Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_17-cv-02658/USCOURTS-cand-3_17-cv-02658-0/pdf.json

Parties Involved:
Nancy A. Berryhill
Defendant
Julie Emma Regan
Plaintiff

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United States District Court

Northern District of California

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

JULIE EMMA REGAN,

Plaintiff,

v.

NANCY A. BERRYHILL,

Defendant.

Case No.17-cv-02658-EDL 

ORDER GRANTING PLAINTIFF'S 

MOTION FOR SUMMARY JUDGMENT 

AND REMANDING FOR FURTHER 

PROCEEDINGS; DENYING

DEFENDANT'S MOTION FOR 

SUMMARY JUDGMENT

Re: Dkt. Nos. 15, 18

On May 8, 2017, Plaintiff Julie Emma Regan filed a complaint for judicial review pursuant 

to 42 U.S.C. Section 405(g) of the Social Security Administration Commissioner’s decision to 

deny her applications for disability benefits under Titles II and XVI. Both Plaintiff and the 

Commissioner have filed motions for summary judgment. For the reasons set forth below, the 

Court grants Plaintiff’s motion for summary judgment, denies Defendant’s motion for summary 

judgment, and remands for further proceedings to reconsider the issue of Plaintiff’s credibility as 

to the intensity, persistence, and limiting effects of her symptoms, as well as Plaintiff’s husband’s 

written testimony.

I. BACKGROUND

Plaintiff was 57 years old on the alleged date of the onset of her disability. AR 266-67. 

She obtained a high school education. AR 268. Her past work was as an administrative clerk for 

an electronics company. AR 268. In her applications, she claimed to be disabled because of

mental difficulties, diabetes, and tingling in her hands and legs. AR 267.

A. Procedural History

On May 23, 2012, Plaintiff applied for disability benefits under Titles II and XVI of the 

Social Security Act, alleging a disability onset date of June 30, 2011. AR 226-32. Her 

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applications were denied. AR 120-25. She requested reconsideration of the decision, but that 

request was denied. AR 126-30. She then requested a hearing with an Administrative Law Judge 

(“ALJ”). AR 133-34. The originally scheduled hearing on January 14, 2015 was continued to 

July 30, 2015 so that Plaintiff could obtain legal representation and undergo a consultative medical 

examination. AR 53. 

The ALJ issued an unfavorable decision denying Title II disability benefits to Plaintiff. 

AR 31-41. Plaintiff appealed the decision to the Appeals Council. AR 18-21. The Appeals 

Council denied the appeal on March 14, 2017. AR 1. On that date, the ALJ’s decision became 

final. Plaintiff filed this lawsuit on May 8, 2017. 

Plaintiff filed a motion for summary judgment on September 11, 2017. Dkt. No. 15. 

Defendant opposed Plaintiff’s motion and filed its own motion for summary judgment on 

November 9, 2017. Dkt. No. 18. Plaintiff filed her reply brief on November 16, 2017. Dkt. No. 

19.

B. Plaintiff’s Medical History

The earliest documents in Plaintiff’s medical record show that she received medical care 

starting in 2009 at Kaiser Permanente, and the physician she saw most frequently was Yasmeen 

Wengrow, M.D. On June 14, 2010, Plaintiff saw Dr. Wengrow and complained of knee pain, 

achiness, and fatigue. AR 470. Based on a review of the medical records, this appears to be the 

first time Plaintiff raised these symptoms. Dr. Wengrow noted the recent death of Plaintiff’s 

brother, her mother’s illness, and Plaintiff’s job layoff, all of which occurred in the six months

prior to the appointment. AR 470. On May 18, 2011, Plaintiff returned to Dr. Wengrow to report 

ongoing fatigue that caused her to sleep throughout most of the day. AR 482. Dr. Wengrow noted 

that Plaintiff was not taking her antidepression medications and Plaintiff did not believe her 

depression was contributing to her fatigue. AR 482. In June 2012, Plaintiff asked Dr. Wengrow 

to consider whether she had developed fibromyalgia. AR 439. 

On December 11, 2012, Plaintiff received a comprehensive psychiatric evaluation from 

Arudra Bodepudi, M.D. AR 487-89. The evaluation was conducted for Plaintiff’s Social Security 

application. AR 487. Dr. Bodepudi’s report noted Plaintiff’s history of depression, anxiety and 

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stress. AR 487. Although she admitted to feeling “helpless, hopeless sometimes,” Plaintiff also 

denied feelings of “worthlessness, suicidality, and Anhedonia.” AR 487. Plaintiff explained that 

she is unable to engage in activities because of her aches and pains. AR 487. The report noted

that she saw a psychologist at Tri City Health Center every two weeks and would seek a 

consultation with a psychiatrist in the near future. AR 487. 

During a mental status examination, Dr. Bodepudi noted that Plaintiff was in no apparent 

discomfort and her gait was okay. AR 488. She was cooperative, her mood and effect were 

appropriate, and her speech was normal in rate and volume with occasional sad tones. AR 488. 

She was goal oriented in thought and she denied suicidal and homicidal ideation, as well as 

delusions and paranoia. AR 488. She was alert and oriented, her intellectual functioning was 

average, and her fund of knowledge was excellent. AR 488. 

Dr. Bodepudi diagnosed her with Depressive D/O, NOS, with panic attacks in her previous 

history. AR 488. She noted that she was on appropriate medication, although it may need 

adjustment, and her prognosis was good. AR 489. She found no impairment in understanding, 

remembering, and completing simple instructions; no impairment in understanding, remembering, 

and completing complex instructions; no impairment to interact appropriately with supervisors, 

coworkers, and the public; and moderate impairment in her ability to perform work activities on a 

consistent basis due to pain, not due to psychiatric reasons. AR 489. She opined that she would 

have no difficulty dealing with the usual stresses of a competitive work environment. AR 489.

Records indicate that Plaintiff began receiving treatment at Tri City Health in 2012 under 

the care of Aruna Reddy, M.D., and Jan Dickey, M.D. Both doctors referred Plaintiff for x-rays to 

investigate her complaints of pain. AR 650-52. X-rays taken of her cervical spine on July 10, 

2012 revealed minimal bilateral uncovertebral spurring without significant foraminal stenosis. AR 

652. There was no radiographically apparent discogenic disease. AR 652. X-rays of her elbows 

on February 21, 2013 were normal. AR 650. X-rays of her hips on February 21, 2013 showed 

mild arthritic changes. AR 651. 

Plaintiff also saw a psychologist, Karla Espinosa, Ph.D., M.P.H., at Tri City Health from 

July 2012 to May 2013. AR 503-24. Dr. Espinosa’s notes include numerous references to 

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Plaintiff’s chronic pain and the effect that her inability to perform normal activities had on her 

mood. Id. Dr. Espinosa’s records also include copies of journal entries in which Plaintiff 

described how she spent her days. AR 505-09, 511-17, 519-23

Dr. Espinosa referred Plaintiff to a psychiatrist, G. Versales, M.D., at Pathways to 

Wellness Medication Clinic, and she saw the psychiatrist on December 19, 2012 and February 20, 

2013. AR 494-502. During the initial assessment, she was diagnosed with General Anxiety 

Disorder, NOS, and possible fibromyalgia. AR 500, 633. Plaintiff noted her chronic pain as

“recent life changes/stressors.” AR 494. With respect to the anxiety diagnosis, the psychiatrist 

noted during both visits that her condition was stable. AR 495, 501. At some point, Plaintiff 

began seeing Mythri Gollapalle, M.D. as her primary care physician. Because of her stable 

condition, Dr. Versales discharged Plaintiff to Dr. Gollapolle’s for management of her care and 

medication. AR 632. Dr. Versales noted that Plaintiff was having blood work done to help 

diagnose her chronic pain. AR 632. That blood work was completed on February 20, 2013, and 

indicated that Plaintiff had a high rheumatoid factor. AR 641. 

On September 20, 2013, Plaintiff received a rheumatology evaluation from Dr. Neuwalt. 

AR 595. Dr. Gollapalle referred her to Dr. Neuwalt because of her chronic pain symptoms. AR 

595. During the examination, Dr. Neuwalt found moderate muscle weakness, definite swelling,

and tender points, and diagnosed Plaintiff with fibromyalgia. AR 595.

On October 11, 2013, P.M. Balson, M.D., reviewed her claim upon reconsideration. AR 

108-18. With respect to her psychiatric condition, he agreed with the original assessment that her 

condition was not severe. AR 113. He noted that the medical record demonstrated that she was 

stable on her medications and that she has situational depression and anxiety, which Plaintiff 

describes as being driven by her pain. AR 113. 

On July 2, 2014, Plaintiff saw Dr. Gollapelle in order to obtain a new rheumatology 

referral. AR 581-85. Dr. Gollapella routinely noted Plaintiff’s complaints of chronic pain and 

fatigue. AR 536-43, 561, 576, 581. Dr. Gollapalle ordered x-rays and referred Plaintiff to Sabiha 

Rasheed, M.D. for a rheumatology consultation. AR 588. In November 2014, Dr. Rasheed 

diagnosed Plaintiff with osteoarthritis of the cervical, lumbar spine, and hands, and mild 

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osteoarthritis of the hips. AR 588. Dr. Rasheed prescribed Sulindac, a glucosamine chondroitin 

supplement, and advised Plaintiff to do neck, lower back, and hand exercises. AR 588. Dr. 

Rasheed did not include an assessment of Plaintiff’s functional limitations.

In order to obtain an independent medical opinion and a functional assessment of 

Plaintiff’s condition, the ALJ sent Plaintiff to Eugene McMillan, M.D. for an internal medical 

evaluation on February 27, 2015. AR 661-73.1 At this evaluation, Plaintiff complained of 

diabetes and fibromylagia. AR 661. With respect to the second condition, Plaintiff explained that 

she began experiencing fatigue in 2009 and generalized pain in 2010. AR 661. She said that she 

had tried various medications for her pain, including Lyrica, gabapentin, prednisone, and sulindac. 

AR 662. After a physical and neurological evaluation, Dr. McMillion opined as to her functional 

capacity assessment. AR 663-64. He found that she could stand and walk for at least six hours in 

an eight-hour work day. AR 664. He found no limitations on the amount of time she could sit. 

AR 664. He concluded that she could stoop, kneel, crouch, or crawl for more than one third of a 

work day. AR 664. She would be able to occasionally lift and carry 20 pounds and frequently lift 

and carry 10 pounds. AR 664. He found no limitations on Plaintiff’s ability to reach in all 

directions, as well as no manipulation and environmental limitations. AR 664.

In March 2015, Plaintiff was referred to Daniel Dal Corso, Psy.D., for an evaluation. AR 

752. She saw Dr. Dal Corso on March 30, 2015, and he noted his impression that she had chronic 

pain syndrome and major depressive disorder, recurrent episode. AR 764. His treatment plan 

encouraged Plaintiff to follow up with a psychiatrist for depression medication and to consider 

attending the chronic pain program. AR 765. 

On July 27, 2015, Plaintiff’s rheumatologist Peter Laurence Hendler, M.D., diagnosed her 

with “classic Fibromyalgia” because of “widespread severe pain, and very tender trigger points, 

[her] disturbed sleep and daytime fatigue.” AR 674. Dr. Hendler also noted that she had already 

tried to take Nortriptyline, Lyrica, and Gabapentin without any noticeable benefit. AR 674. Dr. 

 

1

Plaintiff was previously assessed by Frank Chen, M.D. on December 15, 2012. AR 490-92. 

According to the ALJ, Dr. Chen was removed from the Social Security Administration’s medical 

panel. AR 53. The ALJ did not take Dr. Chen’s assessment into account in deciding Plaintiff’s 

claim. AR 39 n.2. 

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Hendler did not include an assessment of Plaintiff’s functional limitations.

C. ALJ Hearing

The ALJ held a hearing on July 30, 2015 in Oakland, California. AR 63-91. Plaintiff was 

not represented by counsel at the hearing. AR 66. Plaintiff brought two witnesses with her to the 

hearing. AR 66. Because of the limited time available at the hearing, the ALJ left the record open 

for ten days after the hearing to give Plaintiff an opportunity to submit a letter that summarized the 

testimony that her witnesses intended to give. AR 86. If the witnesses submitted letters, the ALJ 

said that he would give their letters full weight as if they had testified at the hearing. AR 86. 

Plaintiff’s husband Neil Regan submitted a letter to the ALJ on August 3, 2015. AR 399-401.

1. Plaintiff’s Testimony

Plaintiff explained that she has been diagnosed with diabetes, fibromyalgia, and 

hypertension. AR 72. She said that her most limiting medical condition however, is her chronic 

fatigue, which makes it impossible for her to complete tasks she used to be able to do. AR 72. 

She testified that as a result of the fatigue she cannot work or even clean her house. AR 72. She 

also experiences trouble sleeping because she is up all night in pain. AR 72. 

With respect to her work history, she testified that she was last employed at ETM 

Electromatic in Newark, California, in 2009. AR 72-73. Her job title was administration clerk. 

AR 73. In that position, she worked on the computer, filed documents, and attended meetings. 

AR 73. She left the job in 2009 during a company-wide layoff. AR 74. She testified that before 

the layoff she was sick, and that she would fall asleep at her desk and call in sick frequently. AR 

74. After being laid off, Plaintiff looked for work until 2011 when she became too sick to 

continue her search for new employment. AR 74-75. 

The ALJ asked Plaintiff to describe her daily activities. Plaintiff explained that she lives 

with her husband and sister-and-law, and she usually does not start her day until two or three 

o’clock in the afternoon because she cannot sleep at night. AR 75-76. Plaintiff said she can take a 

shower, but even that can exhaust her. AR 75. For meals, Plaintiff testified that she is limited to 

cooking something quickly, such as microwaving food, because she cannot stand in the kitchen to 

cook a full meal. AR 76. During the day, she explained that she normally does not do much of 

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anything, although it depends on the day. AR 77. She testified that she may need to attend a 

doctor appointment, or take her mother or husband to one of their doctor appointments. AR 77. 

Otherwise, she said that she usually stays in the house, except for possibly a short walk around the 

house for exercise. AR 78. She testified that she does the laundry, cleans the dishes, and tries to 

clean up after herself, but when she does that she will be forced to stay in bed for a day or two 

afterward because of the resulting pain and fatigue. AR 82.

Plaintiff explained that her main activity is to sleep. AR 79. She will otherwise pray or 

read the bible to try to make the pain go away. AR 79. She said she does not invite friends over 

to her home for social visits because she does not feel like seeing anyone. AR 79. She contrasted 

this with her former active lifestyle when she would attend church and socialize with friends 

outside of the house. AR 79.

She testified that she still drives a car. AR 80. The ALJ asked the farthest she has driven 

in the last year, and she explained that she drove from her home in Fremont to Los Angeles and 

back to take her husband to see his children, although that was a hard trip for her and she had to 

keep stopping to sleep. AR 80. In the end, the trip to Los Angeles took her about ten hours to 

complete. AR 80.

To alleviate the pain she experiences, Plaintiff applies medicated creams to the parts of her 

body that hurt. AR 76. She also takes sulindac and sometimes uses a TENS machine to help with 

the pain. AR 77-78.

2. Vocational Expert Testimony

Robert Cottle testified at the hearing as a vocational expert. Mr. Cottle testified that 

Plaintiff’s past relevant work was the one job as an administrative clerk, and that job is classified 

as DOT listing 209.362-010, SVP-4, light work. AR 83. 

The ALJ used Dr. McMillan’s residual functional assessment to pose a hypothetical to Mr. 

Cottle. AR 83. He asked if Plaintiff would be able to perform the requirements of this job if she 

were limited to light work with occasional postural activities, and she were to avoid concentrated 

exposure to respiratory irritants. AR 83. Mr. Cottle testified that Plaintiff would be able to do the 

administrative clerk job with those limitations. AR 83.

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The ALJ followed-up on the previous hypothetical and asked if Plaintiff would still be able 

to do her past relevant work with the same limitations at the sedentary level. AR 83. Mr. Cottle 

confirmed that she could not do her past relevant work because that was at a light exertional level, 

but she would have transferable skills for sedentary jobs. AR 83-84. For example, Mr. Cottle 

testified that she could do the job of an election clerk or charge account clerk. AR 84. 

The ALJ asked Mr. Cottle if Plaintiff would be able to do work in the general economy if 

she could only work a less than eight-hour work day. AR 84. Mr. Cottle said she would not be 

able to perform any work in the general economy under those work conditions. AR 84. He also 

testified that she would not be able to maintain employment in unskilled jobs in the general 

economy if she missed work two or three times a month due to pain or illness. AR 84. He 

testified that Plaintiff also would not be able to maintain this type of employment if she had 

trouble concentrating and was off task up to 25% of the time. AR 85-85.

D. ALJ’s Decision

1. Step One -- Substantial Gainful Activity

At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity 

during the period from her alleged onset date of June 30, 2011 through her last insured date of 

December 31, 2014. AR 36.

2. Step Two -- Severe Impairment(s)

At step two, the ALJ concluded that Plaintiff had severe impairments of diabetes mellitus 

type 2 and fibromyalgia. AR 36. He explained that her medical records indicate that she also has 

physical impairments of hypertension, GERD, and allergic rhinitis, but those appear to be 

controlled by medication and are not severe. AR 36.

The ALJ also examined the medical record with respect to Plaintiff’s diagnoses of anxiety 

and depressive disorder. AR 37. He found that her treating source at Pathways and the 

consultative examiner, Dr. Bodepudi, concluded that her symptoms were not more than mild. AR 

37. The ALJ noted that Dr. Bodepudi diagnosed her with depressive disorder with a history of 

panic attacks, but found that she had few current symptoms and no functional limitations. AR 37. 

He also noted that she was seen twice at Pathways by a psychiatrist who diagnosed her with 

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generalized anxiety disorder, but she did not return for additional treatment and the psychiatrist 

discharged her ongoing care to her primary care doctor at Tri City Health. AR 37. In concluding 

that she did not have a severe impairment from her anxiety or depressive disorder, the ALJ relied 

on the opinions of the state agency reviewer, Dr. Belson, and consulting psychologist Dr. Dal 

Corso. AR 37. Neither doctor found that she had a severe mental impairment. AR 37.

3. Step Three -- Listed Impairment(s)

The ALJ next concluded that Plaintiff did not have an impairment or combination of 

impairments that met or medically equaled the severity of one of the listed impairments at 20 

C.F.R. Part 404, Subpart P, Appendix 1. AR 37-38. The ALJ determined that fibromyalgia, 

which is not listed, did not medically equal a listing, even when combined with diabetes mellitus 

type 2, based on the medical record. AR 37. Diabetes mellitus type 2 is also not a listed 

impairment for adults as of June 7, 2011. AR 38.

4. Step Four -- Past Relevant Work

At step four, the ALJ determined that Plaintiff has a residual functional capacity (“RFC”) 

to perform light work as defined in 20 C.F.R. Part 404.1567(b), which means that she could lift 

and carry ten pounds frequently and 20 pounds occasionally and sit, stand, or walk for six hours 

out of an eight-hour work day, except that she could occasionally climb, balance, stoop, kneel, 

crouch, and crawl. AR 38. Under this RFC, Plaintiff should also avoid concentrated exposure to 

respiratory irritants. AR 38. Consistent with this RFC, the ALJ concluded that Plaintiff was 

capable of performing her past relevant work as an administrative clerk. AR 40.

In reaching this conclusion, the ALJ found that Plaintiff’s medically determinable 

impairments reasonably could be expected to cause the alleged symptoms of mental impairment, 

tingling in her hands and legs, body aches and pains, disturbed sleep, dizziness, and forgetfulness. 

AR 38. However, he found that Plaintiff’s allegations about the intensity, persistence, and 

limiting effects of those symptoms were not entirely credible. AR 39.

The ALJ reviewed Plaintiff’s medical record and concluded that her pain complaints are 

consistent with having fibromyalgia, but that no treating or examining doctor had suggested 

functional limitations that were more restrictive than those described by Dr. McMillan and 

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incorporated in the ALJ’s RFC. AR 40. Moreover, the ALJ found that the medical record showed 

that Plaintiff was not receiving the level of care that one would expect from a patient who was 

totally disabled by her fibromyalgia. AR 40. To the contrary, the ALJ noted that Plaintiff’s 

doctors had recommended that she engage in greater physical activity to treat her symptoms. AR 

40. Accordingly, the ALJ did not find Plaintiff’s subjective pain complaints completely credible 

and determined that his RFC was supported by Dr. McMillian’s examination and opinion and the 

longitudinal medical record. AR 40. 

In finding that Plaintiff was capable of performing her past relevant work as an 

administrative clerk and therefore was not disabled, the ALJ relied on the vocational expert’s 

opinion that an individual with the above described RFC could perform that job. AR 40. In 

addition, the ALJ noted that the state agency also concluded that Plaintiff could perform her past 

relevant work. AR 40. Based on these findings, the ALJ found that Plaintiff is not disabled.

II. LEGAL STANDARD

This Court has the authority to review the Commissioner’s decision to deny benefits. 42 

U.S.C. § 405(g); see Reddick v. Chater, 157 F.3d 715, 720 (9th Cir. 1998). Substantial evidence is 

defined as relevant evidence that a reasonable person might accept as adequate in support of a 

conclusion; it is “more than a mere scintilla but less than a preponderance.” Id.; see also

Richardson v. Perales, 402 U.S. 389, 401 (1971); Sandgathe v. Chater, 108 F.3d 978, 980 (9th 

Cir.1997). Reasoning not relied upon by the ALJ cannot be relied upon to affirm the ALJ’s 

decision. See Cequerra v. Sec’y, 933 F.2d 735, 738.

To determine whether the ALJ’s decision is supported by substantial evidence, courts 

review the administrative record as a whole, weighing both the evidence that supports and detracts 

from the ALJ’s decision. Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995.) If the evidence 

is susceptible to more than one rational interpretation, the Court must uphold the ALJ’s 

conclusion. Id. at 1030-40. The trier of fact, not the reviewing court, must resolve conflicting 

evidence, and if the evidence can support either outcome, the reviewing court may not substitute 

its judgment for the judgment of the ALJ. Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005); 

see also Matney v. Sullivan, 981 F.2d 1016, 1019 (9th Cir.1992). An ALJ’s decision will not be 

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reversed for harmless error. Id.; see also Curry v. Sullivan, 925 F.2d 1127, 1131 (9th Cir. 1991).

A. Definition of Disability

In order to qualify for disability insurance benefits, a plaintiff must demonstrate an 

“inability to engage in any substantial gainful activity by reason of any 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 12 months.” 42 U.S.C. § 423(d)(1)(A). 

The Social Security Administration (“SSA”) utilizes a five-step sequential evaluation process in 

making a determination of disability. 20 C.F.R. § 404.1520; see Reddick, 157 F.3d 715, 721. If 

the SSA finds that the claimant is either disabled or not disabled at a step, then the SSA makes the 

determination and does not go on to the next step; if the determination cannot be made, then the 

SSA moves on to the next step. 20 C.F.R. § 404.1520.

B. Determination of Disability

First, the SSA looks to the claimant’s work activity, if any; if the claimant is engaging in 

substantial gainful activity, she is not disabled. 20 C.F.R. § 404.1520(a)(4)(I). Second, the SSA 

considers the severity of impairments; the claimant must show that he has a severe medically 

determinable physical or mental impairment (or combination of severe impairments) which has 

which has lasted or is expected to last twelve months or end in death. 20 C.F.R. § 

404.1520(a)(4)(ii). Third, the SSA considers whether a claimant’s impairments meet or equal a

listing in 20 C.F.R. Part 404 Appendix 1. If so, the claimant is deemed disabled. 20 C.F.R. § 

404.1520(a)(4)(iii). Fourth, the SSA considers the claimant’s residual functional capacity

(“RFC”) and past relevant work. If the claimant can still engage in past relevant work, he is not 

disabled. 20 C.F.R. § 404.1520(a)(4)(iv). Fifth, the SSA considers whether, in light of the 

claimant’s RFC and age, education, and work experience, the claimant is able to make an 

adjustment to another occupation in the national economy; if so, the claimant is not disabled. 20 

C.F.R. § 404.1520(a)(4)(v); 20 C.F.R. § 404.1560(c). 

The claimant bears the burden on steps one through four. Reddick, 157 F.3d at 721. If a 

claimant establishes an inability to perform her prior work at step four, the burden shifts to the 

SSA to show that the claimant can perform other substantial work that exists in the national 

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economy at step five. Id.

III. DISCUSSION

A. Credibility Determination

The first basis for Plaintiff’s motion for summary judgment is that the ALJ committed 

error when he made a negative credibility finding against Plaintiff’s testimony regarding pain. 

Specifically, she contends that the ALJ did not provide clear and convincing reasons and that he 

failed to consider the entire case record when making his negative credibility determination.

In order to find a claimant’s testimony regarding symptoms unreliable, the ALJ is 

“required to make ‘a credibility determination with findings sufficiently specific to permit the 

courts to conclude that the ALJ did not arbitrarily discredit claimant’s testimony.’” Tommasetti v. 

Astrue, 533 F.3d 1035, 1039 (9th Cir. 2008) (quoting Thomas v. Barnhart, 278 F.3d 947, 958 (9th 

Cir. 2002)). The Ninth Circuit requires the ALJ to conduct a two-step analysis to determine 

whether a claimant’s testimony regarding subjective pain or symptoms is credible. See Garrison 

v. Colvin, 759 F.3d 995, 1014 (9th Cir. 2014). “First, the ALJ must determine whether the 

claimant has presented objective medical evidence of an underlying impairment ‘which could 

reasonably be expected to produce the pain or other symptoms alleged.’” Id. (quoting Lingenfelter 

v. Astrue, 504 F.3d 1028, 1035-36 (9th Cir. 2007)) (internal citations omitted). If the claimant has 

presented evidence to satisfy the first step, “and there is no evidence of malingering, ‘the ALJ can 

reject the claimant’s testimony about the severity of her symptoms only by offering specific, clear, 

and convincing reasons for doing so.’” Garrison, 759 F.3d at 1014-15 (quoting Smolen v. Chater, 

80 F.3d 1273, 1281 (9th Cir. 1996)). The ALJ may consider many factors when weighing the 

claimant’s credibility, including “‘(1) ordinary techniques of credibility evaluation, such as the 

claimant’s reputation for lying, prior inconsistent statements concerning the symptoms, and other 

testimony by the claimant that appears less than candid; (2) unexplained or inadequately explained 

failure to seek treatment or to follow a prescribed course of treatment; and (3) the claimant’s daily 

activities.’” Tommasetti v. Astrue, 533 F.3d 1035, 1039 (9th Cir. 2008) (quoting Smolen, 80 F.3d 

at 1284). “This is not an easy requirement to meet: ‘The clear and convincing standard is the most 

demanding required in Social Security cases.’” Garrison, 759 F.3d at 1015 (quoting Moore v. 

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Comm’r of Soc. Sec. Admin, 278 F.3d 920, 924 (9th Cir. 2002)).

Here, the ALJ determined that Plaintiff had medically determinable impairments, so he

was required to provide clear and convincing reasons in support of his adverse credibility finding. 

See Tommasetti, 533 F.3d at 1039. In finding that Plaintiff’s fibromyalgia constituted a severe 

impairment, the ALJ credited her testimony about her fibromyalgia symptoms, but cited multiple 

reasons for finding that these symptoms did not render her totally disabled. To start, the ALJ 

explained that her treating doctors diagnosed her with fibromyalgia but no treating doctor 

suggested functional limitations that were more restrictive than the light work restrictions that 

were described by Dr. McMillian in his functional assessment. At least two of her treating doctors 

recommended that she increase her physical activity to alleviate her symptoms of fibromyalgia. 

These recommendations show that her doctors considered her capable of greater activity and that, 

importantly, greater activity would be beneficial to her condition. 

Plaintiff contends that the ALJ’s finding about her conservative treatment is not a clear and 

convincing reason for discounting her credibility because the conservative treatments of increased 

physical activity are not equivalent to the RFC assessment that Plaintiff is capable of sitting, 

standing, or walking for six hours of an eight-hour work day. As Defendant points out, the ALJ 

did not find that these recommended treatments equated to activities of daily living. Instead, the 

ALJ found that her complaints about pain and fatigue were not credible in light of the limited 

treatment she received for her symptoms. See Edginton v. Colvin, 625 Fed. App’x 334, 336 (9th 

Cir. 2015) (“The ALJ reasonably concluded that [claimant’s] treatment for his back condition was 

‘routine and conservative’ and not the treatment expected for an individual suffering from the 

disabling symptoms that [claimant] described.”); Hanes v. Colvin, 651 Fed. App’x 703, 705 (9th 

Cir. 2016) (discounting pain complaints given conservative treatment plan of minimal medication, 

limited injections, physical therapy, and gentle exercise). 

Over the last two decades as fibromyalgia has come to be more recognized and better 

understood, the Ninth Circuit has had several occasions to consider disability claims that are based 

on fibromyalgia and its attendant symptoms of pain and fatigue. One line of cases in particular 

highlights the evolving understanding of fibromyalgia and the available treatments for the 

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condition. In Revels v. Berryhill, 874 F.3d 648, 667 (9th Cir. 2017), the Ninth Circuit found that 

the ALJ erred by concluding that the treatment the plaintiff was receiving was “conservative” 

where the claimant with diagnosed fibromyalgia was prescribed “a variety of medications for her 

pain, including Valium, Vlector, Soma, Vicodin, Percocet, Neurontin, Robaxin, Trazodone, and 

Lyrica” and “received facet and epidural injections in her neck and back, as well as steroid 

injections in her hands.” While Plaintiff’s treatment is more in line with the treatment addressed 

seventeen years ago in Rollins v. Massanari, 261 F.3d 853, 856 (9th Cir. 2001) in which the Ninth 

Circuit found that the main recommendation for the avoidance of strenuous activity qualified as 

“conservative,” the Ninth Circuit has recently expressed skepticism that its opinion in Rollins

could hold up in light of the more fully developed understanding of fibromyalgia that is now

accepted in the medical community and embodied in the Social Security regulations. See Revels, 

874 F.3d at 667 n.6. Indeed the most recent medical opinion from Plaintiff’s treating physician, 

rheumatologist Dr. Hendler, stated that she has “classic fibromyalgia” and she has tried several 

standard treatments for fibromyalgia without any noticeable benefit. AR 674. There is no 

evidence in the record that any greater level of care for fibromyalgia would be available to 

Plaintiff to relieve her pain symptoms. Therefore, the Court concludes that Plaintiff’s level of 

treatment was not a clear and convincing reason to discount her symptoms as it failed to take into 

account the nature of her condition and the treatment available for it. 

The ALJ also rested his credibility determination on the finding that her reported 

symptoms were not consistent with the overall medical record. Recent cases addressing credibility 

determinations where the claimant has fibromyalgia also seriously undermine the lack of 

supporting objective medical evidence as a valid reason for discounting a fibromyalgia patient’s 

subjective complaints. In Hamilton-Carneal v. Colvin, 670 Fed. App’x 613 (9th Cir. 2016), for 

example, the Ninth Circuit reversed the district court’s affirmance of the denial of a claimant’s 

disability insurance application relating to her fibromyalgia diagnosis. The ALJ had discounted 

the claimant’s “subjective complaints and limitations” as “simply out of proportion to and not 

corroborated by the objective medical evidence.” Id. at 614. The Ninth Circuit found that this 

was error because the disease is poorly understood, diagnosed entirely on the patient’s reports of 

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pain and other symptoms, and there are no laboratory tests to confirm the diagnosis. Id. This 

holding is echoed in the Social Security regulations’ focus on a claimant’s complaints of pain and 

evidence that other causes have been excluded as the underlying cause for the complaints, along 

with clinical observations that are consistent with fibromyalgia including tender points or other 

repeated manifestations of the disease such as fatigue, cognitive difficulties, and depression. See

SSR 12-2p. Here, the ALJ’s opinion did not consider the fact that fibromyalgia is an incurable 

condition and that it is usually diagnosed and treated exclusively based on a patient’s subjective 

complaints about her symptoms. The ALJ also did not address the fact that Plaintiff has been 

prescribed and used several commonly prescribed medications for fibromyalgia, none of which 

produced strong results for the alleviation of Plaintiff’s condition. 

Plaintiff does not squarely address the fact that the ALJ concluded that her complaints of 

disabling pain and fatigue should be partially discredited because they were not consistent with 

other aspects of the overall medical record. The Court’s review of the overall medical records 

reflect Plaintiff’s ongoing complaints that she suffered from body pains and fatigue that she 

reported limited her ability to live a fully-functioning life. She raised these symptoms with her 

doctors starting in 2010, and she continued doing so through 2015, which are the latest medical 

records in the administrative record. Multiple doctors’ diagnosis of fibromyalgia, a condition that 

is characterized by widespread body pain and fatigue, indicate that Plaintiff’s doctors credited her 

complaints. 

However, there is some evidence that is not entirely consistent with Plaintiff’s complaints. 

For example, the ALJ reviewed two physicians’ analysis of x-rays taken of Plaintiff’s elbows, 

hips, and spine. Both physicians noted normal results or, at most, mild signs of arthritis. The 

diagnostic results from Plaintiff’s treating physicians are consistent with Dr. McMillian’s 

evaluation of Plaintiff’s functional limitations, as noted by the ALJ. But, as the Ninth Circuit 

recognized in Revels, normal examination results “are perfectly consistent with debilitating 

fibromyalgia” for the specific reasons that it is “diagnosed ‘entirely on the basis of patients’ 

reports of pain and other symptoms,’” “‘there are no laboratory tests to confirm the diagnosis,’” 

and “fibromyalgia is diagnosed, in part, by evidence showing that another condition does not 

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account for a patient’s symptoms.” Revels, 874 F.3d at 666 (quoting Benecke v. Barnhart, 379 

F.3d 587, 590 (9th Cir. 2004)).2

The ALJ provided no reasons for discrediting Plaintiff’s complaints of pain and fatigue 

aside from the lack of corroborating objective medical evidence and the treatments that he 

considered conservative. These reasons are insufficient to meet the high “clear and convincing” 

reasons standard. In failing to provide any additional reasons, the ALJ erred. 

B. Layperson Testimony

Plaintiff argues that the ALJ also erred by failing to consider the written testimony of her 

husband Neil Regan about her medical condition. At the ALJ’s request, Mr. Regan submitted a 

letter setting forth his testimony which was received by the Social Security Administration on 

August 3, 2015. AR 399-401. Mr. Regan stated broadly that Plaintiff “is in pain most of the time 

and is unable to do much without exhaustion.” AR 400. He went on to conclude that “[i]f she 

can’t function at home it would be not plausible in a job environment” and he felt that “her 

attendance due to illness would be outside the parameters allowed to keep a job.” AR 400. He 

also asked the ALJ to take into consideration several points about her medical record and 

treatment, including the fact that fibromyalgia is not curable, she has been diagnosed with 

fibromyalgia, her x-rays show an arthritic condition, she has been prescribed and has taken Lyrica 

without success, and only a rheumatology specialist knew the exact tests to conduct to diagnose 

 

2

The Court does not find Plaintiff’s argument about her inability to obtain additional care because 

of her financial situation and insurance coverage to be particularly persuasive. Plaintiff’s motion 

cites letters she wrote to the ALJ before the hearing, stating that she was having trouble seeing a 

rheumatology specialist because only a limited number of doctors accepted her insurance and 

there were wait lists to see them. AR 369, 371. However, Plaintiff was able to see at least two 

rheumatology specialists (Dr. Rasheed and Dr. Neuwalt) in 2014 and 2015, both of whom 

diagnosed her with fibromyalgia. Plaintiff was also treated by Dr. Hendler in July 2015, before 

the ALJ’s hearing, and his diagnosis of fibromyalgia and comments about Plaintiff’s unsuccessful 

use of commonly-prescribed fibromyalgia medications were entered into the record and addressed 

in the ALJ’s opinion. Moreover, Plaintiff’s early troubles paying for health insurance appear to 

have been at least partially relieved by her access to insurance through the Covered California 

program because her medical records from 2012 through 2015 indicate that she had frequent 

contact with her primary care physicians and specialists and received the recommended diagnostic 

testing, such as x-rays and laboratory work. Finally, this argument about Plaintiff’s alleged 

difficulty accessing health care is not directly responsive to the ALJ’s contention that the 

conservative treatment that her doctors recommended for her (and not what was recommended but 

she was unable to receive) supports a finding that her symptoms are not as serious as alleged.

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fibromyalgia and the Social Security doctor did not have the appropriate experience to diagnosis 

Plaintiff accurately. AR 400.

“Lay testimony as to a claimant’s symptoms is competent evidence which the Secretary 

must take into account, unless he expressly determines to disregard such testimony, in which case 

‘he must give reasons that are germane to each witness.’” Nguyen v. Chater, 100 F.3d 1462, 1467 

(9th Cir. 1996) (quoting Dodrill v. Shalala, 12 F.3d 915, 919 (9th Cir. 1993)) (emphasis in 

original). Lay testimony about a claimant’s medical diagnoses, however, is “beyond the 

competence of lay witnesses and therefore do not constitute competent evidence.” Id. If the ALJ 

does not take into account “competent lay testimony favorable to the claimant, a reviewing court 

cannot consider the error harmless unless it can confidently conclude that no reasonable ALJ, 

when fully crediting the testimony, could have reached a different disability determination.” Stout 

v. Commissioner, 454 F.3d 1050, 1056 (9th Cir. 2006). 

Defendant cites Valentine v. Astrue, 574 F.3d 685 (9th Cir. 2009), for the proposition that 

no error was committed because Mr. Regan’s testimony was duplicative of Plaintiff’s testimony 

and the ALJ gave valid reasons for discounting Plaintiff’s testimony. However, Valentine is not 

applicable here because the ALJ’s opinion in that case specifically addressed the lay person’s 

duplicative testimony, whereas the ALJ’s opinion in this case did not even mention Mr. Regan’s 

testimony. 

Here, the ALJ’s opinion did not reference Mr. Regan’s letter or provide any “germane” 

reasons for disregarding it. Certain portions of the letter discussed Plaintiff’s medical diagnosis 

and did not need to be considered by the ALJ in reaching his disability determination. See

Nguyen, 100 F.3d at 1467. Other portions, however, provided Mr. Regan’s assessment of

Plaintiff’s alleged symptoms of severe pain and fatigue, and his perception that these symptoms 

impacted her ability to work. In Stout, the Ninth Circuit found that the ALJ’s failure to discuss 

similar lay testimony about how the claimant’s impairments affected his ability to work 

constituted reversible error. See Stout, 454 F.3d at 1054-56. In this case, if the ALJ fully credited 

Mr. Regan’s written testimony, particularly the opinion that Plaintiff’s impairments would keep 

her from work several days a month, then it is possible that the ALJ would have come to a 

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different conclusion about whether Plaintiff is disabled. The ALJ fully credited the vocational 

expert’s testimony in his opinion, and the vocational expert testified that Plaintiff would not be 

able to do her past relevant work or any other work in the national economy if she missed several 

days of work each month. AR 84. Thus, his failure to appropriately consider Mr. Regan’s letter 

in the course of rendering his decision was not harmless error.3

C. Whether to Remand or Award Benefits

Because the Court has concluded that the ALJ erred in his credibility determination and 

his failure to consider Mr. Regan’s written testimony, the final question is whether to remand for 

additional proceedings or award benefits. “The decision whether to remand a case for additional 

evidence, or simply to award benefits[,] is within the discretion of the court.” Sprague v. Bowen, 

812 F.2d 1226, 1232 (9th Cir. 1987). “‘[I]f additional proceedings can remedy defects in the 

original administrative proceeding, a social security case should be remanded’” for further 

proceedings. Garrison v. Colvin, 759 F.3d 995, 1019 (9th Cir. 2014) (quoting Lewin v. 

Schweiker, 654 F.2d 631, 635 (9th Cir. 1981)). However, a court may also reverse and remand 

with instructions to calculate and award benefits “when it is clear from the record that a claimant 

is entitled to benefits.” Id. The Ninth Circuit uses a three-part test to determine whether a court 

should remand to an ALJ with instructions to calculate and award benefits: “(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 reject 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.” Id. at 1020. There is 

“flexibility” in applying the credit-as-true rule which allows the district court to remand for further 

proceedings even when all three conditions are satisfied “when the record as a whole creates 

serious doubt as to whether the claimant is, in fact, disabled within the meaning of the Social 

 

3

Plaintiff’s motion originally raised the additional argument that the ALJ erred in not obtaining a 

medical opinion in abdication of his “independent ‘duty to fully and fairly develop the record and 

to assure that the claimant’s interests are considered.’” Tonapetyan v. Halter, 242 F.3d 1144, 1150 

(9th Cir. 2001) (quoting Smolen v. Chater, 80 F.3d 1273, 1288 (9th Cir. 1996)). In her reply brief, 

Plaintiff abandoned this argument, so the Court need not address it.

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Security Act.” Id. at 1021. “[E]ven when those ‘rare circumstances’” identified in the three-part 

test are satisfied, “‘[t]he decision whether to remand a case for additional evidence or simply to 

award benefits is in [the court’s] discretion.’” Treichler v. Comm’r of Soc. Sec. Admin., 775 F.3d 

1090, 1101-02 (9th Cir. 2004) (quoting Swenson v. Sullivan, 876 F.2d 683, 689 (9th Cir. 1989)).

In this case, it is not clear that all three conditions of the credit-as-true test are satisfied and 

that Plaintiff is entitled to benefits. Principally, the issue of whether there are additional reasons 

for discounting Plaintiff’s credibility should be resolved by an ALJ who has the benefit of 

assessing Plaintiff’s testimony in person. For example, not all of Plaintiff’s testimony was 

consistent with her stated symptoms, such as the testimony that she recently drove from her home 

in the San Francisco Bay area to Los Angeles and back. On remand, the ALJ may also be able to 

take Mr. Regan’s testimony in person, rather than depend upon a written letter, which would 

similarly provide a more accurate assessment of the weight it should be given. Moreover, 

although the Court has not ruled on whether it was error to not solicit one in the first instance, it is 

possible that the ALJ would benefit, on remand, from obtaining an additional medical opinion 

from a fibromyalgia specialist. For these reasons, the Court cannot say with certainty that further 

administrative proceedings would serve no useful purpose and exercises its discretion to remand 

for further proceedings.

IV. CONCLUSION

For these reasons, the Court GRANTS Plaintiff’s motion for summary judgment and 

DENIES Defendant’s motion for summary judgment, and remands the case for further 

administrative proceedings to reconsider the issue of Plaintiff’s credibility as to the intensity, 

persistence, and limiting effects of her symptoms, as well as Plaintiff’s husband’s written 

testimony.

IT IS SO ORDERED.

Dated: March 28, 2018

ELIZABETH D. LAPORTE

United States Magistrate Judge

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