347 She could frequently 

(cumulatively 1/3 to 2/3 of an eight-hour day) lift and/or carry (including upward pulling) 25 

pounds.348 She could stand and/or walk (with normal breaks) for a total of about six hours in an 

eight-hour workday.349 She could sit (with normal breaks) for a total of about six hours in an 

eight-hour workday.350 She could push and/or pull (including operation of hand and/or foot 

controls) “unlimited, other than shown, for lift and/or carry.”351

 

340 Id.

341 Id.

342 Id.

343 Id.

344 Id.

345 AR 117-19.

346 AR 118.

347 Id.

348 Id.

349 Id.

350 Id.

351 Id.

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Dr. Pham also noted Ms. Osborn had postural limitations, and rated them as follows.352 She 

was “unlimited” in climbing ramps/stairs, climbing ladders/ropes/scaffolds, balancing, kneeling, 

crouching, and crawling.353 She was “frequently” limited in stooping.354 Dr. Pham concluded that 

Ms. Osborn had no manipulative, visual, communicative, or environmental limitations.355

Dr. Scott completed the mental residual-functional-capacity assessment.

356 He noted Ms. 

Osborn had no understanding and memory limitations, and had sustained concentration and 

persistence limitations.357 He rated her sustained concentration and persistence limitations as 

follows.358 Her abilities to carry out very short and simple instructions and detailed instructions 

were not significantly limited.359 Her abilities to maintain attention and concentration for extended 

periods, to perform activities within a schedule, maintain regular attendance, and be punctual 

within customary tolerances were moderately limited.360 She was not significantly limited in her

ability to sustain an ordinary routine without special supervision, to make simple work-related 

decisions, to complete a normal workday and workweek without interruptions from 

psychologically based symptoms, or to perform at a consistent pace without an unreasonable 

number and length of rest periods.361 Her ability to work in coordination with or in proximity to 

others without being distracted by them was moderately limited.362 Dr. Scott explained her 

sustained concentration and persistence limitations above as “able to sustain a routine of simple 

tasks under ordinary supervision.”363

 

352 Id.

353 Id.

354 Id.

355 Id.

356 AR 119-20.

357 AR 119.

358 Id.

359 Id.

360 Id.

361 Id.

362 Id.

363 Id.

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Dr. Scott also noted Ms. Osborn had social interaction limitations, and rated them as 

follows.364 Her ability to interact appropriately with the general public was moderately limited.365

Her abilities to ask simple questions or request assistance, to maintain socially appropriate 

behavior, and to adhere to basic standards of neatness and cleanliness were not significantly 

limited.366 There was no evidence of limitations on her abilities to accept instructions and respond 

appropriately to criticism from a supervisor, or her ability to get along with coworkers or peers 

without distracting them or exhibiting behavioral extremes.367 Dr. Scott explained her social 

interaction limitations above as “depression will limit her tolerance for social interaction, and will 

restrict her to low public contact settings. [She is] able to relate adequately to familiar coworkers 

and supervisors in superficial work-related contact.”368 Dr. Scott concluded by noting Ms. Osborn 

had no adaptation limitations.369

The Disability Determination Explanation finished by listing Ms. Osborn’s past relevant work 

as a caregiver, with additional past work as a cocktail waitress, waitress, and cashier.370 It went on 

to conclude that Ms. Osborn had the residual functional capacity to perform her past relevant 

work, which she could do as “actually performed.”371 “The evidence shows that [Ms. Osborn] has 

some limitations in the performance of certain work activities; however, these limitations would 

not prevent the individual from performing past relevant work as [a] caregiver.”372 Ms. Osborn 

was classified as “not disabled.”

373

 

364 AR 119-20.

365 AR 120.

366 Id.

367 Id.

368 Id.

369 Id.

370 AR 120-21.

371 AR 121.

372 Id.

373 Id.

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2.2.2 Reconsideration request for disability: Drs. Helen C. Patterson, Ph.D. and 

Nathan Strause, M.D.

In March and April 2012, SSA non-examining Drs. Patterson and Strause reviewed Ms. 

Osborn’s medical records.

374 In addition to the records reviewed for the initial claim, both SSA 

non-examining doctors also reviewed records from Vista Family Health Center.375 The 

reconsideration report noted that the alleged impairments of back problems/discs/pinched sciatic 

nerve, pinched sciatica nerve, ulcer/stress, depression, and anxiety, were unchanged since her 

initial claim for disability.

376 It went on to note that no new physical or mental limitations had 

arisen since the last disability report, and that Ms. Osborn had not worked since then.377

Dr. Patterson completed the findings of fact and analysis of evidence.

378 She wrote that “Dr. 

Zipperle has established [a] pattern of forming extreme conclusions when compared with [the] 

balance of a record. Nothing in the [medical evidence record] preceding her [examination] shows 

evidence that [Ms. Osborn] has a bipolar disorder. [Ms. Osborn] alleges anxiety and depression, 

along with her physical allegations, but she has no history of treatment for a psychiatric 

disorder.”379 Dr. Patterson briefly summarized Ms. Osborn’s history of methamphetamine abuse, 

discussions of depression with treating doctors, her claimed abstinence from drugs, a doctor’s 

refusal to prescribe medication, and a meth-positive urine toxicology screen.380 Thus, Dr. 

Patterson concluded that the medical evidence record “shows mood symptoms reported but in 

[the] context of active drug abuse.”381 Dr. Patterson noted that Ms. Osborn “entered a drug rehab 

program and is indicated to be living in [a] sober living facility.”382 She also wrote that since SSA 

non-examining Dr. Scott’s review in October 2011, updated treating-source records “have shown 

 

374 AR 138-49. AR 150-61 is identical. 

375 AR 139-42.

376 AR 138-39.

377 AR 139.

378 AR 143.

379 Id.

380 Id.

381 Id.

382 Id.

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zero evidence of mood disturbance, despite the claimant having no treatment. On routine 

screenings at OVs for physical, [Ms. Osborn] has denied any mood disturbance symptoms.”383

The report concluded with the assertion that Ms. Osborn “appears to have improved over time and 

[is] maintaining abstinence from drugs. PRTF completed to indicated condition is currently nonsevere.”384

Next, Dr. Patterson reported that Ms. Osborn had the following medically determinable 

impairments: (1) “disorders of back-discogenic and degenerative” (primary priority, severe); (2)

peptic ulcer (other priority, non-severe); (3) obesity (other priority, non-severe); (4) affective 

disorders (other priority, non-severe); and (5) substance addiction disorders (secondary priority, 

non-severe).385

Dr. Patterson determined affective disorders caused mild restrictions on Ms. Osborn’s daily 

activities, and mild difficulties in maintaining social function, concentration, persistence, or 

pace.

386 Ms. Osborn had no repeated episodes of decompensation of extended duration.387 Dr. 

Patterson additionally explained that “objective evidence shows substantial improvement since 

initial determination five months ago.”388 The listings considered were 12.04 affective disorders, 

12.09 substance addiction disorders, and 1.04 spine disorders.389

Dr. Patterson completed the assessment of policy issues.390 She reported that one or more of 

Ms. Osborn’s medically determinable impairments could reasonably be expected to produce her

pain or other symptoms.

391 She wrote that Ms. Osborn’s statements about intensity, persistence, 

and functionally limiting effects of the symptoms were not substantiated by the objective medical 

 

383 Id.

384 Id.

385 AR 143-44.

386 AR 144.

387 Id.

388 Id.

389 AR 144-45.

390 AR 145.

391 Id.

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evidence alone.392 She considered the “ADLs” as most informative in assessing the credibility of 

Ms. Osborn’s statements.

393 She assessed the credibility of her statements regarding symptoms 

considering the total medical and non-medical evidence as “partially credible.”

394 She explained 

this credibility assessment as “[Ms. Osborn]’s abilities for functioning per ADL and functional 

accounts are not consistent with her alleged limitations due to mental impairment.”395

She weighed Drs. Zipperle and Alchemy’s opinions as “other weight.”

396 She explained this as 

follows: Dr. Alchemy’s “functional assessment is supported by his objecting findings. I assign him 

other [weight] because of MRI (2/1/2010) indicated evidence I feel some postural. Dr. Zipperle’s 

report contains [diagnoses] and conclusions that have no objective support elsewhere in the record. 

Updated records from [primary care provider] show signs of active mood disorder. [Dr. 

Zipperle’s] report is read but not given weight. No limitations.”

397

Dr. Strause conducted the physical residual-functional-capacity assessment.398 He rated Ms. 

Osborn’s exertional limitations as follows.399 She could occasionally (cumulatively 1/3 or less of 

an eight-hour day) lift and/or carry (including upward pulling) 20 pounds.400 She could frequently 

(cumulatively 1/3 up to 2/3 of an eight-hour day) lift and/or carry (including upward pulling) 10 

pounds.401 She could stand and/or walk (with normal breaks) for a total of about six hours in an 

eight-hour workday.402 She could sit (with normal breaks) for a total of more than six hours on a 

 

392 Id. 

393 Id.

394 Id.

395 Id.

396 Id.

397 Id.

398 AR 146.

399 Id.

400 Id.

401 Id.

402 Id.

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sustained basis in an eight-hour workday.403 She could push and/or pull (including operation of 

hand and/or foot controls) “unlimited, other than shown, for lift and/or carry.”404

Dr. Strause also noted Ms. Osborn had postural limitations, and rated them as follows.405 She 

was “unlimited” in climbing ramps/stairs, and balancing.406 She could never climb 

ladders/ropes/scaffolds.407 She could occasionally stoop.408 She was “frequently” limited in 

kneeling, crouching, and crawling.409 Dr. Strause found that Ms. Osborn had no manipulative, 

visual, communicative, or environmental limitations.410 He additionally explained that for both her 

Title II and Title XVI claims, “there is continuous [medical record evidence] from 2006 until the 

present continuously documenting her [lumbar-spine] condition. An RFC at the DLI would not be 

significant[ly] different from this RFC.”411 He went on to opine that even though the initial 

disability determination report from September 18, 2011 gave Ms. Osborn no limitations, “her 

back is persistent and subsequent MER indicates that her pain is reasonably controlled with 

Vicodin.”412 Not one MER since the previous claim and the CE report had adequately reported

back, motor, or neurological evaluations.413 However, three MRIs of Ms. Osborn’s lumbar spine 

have been reported (2007, 2010, and 2011) which “all indicated [degenerative-disc disease], disc 

bulging, effacement of thecal sac and the most recent indicating advanced [degenerative-disc 

disease] with impingement of the L5 nerve root. This is strong objective data. This evidence 

supports her allegations over the period from 2006 until the present.”414

 

403 Id.

404 Id.

405 Id.

406 Id.

407 Id.

408 Id.

409 Id.

410 AR 147.

411 Id.

412 Id.

413 Id.

414 Id.

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Dr. Strause noted that “although [Ms. Osborn’s] [symptoms] are not always persistent she has 

had significant radicular [symptoms] and severe pain requiring significant narcotics and epidurals. 

Therefore [he] [felt] that some weight must be given to the alleged limitations reported at PCP 

visits and in function report (affected by medication suppressing her pain).”415 He especially took 

into consideration the prolonged history of Ms. Osborn’s condition.

416 His recommended 

limitations also included allowances for activities that “would potentially aggravate [Ms. Osborn’s 

condition] by increasing pressures in the thecal sac, the documented abnormalities in the lumbar 

spine, the spinal cord, and the nerve roots.”417 Dr. Strause concluded by noting Ms. Osborn’s “GI 

ulcer and stress GI problems do not indicate any limitations.”418

As to Dr. Zipperle’s opinion, Dr. Strause noted it was more restrictive than his findings by 

explaining that it “relies heavily on the subjective report of symptoms and limitations provided by 

[Ms. Osborn], and the totality of the evidence does not support the opinion. The opinion is without 

substantial support from other evidence of record, which renders it less persuasive. [The] opinion 

is an overestimate of the severity of [Ms. Osborn’s] restrictions/limitations and based only on a 

snapshot of [her] functioning.”419

Dr. Strause listed Ms. Osborn’s past relevant work as caregiver, with additional past work as a 

cocktail waitress, waitress, and cashier.420 He determined Ms. Osborn had the residual functional 

capacity to perform her relevant past work, which can be performed as “actually performed.”

421

“The evidence shows that [Ms. Osborn] has some limitations in the performance of certain work 

activities; however, these limitations would not prevent the individual from performing past 

relevant work as [a] caregiver.”422 Ms. Osborn was again classified as “not disabled.”

423

 

415 Id.

416 Id.

417 Id.

418 Id.

419 AR 148.

420 Id. 

421 Id.

422 Id.

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2.3 Initial Hearing Before the ALJ: January 17, 2013

Ms. Osborn, her non-attorney representative Dan McCaskell, and vocational expert Gene 

Jackson were all present before the ALJ at the initial hearing.424 First, Mr. McCaskell confirmed 

that Ms. Osborn’s alleged severe impairments were a lumbar condition, depression, anxiety, and 

obesity.425 Next, Ms. Osborn was questioned and testified about how her impairments have 

affected her life in support of her disability claim.426

2.3.1 Ms. Osborn’s testimony

Ms. Osborn testified to the following: she was 221 pounds at the hearing, and recently lost 20 

pounds in four months from walking and dietary changes.427 She had three children — ages 

fifteen, five, and two — and they all moved back in with her parents.428 She has received state 

disability in the past, but not workers’ compensation.429 She drove her kids to and from school five 

days a week, received her GED, and had not worked since December 1, 2006 due to her back pain

“killing [her].”

430 Ms. Osborn was working as a caregiver for a quadriplegic woman when she bent 

over to turn the patient (while pregnant), stood up, and “felt [her] back stop and [she] couldn’t 

move.”431 Her previous jobs were caregiving, waitressing, and cashiering.432

Ms. Osborn felt that, primarily, her back prevented her from working.

433 On good days, she 

could sit for thirty minutes, and then she has to get up and walk around for at least thirty

minutes.434 On bad days, it was ten to fifteen minutes of sitting, then ten to fifteen minutes of 

 

423 Id.

424 AR 77.

425 AR 84-85.

426 AR 85-101.

427 AR 85-86.

428 AR 86-87.

429 AR 88.

430 AR 88-89.

431 AR 89.

432 AR 90-91.

433 AR 91.

434 Id. 

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getting up and walking around.435 Her right leg has become numb from a pinched nerve.

436 At the 

time of the hearing, she was only taking ibuprofen and Tylenol — no narcotics — because of her 

drug history.437 May 10, 2011 marked her clean and sober date — including cigarettes — after 

multiple attempts at residential rehabilitation programs.

438 Since rehab she felt physically sore and 

mentally “not stable,” but she was adjusting.439 Her back hurt worse because she “used to use the 

meth as . . . medication.”440 She did feel healthier, but her medications were “not really” helping 

— they were not strong enough and Ms. Osborn felt “the same.”441

She was not taking any mental medication at the time of the hearing.

442 Ms. Osborn took 

Prozac in 2002 and Zoloft during her residential treatment but stopped because she did not like the 

way Prozac made her feel and Zoloft did not work.443 She was also not receiving any other mentalhealth treatment at the time of the hearing, but had attended therapy in 2011 and 2012.444 She 

stopped anxiety and depression therapy in 2011-12 “because [she] didn’t feel [it] was helping [her]

and [she] found a new therapist that [she was] thinking about seeing.”445 She has never been 

hospitalized for her mental health.446

She had had no surgeries, but UCSF Dr. Yablon recommended that a new disc be put in after 

she lost weight.

447 Previous steroid injections have helped, but the second time “didn’t help 

 

435 Id.

436 AR 92.

437 Id.

438 AR 92-93.

439 AR 93.

440 Id.

441 AR 93-94.

442 Id.

443 AR 94-95.

444 AR 97.

445 Id.

446 Id.

447 AR 95.

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because they nicked my spine.”

448 This second injection made her “more paralyzed for a few 

days,” but the first injection helped for a few months.449 She “went to physical therapy in 2007 or 

2008, and it wasn’t helping.”

450 She has also tried the back exercises her doctors told her to do 

before getting in and out of bed, but “they’re just not helping anymore.”451 She does not need to 

use a splint or brace, and has never used a TENS unit or cane.452

She described the location of her pain as “all through [her] lower back, mainly from the middle 

to the right more. It shoots a stabbing pain down [her] right leg. [Her] whole right side from about 

[her] knee up on the side of the . . . [is] all tingly. At night and during the day it just pinches, 

pinches, stabs, stabs.”453 She was often in pain all day and night, disrupting and causing her to 

“barely sleep.”454 Reclining, putting her feet up, and “putting the heating pad” helped her pain.455

Her depression and anxiety “doesn’t really affect [her] too much.”

456

Her typical day included getting up at 6:30 a.m., making lunch for her kids, and sitting down 

while they got ready for school.457 Her family would help her, and she would drive them to school

two miles away.458 She would then return to her parent’s house, and “put [her] feet back up and 

pretty much watch TV.”459 On good days she gets up every half hour, and on bad days it was

every ten or fifteen minutes of walking in circles around the kitchen and through the living 

room.

460 She had on average four bad days and three good days in a week.461

 

448 AR 95-96.

449 AR 96.

450 Id.

451 Id.

452 AR 96-97.

453 AR 97-98.

454 AR 98.

455 Id.

456 Id.

457 Id.

458 AR 98-99.

459 AR 99.

460 AR 99.

Case 3:15-cv-03599-LB Document 25 Filed 10/17/16 Page 41 of 70
ORDER (No. 3:15-cv-3599-LB) 42

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It became harder for her to put on her shoes.462 She testified: “I can lift my left leg over my 

right leg just fine but my right leg doesn’t want to bend over my left leg to tie my shoes. So then I 

have to bend over and stress my back out even worse on this side or ask my daughter or somebody 

to tie my shoe.”463 She could cook, she could not put laundry in, but could fold the laundry with 

time, and she could grocery shop as long as there was a shopping cart to lean on.

464 Outside of the 

home, she attended AA meetings about three times a week to “sit in the back and soak in the 

peace.”

465 She would use her laptop, and had no hobbies or pets.466 Her parents would help care

for her youngest child during the day.467 Finally, during an eight-hour period from 8:00 AM to 

5:00 PM, she would spend at least four hours reclined.

468

2.3.2 Vocational expert Mr. Gene Johnson’s testimony

The ALJ first asked the vocational expert (“VE”) to classify Ms. Osborn’s past work.469 He 

stated that Ms. Osborn was a cashier and waitress, both performed at light exertion level, and 

home attendant, performed at a medium exertion level.470

The ALJ then posed a hypothetical to the VE: whether an individual with the previous jobs 

described could continue to perform these jobs with Ms. Osborn’s limitations to light work; never 

climbing ladders, ropes or scaffolds; occasional stooping; frequent kneeling, crouching and 

crawling; and requiring a sit/stand option for ten to fifteen minutes.471 He answered that a home 

attendant’s exertion level eliminated it from the outset, and the required sit/stand options eliminate 

 

461 Id.

462 Id.

463 Id.

464 AR 99-100.

465 AR 100.

466 Id.

467 Id. 

468 Id.

469 AR 102.

470 AR 102-03.

471 Id.

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ORDER (No. 3:15-cv-3599-LB) 43

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cashiering and waitressing.472 The ALJ then asked the VE whether this individual could perform 

any other work.473 He answered that in the light category, the individual could be an assembler of 

small products, a school bus monitor, or a bench worker.

474 In the sedentary category, the 

individual could be a telephone order clerk or packing finishing operator.475 He pointed out that all 

of these jobs would be subject to the sit/stand option, which was not provided for by the SSA’s 

Dictionary of Occupational Titles.

476 The VE explained he was able to provide these answers 

through analysis of their job descriptions and requirements.477

The ALJ added a limitation to the hypothetical: in both light and sedentary work, the 

individual would require twenty percent time off for additional breaks beyond normal breaks in an 

eight-hour work day.478 The VE was unable to provide potential work suitable with this added 

limitation.479

Mr. McCaskell changed the initial hypothetical from a sit/stand option to a sit/walk and asked 

the VE whether that individual would still be able to perform the aforementioned other work.480

The VE responded that bus monitors, order clerks, and packing/coding operators would be unable

to walk away from the workstation.481

The ALJ then changed her initial hypothetical to never climbing ladders, ropes or scaffolds; 

occasional stooping; frequent kneeling, crouching and crawling, with a sit/walk option for ten to 

fifteen minutes.482 The VE was unable to provide any jobs available with these limitations.483

 

472 AR 103-04.

473 AR 104.

474 Id.

475 Id.

476 AR 104-05.

477 AR 105.

478 AR 105-06.

479 AR 106.

480 AR 106-07.

481 Id.

482 AR 108.

483 Id.

Case 3:15-cv-03599-LB Document 25 Filed 10/17/16 Page 43 of 70
ORDER (No. 3:15-cv-3599-LB) 44

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The ALJ concluded the hearing by stating that Ms. Osborn would be sent for a neurologist 

consultative examination with an updated medical record.

484

2.4 Supplemental Hearing Before the ALJ: September 5, 2013

Ms. Osborn, Mr. McCaskell, and non-examining medical expert Dr. William Rack were all 

present before the ALJ at the supplemental hearing.485 Mr. McCaskell informed the ALJ that Ms. 

Osborn had obtained three more MRIs of her cervical and lumbar spine for submission into 

evidence.

486 The ALJ responded that she would decide at the end of the hearing whether to keep 

the record open in consideration of the medical expert’s testimony.487 Ms. Osborn and Dr. Rack 

testified about her disability.

2.4.1 Ms. Osborn’s testimony

Ms. Osborn testified that she was living with her fiancé, his parents and sister, and her 

children.

488 She also said that she weighed 215 pounds.489 Since the initial hearing, she had been 

put on an increased dosage of Percocet, and the “pain in [the] right side of [her] back is so bad 

now that [she was] limping around because it’s going down [her] leg.”490 She discussed her recent 

MRIs with her doctors, who put in another referral for neurosurgical evaluation.491 The Percocet

helped on good days, but on bad days she required additional ibuprofen.492There had been no 

recommendation for surgery yet.493 At the time of the hearing, she did not need for a cane or

assistive device.494 She started taking venlaxafine in February or March for her mental health

 

484 Id.

485 AR 39.

486 AR 43.

487 Id.

488 AR 46. 

489 Id.

490 AR 46-47.

491 AR 47.

492 Id.

493 Id. 

494 Id.

Case 3:15-cv-03599-LB Document 25 Filed 10/17/16 Page 44 of 70
ORDER (No. 3:15-cv-3599-LB) 45

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which had been helping “a little bit.”

495 She was not receiving any other treatment, counseling, or 

therapy for her mental health, but her nurse wanted her to “get into therapy.”496 Ms. Osborn 

affirmed her sober date of May 10, 2011.497 She described the location and feeling of her pain:

“it’s through my whole lower back, mostly on the right side. It’s like a constant stabbing, stabbing, 

and when I move to walk . . . it’s constantly down my right leg, like a stabbing all the way down. 

So now when I’m walking, it’s like I can’t even put weight on my right leg.”498 At night, she tried

to sleep with ice, heat, and muscle rubs.499 The pain has caused her depression and anxiety, and 

has affected her concentration but not her memory.

500 Ms. Osborn was feeling depressed due to 

her inability to help around the house and play with her kids.

501

Her typical day comprised of standing and sitting for at least three-quarters or eight hours of 

the day, lying down with ice on her back, then standing and trying to walk.502 Her fiancé

accompanied her to the grocery store, and she had to hold onto the cart.503 Her fiancé did the 

laundry and “deal[t] with the kids,” but she still made their lunch.

504 Her fiancé took them to 

school and helped her shower.

505 She could start washing dishes for five minutes, but then her 

mother-in-law would finish them.

506 She started attending paralegal school two nights a week for 

three hours per night.

507 But her back problems and a recent unrelated surgery forced her to 

 

495 AR 48.

496 Id.

497 AR 48-49.

498 AR 49.

499 Id.

500 AR 49-50.

501 AR 50.

502 Id.

503 Id.

504 AR 50-51.

505 AR 51.

506 Id.

507 AR 51-53.

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ORDER (No. 3:15-cv-3599-LB) 46

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occasionally leave class early.

508 She alternated between sitting and standing against a wall during 

class.

509

2.4.2 Medical expert Mr. William Rack’s testimony

First, the medical expert (“ME”) informed the ALJ that he had only reviewed Ms. Osborn’s 

medical records dating to February 2010 with some undetailed historical information regarding her 

lower-back treatment dating to February 2008, including an epidural injection.

510 He noted that 

there was only “a single line indicating [Ms. Osborn] had symptoms dating back to 2006,” without 

any significant history of neurological examination.511 The ME was aware of these time periods 

only from a historical perspective and without significant information or examination.512

Next, he stated that Ms. Osborn’s primary impairment, from a neurological point of view, was 

lower-back pain associated with degenerative changes of an osteoarthritic and disc nature.513 She 

also suffered associated discomfort into the right, lower extremities which, for a long time, was 

intermittent, but now appeared constant.

514 Despite this problem from a symptom point of view, 

“there ha[d] not been substantial neurologic abnormality described, per examination,” meaning no 

atrophy, reflex changes, or consequential losses of strength or sensation.515 He pointed out that 

Ms. Osborn’s problem did not meet the UCSF neurosurgeon’s criteria for referring her for surgery 

in February 2012.516 Historically, on the basis of Ms. Osborn’s statements, her condition worsened 

with constant, right, lower extremity pain, and she had difficulty in maintaining her upright 

posture because her symptoms.

517

 

508 Id.

509 Id.

510 AR 55-56.

511 AR 56.

512 Id.

513 AR 57.

514 Id.

515 Id.

516 AR 58.

517 Id.

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ORDER (No. 3:15-cv-3599-LB) 47

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The ME testified that the neurologic aspect was complicated by her poly-substance abuse, 

bipolar disorder, depression, anxiety, and obesity (but noted her recent weight loss).

518 The ME 

could not comment on her psychological or substance-abuse status, but he opined that her back 

problem stemmed from mechanical disturbances in her back, namely osteoarthritic and 

degenerative-disc disease.

519 He said “[t]here has not been any distinction [between the] 

neurologic abnormality associated with these symptoms which is, [in his opinion], the reason that 

a conservative course of action has been undertaken over this period of time.”

520 He went on to 

opine that if the upcoming neurological assessment presented abnormalities, or pain is at a 

sufficient magnitude to warrant a different approach, then that would make a big difference (from 

the disability point of view).

521 The ME acknowledged that the MRI studies have been abnormal, 

and that a repeat study and report would be important and helpful.

522

The ALJ asked him whether Ms. Osborn’s impairments met or equaled any impairment 

described in the SSA’s Listings of Impairments.523 He responded that prior to the hearing, he 

believed the absence of neurologic deficits — despite the presence of back discomfort and 

complicating factors from the poly-substance abuse — meant she did not meet the impairment 

criteria listed in Section 1.04 of the SSA’s Listing of Impairments.

524 But Ms. Osborn’s worsening 

pain (in light of her recent weight loss), increasing difficulty getting around, and the “acute 

assessment” made him lean towards concluding that she met the listed criteria.

525 An assessment 

in six months would be reasonable, particularly concerning the neurosurgical opinion.526

 

518 Id.

519 Id.

520 AR 58-59.

521 AR 59.

522 Id.

523 Id.

524 AR 60.

525 Id.

526 Id. 

Case 3:15-cv-03599-LB Document 25 Filed 10/17/16 Page 47 of 70
ORDER (No. 3:15-cv-3599-LB) 48

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The ALJ then asked him to clarify whether Ms. Osborn equaled listing 1.04 or needed further 

assessment.527 The ME responded that “it is much closer at this point to equaling 1.04,” and that 

he would “feel much more comfortable making that judgment knowing what the recent MRIs have 

shown, and knowing what the neurosurgeon finds and thinks.”528 The ME was at the time unable 

to cite to any specific neurological evidence in the record showing Ms. Osborn’s impairments 

equaled the listed criteria, and highlighted that everything was “really being based on a history of 

pain without there being objective findings, as far as the neurologic examination is concerned.”

529

But, as mentioned above, her worsening pain and capabilities made him lean towards concluding 

that her impairments equaled the listing.

530

Moving on to functional and manipulative limitations, the ME testified that Ms. Osborn’s

functional limitations would restrict her to the sedentary level of activity.531 Her manipulative 

limitations included significant restrictions in bending, twisting, turning, crawling, kneeling, or 

any non-sedentary use of her lower-back and extremities.532 She should also refrain from 

considerable leg use because “it’s very difficult to do anything with your legs, particularly your 

hips if, in fact, your back . . . [has] a problem.”533 It would be okay to use her feet in a limited 

way.534 He opined that there would not be restrictions on her upper extremities, shoulders, head, or 

neck so long as they did not necessitate motion in the lumbosacral region.535 She could lift things 

from table height, but should not bend at all to lift anything from the ground or necessitates 

bending her low-back.

536 She could infrequently climb stairs and ramps with handholds.537 She

 

527 Id.

528 AR 61.

529 AR 62.

530 Id.

531 AR 63.

532 AR 63-64.

533 AR 64.

534 Id.

535 Id.

536 Id.

537 AR 65.

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ORDER (No. 3:15-cv-3599-LB) 49

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should never climb ladders, ropes, or scaffolds, but could occasionally stoop, kneel, crawl, or 

couch.538 The ME clarified that “occasionally” meant on the lower side of up to one third of a

day.539 She should also never be at unprotected heights, or be subject to vibration, but he did not 

object to her being in contact with hazardous materials or varying temperatures.

540 When asked to 

cite specific evidence supporting these opinions, the ME cited the medical record in general, 

including references to Ms. Osborn’s MRIs, x-rays, and epidural injections.541

The ALJ asked him how far back Ms. Osborn’s current limitations extended.542 He could not

extend her limitations back to 2006 or 2010 because he didn’t “have any good information back to 

that time,” and only felt comfortable going back to her February 2012 UCSF neurological 

assessment “which [was] really the first detailed assessment that she has had done, from an 

examination point of view, indicating how much [of a] problem[,] or lack of [a] problem[,] [was]

present.”543

Mr. McCaskell questioned the ME about Ms. Osborn’s MRIs that showed evidence of motion 

segment instability and antalgic gait.544 He did not think that those were major findings compared 

to an actual loss of reflex or strength in a particular group of muscles, or loss of sensation in a 

particular area.

545 He clarified that he had no argument with the MRI studies, but that they were

not indicative of whether neurologic abnormalities were present on examination.

546 The ME 

explained that “[t]he presence of MRIs [as] not an indication of whether there are neurologic

changes in the patient. MRIs are an indication that there are changes within the bony structure but 

not necessarily if there are associated neurologic changes. Those are found on examination of the 

 

538 Id.

539 Id.

540 AR 65-66.

541 AR 66-67.

542 AR 67.

543 Id.

544 AR 69-70.

545 AR 70.

546 Id.

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ORDER (No. 3:15-cv-3599-LB) 50

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patient.”

547 The ME concluded by stating that the most important thing was not that the MRIs —

were abnormal (which he conceded), but rather “the neurologic examination of [Ms. Osborn] by a 

sophisticated neurologist or neurosurgeon . . . as to whether she has changed and whether there are 

positive findings now that would indicate something more aggressive has to be done to treat 

her.”

548 Mr. McCaskell confirmed that the upcoming UCSF neurological examination would be 

most important to the ME.549

The ALJ concluded the hearing by stating that she would leave the record open for a month to 

allow submission of the latest MRIs and any additional evidence.

550 She also stated that the ME 

would answer interrogatories to update his opinions after reviewing the additional evidence.

551

Finally, the ALJ noted that the previous hearing’s VE hypotheticals did not reflect exhibit 18F, the 

consultative neurological examination with Dr. Khoury, or the ME’s recent testimony.

552

Therefore, new hypotheticals would need to be propounded by interrogatory.

553

2.5 The ALJ’s Administrative Findings

On December 4, 2013, the ALJ held that Ms. Osborn was not disabled from December 1, 2006 

through the decision date.554 She first noted that the record was left open after the supplemental 

hearing on September 5, 2013.555 No additional evidence was received by the agreed-upon 

deadline, nor was there a request for additional time.556 The ALJ closed the record “long after the 

deadline” and based her decision on the record as of the date of the supplemental hearing.557 The 

 

547 AR 70-71.

548 AR 71-72.

549 AR 72.

550 AR 72-74.

551 AR 74-75.

552 AR 75.

553 Id.

554 AR 32.

555 AR 23.

556 Id.

557 Id.

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ORDER (No. 3:15-cv-3599-LB) 51

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ALF proceeded through the five steps for determining whether Ms. Osborn was disabled under the 

Social Security Act.

At step one, the ALJ found that Ms. Osborn had not engaged in substantial gainful activity 

since December 1, 2006.558

At step two, the ALJ found that Ms. Osborn had the following severe combinations of 

impairments: degenerative-disc disease, osteoarthritis, and obesity.559 Her back pain, exacerbated 

by obesity, limited her ability to perform basic work activities.560 Her physical impairments thus 

were severe.561 Her mental impairments of anxiety and depression — treated as one — did not 

cause more than minimal limitation in the claimant’s ability to perform basic mental work 

activities, and were therefore non-severe.562 In making this finding, the ALJ considered the 

following four broad functional areas of mental disorder evaluation set by the SSA Listing of 

Impairments’ disability regulations (known as the “paragraph B” criteria): (1) activities of daily 

living; (2) social functioning; (3) concentration, persistence or pace; and (4) episodes of 

decompensation.563

For activities of daily living, the ALJ found no limitation because of Ms. Osborn’s ability to 

independently self-care and complete housework.564 The only activity affected by her depression 

was her enjoyment of hobbies.

565

For social functioning, Ms. Osborn had no limitation due to her ability to cohabitate with a 

friend.

566 The ALJ noted that her children were taken, but due to drug abuse and not depression.567

 

558 AR 26.

559 Id.

560 Id.

561 Id.

562 Id.

563 Id.

564 Id.

565 Id.

566 Id.

567 Id.

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ORDER (No. 3:15-cv-3599-LB) 52

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For concentration, persistence or pace, Ms. Osborn had no limitation.568 The ALJ considered 

Dr. Zipperle’s consultative psychiatric evaluation and bipolar diagnosis, but ultimately gave it 

little weight.

569 This was because the record as a whole did not support the diagnosis because no 

other treating or examining source gave a similar diagnosis.570 Also, the ALJ reasoned, Dr. 

Zipperle’s own examination showed no problems with memory, calculations, or concentration.571

Ms. Osborn presented herself at the consultative examination in a “depressed, withdrawn, tearful, 

emotional state of mind,” which caused Dr. Zipperle to predict that she would have problems 

getting along with others.572 But the ALJ said that there was no evidence that a treating source 

ever observed her to be in such an emotional state, and that Ms. Osborn’s demeanor at the hearing 

was not consistent with Dr. Zipperle’s observations.573 Accordingly, the ALJ gave Dr. Zipperle’s 

opinion little weight.574

The ALJ did not find any episode of decompensation “of extended duration.”

575 Because Ms. 

Osborn’s medically determinable mental impairments caused no more than “mild” limitation in 

any of the first three functional areas and “no” episodes of decompensation which have been of 

extended duration in the fourth area, the ALJ found them to be non-severe.576

At step three, the ALJ found no impairment or combination of impairments that met or 

medically equaled the severity of one of the listed impairments.577 She found that Ms. Osborn’s 

spine impairment did not meet or equal Section 1.04 of the Listing of Impairments because there 

was no evidence of nerve root compression, spinal arachnoiditis, or lumbar spine stenosis.578

 

568 Id.

569 Id.

570 Id.

571 Id.

572 Id.

573 Id.

574 Id.

575 AR 27.

576 Id.

577 Id.

578 Id.

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ORDER (No. 3:15-cv-3599-LB) 53

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The ALJ then considered Ms. Osborn’s residual-functional-capacity, finding that she could 

perform sedentary work with limitations of (1) occasionally climbing ramps and stairs; (2) never 

climbing ladders, ropes or scaffolds; (3) occasionally stooping, kneeling, crawling, and crouching; 

and (4) never working at unprotected heights or with vibrations.579 In making this finding, the ALJ 

considered (1) all symptoms and the extent to which these symptoms could reasonably be 

accepted as consistent with the objective medical evidence and other evidence, and (2) opinion 

evidence.580 She followed a two-step process in which it must be determined (1) whether there was 

an underlying medically determinable physical or mental impairment that could be reasonably 

expected to produce Ms. Osborn’s pain or other symptoms, and if so then (2) evaluate the 

intensity, persistence, and limiting effects of Ms. Osborn’s symptoms to determine the extent to 

which they limit her functioning.581 For this purpose, whenever statements about the intensity, 

persistence, or functionally limiting effects of pain or other symptoms are not substantiated by 

objective medical evidence, the ALJ must make a finding on the credibility of statements based on 

a consideration of the entire case record.582

The ALJ included testimony from Ms. Osborn at both hearings regarding her back injury, pain, 

and treatment.583 She injured her back while working as a caregiver in December 2006, and had

not worked since then.584 She was unable to work due to back pain that limited her ability to sit, 

stand, and walk.585 She had good days when she was able to sit for thirty minutes at a time, and 

walk for 30 minutes at a time.586 She also had bad days when she was able to sit and walk for ten

to fifteen minutes at a time, and spent up to four hours sitting in a recliner with a heating pad.587

 

579 Id.

580 Id.

581 AR 27-28.

582 AR 28.

583 Id.

584 Id. 

585 Id. 

586 Id.

587 Id. 

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ORDER (No. 3:15-cv-3599-LB) 54

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She testified that she was not taking any pain medications due to a history of drug abuse prior to 

rehabilitation in 2011.588 She stopped taking Prozac because she did not like how she felt when 

taking it, and she stopped taking Zoloft because it did not work.589 She reported feeling healthier 

without medications, despite increased soreness and mental instability.590 Her depression did not 

affect her functioning.591 Her typical day included getting her children ready for school, making 

lunches, taking them to school, cooking, doing laundry, and grocery shopping.592 She depended on 

her parents to assist her on bad days, which occurred four times per week.593 She also attended

Narcotic Anonymous meetings three times per week, and spent time on the computer.594 She had

been unable to work due to lower-back pain, which she described as “constant stabbing.”595 She 

alleged that the pain made it difficult to move her right leg, therefore she limped when walking.

596

She further alleged that the pain caused concentration problems.597 She testified that she spent her 

day managing her pain by applying ice, and that her fiancé and his mother reportedly did all of the 

household chores.598 She was studying to be a paralegal, and attended classes two nights per week

for three hours each night.599 She spent most of the time at school sitting, and was able to stand if 

necessary.600

 

588 Id. 

589 Id. 

590 Id.

591 Id.

592 Id.

593 Id.

594 Id.

595 Id.

596 Id.

597 Id.

598 Id.

599 Id.

600 Id.

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ORDER (No. 3:15-cv-3599-LB) 55

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The ALJ considered written statements from Ms. Osborn’s father describing the extent of her

daily living capabilities, and found them generally credible.

601 The ALJ found that Ms. Osborn’s 

medically determinable impairments could reasonably be expected to produce her alleged pain and 

symptoms, but found her statements concerning the intensity, persistence and limiting effects of 

those symptoms not entirely credible.602 There were objective findings that established the 

presence of a severe spine impairment, but there were no corresponding neurological deficits.603

The ALJ cited the following evidence in the record that she found to weigh against Ms. 

Osborn’s credibility.

604 Ms. Osborn “has avoided going to physical therapy because she is too 

busy.”605 A treating source advised in 2007 that she “needs to get actively trying to improve and to 

get her work life on track.”606 It was noted in 2008 that she was “not very involved in getting 

better.”607 In 2012, Ms. Osborn was advised that she needed to be involved with treating pain via 

physical therapy, everyday ice/heat application and lower-back stretches, and anti-inflammatory 

medication.

608 She was also advised that losing 50 pounds would likely eliminate her back pain, 

yet she declined gastric bypass surgery because she did not want to lose too much weight and look 

like her friends who had “all that extra skin” after losing weight.609 Her credibility in alleging 

chronic pain was eroded by drug-seeking behavior.610

The ALJ noted three MRI reports showing abnormalities at multiple levels of the spine.611 She 

also noted Ms. Osborn’s February 2012 evaluation by a UCSF neurosurgeon, whose findings upon 

 

601 Id.

602 Id.

603 Id.

604 AR 28-29.

605 Id.

606 AR 29.

607 Id.

608 Id.

609 Id.

610 Id.

611 Id.

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physical examination were normal.

612 No treatment was prescribed, and weight loss was 

recommended.613 A September 2011 internal medicine evaluation by non-examining Dr. Alchemy, 

who opined that Ms. Osborn had no functional limitations, failed to account for MS. Osborn’s 

subjective complaints of pain.614 Accordingly, the ALJ gave this opinion little weight.615

In December 2012, Ms. Osborn’s primary care provider NP McDonald completed a lumbar 

spine residual-functional-capacity form that listed her functional and postural limitations.

616 The 

ALJ found NP McDonald’s opinion as “not a medical source opinion.”617 Although it was cosigned by Dr. Jackson, there was no evidence that she ever treated Ms. Osborn except for one visit 

in February 2013 when Ms. Osborn complained of menstrual problems and seasonal allergies.618

The ALJ noted that this visit occurred after the residual-functional-capacity form was completed, 

and that Dr. Jackson did not co-sign any of NP McDonald’s treatment notes.619 In addition, the 

ALJ noted that the form reflected Ms. Osborn’s symptoms and limitations were present in 2006,

even though the treatment period indicated began in October 2012.620 The ALJ found this to 

suggest that the form was completed based on Ms. Osborn’s own statements as to the nature and 

extent of her symptoms and limitations, and accordingly gave the opinion little weight.621

In March 2013, Ms. Osborn underwent a neurological evaluation by examining Dr. Khoury.622

He noted that Ms. Osborn complained of constant, severe, stabbing pain for which she has had no 

recent treatment except for pain relief (intravenous opiate medications) obtained in the emergency 

 

612 Id.

613 Id.

614 Id.

615 Id.

616 Id.

617 Id.

618 Id.

619 Id.

620 Id.

621 Id.

622 Id.

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room, and oral opiates/anti-inflammatories.623 The only significant abnormalities observed upon 

physical examination were antalgic/abnormal gait and decreased sensation.624 Dr. Khoury listed 

Ms. Osborn’s functional, postural, and manipulative limitations, and noted her high fall risk 

secondary to her gait instability/lumbar radiculitis.

625 He also indicated that Ms. Osborn was

limited to occasional exposure to unprotected heights, operating heavy machinery, working at 

extreme temperatures, working with chemicals/dusts/fumes/gases, and working around excessive 

noise.626 The ALJ gave his opinion great weight.627

The ALJ addressed the ME’s testimony that there was no question of abnormalities in her MRI 

reports, but that such abnormalities were expected considering her age and weight.628 The ME 

explained that it was important to correlate the MRI findings with neurological findings, and that 

the MRI findings were not as important as the neurological findings.629 The ME reported that both

Dr. Yablon and Dr. Khoury detected no positive neurological findings upon physical 

examination.

630

In analyzing Ms. Osborn’s drug-seeking behavior, the ALJ considered notes from various 

doctors and nurses in the medical record.

631 She considered Ms. Osborn’s concern that narcotic 

pain medications would “awaken” her drug addiction, when she left a clinic after being asked for a 

urine sample for drug testing, when she declined opiates after being informed that a urine test 

would be requested, and her referral to AA in 2010 after a positive urine toxicology screen.632 The 

ALJ noted that after going through drug rehabilitation in 2011, Ms. Osborn was controlling her 

 

623 Id.

624 Id.

625 AR 29-30.

626 AR 30.

627 Id.

628 Id.

629 Id.

630 Id.

631 Id.

632 Id.

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pain with exercise and ibuprofen through March 2013 when she went to the emergency room and 

was prescribed Percocet.633 Her primary care provider had prescribed additional and increased 

pain medications, but no other treatments.634 Drug screening was ordered, but there was no 

evidence as to the results.635

State agency medical consultants reviewed Ms. Osborn’s case file, and determined she was 

able to perform work at the medium level of exertion and had no mental impairments.636 The ALJ 

found their mental assessment as consistent with the record as a whole, but gave their physical 

assessments little weight because the record was updated with new evidence indicating greater 

impairment than before.

637

In reconciling NP McDonald’s notes — which indicated the existence of severe chronic back 

pain and significant physical limitations — with the opinions from Drs. Yablon, Khoury, and the 

ME, the ALJ found that the specialists’ opinions were entitled to greater weight.638 The ME 

explained that the absence of neurological findings was a relevant indicator as to the severity of 

Ms. Osborn’s impairment.639 The ALJ noted that Ms. Osborn’s primary care physicians have 

continued to prescribe pain medications despite her “refusal to cooperate with the requirements of 

urine testing.”640 Prior to March 2013, when Ms. Osborn resumed taking pain medications, she 

reported walking for exercise for sixty minutes at a time and her plans to join the YMCA when 

she could afford to do so.641 The ALJ found that this demonstrated ability to control her pain with 

exercise “erodes the credibility of her prior and subsequent requests for pain medications, with no 

 

633 Id.

634 Id.

635 Id.

636 Id.

637 Id.

638 Id.

639 Id.

640 Id.

641 Id.

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corresponding changes in her symptoms or her physician’s findings.”642 In sum, the ALJ found 

that the residual-functional-capacity assessment was supported by the ME’s testimony, which was 

given great weight based on his professional qualifications, knowledge of the requirements for 

disability evaluation under the Social Security Act and Regulations, his familiarity with the record 

as a whole, and his specific references to evidence from the treating sources.643

At step four, the ALJ found that Ms. Osborn was unable to perform any past relevant work.644

The VE testified that her past relevant work as a cashier, waitress, cook, and home attendant were 

all performed above the sedentary level of exertion.645 Accordingly, Ms. Osborn was unable to 

perform past relevant work.646

At step five, in considering Ms. Osborn’s age, education, work experience, and residualfunctional-capacity, the ALJ found that there are jobs that exist in significant numbers in the 

national economy that Ms. Osborn could perform.

647 The ALJ found that Ms. Osborn’s inability to 

(1) perform more than occasional climbing of ramps and stairs; (2) to climb ladders, ropes, and 

scaffolds; and (3) to perform more than occasional stooping, kneeling, crawling, and crouching did 

not have a significant impact on the occupational base of sedentary jobs that she was otherwise 

able to perform.648 Similarly, the ALJ found that “Ms. Osborn’s need to avoid working at 

unprotected heights or with [sic] has only a minimal effect on her ability to perform sedentary 

occupations.”649 The ALJ concluded that, considering Ms. Osborn’s age, education, work 

experience, and residual-functional-capacity, she was capable of making a successful adjustment 

to other work that existed in significant numbers in the national economy.650 The ALJ therefore 

 

642 Id.

643 Id.

644 Id.

645 Id.

646 Id.

647 AR 31.

648 AR 32.

649 Id.

650 Id.

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found that Ms. Osborn was “not disabled” — as defined in the Social Security Act — from 

December 1, 2006, through the decision date of December 4, 2013.651

ANALYSIS

1. Standard of Review

District courts have jurisdiction to review any final decision of the commissioner if the 

claimant initiates the suit within sixty days of the decision. 42 U.S.C. § 405(g). District courts may 

set aside the commissioner’s denial of benefits only if the ALJ’s “findings are based on legal error 

or are not supported by substantial evidence in the record as a whole.” Vasquez v. Astrue, 572 F.3d 

586, 591 (9th Cir. 2009) (internal quotation omitted). “Substantial evidence means more than a 

mere scintilla but less than a preponderance; it is such relevant evidence as a reasonable mind 

might accept as adequate to support a conclusion.” Andrews v. Shalala, 53 F.3d 1035, 1039 (9th 

Cir. 1995). If the evidence in the administrative record supports both the ALJ’s decision and a 

different outcome, the court must defer to the ALJ’s decision and may not substitute its own 

decision. See id. at 1039-40; Tackett v. Apfel, 180 F.3d 1094, 1097-98 (9th Cir. 1999).

2. Applicable Law

An SSI claimant is considered disabled if he suffers from a “medically determinable physical 

or mental impairment which can be expected to result in death or which has lasted or can be 

expected to last for a continuous period of not less than twelve months,” and the “impairment or 

impairments are of such severity that he is not only unable to do his previous work but cannot, 

considering his age, education, and work experience, engage in any other kind of substantial 

gainful work which exists in the national economy.” 42 U.S.C. § 1382c(a)3(A) & (B).

2.1 Five-step analysis to determine disability

There is a five-step analysis for determining whether a claimant is disabled within the meaning 

of the Social Security Act. See 20 C.F.R. § 404.1520. The five steps are as follows:

 

651 Id.

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Step One. Is the claimant presently working in a substantially gainful 

activity? If so, then the claimant is “not disabled” and is not entitled to 

benefits. If the claimant is not working in a substantially gainful activity, 

then the claimant’s case cannot be resolved at step one, and the evaluation 

proceeds to step two. See 20 C.F.R. § 404.1520(a)(4)(i).

Step Two. Is the claimant’s impairment (or combination of impairments) 

severe? If not, the claimant is not disabled. If so, the evaluation proceeds to 

step three. See 20 C.F.R. § 404.1520(a)(4)(ii).

Step Three. Does the impairment “meet or equal” one of a list of specified 

impairments described in the regulations? If so, the claimant is disabled and 

is entitled to benefits. If the claimant’s impairment does not meet or equal 

one of the impairments listed in the regulations, then the case cannot be 

resolved at step three, and the evaluation proceeds to step four. See 20 

C.F.R. § 404.1520(a)(4)(iii).

Step Four. Considering the claimant’s residual functional capacity

(“RFC”), is the claimant able to do any work that he or she has done in the 

past? If so, then the claimant is not disabled and is not entitled to benefits. If 

the claimant cannot do any work he or she did in the past, then the case 

cannot be resolved at step four, and the case proceeds to the fifth and final 

step. See 20 C.F.R. § 404.1520(a)(4)(iv).

Step Five. Considering the claimant’s RFC, age, education, and work 

experience, is the claimant able to “make an adjustment to other work?” If 

not, then the claimant is disabled and entitled to benefits. See 20 C.F.R. § 

404.1520(a)(4)(v). If the claimant is able to do other work, the 

Commissioner must establish that there are a significant number of jobs in 

the national economy that the claimant can do. There are two ways for the 

Commissioner to show other jobs in significant numbers in the economy: 

(1) by testimony of a vocational expert or (2) by reference to the MedicalVocational Guidelines at 20 C.F.R., part 404, subpart P, app. 2. See 20 

C.F.R. § 404.1520(a)(4)(v).

For steps one through four, the burden of proof is on the claimant. Tackett, 180 F.3d at 1098. 

At step five, the burden shifts to the commissioner. Id.

3. Application

Ms. Osborn alleges that the ALJ erred in “rejecting” Dr. Zipperle’s medical opinion, NP 

McDonald and Dr. Jackson’s co-authored lumbar spine residual-functional-capacity form, and Ms. 

Osborn’s testimony.652 The court begins by clarifying that the ALJ did not “reject” any of the 

 

652 See generally Motion for Summary Judgment — ECF No. 14.

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foregoing evidence, but rather accorded the medical opinions “little weight” and deemed Ms. 

Osborn’s testimony less credible after consideration.

653

3.1 The ALJ Did Not Err by Giving Little Weigh to Dr. Zipperle’s Medical Opinion

Social Security regulations distinguish three types of physicians: treating physicians; 

examining physicians; and non-examining physicians. 20 C.F.R. § 416.927(c), (e); Lester v. 

Chater, 81 F.3d 821, 830 (9th Cir. 1995). “Generally, a treating physician’s opinion carries more 

weight than an examining physician’s, and an examining physician’s opinion carries more weight 

than a reviewing physician’s.” Hollohan v. Massanari, 246 F.3d 1195, 1202 (9th Cir. 2001) (citing 

Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995)). The opinion of a treating physician is given 

the greatest weight because the treating physician is employed to cure and has a greater 

opportunity to understand and observe a claimant. See Smolen v. Chater, 80 F.3d 1273, 1285 (9th 

Cir. 1996).

In determining whether a claimant is disabled, the ALJ must consider each medical opinion in 

the record, together with the rest of the relevant evidence. 20 C.F.R. § 416.927(b); Zamora v. 

Astrue, No. C 09-3273 JF, 2010 WL 3814179, at *3 (N.D. Cal. Sept. 27, 2010). “If a treating 

physician’s opinion is ‘well-supported by medically acceptable clinical and laboratory diagnostic 

techniques and is not inconsistent with the other substantial evidence in [the] case record, [it will 

be given] controlling weight.’” Orn v. Astrue, 495 F.3d 625, 631 (9th Cir. 2007) (quoting 20 

C.F.R. § 404.1527(d)(2)). “If a treating physician’s opinion is not given ‘controlling weight’ 

because it is not ‘well-supported’ or because it is inconsistent with other substantial evidence in 

the record, the [Social Security] Administration considers specified factors in determining the 

weight it will be given.” Id. “Those factors include the ‘[l]ength of the treatment relationship and 

the frequency of examination’ by the treating physician; and the ‘nature and extent of the 

treatment relationship’ between the patient and the treating physician.” Id. (citing 20 C.F.R. § 

404.1527(b)(2)(i)-(ii)). “Additional factors relevant to evaluating any medical opinion, not limited 

 

653 AR 26, 29, 31.

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to the opinion of the treating physician, include the amount of relevant evidence that supports the 

opinion[,] . . . the quality of the explanation provided[, and] the consistency of the medical opinion 

with the record as a whole; the specialty of the physician providing the opinion . . . .” Id. (citing 20 

C.F.R. § 404.1527(d)(3)-(6)). Nonetheless, even if the treating physician’s opinion is not entitled 

to controlling weight, it still is entitled to deference. See id. at 632 (citing SSR 96-02p at 4 (Cum. 

Ed. 1996)). Indeed, “[i]n many cases, a treating source’s medical opinion will be entitled to the 

greatest weight and should be adopted, even if it does not meet the test for controlling weight.” 

(SSR 96-02p at 4 (Cum. Ed. 1996)).

Accordingly, “[i]n conjunction with the relevant regulations, [the Ninth Circuit has] developed 

standards that guide [the] analysis of an ALJ’s weighing of medical evidence.” Ryan v. Comm’r of 

Soc. Sec., 528 F.3d 1194, 1198 (9th Cir. 2008) (citing 20 C.F.R. § 404.1527). “To reject [the] 

uncontradicted opinion of a treating or examining doctor, an ALJ must state clear and convincing 

reasons that are supported by substantial evidence.” Id. (quotation and citation omitted). “If a 

treating or examining doctor’s opinion is contradicted by another doctor’s opinion, an ALJ may 

only reject it by providing specific and legitimate reasons that are supported by substantial 

evidence.” Id. (quotation omitted). Opinions of non-examining doctors alone cannot provide 

substantial evidence to justify rejecting either a treating or examining physician’s opinion. See 

Morgan v. Comm’r of Soc. Sec. Admin, 169 F.3d 595, 602 (9th Cir. 1999). An ALJ may rely 

partially on the statements of non-examining doctors to the extent that independent evidence in the 

record supports those statements. Id. Moreover, the “weight afforded a non-examining physician’s 

testimony depends ‘on the degree to which they provide supporting explanations for their 

opinions.’” See Ryan, 528 F. 3d at 1201 (quoting 20 C.F.R. § 404.1527(d)(3)).

Ms. Osborn argues that the ALJ, in rejecting Dr. Zipperle’s lone bipolar diagnosis, arbitrarily 

substituted her own judgment for a competent medical opinion, played doctor and made her own 

independent medical findings.654 The Commissioner argues that the ALJ was not diagnosing Ms. 

 

654 Id. at 9.

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Osborn but rather “validly pointing out that Dr. Zipperle’s assessment finds no other support in the 

longitudinal medical evidence[.]”655 The court agrees with the Commissioner. 

First, Dr. Zipperle is an examining doctor, although she saw Ms. Osborn only once.656 Second, 

non-examining Drs. Patterson and Strause both separately contradicted Dr. Zipperle’s opinion.

657

They opined that Dr. Zipperle’s diagnosis formed extreme conclusions unsupported by the 

medical record as a whole.658 Third, the ALJ provided specific and legitimate reasons supported 

by substantial evidence: no other treating or examining medical source ever diagnosed bipolar

disorder; Dr. Zipperle’s own report showed Ms. Osborn’s proficiency in memory, calculations, 

and concentration; and Ms. Osborn’s hearing demeanor which was inconsistent with Dr. 

Zipperle’s observations.

659 Fourth, non-examining doctor opinions did not provide the only 

substantial evidence that the ALJ used in giving Dr. Zipperle’s bipolar diagnosis little weight.660

Finally, evidence in the record supports the ALJ’s theory that the opinion is an outlier in the

medical record, and the court may not substitute its judgment for that of the ALJ.

661

A similar recent ruling from this district affirmed an ALJ’s decision to reject a psychiatrist’s 

opinion because it was not supported by any other evidence in the record. Smith v. Colvin, No. 14-

CV-05082-HSG, 2015 WL 9023486, at *8 (N.D. Cal. Dec. 16, 2015). The plaintiff in that case 

“did not report any symptoms of depression to her treating physicians and denied feeling 

depressed when asked [by a care provider,]” and “testified that she was not receiving any 

treatment for mental health issues.” Id. Here, Ms. Osborn consistently denied having depression 

symptoms to NP McDonald during their many routine check-ups.

662 At the initial ALJ hearing she

testified that she was on Prozac in 2002, on Zoloft during residential treatment, and dropped 

 

655 Cross-Motion for Summary Judgment — ECF No. 23, at 3.

656 AR 502-05.

657 AR 143, 147-48.

658 Id.

659 AR 26.

660 Id.

661 AR 143, 147-48.

662 AR 143, 540, 547, 646.

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therapy in 2011 or 2012.663 She also testified, however, that no doctor prescribed mental-health 

medication since the Prozac and Zoloft were stopped, she was no longer on any mental health 

medication, she was not receiving any mental health treatment, and she had never been 

hospitalized for her mental health.664 The court finds that the ALJ did not diagnose Ms. Osborn, 

“play doctor,” or make her own independent medical findings. She simply pointed out the 

substantial lack of medical evidence corroborating the bipolar diagnosis.

Ms. Osborn’s next argument — that Dr. Zipperle’s mental-status examination, which showed

no problems with memory, calculations, or concentration, actually supports the bipolar diagnosis

— is not convincing. As the Commissioner argues, Dr. Zipperle seemed to exceed Ms. Osborn’s 

own allegations regarding her mental health and limitations.665 The lack of problems with 

memory, calculations, or concentration found by Dr. Zipperle can be contrasted with her finding 

of moderate limitations with social interaction, work related stress, and pacing difficulties. There 

is substantial evidence in the record supporting this: Ms. Osborn testified that her back pain was 

the only pain preventing her from working, she was not taking any mental-health medications or

receiving any mental health treatment, she had never been hospitalized for her mental health, and 

her depression and anxiety “doesn’t really affect [her] too much.”666 Ms. Osborn did not 

personally claim severe mental limitations, and yet Dr. Zipperle still diagnosed her with bipolar 

disorder.667

Ms. Osborn contends that “mental impairments are underreported and undertreated” (citing 

Nguyen v. Chater, 100 F.3d 1462, 1465 (9th Cir. 1996)).668 She further argues that there is 

evidence in the record showing depression symptoms.669 Even if both were true, they are not 

 

663 AR 94, 97.

664 Id.

665 Cross-Motion for Summary Judgment at 5.

666 AR 91, 94, 97, 98.

667 See AR 502-05.

668 Motion for Summary Judgment at 15.

669 Id.

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dispositive on the existence of a mental impairment. Additionally, Ms. Osborn testified that her 

back pain was the only pain preventing her from working, she was never hospitalized for her 

mental health, she discontinued treatment for the same, and it did not affect her greatly.670

Ms. Osborn argues that the ALJ substituted her own judgment and “play[ed] doctor” again by 

using her observations of Ms. Osborn’s hearing demeanor in rejecting Dr. Zipperle’s opinion.671

Observations about demeanor are not inappropriate. Moreover, as discussed above, evidence in the 

record supports the ALJ’s conclusion that Dr. Zipperle’s opinion is an outlier in the medical 

record and that other evidence in the record was inconsistent with a bipolar diagnosis.672 The court 

may not substitute its judgment for that of the ALJ.

Ms. Osborn also contends that the ALJ failed to provide “legally sufficient reasons” for 

rejecting Dr. Zipperle’s opinion.673 The Commissioner argues that Dr. Zipperle “appears to have 

reached her conclusions based on [Ms. Osborn’s] subjective symptom presentation . . . [and] . . .

seemed to accept many of [Ms. Osborn’s] claims.”674 The ALJ explained the same: that Ms. 

Osborn presented herself in a “depressed, withdrawn, tearful, emotional state of mind” which 

caused Dr. Zipperle to predict her difficulty getting along with others.675 The SSA doctors raised 

identical concerns: that Dr. Zipperle relied on subjective complaints and the bipolar disorder is 

unsupported by the medical record.676 Again, the court may not substitute its judgment for the 

ALJ’s.

“The ALJ need not accept the opinion of any physician, including a treating physician, if that 

opinion is brief, conclusory, and inadequately supported by clinical findings.” Thomas v. 

Barnhart, 278 F.3d 947, 957 (9th Cir. 2002). First, the ALJ is not required to provide “legally 

 

670 AR 91, 94, 97, 98.

671 Motion for Summary Judgment at 10-11.

672 AR 26.

673 Motion for Summary Judgment at 17.

674 Cross-Motion for Summary Judgment at 5.

675 AR 26.

676 AR 145, 147-48.

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sufficient reasons” for disregarding a brief, conclusory, and inadequately supported physician 

opinion. See id. (quotations added); see also Sivilay v. Comm’r of Soc. Sec., 32 Fed. App’x 911, 

913-14 (9th Cir. 2002) (ALJ correctly rejected a psychiatrist’s opinion based on (1) the 

psychiatrist’s reliance on the claimant’s subjective complaints rather than clinical observations, 

and (2) the inconsistency between the clinical diagnosis and the treatment notes). Second, Dr. 

Zipperle’s opinion is brief, conclusory, and not supported by clinical findings. Apart from a few 

observations about Ms. Osborn’s appearance, the opinion mostly comprises of medical 

conclusions reached from a single psychiatric evaluation based on self-reporting. For example, she

concluded that Ms. Osborn “became very depressed when her children were removed and suffers 

from depression . . .[,] [s]he is depressed every day . . .[, and] [s]he also has mood swings . . .

[and] problems getting along with other people.”

677

The court acknowledges the presence of depression, anxiety, and symptoms of mental 

instability in Ms. Osborn’s medical record.678 Dr. Patterson opined that these occurrences were

attributable to problems stemming from Ms. Osborn’s then-active drug abuse.

679 She also noted

sobriety (starting in May 2011) brought improvement and an absence of mood disturbance.

680

In sum, the record as a whole supported the ALJ’s conclusion. 

3.2 The ALJ Erred in Giving Little Weight to NP McDonald and Dr. Jackson’s CoAuthored Lumbar Spine Residual-Functional-Capacity Form

Ms. Osborn argues that the ALJ erred by not crediting the treating opinion of Dr. Jackson and 

NP McDonald reflected on the lumbar spine residual-capacity questionnaire.

681 The ALJ rejected 

the nurse practitioner’s opinion because she is not an accepted medical source, and she found no 

evidence that Dr. Jackson treated Ms. Osborn, save for one visit in February 2013.682 As support, 

 

677 AR 502

678 AR 50, 417, 420, 436-38, 450-51.

679 AR 143.

680 Id.

681 Motion for Summary Judgment at 19–21.

682 AR 29.

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the ALJ pointed to Dr. Jackson’s failure to sign NP Jackson’s other treatment notes.683 The ALJ 

also noted that the form reflected Ms. Osborn’s symptoms and limitations from 2006, but the 

treatment period did not begin until October 2011.684 The ALJ concluded that this suggests that 

the form was completed based only on Ms. Osborn’s own statements about her limitations and 

thus gave the form little weight.685

The ALJ’s conclusion is belied by the form itself, which gives a detailed basis for the 

diagnosis (including an MRI), leads with Dr. Jackson’s name on page one, and ends with her 

signature (and NP McDonald’s).686 There is no basis in the record to ignore the opinion of a 

treating physician. 

Moreover, NP McDonald worked at Vista Family Health Center with Dr. Jackson.687 She had 

a prolonged treatment history with Ms. Osborn. Even if she alone is not an acceptable medical 

source and instead is an “other source” that the ALJ may reject with some reasons, those reasons 

do not exist in the administrative record. See 20 C.F.R. § 404.1502; Britton v. Colvin, 787 F.3d 

1011, 1013 (9th Cir. 2015) (citing Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012)). For 

example, an ALJ may accord less weight to a nurse practitioner’s notes if they are based on the 

plaintiff’s self-reports rather than her independent, objective medical opinion. See Koepke v. 

Comm'r of Soc. Sec. Admin., 490 F. App’x 864, 866 (9th Cir. 2012). 

That is not the case here. The questionnaire is complete, signed by Dr. Jackson, and is based 

on (1) an MRI showing an L4-L5 spinal stenosis, L5-L1 advanced DDD, and an impingement on 

the L5 nerve root; and (2) positive objective signs, such as reduced range of motion.688 It is 

consistent with previous MRIs and medical evidence from 2011 and 2012 (as summarized above).

 

683 Id.

684 Id.

685 Id.

686 AR 595-99.

687 AR 599

688 AR 595-96.

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In sum, given the extensive treatment history, the bases for the diagnoses (including an MRI 

and objective signs), and Dr. Jackson’s obvious participation in the questionnaire, the ALJ’s 

conclusion that there was no relationship between NP McDonald and Dr. Jackson is not supported 

by the record. The court therefore remands the case because the ALJ did not credit the co-authored 

opinion. 

3.3 The ALJ Erred By Not Crediting Ms. Osborn’s Testimony

An ALJ must not reject a claimant’s pain testimony supported by “objective medical evidence 

of an underlying impairment . . . based solely on a lack of medical evidence to fully corroborate 

the alleged severity of pain.” Burch v. Barnhart, 400 F.3d 676, 680 (9th Cir. 2005) (citing Bunnell 

v. Sullivan, 947 F.2d 341, 345 (9th Cir. 1991)). An ALJ may take into account “ordinary 

techniques of credibility evaluation,” including reputation for truthfulness and inconsistencies in 

testimony. Id. Additional factors that the ALJ may consider include: (1) the nature, location, onset, 

duration, frequency, radiation, and intensity of any pain; (2) precipitating and aggravating factors 

(e.g., movement, activity, environmental conditions); (3) type, dosage, effectiveness, and adverse 

side-effects of any pain medication; (4) treatment, other than medication, for relief of pain; (5) 

functional restrictions; and (6) the claimant's daily activities. Id. (citing Bunnell, 947 F.2d at 346).

Ms. Osborn argues that the ALJ improperly rejected her testimony due to a lack of objective 

medical findings even though her MRIs showed spinal abnormalities.689 The court agrees. The 

ALJ rejected Ms. Osborn’s testimony based on her previous drug-seeking behavior, and instances 

when Ms. Osborn has not been active in her recovery.690 The ALJ did not identify inconsistencies 

in Ms. Osborn’s testimony, or a reputation for untruthfulness.691 There is substantial objective 

medical evidence that shows an underlying impairment, and supports Ms. Osborn’s pain 

testimony. Treating physician Dr. Pace referred Ms. Osborn for two lumbar epidural steroid 

injections for pain relief.692 Treating physician Dr. Fernandez, who administered these epidural 

 

689 Id. at 19.

690 AR 28-29.

691 Id.

692 AR 443, 428.

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injections, post-procedurally diagnosed Ms. Osborn with degenerative-disc disease.693 Nonexamining physician Dr. Schmidt found disc desiccation, mild disc space narrowing, disc 

protrusions, and disc bulging in her 2007 MRI.694 Non-examining physician SSA Dr. Strause 

opined that her three MRIs (2007, 2010, and 2011) all indicated at least degenerative-disc disease, 

disc bulging, and nerve root impingement, opining that “this is strong objective data” that 

“supports [Ms. Osborn’s] allegations over the period from 2006 until the present.”695 The 

assessment by Dr. Jackson and NP McDonald supports the conclusion, too. And the ALJ 

acknowledged herself that “there are objective findings that establish the presence of a severe 

spine impairment.”696 Accordingly, the court finds that the ALJ erred in discrediting Ms. Osborn’s 

testimony.

CONCLUSION

Ms. Osborn’s motion for summary judgment is granted in part and denied in part, and the 

Commissioner’s cross-motion for summary judgment is granted in part and denied in part. The 

case is remanded for further proceedings consistent with this order.

This disposes of ECF Nos. 14 and 23.

IT IS SO ORDERED.

Dated: October 17, 2016

______________________________________

LAUREL BEELER

United States Magistrate Judge

 

693 AR 472.

694 AR 409, 413-14, 491

695 AR 147.

696 AR 28.

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