Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_14-cv-01548/USCOURTS-caed-1_14-cv-01548-4/pdf.json

Parties Involved:
Commissioner of Social Security
Defendant
Margaret Martinez
Plaintiff

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UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

Plaintiff Margaret Martinez, by her attorney, seeks judicial review of a final decision of the 

Commissioner of Social Security (“Commissioner”) denying her application for disability 

insurance and supplemental insurance benefits pursuant to Titles II and XVI of the Social Security 

Act (42 U.S.C. § 301 et seq.) (the “Act”). The matter is currently before the Court on the parties’ 

cross-briefs, which were submitted, without oral argument, to the Honorable Sandra M. Snyder, 

United States Magistrate Judge. Following a review of the complete record and applicable law, 

this Court finds the decision of the Administrative Law Judge (“ALJ”) to be supported by 

substantial evidence in the record as a whole and based on proper legal standards.

I. Background

A. Procedural History

In February 2011, Plaintiff filed applications for disability insurance benefits and 

supplemental security income, alleging an onset of disability date of January 1, 2008. The 

Commissioner initially denied the claims on August 15, 2011, and upon reconsideration again 

denied the claims on February 15, 2012. On February 22, 2012, Plaintiff filed a timely request for 

MARGARET MARTINEZ,

Plaintiff,

v.

CAROLYN W. COLVIN, Acting 

Commissioner of Social Security,

Defendant.

CASE NO. 1:14-CV-1548-SMS 

ORDER AFFIRMING AGENCY’S 

DENIAL OF BENEFITS AND ORDERING 

JUDGMENT FOR COMMISSIONER

(Doc. 21)

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a hearing.

On December 19, 2012, and represented by counsel, Plaintiff appeared and testified at a 

hearing presided over by John Cusker, Administrative Law Judge (“the ALJ”). See 20 C.F.R. 

404.929 et seq. An impartial vocational expert, Thomas C. Dachelet (“the VE”), also appeared 

and testified. 

On March 11, 2013, the ALJ denied Plaintiff’s application. The Appeals Council denied 

review on July 29, 2014. The ALJ’s decision thus became the Commissioner’s final decision. See 

42 U.S.C. § 405(h). On October 2, 2014, Plaintiff filed a complaint seeking this Court’s review 

pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3).

B. Plaintiff’s Testimony

At the administrative hearing, Plaintiff was fifty-three years old. She was unable to drive, 

and her daughter-in-law had brought her to the hearing. Plaintiff was a high school graduate. She 

had last worked for several years as an in-home care provider to a relative. She had also worked as 

a field worker, but did not recall when. She remembered working “a lot of places” but did not 

remember what type of work or when it was performed. 

Plaintiff testified that she had last worked in 2008 and could no longer work due to side 

effects from her several medications. She testified that she had neck, back, and arm pain, and 

depression. In 2009, Plaintiff had lost her house and was in the process of applying for social 

security and disability insurance benefits. She left her children and went to a park. She drank what 

she thought was soda, went home and took “a bunch of my medications.” Her daughter called an 

ambulance. She stated that she did not trust anyone nor did she go out after that. 

At the time of the hearing, Plaintiff was taking four types of narcotics for back pain. She 

testified that they did not relieve her pain symptoms all the time and that she had side effects such 

as blurred speech, poor memory, and sleepiness. The day of the hearing, she took four morphine 

doses in order to be able to sit through the hearing. The medication reduced her pain enough to 

allow her to sit there. Plaintiff testified that her back had “on and off constant” pain, and was 

aggravated by being bumped. Lying down was the most comfortable position for her back, and she 

lied down for about four hours, on and off, depending on the day. 

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Plaintiff also testified that she had neck pain. Sometimes she would move the wrong way, 

twitch a nerve, and feel that she wanted to cut off her neck. Plaintiff tried to limit her head 

movement. Plaintiff had suffered more than one fall. Once, she hit her head and needed stiches. 

Plaintiff had headaches that came and went. Medication would alleviate a headache for half an 

hour. 

Plaintiff testified that she had trouble focusing on things. She did not know what PTSD 

was. Regarding depression, she testified that she constantly wanted to be left alone and sometimes 

did not care about life. She was receiving mental health treatment at Reedley Turning Point. She 

would go there and talk about how she felt and what was going on with her. Plaintiff had 

flashbacks to being raped. 

Plaintiff testified that she was married but she did not know if her spouse was employed. 

She testified that he visited her home in Reedley about once a month. The ALJ pointed out that a 

hospital record noted that her husband had returned from a business trip and found Plaintiff at 

home barely responsive. The ALJ also pointed out that Plaintiff had testified in a prior 

administrative hearing that she did not know where her husband lived. Plaintiff testified that he 

lived nearby in Reedley, but she did not know specifically where. 

Plaintiff lived with her two younger children, aged seventeen and fourteen. Her twenty-one 

year-old son also stayed with her sometimes. Her oldest son and his wife would check on her. The 

younger children went to school, leaving her home alone. Plaintiff was able to dress and bathe 

herself, but she would not bathe herself unless someone else was at home. She did not prepare 

meals. When someone else was around, she could go shopping or do some housework such as 

wash dishes. She needed someone else to be there to make sure she didn’t fall or hurt herself. She 

did not have any hobbies. She spent her time resting or talking with her children. She napped four 

to five times a day, each nap ranging from about twenty minutes to three hours. Plaintiff had 

difficulty sleeping because of pain. 

C. Relevant Medical Record

Physical Impairments 

In May 2007, Plaintiff’s MRIs indicated chronic neck pain and chronic low back pain. AR 

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566-567. The MRIs revealed slight scoliosis, degenerative disc disease at facet arthropathy, disc 

space narrowing, and disc bulging. In July 2008, Plaintiff’s MRIs indicated cervical osteophytosis 

and spinal stenosis and revealed similar findings. AR 441-442. In June 2011, Plaintiff’s MRIs 

indicated low back pain and similar findings. AR 449. In June 2011, the radiologist suspected mild 

lower lumbar degenerative disc disease and facet athropathy. 

During 2008-2011, the Plaintiff attended regular appointments at Sierra Kings Family 

Health Center, primarily for monthly refills of her medication. Plaintiff complained of 

hypertension, hyperlipidemia, asthma, and lower back pain. In November 2008, these conditions 

were stable. AR 425. 

In June 2011, consultative examiner Roger Wagner, M.D., performed a comprehensive 

internal medicine evaluation. AR 450-455. He noted Plaintiff’s complaints of low back pain and 

her assertion that she could only walk for two blocks and sit for two hours. He noted that she was 

sitting comfortably on the tailgate of a vehicle for about half an hour prior to the exam in the early 

morning. He noted her vague complaints of weakness in her legs and numbness in hands. He 

noted that she does light cooking and cleaning, shops, performs her own activities of daily living, 

and walks for exercise. He noted her fifteen different medications. Dr. Wagner also noted that 

Plaintiff did not have problems maneuvering during the examination. She was easily able to get up 

and walk to the examination room without assistance, sit comfortably, get on and off the 

examination table, and bend over to take her shoes and socks off and on. Dr. Wagner noted that 

she had a normal gait and did not need an assistive device. Dr. Wagner diagnosed Plaintiff with 

“some low back pain,” likely due to degenerative disc disease, arthritic pain, and muscular strain, 

with a reasonable walking tolerance of two blocks and the ability to sit for up to two hours. He 

also diagnosed her with neck pain due to degenerative joint disease. Plaintiff had a full range of 

motion in the shoulders and fairly good range of motion of the neck. Dr. Wagner noted that 

Plaintiff’s asthma appeared stable. Based on his examination findings, Dr. Wagner opined that 

Plaintiff could stand and walk up to six hours, sit without limitations, lift twenty pounds 

occasionally and ten pounds frequently, could not repeatedly lift above shoulder level, and should 

not work around chemicals, dust, fumes, or gasses. 

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In July 2011, M. Nawar, M.D., provided a case analysis which discussed Plaintiff’s 

physical complaints and depression. AR 480-482. He also completed a physical residual 

functional capacity assessment. AR 475-479. Dr. Nawar diagnosed Plaintiff with degenerative 

disc disease and asthma. Dr. Nawar opined that Plaintiff could lift and carry twenty pounds 

occasionally and ten pounds frequently, stand and walk about six hours and sit about six hours in 

an eight-hour workday. He opined that Plaintiff had unlimited push/pull capacity. He opined that 

Plaintiff could frequently perform all postural requirements except only occasionally climb 

ladders, ropes, or scaffolds. He assessed no manipulative or visual limitations. He found that 

Plaintiff should avoid concentrated exposure to fumes, odors, etc. due to asthma. In February 

2012, Karl Boatman, M.D., reviewed the medical evidence and affirmed Dr. Nawar’s assessment. 

AR 527.

In September 2011, Plaintiff’s primary care physician Dr. Antonio Villalvazo, M.D., 

completed a questionnaire, in which he noted that her medical problems would preclude her from 

performing any full-time work at any exertional level. AR 509-510. He noted that she had lower 

and upper back pain based on instability walking and difficulty moving. Dr. Villalvazo estimated 

that Plaintiff could sit for one or two hours and stand for thirty minutes in an eight-hour workday.

In about October 2011 to November 2012, Plaintiff began receiving primary care at 

Reedley Wellness Center with Jacob Peters, M.D. Dr. Peters also noted her injury in 1988. 

Plaintiff presented with neck pain, arthritis, hypothyroidism, hypertension, hyperlipidemia, 

gastritis, anxiety, and pulmonary disease related to smoking. He recommended daily vigorous 

exercise. AR 542-548. Her progress notes usually only indicated that she was refilling her 

medication. See AR 549-562. 

Mental Impairments

Plaintiff complained of depression to her primary care physician as early as October 2008. 

AR 426. Plaintiff’s medical notes began to indicate depression regularly around September 2010. 

AR 399. She first requested to see a psychiatrist in March 2011. AR 392. The notes do not 

mention a prescription for any mental health medications prior to July 2011. 

In June 2011, social worker Veronica De Alba, L.C.S.W, completed a mental health 

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assessment. AR 459-465. She noted moderate to severe problems in most domains, including 

depression, traumatic stress, relationships, work, anxiety, thought process, and cognitive process. 

Ms. De Alba noted no problems with behavior at home and in the socio-legal domain. She also 

noted that Plaintiff’s primary care physician, Dr. Villalvazo prescribed Paxil a year prior. 

In July 2011, Plaintiff was evaluated by psychiatrist Norberto Tuason, M.D., at Turning 

Point of Central California. AR 457-458. He noted that Plaintiff said that her son recommended 

that she seek psychiatric help because of worsening depression. Dr. Tuason noted that Plaintiff 

was separated from her siblings since age seven, which triggered her depression. Plaintiff lived 

with her grandmother and her siblings went to foster homes. Plaintiff was sexually abused at that 

age. She felt paranoid and heard voices but could not remember the onset. Plaintiff started to use 

alcohol at age twenty-one, but stopped several years ago. Plaintiff suffered a fall twenty-two years 

prior and had been unable to work since then due to recurrent neck and lower back pain. Dr. 

Tuason diagnosed Plaintiff with major depression recurrent severe with psychotic features, and 

alcohol abuse by history. He recommended Zoloft, Risperdal, and Benadryl. 

In July 2011, clinical psychologist Steven Swanson, PhD, performed a psychological 

assessment on behalf of DSS. AR 467-473. Plaintiff told Dr. Swanson that she was raised by her 

father and stepmother. She was a slow learner, but graduated from high school. She began doing 

farm labor with her father at a young age. She had been married twice and had four children. She 

historically consumed alcohol heavily, but did not drink heavily in recent years. She was a longtime smoker. She injured her back in 1988. Dr. Swanson noted that Plaintiff was adequately 

oriented, friendly, and cooperative with normal eye-contact. Nothing atypical was observed in her 

gait, posture, or motor movement. Her mood was mostly euthymic. Her thought content was 

normal. There was no evidence of delusion, perception disorder, or psychosis. Short-term, recent, 

and remote memories were normal. She had adequate abstraction ability, concentration, and 

judgment. Dr. Swanson performed an adult intelligence test. He diagnosed Plaintiff with alcohol 

abuse in partial remission and borderline intellectual functioning. Dr. Swanson opined that 

Plaintiff was able to maintain concentration and related appropriately to others in a job setting. She 

could handle funds, understand and carry out simple instructions, and respond to work situations 

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such as attendance and safety. He noted that changes in routine would not be excessively 

problematic for her and there were no substantial restrictions in daily functioning or maintaining 

social relationships. 

In August 2011, Anna Franco, PsyD., completed a mental residual functional capacity 

assessment. AR 484-486. She found that Plaintiff was moderately limited in the ability to 

understand, remember, and carry out detailed instructions. Otherwise, she found that Plaintiff was 

not significantly limited in any areas of understanding and memory, sustained concentration and 

persistence, social interaction, or adaptation. Dr. Franco noted that Plaintiff had mild limitation in 

activities of daily living, and moderate difficulties in maintaining concentration, persistence, and 

pace. AR 498. She opined that Plaintiff was capable of simple, repetitive work, could sustain 

concentration, persistence, and pace, and could engage in appropriate social interactions and adapt 

accordingly. In February 2012, Cynthia Kampschaefer, PsyD., reviewed the medical evidence and 

affirmed Dr. Franco’s assessment. AR 526. 

Plaintiff began attending monthly appointments with Dr. Tuason at Turning Point. In 

August 2011, Dr. Tuason noted that Plaintiff’s sleep and appetite were within normal limits, her 

behavior and sensorium were within normal limits, but her appearance was disheveled, her speech 

was slow, and her affect was flat, and there was no assessment of suicide risk. AR 515. In October 

2011, Dr. Tuason noted that Plaintiff felt better with her medications, her sleep and appetite were 

within normal limits, her behavior, speech, and sensorium were within normal limits, but her 

appearance was disheveled and her affect was flat, and there was no assessment of suicide risk. 

AR 514. In September 2011, Dr. Tuason noted that Plaintiff said she was doing well and had 

partially improved, her sleep, appetite, and mood were within normal limits, her appearance, 

behavior, speech, sensorium, and affect were within normal limits, and there was no assessment of 

suicide risk. AR 539. In November 2011, Dr. Tuason noted that Plaintiff had partially improved, 

her sleep and appetite were within normal limits, her appearance, behavior, speech, sensorium, and 

affect were within normal limits, and there was no assessment of suicide risk. AR 513. In January 

2012, Dr. Tuason noted chronic pain due to cervical disc problem, which was more likely keeping 

her depressed with insomnia. AR 538. 

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In September 2011, Dr. Tuason provided a psychiatric medical source statement. AR 504-

508. He found that she had extreme (almost constant impact on work or total limitation) 

limitations in almost all of her social abilities, including her ability to interact with supervisors and 

coworkers, and her ability to understand and carry out simple one-or-two step job instructions. He 

noted that she had depressive syndrome characterized by every possible characteristic, including 

sleep and appetite disturbance, difficulty concentrating, and thoughts of suicide. He also noted 

anxiety with motor tension. 

In May 2012, Robert Ensom, M.D. had become Plaintiff’s treating psychiatrist and noted 

that Plaintiff’s sleep and appetite were impaired due to pain, but her behavior, speech, sensorium, 

and affect were within normal limits. AR 537. 

In November 2012, Plaintiff’s primary care physician Dr. Peters completed a psychiatric 

medical source statement. AR 598. He noted that she had a moderate ability to perform most work 

functions, except that she had an extreme limitation in her ability to withstand stress and pressure 

associated with an eight-hour workday. Dr. Peters noted that she had severe neck and back pain

since 1988, which was disabling. He opined that she was unable to work. 

In December 2012, Dr. Ensom completed a mental disorder questionnaire, indicating that 

Plaintiff’s mental health affected her ability to manage basic daily activities and impaired her 

ability to socialize in a culturally acceptable manner. AR 600-602. He noted that she had 

significant impairments in memory, concentration, and judgment, but no impairment in 

intelligence. Dr. Ensom noted that Plaintiff was unable to care for herself without family 

assistance. Dr. Ensom noted that his first examination of Plaintiff was July 2011, and the last was 

May 2012, with appointments every three months. His next appointment was scheduled for later in 

December 2012. 

D. Vocational Expert Testimony

At the administrative hearing, the VE classified Plaintiff’s past work as home health aide

(DOT # 354.377-014, medium (performed at heavy), SVP 3), field work with fruit (DOT # 

403.687-010, medium, SVP 2), production sorter (DOT # 529.687-186, light, SVP 2), and 

production packer (DOT # 920.587-018, medium, SVP 2). The ALJ asked the VE to assume a 

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hypothetical person of Plaintiff’s same age, education, and work experience who could stand and 

walk up to six hours, could sit without limitation with normal breaks, did not need an assistive 

device, could lift and carry up to twenty pounds occasionally and ten pounds frequently, must 

avoid lifting above the shoulder, and should not work around chemicals, dusts, fumes, or gases.

The VE opined that such person could not perform any of Plaintiff’s past jobs, but could perform 

at the light and unskilled level, without overhead lifting. 

The ALJ then directed the VE to assume a second hypothetical person with the same 

limitations as the first hypothetical person and was capable of simple, repetitive work; could 

sustain concentration, persistence and pace; could engage in appropriate social interactions and 

adapt accordingly. The VE opined that this hypothetical person could perform work in several 

jobs and gave some representative titles. The VE testified that the second hypothetical person 

could perform work as a packing line worker (DOT # 753.687-038), garment sorter (DOT # 

222.687-014, and ampoule filler (DOT # 559.685-018. The VE testified that these jobs existed in

significant numbers in the California and national economy. 

For the third hypothetical, the ALJ directed the VE to assume a person who was able to lift 

and carry twenty pounds occasionally and ten pounds frequently; stand and/or walk with normal 

breaks for about six hours and sit with normal breaks for about six hours in an eight-hour 

workday; push and pull without limitation; occasionally climb ladders, ropes, and scaffolds; and 

should avoid concentrated exposure to fumes, odors, dusts, gases, poor ventilation, etc. This 

hypothetical person had no manipulative, visual, or communicative limitations. The VE opined 

that this hypothetical individual could perform the jobs identified in response to the second 

hypothetical. 

For the fourth hypothetical, the ALJ directed the VE to assume the same physical 

limitations as the third hypothetical person, but also is expected to understand, carry out, and 

remember simple instructions; is able to respond appropriately to usual work situations including 

matters such as attendance and safety; and could handle changes in routine. The VE opined that 

this hypothetical individual could also perform the jobs identified in response to the second 

hypothetical.

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E. Disability Determination

After considering the evidence, the ALJ found that Plaintiff met the insured status 

requirements through December 31, 2011. The ALJ found that Plaintiff had not engaged in 

substantial gainful activity since August 6, 2009, the day following the prior administrative 

decision. The ALJ found that Plaintiff had the following severe, medically determinable 

impairments: degenerative disc disease of the cervical spine and lumbar spine; opioid abuse and/or 

dependence, and borderline intellectual functioning. The ALJ found that Plaintiff’s hypertension, 

headaches, and vision problems were non-severe. The ALJ found that Plaintiff did not have an 

impairment or combination of impairments that met or medically equaled the severity of one of 

the listed impairments in 20 C.F.R Part 404, Subpart P, Appendix 1. He found that Plaintiff had 

the residual functional capacity (“RFC”) to lift and carry twenty pounds occasionally and ten 

pounds frequently; stand and/or walk for six hours and sit for six hours in an eight-hour workday; 

push and pull without limitation; occasionally climb ladders, ropes, and scaffolds; frequently 

climb ramps and stairs; frequently balance, stoop, kneel, crouch, and crawl; and should avoid 

fumes, odors, dusts, gases, poor ventilation, etc. The ALJ found that Plaintiff could understand, 

carry out, and remember simple instructions, and had the ability to respond appropriately to usual 

work situations including attendance and safety. The ALJ found that changes in routine would not 

be excessively problematic for her. The ALJ found that Plaintiff was unable to perform any of her

past relevant work. However, the ALJ found that Plaintiff could perform jobs that existed in 

significant numbers in the national economy. Hence, he determined that Plaintiff was not disabled. 

II. Legal Standard

A. The Five-Step Sequential Analysis

An individual is considered disabled for purposes of disability benefits if she is unable to 

engage in any substantial, gainful activity by reason of any medically determinable physical or 

mental impairment that can be expected to result in death or that has lasted, or can be expected to 

last, for a continuous period of not less than twelve months. 42 U.S.C. §§ 423(d)(1)(A), 1382c(a) 

(3)(A); see also Barnhart v. Thomas, 540 U.S. 20, 23 (2003). The impairment(s) must result from 

anatomical, physiological, or psychological abnormalities that are demonstrable by medically 

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accepted clinical and laboratory diagnostic techniques and must be of such severity that the 

claimant is not only unable to do her previous work but cannot, considering her age, education, 

and work experience, engage in any other kind of substantial, gainful work that exists in the 

national economy. 42 U.S.C. §§ 423(d)(2)-(3), 1382c(a)(3)(B), (D). 

To encourage uniformity in decision making, the Commissioner has promulgated 

regulations prescribing a five-step sequential process for evaluating an alleged disability. 20 

C.F.R. §§ 404.1520 (a)-(f); 416.920 (a)-(f). In the five-step sequential review process, the burden 

of proof is on the claimant at steps one through four, but shifts to the Commissioner at step five. 

See Tackett v. Apfel, 180 F.3d 1094, 1099 (9th Cir. 1999). If a claimant is found to be disabled or 

not disabled at any step in the sequence, there is no need to consider subsequent steps. Id. at 

1098–99; 20 C.F.R. §§ 404.1520, 416.920.

In the first step of the analysis, the ALJ must determine whether the claimant is currently 

engaged in substantial gainful activity. 20 C.F.R. §§ 404.1520(b), 416.920(b). If not, in the 

second step, the ALJ must determine whether the claimant has a severe impairment or a 

combination of impairments significantly limiting her from performing basic work activities. Id. 

§§ 404.1520(c), 416.920(c). If so, in the third step, the ALJ must determine whether the claimant 

has a severe impairment or combination of impairments that meets or equals the requirements of 

the Listing of Impairments, 20 C.F.R. 404, Subpart P, App. 1. Id. §§ 404.1520(d), 416.920(d). If 

not, in the fourth step, the ALJ must determine whether the claimant has sufficient RFC, despite 

the impairment or various limitations to perform his past work. Id. §§ 404.1520(f), 416.920(f). If 

not, in step five, the burden shifts to the Commissioner to show that the claimant can perform 

other work that exists in significant numbers in the national economy. Id. §§ 404.1520(g), 

416.920(g).

B. Standard of Review

Congress has provided a limited scope of judicial review of the Commissioner’s decision 

to deny benefits under the Act. The record as a whole must be considered, weighing both the 

evidence that supports and the evidence that detracts from the Commissioner’s decision. 

Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007) (citation and internal quotation marks 

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omitted). In weighing the evidence and making findings, the Commissioner must apply the proper 

legal standards. See, e.g., Burkhart v. Bowen, 856 F.2d 1335, 1338 (9th Cir. 1988). If an ALJ 

applied the proper legal standards and the ALJ’s findings are supported by substantial evidence, 

this Court must uphold the ALJ’s determination that the claimant is not disabled. See, e.g., Ukolov 

v. Barnhart, 420 F.3d 1002, 104 (9th Cir. 2005); see also 42 U.S.C. § 405(g). Substantial 

evidence means “more than a mere scintilla but less than a preponderance.” Ryan v. Comm’r of 

Soc. Sec., 528 F.3d 1194, 1998 (9th Cir. 2008). It is “such relevant evidence as a reasonable mind 

might accept as adequate to support a conclusion.” Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 

2005). Where the evidence as a whole can support either outcome, the Court may not substitute its 

judgment for the ALJ’s, rather, the ALJ’s conclusion must be upheld. Id. 

III. Discussion

In this appeal, Plaintiff argues that the ALJ erred in failing to consider all medically 

determinable mental impairments at step-two, discrediting her treating physicians’ opinions, 

discrediting Plaintiff’s credibility, and discrediting laywitness testimony. 

A. Step-Two Severe Impairments

Plaintiff argues in her motion and reply that the ALJ erred in failing to find Plaintiff’s 

major depression disorder and PTSD as severe impairments. Plaintiff argues that the failure to 

consider the severity of all of Plaintiff’s medically determinable mental impairments at step two

affected his findings at the subsequent steps of the sequential evaluation.

Applicable Law

Under the regulations, the procedure at step two is as follows:

At the second step, we consider the medical severity of your impairment(s). If you do not 

have a severe medically determinable physical or mental impairment that meets the 

duration requirement in § 404.1509, or a combination of impairments that is severe and 

meets the duration requirement, we will find that you are not disabled. ... If you do not 

have any impairment or combination of impairments which significantly limits your 

physical or mental ability to do basic work activities, we will find that you do not have a 

severe impairment and are, therefore, not disabled.

20 C.F.R. §§ 404.1520(a)(4)(ii), 404.1520(c).

Thus, at step two, a claimant can only be prejudiced by a finding that he has no severe 

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impairments at all; otherwise, he advances to the next steps. The later steps do not make use of the 

step-two finding. Instead, the ALJ must consider all of Plaintiff's limitations, again and in even 

greater depth. See Taylor v. Comm'r of Soc. Sec. Admin., 659 F.3d 1228, 1233 (9th Cir. 2011) (at

step three, ALJ must consider “the combined effect of [Plaintiff’s] limitations, both severe and 

non-severe,” to determine whether they meet or equal a listing); 20 CFR 404.1545(e) (“we will 

consider the limiting effects of all your impairment(s), even those that are not severe, in 

determining your residual functional capacity” for use at steps four and five). In other words, the 

impairments identified at step two are not intended to be a comprehensive survey. Step two is 

simply “a de minimis screening device to dispose of groundless claims.” Smolen v. Chater, 80 

F.3d 1273, 1290 (9th Cir.1996).

Analysis

Here, the ALJ found that Plaintiff’s severe impairments were degenerative disc disease, 

opioid abuse, and borderline intellectual functioning. Thus Plaintiff advanced to the next steps in 

the sequential analysis. The ALJ did not find that depression and PTSD were among Plaintiff’s 

severe impairments such that it significantly limited her ability to do basic work activities. 

However, Plaintiff is incorrect to assert that the ALJ did not consider her depression and PTSD. 

The ALJ discussed Plaintiff’s depression at various points in his written decision, including her 

RFC which was used at steps four and five. In arriving at Plaintiff’s RFC, the ALJ discussed all of 

Plaintiff’s mental health history including her diagnoses of major depressive disorder and PTSD. 

The ALJ discussed each of Plaintiff’s mental healthcare providers and their notes and opinions, 

including their discussions of her depression and the effects that her mental health impairments 

had on her ability to function in a work setting. The ALJ affirmatively considered Plaintiff’s 

diagnoses of depression and PTSD. He did not find those impairments to be severe at step two, 

such that they had significantly limited her ability to do basic work activities. However, the ALJ 

considered Plaintiff’s depression and other mental impairments in his RFC and found that she was 

able to understand and carry out simple instructions and was able to respond appropriately to usual

work settings. Hence, the ALJ did not err at step-two in failing to consider Plaintiff’s depression 

and PTSD as severe. 

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B. Weighing Medical Evidence

Plaintiff argues that the ALJ failed to give controlling deference to her treating 

psychiatrists Drs. Tuason and Ensom and her primary care physicians Drs. Villalvazo and Peters, 

and failed to give specific and legitimate reasons to reject their opinions. These medical sources 

found that Plaintiff’s capacity was much more limited than that found by the ALJ. 

1. Applicable Law

Physicians render two types of opinions in disability cases: (1) medical, clinical opinions 

regarding the nature of the claimant's impairments and (2) opinions on the claimant's ability to 

perform work. See Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998). An ALJ is “not bound by 

an expert medical opinion on the ultimate question of disability.” Tommasetti v. Astrue, 533 F.3d 

1035, 1041 (9th Cir. 2008); S.S.R. 96-5p, 1996 SSR LEXIS 2.

Three types of physicians may offer opinions in social security cases: “(1) those who 

treat[ed] the claimant (treating physicians); (2) those who examine[d] but d[id] not treat the 

claimant (examining physicians); and (3) those who neither examine[d] nor treat[ed] the claimant 

(nonexamining physicians).” Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1996). A treating 

physician’s opinion is generally entitled to more weight than the opinion of a doctor who 

examined but did not treat the claimant, and an examining physician's opinion is generally entitled 

to more weight than that of a non-examining physician. Id. The Social Security Administration 

favors the opinion of a treating physician over that of nontreating physicians. 20 C.F.R. § 

404.1527; Orn v. Astrue, 495 F.3d 625, 631 (9th Cir. 2007). A treating physician is employed to 

cure and has a greater opportunity to know and observe the patient. Sprague v. Bowen, 812 F.2d 

1226, 1230 (9th Cir. 1987). Nonetheless, a treating physician’s opinion is not conclusive as to 

either a physical condition or the ultimate issue of disability. Magallanes v. Bowen, 881 F.2d 747, 

751 (9th Cir. 1989).

Once a court has considered the source of a medical opinion, it considers whether the 

Commissioner properly rejected a medical opinion by assessing whether (1) contradictory 

opinions are in the record; and (2) clinical findings support the opinions. The ALJ may reject the 

uncontradicted opinion of a treating or examining medical physician only for clear and convincing 

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reasons supported by substantial evidence in the record. Lester, 81 F.3d at 831. The controverted 

opinion of a treating or examining physician can only be rejected for specific and legitimate 

reasons supported by substantial evidence in the record. Andrews v. Shalala, 53 F.3d 1035, 1043 

(9th Cir. 1995). “Although the contrary opinion of a non-examining medical expert does not alone 

constitute a specific, legitimate reason for rejecting a treating or examining physician’s opinion, it 

may constitute substantial evidence when it is consistent with other independent evidence in the 

record.” Tonapetyan v. Halter, 242 F.3d 1144, 1149 (9th Cir. 2001), citing Magallanes, 881 F.2d 

at 752. The ALJ must set forth a detailed and thorough factual summary, address conflicting 

clinical evidence, interpret the evidence and make a finding. Magallanes, 881 F.2d at 751-55. The 

ALJ need not give weight to a conclusory opinion supported by minimal clinical findings. Meanel 

v. Apfel, 172 F.3d 1111, 1113 (9th Cir. 1999); Magallanes, 881 F.2d at 751. The ALJ must tie the 

objective factors or the record as a whole to the opinions and findings that he or she rejects. 

Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir. 1988)

2. Plaintiff’s Treating Psychiatrists

As discussed above, Dr. Tuason opined that Plaintiff had extreme limitations in all areas of 

mental functioning. The ALJ gave Dr. Tuason’s opinion “no weight” because it was inconsistent 

with other medical evidence of record, including Dr. Tuason’s own treatment notes and Plaintiff’s 

presentation to Dr. Swanson. The ALJ specifically and correctly pointed to Dr. Tuason’s notes 

which, prior to offering his opinion, consistently indicated normal limits for sleep and appetite, 

which are in contrast to his opinion that her depression was characterized by sleep and appetite 

disturbance. Dr. Tuason also opined that her depressive syndrome was characterized by thoughts 

of suicide, even though he consistently indicated that there was no assessment of suicide risk. Dr. 

Tuason opined that Plaintiff had extreme limitations in her ability to interact with supervisors and 

carry out simple instructions. However, the examination with Dr. Swanson demonstrated that she 

had no problem interacting with Dr. Swanson, who noted that she was adequately oriented, 

friendly, and cooperative, and was able to carry out instructions such as removing her shoes and 

performing functional motor tests. 

Dr. Ensom opined that Plaintiff was unable to perform activities of daily living without 

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assistance, that her social functioning was deficient, and that she was unable to adapt to common 

work stressors. Dr. Ensom also noted that she was significantly impaired in memory, 

concentration, and judgment, but had no impairment in intelligence. Dr. Ensom appears to have 

treated Plaintiff once prior to completing his opinion. The ALJ gave Dr. Ensom’s opinion no 

weight because it was inconsistent with other medical findings, including findings for Drs. 

Swanson and Tuason, and inconsistent with the record, particularly with regard to daily activities. 

The ALJ correctly found that Dr. Ensom’s opinion was inconsistent with the record. Dr. Swanson 

found that Plaintiff had borderline intellectual functioning, and was capable of normal social 

interaction. Dr. Swanson performed tests which indicated that Plaintiff’s thought content, 

abstraction ability, concentration, judgment and memory were normal. The record also indicated 

that Plaintiff performed personal activities of daily living without assistance. 

In addition, Drs. Tuason and Ensom’s opinions were contradicted by Dr. Swanson’s and 

Dr. Franco’s opinions. The ALJ gave Dr. Swanson’s opinion great weight because his findings 

were consistent with his clinical findings and test results. The ALJ also gave Dr. Franco’s opinion 

great weight because it was substantially supported by and consistent with the evidence in the 

record. Drs. Swanson and Franco opined that Plaintiff was able to understand, remember, and 

carry out simple instructions, and could engage appropriate in work settings. These findings are 

supported by Plaintiff’s ability to interact with her doctors and examiners, her family and friends, 

and perform simple tasks at home and in the examination setting. Thus, the ALJ provided specific 

and legitimate reasons supported by substantial evidence in the record for discrediting Drs. Tuason 

and Ensom’s opinions. 

3. Plaintiff’s Treating Primary Care Physicians

Plaintiff’s primary care physician Dr. Villalvazo found that Plaintiff could not perform 

full-time work at any exertional level. The ALJ gave no weight to this opinion because it was 

inconsistent with the medical evidence of record and Dr. Wagner’s examination. The ALJ 

specifically points to the discrepancy between Dr. Villalvezo’s opinion based on Plaintiff’s 

instability walking and difficulty moving and Dr. Wagner’s observation that Plaintiff had no 

difficulty maneuvering during the examination. She was able to get up and down from a chair, 

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walk around the room without assistance, get on and off the examination table, bend over to 

remove her shoes, and sat comfortably. In addition, Dr. Swanson also noted that nothing atypical 

was observed in Plaintiff’s gait, posture, or motor movement. 

Dr. Peters also opined in a psychiatric medical source statement, that Plaintiff was unable 

to work. He opined that Plaintiff had severe neck and back pain, and that she had extreme 

limitations in her ability to withstand stress and pressure in a work setting. The ALJ gave Dr. 

Peter’s opinion no weight because it was not supported by the medical record or the other medical 

source opinions by better qualified mental health professionals. Dr. Peters was Plaintiff’s primary 

care physician, not a psychiatrist or mental health source. Dr. Peters’ notes mostly indicate that 

Plaintiff was refilling her medication. Regarding mental health, Dr. Peters only noted anxiety. 

Thus Dr. Peters’ opinion regarding Plaintiff’s mental health can properly be discredited. Further, 

Dr. Peters recommended daily vigorous exercise, which is inconsistent with a finding of disability 

due to pain. 

Further, Drs. Villalvazo and Peters’s opinions were contradicted by Drs. Wagner and 

Nawar. Dr. Nawar opined that Plaintiff could perform work according to that adopted by the ALJ. 

He opined that she could stand and walk for six hours and sit for six hours in a workday. She 

could do some lifting, posturing, and manipulating. She was to avoid concentrated exposure to 

irritants due to asthma. Dr. Wagner’s opinion was substantially similar, except he further limited 

Plaintiff’s overhead reaching. The ALJ gave Dr. Nawar’s opinion the most weight because it was 

supported by and consistent with the other medical evidence, including Dr. Wagner’s examination 

findings and treatment records. This finding is supported by the record. MRIs showed mild 

degenerative disc disease and other mild findings. The examination revealed full ranges of motion 

of the cervical and lumbar spine, no assistive device was needed to ambulate, and she had a 

normal gait. She also had a full range of shoulder motion and good range of neck motion. Plaintiff 

reported to Dr. Wagner that she could do light cooking, cleaning, shopping, and walking. She was 

able to sit comfortably in the examination and on the back of a vehicle for some time before the 

examination. Plaintiff reported no change or worsening of her condition. 

The ALJ properly found that Plaintiff’s primary care physicians’ opinions were not 

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supported by the record and that Dr. Nawar’s opinion was. Thus, the ALJ gave specific and 

legitimate reasons supported by substantial evidence in the record to discredit Drs. Villalvazo and 

Peters’ opinions.

4. The Combined Impact of Plaintiff’s Mental and Physical Impairments

Plaintiff argues that the ALJ erred in failing to consider the combined impact of Plaintiff’s 

mental and physical impairments. However, the ALJ’s opinion demonstrates that the ALJ did 

consider the combined effect of Plaintiff’s physical and mental impairments at various steps in his 

decision. The ALJ discussed several of Plaintiff’s medical sources that mentioned the relationship 

between Plaintiff’s physical and mental impairments, specifically, her pain and depression. 

5. Duty to Develop the Record

Plaintiff mentions in passing that the ALJ should have further developed the record. 

Plaintiff argues that the ALJ was required to contact Dr. Villalvazo to ask him the basis of his 

opinion prior to rejecting his opinion. Plaintiff also argues that Dr. Peter’s opinion assessing the 

combined effects of Plaintiff’s mental and physical impairments required the ALJ to further 

develop the record by obtaining an updated medical opinion because it was not reviewed by 

another medical expert. 

An “ALJ’s duty to develop the record farther is triggered only when there is ambiguous 

evidence or when the record is inadequate to allow for proper evaluation of the evidence.” Mayes 

v. Massanari, 276 F.3d 453, 459-60 (9th Cir. 2001); and see Tommasetti v. Astrue, 533 F.3d 1035, 

1041 (9th Cir. 2008)(“[T]he ALJ is the final arbiter with respect to resolving conflicts and 

ambiguities in the evidence.”). Here, the ALJ’s duty to develop the record was not triggered 

because there were no ambiguities and the record was not inadequate to allow for proper 

evaluation of the evidence. Plaintiff’s record included all of her physical and mental health 

treatment notes during the relevant time period and several straightforward opinions. 

C. Plaintiff’s Credibility

Plaintiff argues that the ALJ did not provide specific, clear, and convincing reasons to 

reject Plaintiff’s testimony. The ALJ found that Plaintiff’s medically determinable impairments 

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could reasonably be expected to cause some of the alleged symptoms, but Plaintiff’s statements 

concerning the intensity, persistence, and limiting effects of the symptoms were not credible to the 

extent that they were inconsistent with the ALJ’s RFC analysis. The ALJ discounted Plaintiff’s 

credibility determination based on inconsistent statements, inconsistency with the medical 

evidence, and her less than candid responses at the hearing.

Applicable Law

The Ninth Circuit established two requirements for a claimant to present credible symptom 

testimony: the claimant must produce objective medical evidence of an impairment or 

impairments, and she must show the impairment or combination of impairments could reasonably 

be expected to produce some degree of symptom. Cotton v. Bowen, 799 F.2d 1403, 1407 (9th Cir. 

1986). The claimant, however, need not produce objective medical evidence of the actual 

symptoms or their severity. Smolen v. Chater, 80 F.3d 1273, 1284 (9th Cir. 1996). Where an ALJ 

concludes that a claimant is not malingering, and that she has provided objective medical evidence 

of an underlying impairment which might reasonably produce the pain or other symptoms alleged, 

the ALJ may “reject the claimant’s testimony about the severity of her symptoms only by offering 

specific, clear and convincing reasons for doing so.” Lingenfelter v. Astrue, 504 F.3d 1028, 1036 

(9th Cir. 2007). 

The Commissioner may not discredit a claimant’s testimony on the severity of symptoms 

merely because it is unsupported by objective medical evidence. Reddick v. Chater, 157 F.3d 715, 

722 (9th Cir. 1998); Bunnell v. Sullivan, 947 F.2d 341, 345 (9th Cir. 1991). However, an ALJ is 

entitled to consider whether there is a lack of medical evidence to corroborate a claimant’s 

subjective symptom testimony so long as it is not the only reason for discounting her testimony. 

Burch v. Barnhart, 400 F.3d 676, 680-681 (9th Cir. 2005).

An ALJ is not “required to believe every allegation of disabling pain” or other nonexertional requirement. Orn v. Astrue, 495 F.3d 625, 635 (9th Cir. 2007), quoting Fair v. Bowen, 

885 F.2d 597, 603 (9th Cir. 1989). “[T]he ALJ must identify what testimony is not credible and 

what evidence undermines the claimant’s complaints.” Lester, 81 F.3d at 834, quoting Varney v. 

Secretary of Health and Human Services, 846 F.2d 581, 584 (9th Cir. 1988). He or she must set 

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forth specific reasons for rejecting the claim, explaining why the testimony is unpersuasive. Orn, 

495 F.3d at 635. See also Robbins v. Social Security Admin., 466 F.3d 880, 885 (9th Cir. 2006). 

Although the credibility analysis need not be extensive, the ALJ must provide some reasoning in 

order to meaningfully determine whether the ALJ’s conclusions were supported by substantial 

evidence. Brown-Hunter v. Colvin, 806 F.3d 487, 495 (9th Cir. 2015).

When weighing a claimant’s credibility, the ALJ may consider the claimant’s reputation 

for truthfulness, inconsistencies in claimant’s testimony or between his testimony and conduct, 

claimant’s daily activities, claimant’s work record, and testimony from physicians and third 

parties about the nature, severity and effect of claimant’s claimed symptoms. Light v. Social 

Security Administration, 119 F.3d 789, 792 (9th Cir. 1997). The ALJ may consider “(1) ordinary 

techniques of credibility evaluation, such as 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 v. Chater, 80 F.3d 1273 (9th Cir. 1996). If the 

ALJ’s finding is supported by substantial evidence, the Court may not second-guess his or her 

decision. Thomas, 278 F.3d at 959.

Analysis

Here, the record supports the ALJ’s finding that Plaintiff’s statements concerning the 

limiting effects of her symptoms were not entirely credible. Plaintiff’s testimony at the hearing 

was less than candid. She testified that she did not know where her husband lived, but then later 

testified that he lived nearby and that he visited about once a month. She also testified that she did 

not know if he was employed. 

Some of Plaintiff’s testimony is in conflict with the medical record. She testified that she 

never used illegal drugs, but she had amphetamines in her system in 2009. She testified that she 

had trouble sleeping, but also testified taking four to five naps a day. Treatment notes also 

indicate normal sleep. She testified that she suffered many side effects from her several pain 

medications, but those side effects are not mentioned in the treatment notes. Dr. Wagner’s 

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examination revealed little evidence of physical impairment and substantial mental soundness. 

This is inconsistent with Plaintiff’s complaints of severely disabling pain, confusion, anxiety, and 

depression. Plaintiff’s ability to interact with treating and examining physicians and her family 

also contradicts her claims that she cannot properly socialize. 

The ALJ also pointed to the prior ALJ’s decision, in which the prior ALJ found that 

Plaintiff was less than fully credible as a witness with exaggerated pain behavior and 

uncorroborated allegations of multiple falls. 

In sum, the ALJ found that Plaintiff’s subjective symptom testimony was not credible 

because of inconsistent statements, inconsistency with the medical evidence, and her less than 

candid responses at the hearing. Taken together, these reasons are sufficiently specific, clear, and 

convincing grounds which are supported by substantial evidence in the record to discount 

Plaintiff’s credibility.

D. Laywitness Testimony

Plaintiff argues that the ALJ erred in giving little weight to Plaintiff’s son’s statement 

regarding Plaintiff’s limitations. 

Lay witness testimony is competent evidence to which the ALJ, if he wishes to discount 

lay witness testimony, must give reasons germane to each witness. Stout v. Comm’r, Soc. Sec. 

Admin., 454 F.3d 1050 (9th Cir. 2006). The Ninth Circuit has held that inconsistency with medical 

evidence constitutes a legitimate reason for discrediting the testimony of lay witnesses. See 

Vincent v. Heckler, 739 F.2d 1393, 1395 (9th Cir. 1984); see also Bayliss v. Barnhart, 427 F.3d 

1211, 1218 (9th Cir. 2005); Lewis v. Apfel, 236 F.3d 503, 512 (9th Cir. 2001). To the extent that 

the lay witness statements were of the same general nature as the subjective complaints from the 

plaintiff’s testimony, the ALJ’s legally sufficient reasons for rejecting the plaintiff’s subjective 

symptom testimony also constituted legally sufficient reasons for rejecting the lay witness 

statements. See Valentine v. Commissioner, Social Sec. Admin., 574 F.3d 685, 694 (9th Cir. 2009). 

Further, an ALJ’s failure to comment on lay witness testimony is harmless where the same 

evidence that the ALJ cited in discrediting the claimant’s testimony also discredits the lay witness’

claims. Molina v. Astrue, 674 F.3d 1104, 1122 (9th Cir. 2012).

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Plaintiff’s son provided a written statement describing Plaintiff’s daily activities and 

limitations. It is remarkably similar to Plaintiff’s written statement. The ALJ discussed Plaintiff’s 

son’s statement and accorded it little weight because of inconsistency with other reports, internal 

inconsistency, and a tendency to exaggerate Plaintiff’s limitations which are not supported by 

medical findings. As discussed, the ALJ properly found that Plaintiff’s alleged limitations were 

not supported by the record. The ALJ gave reasons germane to Plaintiff’s son in discrediting his 

testimony. Hence, his consideration of Plaintiff’s son’s testimony is without legal error and 

supported by substantial evidence in the record. 

IV. Conclusion and Order

For the foregoing reasons, the Court finds that the ALJ applied appropriate legal standards 

and that substantial credible evidence supported the ALJ’s determination that Plaintiff was not 

disabled. Accordingly, the Court hereby DENIES Plaintiff’s appeal from the administrative 

decision of the Commissioner of Social Security. The Clerk of Court is DIRECTED to enter 

judgment in favor of the Commissioner and against Plaintiff.

IT IS SO ORDERED.

Dated: March 9, 2016 /s/ Sandra M. Snyder 

UNITED STATES MAGISTRATE JUDGE

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