Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_15-cv-01630/USCOURTS-caed-1_15-cv-01630-1/pdf.json

Parties Involved:
Commissioner of Social Security
Defendant
Grace Jane Fraser
Plaintiff

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UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

GRACE JANE FRASER,

Plaintiff,

v.

CAROLYN W. COLVIN, Acting 

Commissioner of Social Security

Defendant.

Case No. 1:15-cv-1630-GSA

ORDER REGARDING PLAINTIFF’S 

SOCIAL SECURITY COMPLAINT

I. INTRODUCTION

Plaintiff Grace Jane Fraser (“Plaintiff”) seeks judicial review of the final decision of the 

Commissioner of Social Security (“Commissioner” or “Defendant”) denying her applications for 

Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) benefits 

pursuant to Titles II and XVI of the Social Security Act. The matter is currently before the Court 

on the parties’ briefs, which were submitted without oral argument to the Honorable Gary S. 

Austin, United States Magistrate Judge.1 After review of the administrative record, the Court 

finds the ALJ’s decision is not supported by substantial evidence and the Court grants Plaintiff’s 

appeal in part.

///

 

1 The parties consented to the jurisdiction of the United States Magistrate Judge. (Doc. 7, 8, and 16). 

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II. BACKGROUND AND PRIOR PROCEEDINGS

Plaintiff filed an application for DIB and SSI on September 25, 2009, alleging a disability 

onset date of February 9, 2009.

2

 AR 121-124; 125-131. Her applications were denied initially on 

January 29, 2010, and on reconsideration on April 22, 2010. AR 57-59; 62-67. Plaintiff requested 

a hearing before and Administrative Law Judge (“ALJ”). AR 68. ALJ James Berry conducted a 

hearing on July 19, 2011. AR 23-41. He published an unfavorable decision on August 2, 2011. 

AR 8-22. Plaintiff filed an appeal on August 15, 2011. AR 6-7. The Appeals Council denied the 

request for review on September 20, 2012. AR 1-5. Plaintiff timely filed an appeal in the United 

States District Court in this district on November 21, 2012. Fraser v. Comm. of Soc. Sec., 1:12-

cv-1900 SAB. United States Magistrate Judge Stanely A. Boone reversed ALJ’s Berry’s decision 

in part on November 19, 2013, and remanded the matter for further proceedings. AR 538-567. 

While Plaintiff’s case was pending with the District Court, she filed a new application for 

benefits, which was denied initially on March 12, 2013, and on reconsideration on January 13, 

2014. AR 593-598; 601-607. On remand, the Appeals Council consolidated the remanded claim 

with the subsenquent claim. AR 584.

Another hearing was conducted before ALJ Sharon L. Madsen on August 7, 2014. AR 

420-441. On September 19, 2014, ALJ Madsen issued a decision finding that Plaintiff was not 

disabled. AR395-411. Plaintiff timely filed an appeal of the decision with the Appeals Council. 

AR 662-665. The Appeals Council denied Plaintiff’s appeal on August 28, 2015, rendering the 

order the final decision of the Commissioner. AR 389-394.

Plaintiff now challenges the second Appeals Council decision, arguing that the ALJ’s 

assessment of the medical evidence was improper. Specifically, she contends that the ALJ 

erroneously rejected Dr Rush (an examining physician’s) opinion, and improperly relied upon her 

own lay interpretation of the medical record. (Docs. 12, pgs. 3-16; Doc. 14, pgs. 1-5). Defendant 

argues that the ALJ’s provided specific and legitimate reasons to reject Dr. Rush’s opinion by 

relying on other physicians’ opinions and other evidence in the medical record. Therefore, the 

ALJ’s decision is supported by substantial evidence.

 

2 References to the Administrative Record will be designated as “AR,” followed by the appropriate page number. 

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A. Medical Record

The entire medical record was reviewed by the Court. Only evidence relating to 

Plaintiff’s physical condition is summarized below as this is the basis of Plaintiff’s appeal. 

Plaintiff suffered a cerebral vascular accident (stroke) on February 9, 2009. AR 214-280. 

A brain MRI revealed acute left posterior limb of the internalcapsule cerebral infarction; 

underlying moderate to severe microvascular disease with lacuner infarction seen within the left 

corona radiata; and no intracranial hemorrhage. AR 258. On February 11, 2009, Plaintiff was 

evaluated by physical therapy and found to have an unsteady gait and generalized weakness in the 

upper right extremity. AR 276-277. Physical therapy was recommended. AR 276. Plaintiff 

participated in physical therapy and was seen by her primary care physician Dr. Gurinder Narain, 

M.D. several times over the next several months. By May 4, 2009, Plaintiff’s exam was within 

normal limits. AR 311-313; 404-405. 

Plaintiff received her primary medical care through Family Health Network, and reported 

no complaints until October 2009. AR 316; 318; 320; 325; 327. At that time, she complained of 

being depressed, although she still enjoyed hobbies and taking care of her grandchildren. AR 318; 

405. Physician’s Assistant (“PA”) Mae Caragay thought the depression may be due to 

postmenopausal symptoms. AR 318. Plaintiff requested that disability paperwork be completed. 

AR 405; 318. However, the disability papers were subsequently denied because they were not 

signed by a physician. In October 2010, Plaintiff was asked to submit new forms for her doctor’s 

signature. AR 405; 379-380.

On December 20, 2009, Dr. Froehler, M.D. conducted a neurological consultative 

examination. AR 331-334. Dr. Froehler reported a right pronator drift with mild right-sided 

spasticity, and slow finger tapping on the right side. AR 332. Plaintiff’s physical examination 

was normal, with full motor strength, a normal gait, and no assistive device. AR 404; 331-333. 

Dr. Froeher found no physical impairments but found exertional limitations to include climbing 

and balancing. AR 333.

On January 13, 2010, state agency non-examining physician, Dr. Kiger, M.D. reviewed 

the record and provided a residual functional capacity assessment matching Dr. Froehler’s 

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findings. AR 358-360; 404. It was noted that Plaintiff was working three to four hours a day 

assisting elderly and disabled people at their homes, but experienced more fatigue and had some 

difficulty using her right hand for finer, more dexterous movements. AR 359. Dr. Kiger opined 

that Plaintiff was credible as to her impairments, but not completely credible to the extent of her

functional limitations. AR 359-360.

Records from Plaintiff’s physical examinations from June 2010 through March 2011, 

showed Plaintiff with a normal gait and normal physical findings. AR 365; 371; 377; 379-380. 

Except that in November 2010, Plaintiff complained to PA Caragay that she suffered from 

ongoing fatigue and pain in her shoulder, and difficulty lifting her arm or a comb. AR 371.

Plaintiff deferred an x-ray due to financial reasons. AR 372. 

In March 2011, Plaintiff continued to complain of fatigue and intermittent right side 

weakness. AR 365. At that time, her right arm grip strength was 4/5. AR 365. In April 2011, 

Plaintiff requested that disability forms be filled out by her medical provider and presented with 

right side facial droop, slight limp, tremors and 3/5 leg strength. AR 903. 

On May 3, 2011, PA Mae Caragay and Anne Marie Gonzalez, M.D., provided a treating 

assessment of Plaintiff’s residual functioning indicating that Plaitniff could lift and carry up to ten 

pounds occasionally; and that she could sit, stand, and walk for a total of three hours in an eighthour workday. AR 383-384. Additionally, Plaintiff was limited to sitting for thirty minutes at a 

time; standing for ten minutes at a time; walking for fifteen minutes at a time; and required the 

use of a cane. AR 384. The medical providers further opined that Plaintiff could never reach 

overhead with her right arm; could frequently reach in all other directions; and could occasionally 

handle, finger, feel, push, and pull with the right hand. AR 385. The assessment also included 

occasional environmental limitations. AR 387. The ALJ rejected this assessment because 

limitations were not consistent with Plaintiff’s treatment or the medical records. AR 409.

Treatment notes do not resume again until March 2012 when Ms. Fraser presented with 

tenderness to palpation in the bilateral trapezius region and the generalized costal area. The upper 

and lower extremities were unremarkable. AR 879-880.

On June 19, 2012, PA Caragay completed a General Relief Form. AR 843. Ms. Caragay 

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opined that Ms. Fraser could only perform limited part-time work due to her history of CVA, 

right-sided weakness, and decreased strength and mobility. Plaintiff was limited to light work 

only (lifting less than twenty pounds at one-time); no repetitive bending or lifting, no repetitive 

hand movements (use of keyboard less than ten minutes/hour); and standing/walking (less than 

fifteen minutes in a hour). AR 406; 843. 

In February 2013, Plaintiff presented to PA Caragay requesting completion of a discharge 

application for loan repayment and permanent disability form. AR 811. She complained of 

increased tremors and referred for a neurological examination. AR 811. In subsequent visits,

there is no report of any complaint of tremors and no neurological evaluation was completed. AR 

406; 814; 819-820; 825-840.

On February 26, 2013, Dr. Tomas Rios, M.D., conducted an internal medicine 

consultative evaluation. AR 804-808. Dr. Rios observed occasional tremor of Plaintiff’s right 

arm and slight motor weakness in the right upper and lower extremities at 4+/5. AR 807. 

Plaintiff’s grip strength was slightly diminished in the right arm. Dr. Rios noted that Plaintiff had 

a slight deficit from her stroke on her right side, however, her balance and equilibrium remained 

preserved. AR 807. With regard to Plaintiff’s back pian, he noted that there was “only 

tenederness to palpation along the lumbar spine.” AR 807. Given the above, Dr. Rios opined that 

Plaintiff could lift up to fifty pounds occasionally and twenty-five pounds frequently. AR 807-

808. She could stand and walk for six hours and had no sitting limitations. He also opined that 

Plaintiff could frequently climb, balance, stoop, kneel, crouch, and crawl. AR 808. He found no 

manipulative or environmental limitations. AR 808. The ALJ gave this opinion great weight

because Dr. Rios did a thorough examination of the Plaintiff, took all her subjective complaints 

into account, and is board certified in internal medicine. AR 403. 

 On March 12, 2013, state agency, non-examining physician, Dr. K. Quint, M.D. reviewed 

the file and opined that Plaintiff retained the ability to occasionally lift one hundred pounds or 

more; could frequently lift up to fifty pounds; and stand, walk, and sit, for about six hours in an 

eight-hour day. AR 534. Posturally, Dr. Quint opined Plaintiff could occasionally climb 

ramps/stairs and balance, and never climb ladders ropes or scaffolds. AR 534. State agency nonCase 1:15-cv-01630-GSA Document 17 Filed 11/15/16 Page 5 of 15
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examining physician Dr. D. Pong, M.D., reviewed the file on December 24, 2013, and agreed 

with Dr. Quint‟s opinion. AR 520-522. The ALJ gave these opinons limited weight. AR 404.

On December 10, 2013, Dr. Fariba Vesali, M.D. conducted a consultative neurological 

evaluation. AR 864-867. Motor strength and grip strength were normal. AR 866. Plaintiff did 

not have difficulty getting on or off the exam table. AR 865. Plaintiff experienced off-and-on 

hand shakes, but she was able to pick up a paperclip off of the table. AR 865. Plaintiff was using 

a cane, however, she was able to walk without an assistive device. AR 865. Dr. Vesali opined 

that Plaintiff suffered from right shoulder tendonitis and lumbar strain. However, he found that 

Plaintiff could walk, stand, and sit for six hours in an eight-hour workday. He also determined 

that Plaintiff could lift/carry fifty pounds occasionally and twenty-five pounds frequently. She 

could perform frequent postural activities. She could frequently reach and handle with the right 

hand. AR 867. The ALJ gave this opinion great weight because Dr. Vesali did a thorough 

examination of the Plaintiff, took all her subjective acomplaints into account, and is board 

certified in physical medicine and rehabilitation. AR 404.

In January 2014, Plaintiff was involved in a motor vehicle accident when she was rear 

ended by another vehicle while she was stopped at a red light. AR 407; 916-926; 961-974. She 

was diagnosed with strain, contusion, and sprain. AR 919. X-ray of the thoracic spine dated 

January 7, 2014 showed levoconvex scoliosis of the degenerative thoracic spine and no evidence 

of acute fracture or dislocation. AR 924. X-ray of the lumbar spine revealed mild dextroconvex 

curvature of the lumbar spine, and disc space narrowing at L5-S1, but no acute fracture or 

dislocation. AR 925. X-ray of the cervical spine revealed degenerative disc disease at C4-C5 and 

C5-C6, but no evidence of acute fracture or dislocation, and the prevertebral soft tissue and 

epiglottis were unremarkable. AR 925.

Plainitff had chiropractic adjustments from January to March 2014 that resulted in a 

ninety percent improvement in her accident related symptoms. AR 407; 978-983. Physician 

Assistant (“PA”) Stephen Williams examined Plaintiff in February and March 2014 (AR 961-

976), and diagnosed her with whiplash, cervical spine strain, right shoulder pain, lumbar spine 

strain/sprain, and right knee pain and swelling. AR 965; 974. He found impaired mobility in 

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Plaintiff’s spine, as well as limited range of motion on her right side. AR 966. He recommended 

a lumbar spine brace for lumbar support, physical therapy, x-rays of the right shoulder and knee, 

and psychiatric consultation for assistance in coping with the accident. AR 966.

On April 24, 2014, Dr. Samuel B. Rush, M.D. conducted a complete internal medicine 

consultative examination. AR 906-915. Grip strength was seventy, sixty, sixty-five pounds in the 

right hand and forty, forty-five, and forty in the left. AR 907. Range of motion was normal in the 

cervical and lumbar spine and in the shoulder joints. AR 908. Motor strength was 2/5 in the lower 

right extremity and 4/5 in the left lower extremity. Dr. Rush observed a moderate limp favoring 

the right lower extremity due to weakness and noted use of a cane. AR 909.

Dr. Rush opined that Plaintiff retained the ability to lift and carry twenty pounds 

frequently and ten pounds continuously; she could stand for four hours, walk for two hours, and 

sit for eight hours at one time and in an eight-hour workday. AR 911-912. She required a cane to 

ambulate, but was able to use her free hand to carry small objects. AR 912. Plaintiff could reach 

overhead, push/pull occasionally, and feel, finger, handle, and reach in all other directions 

frequently with the right hand, with no limitations to the left. AR 913. Ms. Fraser was able to 

operate foot controls occasionally with the right foot and was able to stoop and climb ramps and 

stairs occasionally, however, she could never balance, kneel, crouch, crawl, or climb ladders or 

scaffolds. AR 914. The ALJ rejected this opinion because it was inconsistent with the treatment 

records and with other physician’s opinons in the record. AR 408.

Dr. Bryan Cruz, M.D. completed a “Physical Residual Function Capacity Medical Source 

Statement.” AR 985-988. He opined that Plaintiff could lift and carry five pounds occasionally 

and less than five pounds frequently. AR 408; 985 She is able to sit, stand, and walk for one 

hour at a time up to four out of eight hours; and should elevate her legs for thirty minutes after 

one hour of sitting. AR 986-987. She must use an assistive device for all surfaces. AR 987. She 

was able to grasp, turn, and twist objects twenty-five percent of the time, perform fine 

manipulation fifty percent of the time, and reach twenty-five percent of the time. AR 987. She 

could climb stairs and ramps, but no ladders, ropes, or scaffolds. AR 987. She would be off task 

twenty-five percent of the time, absent from work four days per month, and unable to complete an 

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eight-hour day four times per month. AR 988. The ALJ rejected this opinion because there is no 

evidence that the doctor ever examined Plaintiff, and his opinion that she suffered from bilateral 

mamipulative limitations was not supported by the record. AR 408.

III. THE DISABILITY DETERMINATION PROCESS

To qualify for benefits under the Social Security Act, a plaintiff must establish that he or 

she is unable to engage in substantial gainful activity due to a medically determinable physical or 

mental impairment that has lasted or can be expected to last for a continuous period of not less 

than twelve months. 42 U.S.C. § 1382c(a)(3)(A). An individual shall be considered to have a 

disability only if:

. . . his physical or mental impairment or impairments are of such severity that he 

is not only unable to do his previous work, but cannot, considering his age, 

education, and work experience, engage in any other kind of substantial gainful 

work which exists in the national economy, regardless of whether such work 

exists in the immediate area in which he lives, or whether a specific job vacancy 

exists for him, or whether he would be hired if he applied for work.

42 U.S.C. § 1382c(a)(3)(B).

To achieve uniformity in the decision-making process, the Commissioner has established 

a sequential five-step process for evaluating a claimant’s alleged disability. 20 C.F.R. §§

404.1502(a)-(f), 416.920(a)-(f). The ALJ proceeds through the steps and stops upon reaching a 

dispositive finding that the claimant is or is not disabled. 20 C.F.R. §§ 416.920(a)(4) and 

404.1502(a)(4). The ALJ must consider objective medical evidence and opinion testimony. 20 

C.F.R. §§ 404.1527, 416.1529, 416.927, and 416.929.

Specifically, the ALJ is required to determine: (1) whether a claimant engaged in 

substantial gainful activity during the period of alleged disability, (2) whether the claimant had 

medically-determinable “severe” impairments,

3

(3) whether these impairments meet or are 

medically equivalent to one of the listed impairments set forth in 20 C.F.R. § 404, Subpart P, 

Appendix 1, (4) whether the claimant retained the residual functional capacity (“RFC”) to 

perform his or her past relevant work,

4

and (5) whether the claimant had the ability to perform 

 

3

“Severe” simply means that the impairment significantly limits the claimant’s physical or mental ability to do basic 

work activities. See 20 C.F.R. §§ 404.1520(c), 416.920(c).

4 Residual functional capacity captures what a claimant “can still do despite [his or her] limitations.” 20 C.F.R. §§

404.1545, 416.945. “Between steps three and four of the five-step evaluation, the ALJ must proceed to an 

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other jobs existing in significant numbers at the regional and national level. 20 C.F.R. §§

404.1520(a)-(f), 416.920(a)-(f).

A. The ALJ’s Decision

Using the Social Security Administration’s five-step sequential evaluation process, the 

ALJ determined that Plaintiff did not meet the disability standard. AR 398-411. Specifically, the 

ALJ found that Plaintiff met the insured status requirements through September 30, 2015. AR 

400. The ALJ further found that Plaintiff had not engaged in substantial gainful activity since 

February 9, 2009, the alleged onset date in the appliations. AR 400. The ALJ identified obesity, 

history of cerebral ascular accident, hypertenston, lumbar degernative joint disease, 

thoracolumbar scoliosis, and right shoulder tendonitis as severe impairments. AR 400-402. 

Nonetheless, the ALJ determined that Plaintiff did 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. AR 402.

Based on the review of the entire record, the ALJ determined that Plaintiff had the residual 

functional capacity (“RFC”) to perform medium work. AR 402. Specifcially, the ALJ found that 

Plaintiff was limited to lifting and carrying fifty pounds occasionally and twenty-five pounds 

frequently; and that she could stand, walk, and/or sit for six to eight hours in an eight-hour work 

day. AR 402. The ALJ further determined that Plaintiff was able to occasionally balance and 

climb ramps and stairs, but is unable to climb ladders, ropes, and scaffolds. AR 402. Based on 

this RFC, the ALJ determined that Plaintiff could perform her past relevant work as a nurse 

assistant and home attendant. AR 410. 

IV. STANDARD OF REVIEW

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

to deny benefits under the Act. In reviewing findings of fact with respect to such determinations, 

this Court must determine whether the decision of the Commissioner is supported by substantial 

evidence. 42 U.S.C. § 405(g). Under 42 U.S.C. § 405(g), this Court reviews the Commissioner's 

 

intermediate step in which the ALJ assesses the claimant’s residual functional capacity.” Massachi v. Astrue, 486 

F.3d 1149, 1151 n. 2 (9th Cir. 2007).

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decision to determine whether: (1) it is supported by substantial evidence; and (2) it applies the 

correct legal standards. See Carmickle v. Commissioner, 533 F.3d 1155, 1159 (9th Cir. 2008); 

Hoopai v. Astrue, 499 F.3d 1071, 1074 (9th Cir. 2007).

“Substantial evidence means more than a scintilla but less than a preponderance.” 

Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002). It is “relevant evidence which, 

considering the record as a whole, a reasonable person might accept as adequate to support a 

conclusion.” Id. “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.” Id.

V. DISCUSSION

A. The ALJ Improperly Weighed the Medical Evidence.

Plaintiff argues that the ALJ improperly evalulated the physicians’ opinions by failing to 

consider the limitations outlined in Dr. Rush’s report. Specifically, she contends that the ALJ’s 

reliance on Dr. Rios and Vesalis’ opinions in lieu of Dr. Rush’s findings was improper because 

Plaintiff was in a car accident in January 2014, after Drs. Rios and Vesalis completed their

evaluations. As a result of this accident, Plaintiff suffered additional back injuries that these 

doctors did not consider as part of their evaluations. Plaintiff asserts that when rejecting Dr. 

Rush’s opinion, the ALJ relied on her own interpretation of post-accident medical records rather 

than on a medical opinion which is improper. (Docs.12, pgs. 3-16; Doc. 14, pgs. 3-5). Because 

Dr. Rush’s opinion includes an evaluation of her post-accident injuries and results in a findng of 

disablity, the case should be remamded for an award of benefits or alternatively, for further 

consideration of the medical record.

The Defendant argues that that ALJ properly considered the entire medical record and 

gave specific and legitimate reasons for rejecting Dr. Rush’s opinion including relying on other 

doctor’s opinions and the medical record. Additionally, the ALJ found that Plaintiff’s symptoms 

were not credible because her symptomatology varied from setting to setting and increased when 

she was requesting disability. Therefore, the ALJ’s evlaution of the medical record is supported 

by substantial evidence. (Doc. 13, pgs. 7-11).

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1. The Law

The opinions of treating physicians, examining physicians, and non-examining physicians 

are entitled to varying weight in disability determinations. Lester v. Chater, 81 F.3d 821, 830 

(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, 1285 (9th Cir. 1996). 

However, the opinions of a treating or examining physician are “not necessarily 

conclusive as to either the physical condition or the ultimate issue of disability.” Morgan v. 

Comm’r of Soc. Sec. Admin., 169 F.3d 595, 600 (9th Cir. 1999). 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. Similarly, the opinion of a non-examining physician 

may constitute substantial evidence when it is “consistent with independent clinical findings or 

other evidence in the record.” Thomas, 278 F.3d at 957. Such independent reasons may include 

laboratory test results or contrary reports from examining physicians, and Plaintiff's testimony 

when it conflicts with the treating physician's opinion. Lester, 81 F.3d at 831, citing Magallanes

v. Bowen, 881 F.2d 751–755 (9th Cir. 1989). 

2. Analysis

Here, the ALJ gaver greater weight to Dr. Rios and Vesalis’ reports and rejected Dr. 

Rush’s opinion. In doing so, the ALJ gave a detailed summary of all the medical records and 

physician’s opinions. AR 402-410. When reviewing Dr. Rush’s opinion, the ALJ stated as 

follows:

I give little weight to Dr. Rush’s opinion because it is inconsistent with the 

treatment records and with the findings of other examining specialists. Dr. 

Rios examined the claimant in February 2013 and found that she had a 

normal gait and 4+/5 right arm and leg strength and right hand grip. Dr. 

Vesali examined the claimant in December 2013 and found the claimiant 

had normal gait and full motor strength of 5/5 in the upper and lower 

extremities and hand grip. There is no mention in the treatment record of 

any event that would have caused such a drastic decline in strength just 

five months later, especially considering the stoke occurred more than four 

years earlier, and strength is a highly subjective area.

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AR 408. Because Dr. Rush’s opinion was contradicted by another doctor, the ALJ was required 

to give specific and legitimate reasons for rejecting the opinion. The ALJ did not do so in this 

case. The Court recognizes that “the ALJ is responsible for determining credibility and resolving 

conflicts in medical testimony.” Magallanes v. Bowen, 881 F.2d at 750. As a result, an ALJ may 

choose to give more weight to an opinion that is more consistent with the evidence in the record. 

20 C.F.R. §§ 404.1527(c)(4), 416.927(c)(4) (“the more consistent an opinion is with the record as 

a whole, the more weight we will give to that opinion”); Tonapetyan v. Halter, 242 F.3d 1144, 

1149 (9th Cir. 2001) (examining physician’s opinion “alone constitutes substantial evidence” to 

reject treating physician’s opinion where it “rests on his own independent examination”). 

In this case, the ALJ rejected Dr. Rush’s findings on the basis there is no mention of any 

event in the medical record that would have caused a drastic decline in strength just five months 

after Dr. Rios and Dr. Vesali’s opinions. AR 408. Although reliance on an examining physician’s 

opinion can constitute substantial evidence, here, the ALJ’s reasoning is not legitimate because 

she does not adequately address the injuries Plaintiff she suffered in the January 2014 car 

accident. Although the ALJ discusses the the accident earlier in the opinion, her recitation of the 

medical evidence was not comprehensive. When discussing the accident, the ALJ states as 

follows : 

The Claimant went to the emergency room after a motor vehicle accident 

in January 2014. She complained of neck, back, and head pain. X-rays 

showed levoconvex scoliosis of the degernative thoracic spine, but no acute 

fracture or dislocation at any level of the spine. The doctor diagnosed back 

strain and prescribed Viocodin. The Claimant had chirpopractic 

adjustments from January to March 2014 that resulted in 90% 

improvement in her accident related symptoms. The claimiant saw 

Stephen Willimas, PA-C in February and March 2014 for accident-related 

pain and referral from her chiropractor. He diagnosed the claimaint with 

wiplash; cervical spine/sprain; right shoulder pain; lumbar spine/sprain; 

and right knee pain and swelling. Mr. Williams prescribed Omeprzaole, 

Vicodin, Norco, Cartivisc, Gabapentin, Ibuprofen, Napro Cream, and 

Tramadol. Again, neither of these providers mentioned tremor or rightsided weakness.

AR 407. Although the ALJ correctly notes that on March 14, 2014, the chiropracter noted a

ninety percent improvement in Plaintiff’s condition (AR 979), there is no mention of the fact that 

three days prior, PA Williams evaluated Plaintiff and found impaired mobility in her spine, as 

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well as limited range of motion on her right side. AR 966. Mr. Williams recommended continuing 

physical therapy, a back brace, and additional x-rays of Plaintiff’s knee and shoulder. AR 966. 

The ALJ does not reference those findings in the decision, but instead makes a general reference 

to Mr. William’s diagnosis to support her finding that no signicant event occurred after Drs. Rios 

and Versalis’ opinions. By relying on the post-accident treatment records in this manner, the ALJ 

relied on her own independent medical assessment of the diagnostic data contained in Mr. 

William’s evaluation. No other physician had performed a functional assessment of Plaintiff’s 

capabilities after the accident except for Dr. Rush and Dr. Cruz, and the ALJ rejected both of

those those opinions. An ALJ is not permitted to substitute her own interpretation of the medical 

evidence for the opinion of the medical professionals. Rutherford v. Barnhart, 399 F.3d 546, 554 

(3d Cir. 2005); Boiles v. Barnhart, 395 F.3d 421, 425 (7th Cir. 2005); Clifford v. Apfel, 227 F.3d 

863, 870 (7th Cir. 2000). Thus, the basis to reject Dr. Rush’s opinion is not a legitimate one, and 

the ALJ’s decision in this regard is not based on substantial evidence. 

B. The Case Shall Be Remanded For Further Proceedings

Given the above error, Plaintiff argues that the case should be remanded for benefits 

because theVE testified that if limitations outlined in Dr Rush’s opinion are adopted, Plaintiff is 

disabled. However, the court has the discretion to remand for further proceedings or reverse and 

award benefits b ased on the “credit-as-true” rule. McAllister v. Sullivan, 888 F.2d 599, 603 (9th 

Cir. 1989). A case may be remanded under the “credit-as-true” rule for an award of benefits 

where:(1) the record has been fully developed and further administrative proceedings would serve 

no useful purpose; (2) the ALJ has failed to provide legally sufficient reasons for rejecting 

evidence, whether claimant testimony or medical opinion; and (3) if the improperly discredited 

evidence were credited as true, the ALJ would be required to find the claimant disabled on 

remand. Garrison v. Colvin, 759 F.3d 995, 1020 (9th Cir. 2014). Even where all the conditions 

for the “credit-as-true” rule are met, the court retains “flexibility to remand for further 

proceedings when the record as a whole creates serious doubt as to whether the claimant is, in 

fact, disabled within the meaning of the Social Security Act.” Id. at 1021. See also, Treichler v. 

Commissioner of Social Sec. Admin., 775 F.3d 1090, 1105 (9th Cir. 2014) (“Where . . . an ALJ 

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makes a legal error, but the record is uncertain and ambiguous, the proper approach is to remand 

the case to the agency.”).

In this instance, after reviewing the record, the Court has some doubts that the Plaintiff is 

disabled. As the Commissioner has argued, the ALJ found Plaintiff was not credible. The ALJ 

also correctly noted that there is a lack of additional treatment records after PA William’s 

examination indicating that Plaintiff pursued additional treatmemt or diagnoistic tests to treat her 

condition. AR 406. Further, the record supports the ALJ’s finding that Plaintiff’s

symptomatology has been inconsistent, varies from setting to setting, and increases when she is 

requesting disability forms. AR 318; 409; 819-820; 825-840; 843; 903.

Notwithstanding the above, the Court is unable sustain the ALJ’s RFC finding that 

Plaintiff is able to lift and carry fifty pounds occasionally and twenty-five pounds frequently, or 

perform her past work as a nurse assistant or home attendant given the lack of a physician’s

medical evaluation supporting that finding.5 As such, further administrative proceedings would 

serve a useful purpose. On remand, the ALJ shall further develop the record, including having a 

doctor review Plaintiff’s post-accident condition, and devise an RFC that is supported by medical 

opinions. Once this a new RFC is devised, the ALJ shall obtain the testimony of a VE (if needed) 

and determine what jobs, if any, Plaintiff is able to perform.

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5 The Court is not persuaded by the Commissioner’s argument that Dr. Rush’s opinion is not inconsistent with her 

ability to perform light work and therefore, she could perform her past job as a home attendant. (Doc. 13, pg. 8). Dr. 

Rush opined that Plaintiff could only occasionally climb stairs and ramps, stoop, reach overhead, and push/pull. AR 

913-914. The vocational expert indicated that a person with these limitations would not be able to perform Plaintiff’s 

past work as a home attendant or a nurse assistant. AR 439.

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VI. CONCLUSION

Based on the foregoing, the Court finds that the ALJ's decision is not supported by 

substantial evidence in the record as a whole. Accordingly, this Court ORDERS that Plaintiff's 

appeal from the administrative decision of the Commissioner of Social Security be GRANTED

IN PART. The Court further ORDERS this case be remanded for further proceedings consistent 

with this order. The Clerk of this Court is DIRECTED to enter judgment in favor of Plaintiff, 

Grace Jane Fraser, and against Defendant Carolyn W. Colvin, Commissioner of Social Security, 

and close this case.

IT IS SO ORDERED.

Dated: November 14, 2016 /s/ Gary S. Austin 

 UNITED STATES MAGISTRATE JUDGE

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