Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_14-cv-02572/USCOURTS-caed-2_14-cv-02572-3/pdf.json

Parties Involved:
Commissioner of Social Security
Defendant
Lynn Ann Long
Plaintiff

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UNITED STATES DISTRICT COURT 

FOR THE EASTERN DISTRICT OF CALIFORNIA 

LYNN ANN LONG, 

Plaintiff, 

v. 

CAROLYN W. COLVIN, Acting 

Commissioner of Social Security 

Defendant. 

No. 2:14-cv-2572-EFB 

ORDER 

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

(“Commissioner”) denying her application for a period of disability and Disability Insurance 

Benefits (“DIB”) under Title II of the Social Security Act. The parties have filed cross-motions 

for summary judgment. For the reasons discussed below, plaintiff’s motion is granted, the 

Commissioner’s motion is denied, and the matter is remanded for further proceedings. 

I. BACKGROUND 

Plaintiff filed an application for a period of disability and DIB, alleging that she had been 

disabled since October 13, 2008. Administrative Record (“AR”) 162-170. Her application was 

denied initially and upon reconsideration. Id. at 104-107, 110-114. On March 13, 2013, a 

hearing was held before administrative law judge (“ALJ”) G. Ross Wheatley. Id. at 37-77. 

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Plaintiff was represented by counsel and she and a vocational expert (“VE”) testified. Id. 

On April 11, 2013, the ALJ issued a decision finding that plaintiff was not disabled under 

sections 216(i) and 223(d) of the Act.1 Id. at 21-32. The ALJ made the following specific 

findings: 

1. The claimant meets the insured status requirements of the Social Security Act through 

December 31, 2014. 

2. The claimant has not engaged in Substantial Gainful Activity (SGA) since October 13, 

2008, the alleged onset date (20 CFR 404.1571 et seq.). 

3. The claimant has the following severe impairments: rheumatoid arthritis; fibromyalgia 

syndrome; obesity; and Osgood-Schlatter disease in bilateral knees (20 CFR 404.1520(c)). 

 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 (“SSI”) is paid 

to disabled persons with low income. 42 U.S.C. §§ 1382 et seq. Under both provisions, 

disability is defined, 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 five-step sequential evaluation governs eligibility for benefits. See 20 C.F.R. 

§§ 423(d)(1)(a), 416.920 & 416.971-76; Bowen v. Yuckert, 482 U.S. 137, 140-42 (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. Yuckert, 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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* * * 

4. 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 (20 CFR 404.1520(d), 404.1525, and 404.1526). 

* * * 

5. After careful consideration of the entire record, the undersigned finds that the claimant has 

the Residual Functional Capacity (RFC) to perform less than the full range of Sedentary 

work as defined in 20 CFR 404.1567(a) except she cannot climb ladders, ropes or 

scaffolds; she can occasionally climb ramps and stairs; she can frequently balance; she can 

occasionally stoop, crouch, kneel, and crawl; and use of both hands for handling and 

fingering is limited to frequent. 

* * * 

6. The claimant is capable of performing Past Relevant Work (PRW) as a Program Director 

and Intake Coordinator. This work does not require the performance of work-related 

activities precluded by the claimant’s Residual Functional Capacity (RFC) (20 CFR 

404.1565). 

* * * 

7. The claimant has not been under a disability, as defined in the Social Security Act, from 

October 13, 2008, through the date of this decision (20 CFR 404.1520(f)). 

Id. at 23-32. 

Plaintiff’s request for Appeals Council review was denied on August 29, 2014, leaving the 

ALJ’s decision as the final decision of the Commissioner. Id. at 1-7. 

II. LEGAL STANDARDS 

The Commissioner’s decision that a claimant is not disabled will be upheld if the findings 

of fact are supported by substantial evidence in the record and the proper legal standards were 

applied. Schneider v. Comm’r of the Soc. Sec. Admin., 223 F.3d 968, 973 (9th Cir. 2000); 

Morgan v. Comm’r of the Soc. Sec. Admin., 169 F.3d 595, 599 (9th Cir. 1999); Tackett v. Apfel, 

180 F.3d 1094, 1097 (9th Cir. 1999). 

 The findings of the Commissioner as to any fact, if supported by substantial evidence, are 

conclusive. See Miller v. Heckler, 770 F.2d 845, 847 (9th Cir. 1985). Substantial evidence is 

more than a mere scintilla, but less than a preponderance. Saelee v. Chater, 94 F.3d 520, 521 (9th 

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Cir. 1996). “‘It means such evidence as a reasonable mind might accept as adequate to support a 

conclusion.’” Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consol. Edison Co. v. 

N.L.R.B., 305 U.S. 197, 229 (1938)). 

 “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). “Where the evidence is susceptible to more than one rational 

interpretation, one of which supports the ALJ’s decision, the ALJ’s conclusion must be upheld.” 

Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002). 

III. ANALYSIS 

 Plaintiff argues that the ALJ erred in (1) weighing the medical opinion evidence and (2) 

discrediting plaintiff’s subjective testimony without clear and convincing reasons. ECF No. 13 at 

19-31. 

 A. The ALJ Erred in Rejecting the Opinion from Plaintiff’s Treating Physician 

 Plaintiff first argues that the ALJ erred in rejecting the opinion of her treating physician in 

favor of opinions rendered by non-examining physicians. Id. at 19-26. The weight given to 

medical opinions depends in part on whether they are proffered by treating, examining, or nonexamining professionals. Lester v. Chater, 81 F.3d 821, 834 (9th Cir. 1996). 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, 1295 (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 

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

However, “[w]hen an examining physician relies on the same clinical findings as a treating 

physician, but differs only in his or her conclusions, the conclusions of the examining physician 

are not ‘substantial evidence.’” Orn v. Astrue, 495 F.3d 625, 632 (9th Cir. 2007). 

 The treating opinion discounted by the ALJ is that of Dr. Hajra Tily. Dr. Tily began 

treating plaintiff for rheumatoid arthritis in August 2009. AR 390-396, 640. In September 2011, 

Dr. Tily opined that plaintiff could sit, stand, and walk for less than 2 hours in an 8-hour 

workday; would need to lie down and elevate her legs for 20-30 minutes 2 to 3 times in an 8-hour 

workday; and would have problems using her hands. Id. at 640-641. She further opined plaintiff 

could lift less than 5 pounds; only spend 10 percent of an 8-hour workday reaching, handling, 

pushing/pulling, grasping; could only reach or handle for 15-20 minutes at a time, push/pull for 

15 minutes at a time, grasp for 20-30 minutes at a time; and would have trouble with 

concentration, memory, and coping with stress. Id. 

 Dr. Tily provided a second opinion in March 2013. Id. at 955-956. This time she opined 

plaintiff could lift less than 10 pounds frequently and 5 pounds occasionally; sit, stand and walk 

for less than 1 hour in an 8-hour workday; use her hands for reaching, handling, feeling, 

pushing/pulling, and grasping for less than 30 minutes at one time for a total of less than 20 

percent of a workday. Id. She further opined that plaintiff would need to elevate her legs during 

the workday and that stress would make plaintiff’s pain worse. Id. at 955. 

 The record also contains an opinion from Dr. R. Fast, M.D., a non-examining physician. 

Id. at 96-97. Dr. Fast opined that plaintiff could lift or carry 10 pounds frequently and 

occasionally; stand or walk for 2 hours in an 8-hour workday; sit for about 6 hours in an 8-hour 

workday; occasionally climb ramps and stairs; never climb ladders, ropes, or scaffolds; frequently 

balance; and occasionally stoop, kneel, crouch, and crawl. Id. at 96-97. 

 Dr. C. De La Rosa, M.D., also a non-examining physician, opined that plaintiff could lift 

or carry 20 pounds occasionally and 10 pounds frequently; stand and/or walk for about 6 hours in 

an 8-hour workday; sit for 6 hours in an 8-hour workday; occasionally climb ramps/stairs, but 

///// 

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never ladders, ropes, scaffolds; frequently balance; and occasionally stoop, kneel, crouch, or 

crawl. Id. at 85-86. 

 In assessing plaintiff’s Residual Functional Capacity (“RFC”), the ALJ gave “little 

weight” to Dr. Tily’s opinions, “great weight” to Dr. Fast’s opinion and “partial weight” to Dr. 

De La Rosa’s opinion. Id. at 30-31. As Dr. Tily’s opinion was contradicted by Drs. Fast and De 

La Rosa’s opinions, the ALJ was required to give “specific and legitimate” reasons for rejecting 

her treating opinion. See Orn, 495 F.3d at 632. The ALJ provided several reasons for rejecting 

Dr. Tily’s opinion. However, as discussed below, none of the reasons satisfy the specific and 

legitimate standard. 

 First, the ALJ found that Dr. Tily’s opinion was inconsistent with her own treatment and 

the evidence in the record as a whole. AR 31. An ALJ may reject a treating physician’s opinion 

that is inconsistent with other medical evidence, including the physician’s own treatment notes. 

Tommasetti v. Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008). The ALJ concluded that contrary to 

Dr. Tily’s opinion, the medical records indicated that plaintiff’s symptoms were stable overall and 

that she reported and demonstrated improvement. AR 31. In reaching this finding, the ALJ relied 

on a November 2012 treatment record that “noted that [plaintiff’s] rheumatoid arthritis was mild 

to minimally active and she was stable on medication.” Id. (citing AR at 919). 

 The ALJ’s finding is not supported by the record. Nothing in the November 2012 

treatment note is inconsistent with Dr. Tily’s opinion or demonstrates that plaintiff experienced 

improvement in her symptoms. Although the treatment note provides that plaintiff’s rheumatoid 

arthritis was “overall stable” on a medication regiment, Dr. Tily did not indicate any 

improvement in plaintiff’s condition. See AR 919. The mere fact that there was no change in the 

severity of plaintiff’s arthritis does not demonstrate improvement in her condition or an absence 

of severe limitations. 

 Furthermore, the ALJ’s reliance on the treatment note’s reference to plaintiff arthritis as 

“mild to minimally active” is misplaced. Dr. Tily did not find that plaintiff’s arthritis caused only 

mild to minimal limitations. Instead, Dr. Tily noted that when plaintiff was examined in July 

2012, her arthritis was “mild to minimally active,” which necessitated an increase in one of her 

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medications. Id. at 918 (emphasis added). The same treatment notes also indicated that 

plaintiff’s symptoms were “quite worse,” she experienced stiffness in the morning, and reported 

having good days and bad days. Id. at 918-919. Simply put, the November 2012 treatment note 

is not inconsistent with Dr. Tily’s opinion, it supports it. Furthermore, the ALJ fails to cite to any 

other evidence that he believed was contrary to Dr. Tily’s opinion. Accordingly, this first reason 

was not a proper basis for Dr. Tily’s treating opinion. 

 The ALJ also concluded that plaintiff’s “improvement is evidence by her ability to engage 

in multiple activities on a regular basis.” AR 31. The ALJ, however, fails to identify any 

activities that demonstrated an improvement in plaintiff’s condition or otherwise undermined Dr. 

Tily’s opinion. Rather, he provides only his conclusion that plaintiff’s ability to perform 

unspecified activities demonstrates improvement in her symptoms. The ALJ’s conclusion, 

without discussion of any particular activities does not constitutes a legitimate reasons for 

rejecting Dr. Tily’s opinion. See Burrell v. Colvin 775 F.3d 1133, 1138 (9th Cir. 2014) (ALJ 

impermissibly rejected plaintiff’s testimony based on daily activities where ALJ failed to 

elaborate which daily activities conflicted with the plaintiff’s testimony). 

Next, the ALJ found that “the evidence in the record does not establish that [plaintiff] 

sought out or was referred to additional treatment or specialist evaluations.” AR 31. The ALJ’s 

reliance on this reason is perplexing. Dr. Tily is a rheumatologist treating plaintiff’s rheumatoid 

arthritis. Id. at 390-396. She is the appropriate specialist for treating plaintiff’s condition. 

Moreover, the ALJ does not identify what type of referral he believed would have been 

appropriate given plaintiff’s impairments. The ALJ also fails to identify what additional 

treatment should have been prescribed by the treating rheumatologist for plaintiff arthritis. 

Accordingly, this reason falls vastly short of the specific and legitimate standard. 

 Lastly, the ALJ rejected Dr. Tily’s opinions because she did not include a detailed 

discussion of what evidence formed the basis for her opinions and that it appeared the opinions 

relied heavily on plaintiff’s subjective complaints. Id. at 31. The opinion of a treating physician 

may be rejected where it is premised primarily on plaintiff’s subjective complaints and the ALJ 

properly discounted plaintiff’s credibility. Tonapetyan v. Halter, 242 F.3d 1144, 1149 (9th Cir. 

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2001). However, “an ALJ does not provide clear and convincing reasons for rejecting [a] 

physician’s opinion by questioning the credibility of the [plaintiff’s] complaints where the doctor 

does not discredit those complaints and supports his ultimate opinion with his own observations.” 

Ryan v. Comm’r of Soc. Sec. Admin, 528 F.3d 1194, 1200-01 (9th Cir. 2008). 

 There can be no dispute that Dr. Tily relied, at least to some degree, on plaintiff’s subject 

complaints, which are documented in the record. See generally AR 264-453, 568-601, 809-817, 

914-926. However, her treatment notes are replete with objective findings supporting her 

opinion. For example, an examination from June 2010 showed soft tissue swelling, stiffness in 

joints, and tenderness in plaintiff’s upper extremities. Id. at 329-330. Plaintiff was unable to 

make a fist and also had tenderness in her lower extremities, limited range of motion with pain in 

her knees, and a prominent muscle spasm around the lower spine. Id. at 330. Treatment notes 

from February 2011, reflect a limited range of motion in plaintiff’s shoulders, with pain on 

movement. Id. at 284. She also had wrist pain with movement; a positive Tinnel test; swelling 

and tenderness in her hands; and decreased range of motion, tenderness, and pain with movement 

in her knees. Id. at 285. 

 May 2011 treatment records reflect tenderness in plaintiff’s hands, wrists, and elbow, and 

difficulty making a fist. Id. at 275. She had soft tissue swelling over her wrist and elbow, and 

pain with range of motion at the wrist, elbow, and shoulder. Id. In July 2011, Dr. Tily found 

tenderness in plaintiff’s hands, some tenderness in her lower extremities, and positive findings at 

all fibromyalgia tender points. Id. at 264. The entire record contains similar objective findings 

from Dr. Tily. See generally id. 264-453, 568-601, 809-817, 914-926. 

 Thus, the ALJ’s conclusion that Dr. Tily failed to support her opinions with objective 

medical findings, and instead relied heavily on plaintiff’s subjective complaints, simply misstates 

the record. 

 Accordingly, the ALJ failed to provide legally sufficient reasons for rejecting Dr. Tily’s 

opinion. 

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 B. Remand for Further Proceedings 

 “A district court may reverse the decision of the Commissioner of Social Security, with or 

without remanding the cause for a rehearing, but the proper course, except in rare circumstances, 

is to remand to the agency for additional investigation or explanation.” Dominguez v. Colvin, 808 

F.3d 406, 407 (9th Cir. 2015) (internal quotes and citations omitted). “Unless the district court 

concludes that further administrative proceedings would serve no useful purpose, it may not 

remand with a direction to provide benefits.” Id. 

 Here, the court finds that further consideration of the medical evidence is necessary for 

determination of whether plaintiff is disabled under the Social Security Act. Accordingly, 

remand for further proceedings is appropriate.2

 

IV. CONCLUSION 

 Therefore, IT IS ORDERED that: 

 1. Plaintiff’s motion for summary judgment is granted; 

 2. The Commissioner’s cross-motion for summary judgment is denied; 

3. The matter is remanded for further consideration consistent with this order; 

 4. The Clerk is directed to enter judgment in plaintiff’s favor. 

DATED: March 30, 2016. 

 2

 As the matter must be remanded for further consideration of the medical evidence, the 

court declines to address plaintiff’s remaining argument. 

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