Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_15-cv-00463/USCOURTS-caed-2_15-cv-00463-4/pdf.json

Parties Involved:
Commissioner of Social Security
Defendant
Claude Timothy Stevenson
Plaintiff

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UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF CALIFORNIA

CLAUDE TIMOTHY STEVENSON,

Plaintiff,

v.

CAROLYN W. COLVIN, Acting 

Commissioner of Social Security,

Defendant.

No. 2:15-cv-0463-CKD

ORDER

Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security 

(“Commissioner”) denying an application for Supplemental Security Income (“SSI”) under Title 

XVI of the Social Security Act (“Act”). For the reasons discussed below, the court will grant 

plaintiff’s motion for summary judgment, deny the Commissioner’s cross-motion for summary 

judgment, and remand this matter under sentence four of 42 U.S.C. § 405(g). 

I. BACKGROUND

Plaintiff, born February 15, 1962, applied on February 24, 2010 for SSI, alleging 

disability beginning January 1, 2006. Administrative Transcript (“AT”) 248-55. Plaintiff alleged 

he was unable to work due to hepatitis C, gastrointestinal problems, cirrhosis of the liver, and 

psychotic and depressive disorders, among other impairments. AT 439, 468. In a decision dated

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June 27, 2014, the ALJ determined that plaintiff was not disabled.1 AT 17-26. The ALJ made 

the following findings (citations to 20 C.F.R. omitted):

1. The claimant has not engaged in substantial gainful activity 

since February 24, 2010, the application date.

2. The claimant has the following severe combination of 

impairments: psychotic disorder not otherwise specified, mood 

disorder not otherwise specified, a history of heroin dependence, 

hepatitis C virus, schizoaffective disorder, anti-social personality 

disorder, gastroesophageal reflux disease, a history of acute 

pancreatitis, a history of bilateral thumb and right foot surgery with 

arthritis and residual pain, degenerative disc disease of the lumbar 

spine, degenerative disc disease and stenosis of the cervical spine 

with radiculopathy and C5 nerve root involvement, right carpal 

tunnel syndrome, and chronic obstructive pulmonary disorder.

 

1 Disability Insurance Benefits are paid to disabled persons who have contributed to the 

Social Security program, 42 U.S.C. § 401 et seq. Supplemental Security Income is paid to 

disabled persons with low income. 42 U.S.C. § 1382 et seq. Both provisions define disability, in 

part, as an “inability to engage in any substantial gainful activity” due to “a medically 

determinable physical or mental impairment. . . .” 42 U.S.C. §§ 423(d)(1)(a) & 1382c(a)(3)(A). 

A parallel five-step sequential evaluation governs eligibility for benefits under both programs. 

See 20 C.F.R. §§ 404.1520, 404.1571-76, 416.920 & 416.971-76; Bowen v. Yuckert, 482 U.S. 

137, 140-142, 107 S. Ct. 2287 (1987). The following summarizes the sequential evaluation: 

Step one: Is the claimant engaging in substantial gainful 

activity? If so, the claimant is found not disabled. If not, proceed 

to step two. 

Step two: Does the claimant have a “severe” impairment? 

If so, proceed to step three. If not, then a finding of not disabled is 

appropriate. 

Step three: Does the claimant’s impairment or combination 

of impairments meet or equal an impairment listed in 20 C.F.R., Pt. 

404, Subpt. P, App.1? If so, the claimant is automatically 

determined disabled. If not, proceed to step four. 

Step four: Is the claimant capable of performing his past 

work? If so, the claimant is not disabled. If not, proceed to step 

five. 

Step five: Does the claimant have the residual functional 

capacity to perform any other work? If so, the claimant is not 

disabled. If not, the claimant is disabled.

 

Lester v. Chater, 81 F.3d 821, 828 n.5 (9th Cir. 1995). 

The claimant bears the burden of proof in the first four steps of the sequential evaluation 

process. Bowen, 482 U.S. at 146 n.5, 107 S. Ct. at 2294 n.5. The Commissioner bears the 

burden if the sequential evaluation process proceeds to step five. Id.

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3. The claimant does not have an impairment or combination of 

impairments that meets or medically equals the severity of one of 

the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1.

4. After careful consideration of the entire record, I find that the 

claimant has the residual functional capacity to perform a wide 

range of light work as defined in 20 CFR 416.967(b). He can lift 

and/or carry 20 pounds occasionally and 10 pounds frequently, 

stand and/or walk 6 hours in an 8-hour workday, sit 6 hours in an 8-

hour workday; the claimant cannot climb ladders, ropes, or 

scaffolds, the claimant can occasionally climb ramps and stairs, 

balance, stoop, kneel, crouch, crawl; the claimant can have 

occasional face-to-face interaction with the general public; the 

claimant can frequently push and pull, perform fine manipulation 

and gross manipulation activities, and the claimant can perform 

only simple, routine, and repetitive tasks. In addition, he must 

avoid concentrated exposure to pulmonary irritants, hazards, and 

temperature extremes.

5. The claimant has no past relevant work.

6. The claimant was born on February 15, 1962, which is defined 

as a younger individual age 18-49, on the date the application was 

filed. The claimant subsequently changed age category to closely 

approaching advanced age.

7. The claimant has a limited education and is able to communicate 

in English.

8. Transferability of job skills is not an issue because the claimant 

does not have past relevant work. 

9. Considering the claimant’s age, education, work experience, and 

residual functional capacity, there are jobs that exist in significant 

numbers in the national economy that the claimant can perform.

10. The claimant has not been under a disability, as defined in the 

Social Security Act, since February 24, 2010, the date the

application was filed.

AT 19-25.

 

II. ISSUES PRESENTED

Plaintiff argues that the ALJ committed the following errors in finding plaintiff not 

disabled: (1) failed to fully and fairly develop the record with regard to the impact plaintiff’s 

impairments had on his ability to perform work-related functions; (2) failed to obtain an updated 

medical opinion from a medical expert regarding whether plaintiff’s spinal impairments were 

equivalent to Listing 1.04; and (3) failed to provide clear and convincing reasons for finding 

plaintiff’s testimony less than fully credible.

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III. LEGAL STANDARDS

The court reviews the Commissioner’s decision to determine whether (1) it is based on 

proper legal standards pursuant to 42 U.S.C. § 405(g), and (2) substantial evidence in the record 

as a whole supports it. Tackett v. Apfel, 180 F.3d 1094, 1097 (9th Cir. 1999). Substantial 

evidence is more than a mere scintilla, but less than a preponderance. Connett v. Barnhart, 340 

F.3d 871, 873 (9th Cir. 2003) (citation omitted). It means “such relevant evidence as a reasonable 

mind might accept as adequate to support a conclusion.” Orn v. Astrue, 495 F.3d 625, 630 (9th 

Cir. 2007) (quoting Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005)). “The ALJ is 

responsible for determining credibility, resolving conflicts in medical testimony, and resolving 

ambiguities.” Edlund v. Massanari, 253 F.3d 1152, 1156 (9th Cir. 2001) (citations omitted). 

“The court will uphold the ALJ’s conclusion when the evidence is susceptible to more than one 

rational interpretation.” Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 2008).

The record as a whole must be considered, Howard v. Heckler, 782 F.2d 1484, 1487 (9th 

Cir. 1986), and both the evidence that supports and the evidence that detracts from the ALJ’s 

conclusion weighed. See Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). The court may not 

affirm the ALJ’s decision simply by isolating a specific quantum of supporting evidence. Id.; see 

also Hammock v. Bowen, 879 F.2d 498, 501 (9th Cir. 1989). If substantial evidence supports the 

administrative findings, or if there is conflicting evidence supporting a finding of either disability 

or nondisability, the finding of the ALJ is conclusive, see Sprague v. Bowen, 812 F.2d 1226, 

1229-30 (9th Cir. 1987), and may be set aside only if an improper legal standard was applied in 

weighing the evidence. See Burkhart v. Bowen, 856 F.2d 1335, 1338 (9th Cir. 1988).

IV. ANALYSIS

A. The ALJ Failed to Fully and Fairly Develop the Record

First, plaintiff argues that the ALJ failed to fully and fairly develop the record because he 

did not obtain a consultative examination for plaintiff’s physical and mental impairments, and 

based his residual functional capacity (“RFC”) determination on an incomplete medical record 

that did not permit the ALJ to engage in a proper evaluation of the medical evidence.

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“The ALJ always has a ‘special duty to fully and fairly develop the record and to assure 

that the claimant’s interests are considered . . . even when the claimant is represented by 

counsel.’” Celaya v. Halter, 332 F.3d 1177, 1183 (9th Cir. 2003) (citing Brown v. Heckler, 713 

F.2d 441, 443 (9th Cir. 1983)). “When the claimant is unrepresented, . . . the ALJ must be 

especially diligent in exploring for all the relevant facts.” Tonapetyan v. Halter, 242 F.3d 1144, 

1150 (9th Cir. 2001). 

It is well established that a claimant bears the burden of providing medical and other 

evidence that support the existence of a medically determinable impairment. Bowen v. Yuckert, 

482 U.S. 137, 146 (1987); Tidwell v. Apfel, 161 F.3d 599, 601 (9th Cir. 1998) (“At all times, the 

burden is on the claimant to establish her entitlement to disability insurance benefits.”). Indeed, it 

is “not unreasonable to require the claimant, who is in a better position to provide information 

about his own medical condition, to do so.” Yuckert, 482 U.S. at 146 n.5.

Nevertheless, as the Ninth Circuit Court of Appeals has also explained:

The ALJ in a social security case has an independent duty to fully 

and fairly develop the record and to assure that the claimant’s 

interests are considered. This duty extends to the represented as 

well as to the unrepresented claimant. When the claimant is 

unrepresented, however, the ALJ must be especially diligent in 

exploring for all the relevant facts ... The ALJ’s duty to develop the 

record fully is also heightened where the claimant may be mentally 

ill and thus unable to protect her own interests. Ambiguous 

evidence, or the ALJ’s own finding that the record is inadequate to 

allow for proper evaluation of the evidence, triggers the ALJ’s duty 

to conduct an appropriate inquiry.

Tonapetyan v. Halter, 242 F.3d 1144, 1150 (9th Cir. 2001) (citations and quotation marks 

omitted). In short, “[a]n ALJ’s duty to develop the record further is triggered only when there is 

ambiguous evidence or when the record is inadequate to allow for proper evaluation of the 

evidence.” Mayes v. Massanari, 276 F.3d 453, 459-60 (9th Cir. 2001) (citing Tonapetyan, 242 

F.3d at 1150).

“The ALJ may discharge this duty in several ways, including: subpoenaing the claimant’s 

physicians, submitting questions to the claimant’s physicians, continuing the hearing, or keeping 

the record open after the hearing to allow supplementation of the record.” Id. However, as some 

courts have persuasively observed, the ALJ “does not have to exhaust every possible line of 

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inquiry in an attempt to pursue every potential line of questioning. The standard is one of 

reasonable good judgment.” Hawkins v. Chater, 113 F.3d 1162, 1168 (10th Cir. 1997) (citation 

omitted). 

Here, the record upon which the ALJ’s physical RFC determination was based was 

inadequate for the ALJ to properly evaluate the medical evidence and arrive at a physical RFC 

conclusion that was supported by substantial evidence. The ALJ determined that plaintiff’s spinal 

impairments warranted a limitation to light work and a limitation on his use of his upper 

extremities. AT 24. However, the sole medical opinion in the record was that of Dr. Pancho, a 

State agency non-examining physician who reviewed plaintiff’s medical records then-existing on 

December 20, 2010 and determined that plaintiff did not have a severe impairment. AT 766-67. 

Dr. Pancho’s opinion was based solely on a review of the limited medical evidence developed 

between November 2008 and June 2010. Id. This evidence did not include any of plaintiff’s 

treating records regarding the progression of his spinal impairments, which were developed after 

the date of Dr. Pancho’s opinion. Furthermore, the medical record contained no opinion evidence 

from any of plaintiff’s treating physicians, nor did plaintiff undergo a consultative examination 

regarding the functional impact of his physical and mental impairments.2 The only medical 

evidence in the record regarding plaintiff’s spinal impairments is plaintiff’s treating records

spanning from November 2011 to May 2014. See AT 907, 1068. While some of these records 

indicate that plaintiff’s spinal problems were “severe,” e.g., AT 931, 986, 1068, they do not 

describe the impact of these impairments on a function-by-function basis in a manner that would 

provide the ALJ with a sufficient medical foundation to properly consider plaintiff’s physical 

RFC. 3 See Manso-Pizarro v. Secretary of Health and Human Services, 76 F.3d 15, 17 (1st Cir.

 

2

The record shows that plaintiff was scheduled to attend two psychological consultative 

examinations but that plaintiff did not appear for either appointment due to his incarceration on 

those dates. AT 950-53, 963. However, it appears from the record that no physical consultative 

examinations were ever scheduled.

3

The court notes, however, that the record includes a California Department of Corrections 

disability placement program verification form dated December 1, 2008 that indicates that 

plaintiff had a “mobility impairment,” required the use of a cane, had a restriction from using 

stairs, and could only sleep in a lower bunk. AT 305. While this note does not directly attribute 

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1996) (“With few exceptions, . . . an ALJ, as a layperson, is not qualified to interpret raw data in a 

medical record.”).

While the ALJ discussed the medical records regarding plaintiff’s spinal impairments 

when determining the impact those impairments had on his physical RFC, it is evident from the 

ALJ’s discussion of that evidence that he made an independent evaluation and improperly 

substituted his judgement for that of a medical expert. The Commissioner argues that this was 

not the case because the ALJ cited to treating records in his discussion of plaintiff’s physical 

impairments that included the medical impressions and findings of a medical clinician in support 

of his physical RFC determination. However, while the treating records reviewed by the ALJ 

include medical impressions from plaintiff’s treating physicians; those impressions consist of 

diagnoses and descriptions of plaintiff’s spinal impairments obtained from imaging records of 

plaintiff’s back. E.g., AT 905, 907, 973, 986. They do not indicate the impact those diagnosed

impairments had on plaintiff’s ability to work on a function-by-function basis.

4

 Nevertheless, the 

ALJ reviewed the medical findings in these records and made a physical RFC determination 

based on his own interpretation of that raw medical evidence. Such a determination was

impermissible and cannot form the basis of an ALJ’s RFC conclusions. See Day v. Weinberger,

522 F.2d 1154, 1156 (9th Cir. 1975) (the ALJ was not qualified as a medical expert and therefore 

could not permissibly go outside record to consult medical textbooks for purpose of making his 

 

these limitations to plaintiff’s spinal impairments, they do reasonably indicate that such 

impairments may have caused plaintiff physical limitations as early as 2008. The ALJ did not 

address the potential significance of this evidence in his physical RFC discussion. See AT 22-23. 

4 A treating note dated February 19, 2013 appears to indicate that Dr. Gregorious, one of 

plaintiff’s treating physicians, reviewed an MRI of plaintiff’s spine and determined that plaintiff’s 

lumbar degenerative disc disease rendered plaintiff permanently disabled. AT 976. The 

Commissioner contends that it is not clear from this note that this opinion was issued by Dr. 

Gregorious or another proper medical source due to an ambiguous initial on the document. It is

also unclear whether Dr. Gregorious actually assessed plaintiff as disabled or whether he merely 

recorded plaintiff’s own report of disability. See id. Furthermore, the ALJ failed to specifically 

discuss this record when determining plaintiff’s RFC. See AT 22-23. Given the ambiguities in 

Dr. Gregorious’ ostensible opinion, the ALJ should have made an appropriate inquiry to clarify 

these ambiguities and should have specifically addressed this evidence in his decision. See

Mayes, 276 F.3d at 459-60 (an ALJ’s duty to develop the record arises when the record contains 

ambiguous evidence).

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own assessment of the claimant’s physical condition); Nguyen v. Chater, 172 F.3d 31, 35 (1st Cir. 

1999) (“As a lay person, . . . , the ALJ was simply not qualified to interpret raw medical data in 

functional terms and no medical opinion supported the determination.”); Manso-Pizarro, 76 F.3d 

at 17; Rohan v. Chater, 98 F.3d 966, 970 (7th Cir. 1996) (“ALJs must not succumb to the 

temptation to play doctor and make their own independent medical findings.”).

Given the dearth of medical evidence in the record indicating the degree to which

plaintiff’s spinal impairments impacted his physical functional capacity, the ALJ had a duty to 

further develop the record. However, he did not fulfill that duty. He did not seek to have plaintiff 

undergo a physical examination, or even obtain further review of plaintiff’s treating records by a 

State agency physician based on the medical records developed after 2010. Nor did the ALJ keep 

the record open after the hearing to allow for further supplementation.5Furthermore, the ALJ 

improperly interpreted the treating records that were available and made an RFC determination 

based on that raw medical data. Accordingly, the ALJ committed prejudicial error that 

invalidated his physical RFC findings. See Tonapetyan, 242 F.3d at 1151 (reversing and 

remanding for further proceedings where ALJ’s RFC determination was based on an inadequately 

developed medical record); Nguyen, 172 F.3d at 35 (reversing and remanding for further 

proceedings where the ALJ rendered an RFC determination was based on his own interpretation 

of raw medical data that was not supported by medical opinion evidence).

B. The ALJ’s Error Warrants Remand for Further Proceedings

When the court finds that the ALJ committed prejudicial error, it has the discretion to 

remand or reverse and award benefits. McAllister v. Sullivan, 888 F.2d 599, 603 (9th Cir. 1989). 

Generally, if the court finds that the ALJ’s decision was erroneous or not supported by substantial 

evidence, the court must follow the “ordinary remand rule,” meaning that “the proper course, 

except in rare circumstances, is to remand to the agency for additional investigation or 

explanation.” Treichler v. Comm’r of Soc. Sec. Admin., 775 F.3d 1090, 1099 (9th Cir. 2014). A 

 

5

The court also notes that the ALJ did not take such steps to supplement the record even after the 

Appeals Council initially remanded the case back to the ALJ with the direction “to obtain 

additional evidence concerning the claimant’s impairment[s].” AT 17.

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remand for an award of benefits is inappropriate where the record has not been fully developed or 

there is a need to resolve conflicts, ambiguities, or other outstanding issues. Id. at 1101.

Here, the ALJ’s error requires this matter to be remanded for further proceedings. As 

discussed above, the record in this action regarding plaintiff’s spinal impairments has not been 

adequately developed such that the ALJ could make a proper RFC determination regarding the 

functional impact of those impairments on plaintiff’s ability to perform physical work-related 

activities. Accordingly, development of the record through further administrative proceedings is 

warranted.

On remand, the ALJ shall obtain a consultative physical examination by a physician who 

has full access to plaintiff’s past medical records. The consultative examination shall focus on 

the functional limitations caused by plaintiff’s physical impairments, in particular, his spinal 

impairments,6during the relevant time period, but shall also consider whether plaintiff’s 

impairments and functional capacity improved or worsened thereafter through the present.

7

 The 

ALJ shall also obtain clarification of the apparent ambiguities discussed above with regard to the 

treating note in the record dated February 19, 2013. AT 976. Furthermore, the ALJ should also

schedule plaintiff for a further consultative psychological examination.8 The ALJ may obtain 

 

6

The court also notes that the record also does not contain any medical opinions or other records 

directly reflecting upon the functional impact of plaintiff’s wrist impairments and subsequent 

hand surgeries. Accordingly, the consultative physical examiner should also be requested to 

provide an opinion concerning the impact and materiality of plaintiff’s wrist impairments.

7 Although the consultative examination will take place in the present, the consultative examiner 

shall use best efforts, utilizing the findings of the present physical examination, plaintiff’s past

medical records, and the examiner’s clinical expertise and judgment, to render an opinion 

regarding plaintiff’s functional capacity during the relevant period.

8

The court recognizes that the ALJ earlier ordered two consultative psychological examinations 

in this matter that plaintiff failed to attend. AT 950-53. However, plaintiff’s failures to attend 

were a result of his incarceration on the scheduled examination dates, indicating that plaintiff’s 

absences were not willful. AT 963. Furthermore, the only opinion evidence in the record 

regarding the functional impact of plaintiff’s mental impairments is that of Dr. Pancho, a nonexamining State agency physician who only reviewed plaintiff’s medical records developed prior 

to December 2010. Accordingly, the ALJ should obtain opinion evidence that addresses 

plaintiff’s mental impairments for the entire relevant time period. See Garrison v. Colvin, 759 

F.3d 995, 1017-18 (9th Cir. 2014) (cautioning ALJs against drawing the inference that a claimant 

can function effectively in the workplace from medical reports indicating improvement of mental 

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opinions from plaintiff’s treating physicians regarding plaintiff’s physical and mental limitations, 

if necessary. The ALJ is also free to develop the record in other ways, as needed.

Importantly, the court expresses no opinion regarding how the evidence should ultimately 

be weighed, and any ambiguities or inconsistencies resolved, on remand. The court also does not 

instruct the ALJ to credit any particular opinion or testimony. The ALJ may ultimately find 

plaintiff disabled during the entirety of the relevant period; may find plaintiff eligible for some 

type of closed period of disability benefits; or may find that plaintiff was never disabled during 

the relevant period—provided that the ALJ’s determination complies with applicable legal 

standards and is supported by substantial evidence in the record as a whole. 

C. Other Issues

Plaintiff also argues that the ALJ further failed to fulfill his duty to fully and fairly 

develop the record by not obtaining an updated medical opinion from a medical expert regarding 

whether plaintiff’s spinal impairments were equivalent to Listing 1.04, which plaintiff contends 

violated SSR 96-6p.9 Because the court finds the record inadequately developed regarding 

plaintiff’s spinal impairments, it declines to address the substance of this issue at this juncture. 

Further development of the record regarding plaintiff’s spinal impairments will allow the ALJ to 

make an informed decision on remand as to whether SSR 96-6p mandates him to obtain an 

updated medical expert opinion regarding whether plaintiff’s spinal or other impairments are 

equivalent to Listing 1.04, or any other listing in 20 C.F.R. Part 404, Subpart P, Appendix 1.

////

 

impairments “when no doctor or other medical expert has opined, on the basis of a full review of 

all relevant records, that [the claimant] is capable of working or is prepared to return to work” 

(emphasis added)).

9

SSR 96-6p provides, in pertinent part:

[A]n administrative law judge and the Appeals Council must obtain an updated 

medical opinion from a medical expert in the following circumstances: . . . 

When no additional medical evidence is received, but in the opinion of the 

administrative law judge or the Appeals Council the symptoms, signs, and 

laboratory findings reported in the case record suggest that a judgment of 

equivalence may be reasonable[.]

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Finally, plaintiff contends that the ALJ erred in his credibility findings regarding 

plaintiff’s testimony. Because the court will remand this action for further development of the 

record, it declines to address this argument at this time. The ALJ’s reasons for discounting 

plaintiff’s testimony were based largely on discrepancies the ALJ found to exist between 

plaintiff’s testimony and the objective medical evidence in the record. AT 22, 24. Accordingly, 

the ALJ’s findings regarding credibility may change once the record has been more fully 

developed. On remand, the ALJ will have the opportunity to reassess the credibility of plaintiff’s 

testimony in light of the further-developed record.

V. CONCLUSION

For the reasons stated herein, this matter will be remanded under sentence four of 42 

U.S.C. § 405(g) for further development of the record and for further findings addressing the 

deficiencies noted above. Accordingly, IT IS HEREBY ORDERED that:

1. Plaintiff’s motion for summary judgment (ECF No. 25) is granted for purposes of 

further development of the record consistent with the court’s directions set forth above;

2. The Commissioner’s cross-motion for summary judgment (ECF No. 26) is denied; and,

3. This matter is remanded for further proceedings consistent with this order.

Dated: October 27, 2015

11 stevenson0463.ss

_____________________________________

CAROLYN K. DELANEY

UNITED STATES MAGISTRATE JUDGE

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