Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_14-cv-02616/USCOURTS-caed-2_14-cv-02616-4/pdf.json

Parties Involved:
Commissioner of Social Security
Defendant
Rogaciano Vera
Plaintiff

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UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF CALIFORNIA

ROGACIANO VERA,

Plaintiff,

v.

CAROLYN W. COLVIN, Acting 

Commissioner of Social Security,

Defendant.

No. 2:14-cv-2616-CKD

ORDER

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

(“Commissioner”) denying applications for Disability Income Benefits (“DIB”) and

Supplemental Security Income (“SSI”) under Titles II and XVI of the Social Security Act 

(“Act”), respectively. 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 December 19, 1966, applied on August 30, 2011 for DIB and SSI, alleging 

disability beginning September 10, 2009. Administrative Transcript (“AT”) 134-142. Plaintiff 

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alleged he was unable to work due to back and stomach problems, depression, and anxiety. AT 

71. In a decision dated March 19, 2013, the ALJ determined that plaintiff was not disabled.1 AT

12-24. The ALJ made the following findings (citations to 20 C.F.R. omitted):

1. The claimant meets the insured status requirements of the Social 

Security Act through December 31, 2013.

2. The claimant has not engaged in substantial gainful activity since 

September 10, 2009, the alleged onset date.

3. The claimant has the following severe impairments: degenerative 

disc disease and affective mood disorder (depression).

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

impairments that meets or medically equals the severity of one of 

 

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 (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. The Commissioner bears the burden if the sequential 

evaluation process proceeds to step five. Id.

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

5. After careful consideration of the entire record, the undersigned 

finds that the claimant has the residual functional capacity to 

perform a reduced range of sedentary work as defined in 20 CFR 

404.1567(a) and 416.967(a). Specifically, the claimant can lift and 

or carry 10 pounds occasionally and less than 10 pounds frequently; 

he can stand and or walk (with normal breaks) at least two hours in 

an eight hour workday; he can sit (with normal breaks) for about six 

hours in an eight hour workday; he can occasionally climb ramps 

and stairs; he can never climb ladders, ropes or scaffolds; he can 

occasionally balance, stoop, kneel, crouch, or crawl; he is limited to 

simple, routine, repetitive tasks; he is limited to only occasional 

public contact; and he can never work around hazards such as 

moving, dangerous machinery and unprotected heights.

6. The claimant is unable to perform any past relevant work.

7. The claimant was born on December 19, 1966 and was 42 years 

old, which is defined as a younger individual age 18-44, on the 

alleged disability onset date. The claimant subsequently changed 

age category to a younger individual age 45-49.

8. The claimant has at least a high school education and is able to 

communicate in English.

9. Transferability of job skills is not material to the determination 

of disability because using the Medical-Vocational Rules as a 

framework supports a finding that the claimant is “not disabled,” 

whether or not the claimant has transferable job skills.

10. 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.

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

Social Security Act, from September 10, 2009, through the date of 

this decision.

AT 14-24. 

II. ISSUES PRESENTED

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

disabled: (1) improperly assigned reduced weight to the opinions of Dr. Senegor, plaintiff’s 

primary treating physician, and Dr. Bugna, an examining physician, without articulating specific 

and legitimate reasons in support of that determination; and (2) 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 Erred in Considering the Medical Evidence

First, plaintiff argues that the ALJ erred by discounting the opinions of Dr. Senegor, 

plaintiff’s primary treating physician, and Dr. Bugna, an examining physician, without providing 

specific and legitimate reasons for doing so.

The weight given to medical opinions depends in part on whether they are proffered by 

treating, examining, or non-examining professionals. Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 

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1995). Ordinarily, more weight is given to the opinion of a treating professional, who has a 

greater opportunity to know and observe the patient as an individual. Id.; Smolen v. Chater, 80 

F.3d 1273, 1285 (9th Cir. 1996). 

To evaluate whether an ALJ properly rejected a medical opinion, in addition to 

considering its source, the court considers whether (1) contradictory opinions are in the record, 

and (2) clinical findings support the opinions. An ALJ may reject an uncontradicted opinion of a 

treating or examining medical professional only for “clear and convincing” reasons. Lester, 81 

F.3d at 831. In contrast, a contradicted opinion of a treating or examining professional may be 

rejected for “specific and legitimate” reasons that are supported by substantial evidence. Id. at 

830. While a treating professional’s opinion generally is accorded superior weight, if it is 

contradicted by a supported examining professional’s opinion (e.g., supported by different 

independent clinical findings), the ALJ may resolve the conflict. Andrews v. Shalala, 53 F.3d 

1035, 1041 (9th Cir. 1995) (citing Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989)). In 

any event, the ALJ need not give weight to conclusory opinions supported by minimal clinical 

findings. Meanel v. Apfel, 172 F.3d 1111, 1113 (9th Cir.1999) (treating physician’s conclusory, 

minimally supported opinion rejected); see also Magallanes, 881 F.2d at 751. The opinion of a 

non-examining professional, without other evidence, is insufficient to reject the opinion of a 

treating or examining professional. Lester, 81 F.3d at 831.

A. Dr. Senegor

The record demonstrates that Dr. Senegor, a neurological surgeon, acted as plaintiff’s 

primary treating physician from August 4, 2011 through February 7, 2013, and indicates that his 

treating physician relationship with plaintiff continued past that later date. See AT 274, 433. On 

January 25, 2012, Dr. Senegor completed a “Physical Residual Functional Capacity 

Questionnaire,” which provided Dr. Senegor’s opinion regarding the impact plaintiff’s physical 

impairments had on his ability to perform basic work-related functions. AT 342-47. Therein, Dr. 

Senegor diagnosed plaintiff with “spinal lumbar stenosis,” which Dr. Senegor categorized as 

“severe” and as causing plaintiff “low back/bilateral leg pain.” AT 342. He also opined that 

plaintiff’s impairments would “frequently” cause him pain or other symptoms severe enough to 

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interfere with plaintiff’s ability to maintain the level of attention and concentration required to 

perform even simple work tasks, meaning that plaintiff’s impairments would impose such a 

limitation between 34 percent and 66 percent of an eight-hour workday. Id. Furthermore, Dr. 

Senegor opined that plaintiff could walk between one and two blocks before needing rest, stand 

for up to one hour at a time, and sit for up to one hour at a time. AT 344. He also determined 

that plaintiff could sit, stand, or walk for less than two hours each during an eight-hour workday. 

Id. He further opined that plaintiff would need to take 10 minute walks every 45 minutes, a job 

that permits shifting positions at will, and to take unscheduled sitting breaks lasting ten-to-fifteen 

minutes in duration. AT 344-45. Dr. Senegor also opined that plaintiff could occasionally climb 

stairs and lift and carry up to 10 pounds. AT 345-46. He further found that plaintiff could never 

twist, stoop, crouch, or climb ladders, but had no significant limitations in performing repetitive 

reaching, handling, or fingering activities. AT 346. Given plaintiff’s impairments, Dr. Senegor 

determined that plaintiff would need to be absent from work about three days per month pending 

flare ups. Id. Finally, Dr. Senegor determined that plaintiff’s impairments had lasted or could be 

expected to last for at least 12 months. AT 343, 346.

The ALJ gave the following rationale in support of his decision to discount Dr. Senegor’s 

treating opinion:

Generally, a treating physician’s opinion is given more weight because it is more 

likely to be based on a detailed, longitudinal picture of the claimant’s impairments. 

However, although Dr. Senegor is a treating physician, and began treating plaintiff 

about two years ago, the medical evidence of record indicates that the claimant 

saw Dr. Senegor only about four or five times during this two-year period. Also, 

at the claimant’s last visit with Dr. Senegor, the claimant was not scheduled for 

follow up until six months. In addition, Dr. Senegor’s treatment notes indicate that 

the claimant declined treatment recommendations by Dr. Senegor on more than 

one occasion. For these reasons, Dr. Senegor’s opinion is given reduced weight.

AT 20. For the reasons that follow, the court finds these reasons insufficient to justify the ALJ’s 

decision to discount Dr. Senegor’s opinion.

First, the ALJ found the fact that Dr. Senegor examined plaintiff on four or five occasions 

throughout the course of the treating relationship documented in the record undermined his 

opinion. However, the record demonstrates that Dr. Senegor had examined plaintiff more times 

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and had a treating relationship with plaintiff longer than any of plaintiff’s other physicians, thus 

providing him with the greatest familiarity with and best longitudinal view of the impact of 

plaintiff’s impairments of any of the physicians in the record. See 20 C.F.R. § 404.1527(c)(2)(i) 

(“Generally, the longer a treating source has treated you and the more times you have been seen 

by a treating source, the more weight we will give to the source’s medical opinion. When the 

treating source has seen you a number of times and long enough to have obtained a longitudinal 

picture of your impairment, we will give the source’s opinion more weight than we would give it 

if it were from a nontreating source.”); 20 C.F.R. § 416.927(c)(2)(i) (same). Accordingly, the 

ALJ’s reasoning is unsupported by substantial evidence from the record.2

Second, the ALJ determined that the six-month gap between plaintiff’s last-documented 

visit with Dr. Senegor and the next scheduled visit undermined Dr. Senegor’s RFC opinion. The 

mere existence of such a gap in treatment, however, does not demonstrate that plaintiff’s 

condition was improving or that he was not as functionally limited as Dr. Senegor opined. To be 

sure, the record of Dr. Senegor’s follow-up examination of plaintiff after the last visit referenced 

by the ALJ indicates that plaintiff’s spinal impairments continued to worsen.3 AT 433. 

Accordingly, the ALJ’s rationale was not supported by substantial evidence from the record.

Finally, the ALJ determined that Dr. Senegor’s opinion was entitled to reduced weight 

because plaintiff declined Dr. Senegor’s treatment suggestions that he receive epidural injections 

and/or undergo spinal surgery. The Commissioner argues that the ALJ’s reasoning was sufficient

to discount Dr. Senegor’s opinion because 20 C.F.R. §§ 404.1530, 416.930 require a denial of 

benefits when a claimant unreasonably refuses to undergo prescribed treatment. Indeed, in 

 

2

Furthermore, the court notes that the ALJ assigned “substantial weight” to the opinion of Dr. 

Bullard, a State agency physician who only reviewed plaintiff’s records. See Lester, 81 F.3d at 

832 (holding that the ALJ’s reasoning that an examining physician’s opinion was entitled to 

lesser weight because his opinion was “based on ‘limited observation’ of the claimant,” was an 

insufficient “reason to give preference to the opinion of a doctor who has never examined the 

claimant” (emphasis in original)).

3

This record was not before the ALJ, but was submitted for review to the Appeals Council. AT 

5. When the Appeals Council considers evidence provided by a claimant after the ALJ’s decision 

has been issued, the court reviews both the ALJ’s decision and additional material submitted to 

the Appeals Council. Ramirez v. Shalala, 8 F.3d 1449, 1451-52 (9th Cir. 1993).

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general, a claimant seeking disability benefits must follow prescribed treatment that can restore 

his ability to work, unless the claimant has a good reason for not following the prescribed 

treatment. See 20 C.F.R. §§ 404.1530, 416.930. However, the record here does not support a 

finding that plaintiff should be denied benefits under this standard, or, more importantly to the 

issue presently disputed by the parties, that Dr. Senegor’s medical opinion should be entitled to 

lesser weight.

First, the ALJ failed to make any finding that either epidural injections or spinal surgery 

could have restored his ability to work or improved his condition to a degree that would have 

undermined Dr. Senegor’s functional findings. Indeed, while Dr. Senegor suggested plaintiff 

undergo such forms of treatment, he never opined on the probability that those treatment avenues 

would be successful or on plaintiff’s likely level of functioning after he followed through with 

either recommendation. See, e.g., AT 272, 275, 422-23. Accordingly, the ALJ could not 

properly determine that plaintiff’s refusal of these suggested treatments established non-disability

or otherwise demonstrated that the functional limitations opined by Dr. Senegor were overly 

severe because plaintiff would have been less impaired had he undergone these forms of 

treatment. See Dodrill v. Shalala, 12 F.3d 915, 919 (9th Cir. 1993) (rejecting non-disability 

determination premised on the plaintiff’s failure to follow prescribed treatment where the ALJ 

failed to make any factual finding that the plaintiff could reasonably remedy her condition with 

prescribed treatment). 

Second, a claimant must decline prescribed treatment in order to be denied benefits under 

sections 404.1530 and 416.930. Here, Dr. Senegor merely suggested and encouraged plaintiff to 

undergo spinal surgery and/or take epidural injections; he never prescribed such treatment. AT

272, 275, 311, 313, 422-23. Furthermore, the record reflects that plaintiff had not completely 

rejected such treatment. To be sure, a note written by Dr. Senegor dated June 21, 2012 stated that 

plaintiff was still open to the possibility of treating his spinal impairments with epidural 

injections, but wanted to “do some internet research before he decide[d].” AT 423.

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Finally, while plaintiff’s repeated refusals to undergo Dr. Senegor’s suggested treatments 

might reasonably undermine plaintiff’s own subjective complaints regarding the extent of his 

limitations and pain; they do not necessarily undermine Dr. Senegor’s opinion, which was based 

on objective clinical findings and a longitudinal view of the impact plaintiff’s impairments had on 

his physical functioning. In short, the ALJ failed to adequately explain how plaintiff’s failure to 

undergo Dr. Senegor’s suggested treatments somehow undermined the accuracy of the functional 

limitations Dr. Senegor opined.

The ALJ’s three stated reasons for discounting Dr. Senegor’s treating opinion do not 

constitute specific and legitimate reasons for making such a determination. Accordingly, the 

court finds that reversal is warranted based on the ALJ’s failure to properly consider Dr. 

Senegor’s treating opinion. 

B. Dr. Bugna

The ALJ also failed to give specific and legitimate reasons for discounting the opinion of 

Dr. Bugna. On January 4, 2011, Dr. Bugna, an orthopedic surgeon who examined plaintiff in 

connection with a workers’ compensation claim, completed a supplemental report concerning the 

impact of plaintiff’s impairments on plaintiff’s ability to work. AT 243-46. Therein, he noted 

that an imaging study conducted on November 18, 2010 showing “[i]ncreased central disc 

protrusion at L4-5 now causing moderate spinal canal stenosis and mild increase in degree of 

neural foraminal stenosis.” AT 243. Dr. Bugna opined that this study “indicate[d] that 

[plaintiff’s] lumbosacral spine difficulty (degenerative changes and particularly intervertebral disc 

disruption) has indeed become worse.” Id. Based on this data, Dr. Bugna opined that plaintiff 

“has reached maximum medical improvement/permanent and stationary status as of the date 

of the [November 18, 2010] imaging study.” AT 244 (emphasis in original). Dr. Bugna 

recommended that plaintiff initially undergo non-surgical treatment for his back impairment 

“including an ongoing self-monitored spinal exercise program,” but also noted that “the 

possibility of surgical intervention at [plaintiff’s] lumbosacral spine is present and is contingent 

upon the level of symptomology experienced by him.” Id. Based on his findings, Dr. Bugna 

opined that plaintiff would be:

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precluded from job activities that require prolonged sitting or standing without the 

ability to change from one position to the other after approximately 15 to 30 

minutes, ambulation for a distance of greater than approximately 2 blocks, 

activities requiring repetitive spinal flexion as well as repetitive twisting motions, 

pulling and pushing, and repetitive lifting [of] objects weighing greater than 

approximately 5 pounds.

Id. 

The ALJ gave the following reasons for assigning “minimal weight” to Dr. Bugna’s 

opinion:

Dr. Bugna’s opinion is inconsistent with the record as a whole, and was given for 

purposes of workers’ compensation, which uses criteria other than the criteria used 

by the Social Security Administration to determine disability. In addition, Dr. 

Bugna did not have the benefit of reviewing additional evidence received after he 

wrote this letter, including an MRI taken on October 2011 which indicated that the 

claimant had only mild degenerative disc disease, and an MRI in January 2013, 

which indicated a slight reduction in the disc bulges at L4-L5 and L3-L4. For 

these reasons, Dr. Bugna’s opinion is given reduced weight.

AT 21. 

First, the ALJ found that Dr. Bugna’s opinion was inconsistent with the record as a whole, 

but failed to specify what evidence, or lack of evidence, undermined Dr. Bugna’s opinion. 

Embrey v. Bowen, 849 F.2d 418, 421 (9th Cir. 1988) (“To say that medical opinions are not 

supported by sufficient objective findings or are contrary to the preponderant conclusions 

mandated by the objective findings does not achieve the level of specificity our prior cases have 

required . . . .”). By failing to do so, the ALJ has prevented the parties and the court from being 

able to analyze his reasoning. Accordingly, the ALJ could not properly rely on this reason to 

support his decision to discount Dr. Bugna’s opinion.

Second, the ALJ determined that Dr. Bugna’s opinion was entitled to less weight because 

it was given in connection with a workers’ compensation claim rather than plaintiff’s applications 

under the Social Security Act. “Although the California Guidelines for Work Capacity are not 

conclusive in a social security case, . . . , the ALJ is entitled to draw inferences logically flowing 

from the evidence.” Macri v. Chater, 93 F.3d 540, 543-44 (9th Cir. 1996) (citations and quotation 

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marks omitted). Here, while Dr. Bugna’s opinion contained disability ratings not directly 

relevant to an analysis of plaintiff’s impairments under the Social Security Act, it also contained a 

discussion of specific functional limitations that Dr. Bugna found to have been caused by 

plaintiff’s physical impairments. AT 244-45. In particular, Dr. Bugna opined limitations 

regarding the impact plaintiff’s impairments had on his ability to perform work-related functions 

such as sitting, standing, walking, postural activities, pushing and pulling, and lifting and 

carrying. AT 244. Despite the existence of these opined limitations that are directly applicable to

the functional considerations under the Social Security Act, the ALJ decided to discount the 

entirety of Dr. Bugna’s opinion on the basis that it was developed under the criteria used to assess 

plaintiff’s workers’ compensation claim. Such reasoning could not properly support the ALJ’s 

decision to discount the portions of Dr. Bugna’s examining opinion that discussed functional 

limitations that were pertinent to determining plaintiff’s RFC under the Social Security Act. See

Macri, 93 F.3d at 543-44. Cf. Allen v. Comm’r of Soc. Sec., 498 F. App’x 696, 698 (9th Cir. 

2012) (unpublished) (holding ALJ’s failure to consider the California workers’ compensation 

ratings contained in a physician’s opinion not erroneous because such ratings were inapplicable in 

a Social Security case and the ALJ considered the rest of the physician’s report, which indicated 

that the plaintiff did not have a severe mental impairment).

Finally, the ALJ determined that Dr. Bugna’s opinion was entitled to lesser weight 

because Dr. Bugna did not review an x-ray

4

of plaintiff’s spine taken in October of 2011 and an 

MRI of plaintiff’s spine taken in January of 2013 when forming his opinion regarding the 

functional impact of plaintiff’s physical impairments. While an ALJ may use such reasoning to 

discount a physician’s opinion when the record provides evidentiary support indicating that the 

later records are contrary to the physician’s opinion, there is no such support here.

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4 Both parties state in their briefing that the ALJ mistakenly referred to this x-ray as an MRI. 

ECF No. 16-1 at 17; ECF No. 19 at 20, n.2. A review of the record confirms that the ALJ 

mistakenly referred to the x-ray taken of plaintiff’s lumbar spine on October 4, 2011 as an MRI. 

AT 408.

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While the October 4, 2011 x-ray indicated that plaintiff did not have spondylolisthesis, 

had only “mild” degenerative disc disease, and “no abnormal movement with flexion and 

extension” of the lumbar spine, AT 272, 408, other evidence in the record shows that the purpose 

of the x-ray was to determine whether plaintiff had spondylolisthesis in his lumbar spine, AT 275. 

Prior to this x-ray, an MRI was taken of that region of plaintiff’s spine and it was determined that

plaintiff exhibited stenosis in the L4-5 region that was “undoubtedly the cause of his symptoms.” 

Id. The record indicates that the results of the October 2011 x-ray did not conflict with this 

finding. Indeed, Dr. Senegor determined that plaintiff’s “symptoms remain unchanged” even 

after reviewing the October 2011 x-ray results and finding that plaintiff’s lumbar spine “show[ed] 

good alignment” and did not exhibit spondylolisthesis. AT 272. Dr. Bugna reviewed the prior 

MRI when developing his functional opinion, AT 243, and the medical record indicates that the 

October 2011 x-ray did not conflict with that prior assessment.

Similarly, with regard to the January 2013 MRI, the record contains a note from Dr. 

Senegor dated February 7, 2015, wherein Dr. Senegor stated that he had reviewed the MRI results 

and stated that the results showed that plaintiff had “3 degenerated discs at L3-4, L4-5, and L5-S1 

with desiccation, bulging, and some height loss,” and “lumbar stenosis at L3-4 and L4-5, 

substantially worse at L4-5.”5 AT 433. He further determined that a review of the MRI 

demonstrated a “worsening of symptoms and intractability of conservative management.” Id. 

Accordingly, the record indicates that the January 2013 MRI results were not inconsistent with 

Dr. Bugna’s opinion. 

Because the imaging evidence referenced by the ALJ indicates that plaintiff’s spinal 

impairments were not improving after Dr. Bugna issued his opinion on January 4, 2011, the 

ALJ’s reasoning that Dr. Bugna’s findings regarding plaintiff’s functional limitations were too 

severe in light of that later-developed medical evidence was not supported by the record.6

 

5 While Dr. Senegor’s note was added to the record for the first time when this case was before 

the Appeals Council, it is still evidence that the court may consider for purposes of determining 

whether the ALJ’s decision was based on substantial evidence. Ramirez, 8 F.3d at 1451-52.

6

The Commissioner also argues in her cross-motion for summary judgment that the ALJ properly 

discounted the opinions of both Dr. Bugna and Dr. Senegor because they were inconsistent with 

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The ALJ’s stated reasons for discounting Dr. Bugna’s opinion were insufficient to support 

such a determination. Accordingly, reversal of the ALJ’s decision is warranted on the further 

basis that he failed to properly consider Dr. Bugna’s opinion.

C. ALJ’s Assignment of “Substantial Weight” to the Non-Examining Physician’s Opinion

was Erroneous

In light of the ALJ’s failure to provide proper reasons for discounting the opinions of Dr. 

Senegor and Dr. Bugna, the court also finds that the ALJ’s assignment of “substantial weight” 

solely to the non-examining opinion of Dr. Bullard to be in error. The ALJ determined that Dr. 

Bullard’s opinion was entitled to greater weight than those of plaintiff’s treating and examining 

physicians with regard to the functional impact of plaintiff’s physical impairments because it was 

“consistent with the record as a whole, as well as with [plaintiff’s] activities of daily living.” AT 

21. However, the ALJ failed to provide any discussion of what specific evidence from the record 

supported this conclusion. This lack of specificity is especially problematic in a case such as 

here, where the ALJ discounted the opinions of plaintiff’s treating and examining physicians in 

favor of the opinion of a non-examining physician. The opinion of a non-examining physician,

without the support of other evidence, is insufficient to discount the opinion of a treating or 

examining physician. Lester, 81 F.3d at 831. 

Furthermore, the ALJ assigned greater weight to Dr. Bullard’s opinion despite the fact that 

Dr. Senegor was a neurological surgeon and Dr. Bugna was an orthopedic surgeon, making both 

of them specialists with regard to plaintiff’s spinal impairments. Generally, the regulations direct 

an ALJ to give more weight to the opinion of a specialist in the relevant area. See 20 C.F.R. § 

404.1527(c)(5) (“We generally give more weight to the opinion of a specialist about medical 

 

plaintiff’s testimony regarding his daily activities. However, the ALJ never provided such a 

reason in support of his decision to discount these physicians’ opinions. The court is constrained 

to review only the reasoning asserted by the ALJ, and cannot consider post hoc reasoning

provided by the Commissioner. See Connett v. Barnhart, 340 F.3d 871, 874 (9th Cir. 2003) 

(noting that a reviewing court is “constrained to review the reasons the ALJ asserts”). 

Accordingly, the court declines to consider the Commissioner’s additional reason in support of 

the ALJ’s determination that the opinions of Dr. Bugna and Dr. Senegor were entitled to reduced 

weight.

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issues related to his or her area of specialty than to the opinion of a source who is not a 

specialist”); Molina v. Astrue, 674 F.3d 1104, 1112 (9th Cir. 2012) (explaining that an opinion 

concerning mental impairments by a specialist in the relevant field of psychiatry was entitled to 

greater weight). Given that the ALJ failed to provide sufficient reasons to discount the treating 

and examining specialists’ opinions while also inadequately supporting his decision to assign the 

greatest weight to a non-examining physician’s opinion, the court finds that the ALJ committed 

reversible error in making his RFC determination.

D. Remand for Further Consideration of the Record is Warranted

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). 

A case may be remanded under the “credit-as-true” rule for an award of benefits where:

(1) the record has been fully developed and further administrative proceedings 

would serve no useful purpose; (2) the ALJ has failed to provide legally sufficient 

reasons for rejecting evidence, whether claimant testimony or medical opinion; 

and (3) if the improperly discredited evidence were credited as true, the ALJ 

would be required to find the claimant disabled on remand.

Garrison v. Colvin, 759 F.3d 003, 1020 (9th Cir. 2014). However, 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 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.

As an initial matter, the court notes that while plaintiff has made a cursory assertion that 

he is entitled to an award of benefits, ECF No. 16-1 at 19,7he has failed to proffer any substantive 

 

7

In his reply brief, plaintiff somewhat clarifies that remand for benefits is warranted because the 

medical opinions improperly considered by the ALJ “support a finding of disability on remand, 

and the record is fully developed.” ECF No. 20 at 8. However, plaintiff fails to demonstrate 

further administrative proceedings in this matter would serve no useful purpose, especially in 

light of the outstanding issues discussed below.

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argument for that remedy in light of the foregoing case authorities and has made no attempt to 

show that this case raises the rare circumstances that would warrant remand for an award of 

benefits. Accordingly, this circumstance militates in favor of the court exercising its discretion to 

remand for further proceedings. See Vasquez v. Astrue, 572 F.3d 586, 597 (9th Cir. 2008)

(remanding for further proceedings where neither party presented any argument about the effect 

of the ALJ’s errors, meaning that there were no facts presented that clearly indicated the proper 

outcome).

Furthermore, there are still outstanding issues for which further proceedings would prove 

beneficial. For instance, on remand, the ALJ should explain what evidence or lack thereof he is 

relying on in support of his reasoning that Dr. Bugna’s opinion should be given lesser weight 

because it conflicts with the record as a whole. Similarly, he should identify with greater 

particularity the evidence supporting his assignment of “substantial weight” to the non-examining 

opinion of Dr. Bullard. Furthermore, the ALJ should determine whether the treatment methods 

proposed to plaintiff by Dr. Senegor would have materially improved the symptoms of plaintiff’s 

spinal impairments. In addition, the ALJ should consider the additional medical evidence that 

was submitted by plaintiff for the first time to the Appeals Council and its impact on the ALJ’s 

consideration of the medical opinion evidence.

Accordingly, remand for further administrative proceedings is warranted for further 

consideration of the medical opinions in the record, particularly the opinions of Dr. Senegor, Dr. 

Bugna, and Dr. Bullard. The ALJ is also free to develop the record in other ways or reconsider 

other aspects of his decision, 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.

///// 

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E. Other Issues

Plaintiff also asserts that the ALJ erred in his finding that plaintiff’s testimony was not 

credible. Because the court finds that remand for further proceedings is necessary on the basis of 

the ALJ’s erroneous consideration of the medical opinion evidence, it declines to decide the 

credibility issue at this juncture. The ALJ’s reasoning for discounting plaintiff’s testimony was 

based in part on considerations similar to those used to support his erroneous decision to discount 

the opinions of Dr. Senegor and Dr. Bugna. Accordingly, the ALJ’s findings regarding 

credibility may change once those opinions have been reconsidered. On remand, the ALJ will 

have the opportunity to reassess the credibility of plaintiff’s testimony in light of findings made at 

that time with regard to the medical opinion evidence and the record as a whole.

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. 16) is granted for purposes of 

further development and reconsideration of the record consistent with the court’s directions set 

forth above;

2. The Commissioner’s cross-motion for summary judgment (ECF No. 19) is denied; and,

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

Dated: November 18, 2015

11 vera2616.ss

_____________________________________

CAROLYN K. DELANEY

UNITED STATES MAGISTRATE JUDGE

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