Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_08-cv-01271/USCOURTS-caed-1_08-cv-01271-2/pdf.json

Parties Involved:
Commissioner of Social Security
Defendant
Juanita Galvan
Petitioner

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IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF CALIFORNIA

JUANITA GALVAN, Case No. 08-cv-1271-JLT

Plaintiff, ORDER REGARDING PLAINTIFF’S

SOCIAL SECURITY COMPLAINT

vs.

MICHAEL J. ASTRUE,

Commissioner of Social Security,

 

Defendant. 

 /

BACKGROUND

Plaintiff Juanita Galvan (“Claimant” or “Plaintiff”) seeks judicial review of an administrative

decision denying her claim for disability insurance benefits under Title II and supplemental security

income benefits under Title XVI of the Social Security Act (the “Act”), 42 U.S.C. § 401 et seq. 

Pending before the Court is Plaintiff’s appeal from the administrative decision of the Commissioner

of Social Security (“Commissioner”). On August 25, 2008, Plaintiff’s complaint was filed in the

United States District Court for the Eastern District of California. (Doc. 1). Plaintiff filed her

opening brief on May 29, 2009. (Doc. 21). The Commissioner filed his opposition brief on July 1,

2009. (Doc. 24). 

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

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number.

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FACTS AND PRIOR PROCEEDINGS1

On May 11, 2004, Plaintiff filed an application for disability insurance benefits under Title II

and supplemental security income benefits under Title XVI of the Act. AR 21, 56-58, 707-09. 

Plaintiff alleged that she had been under a disability since September 18, 1997, due to disabling

physical problems. Id. at 56, 707. After initial denial of her request for benefits by the Agency,

Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”). Id. at 46. On April 19,

2006, the ALJ held a hearing, and on April 27, 2006, denied benefits. Id. at 18-29. Specifically, the

ALJ found that Plaintiff was not disabled within the meaning of the Act. Id. at 29. The Appeals

Council denied review on June 23, 2008. Id. at 6-9.

Hearing Testimony

The hearing was held on April 19, 2006. AR at 712. Plaintiff and her attorney, Sharon

Kelly, appeared. Id. A vocational expert (“VE”), Susan Cleval, also testified. Id.

Plaintiff testified she was 43 years old and had an eleventh grade education but had not

obtained a GED, although she was literate. AR at 716. She testified that she was five feet, three

inches tall and weighed 180 pounds. Id. She was left handed. Id. at 717. Plaintiff is separated and

has five children, four of whom still live at home. AR 717.

After some confusion, Plaintiff stated she had not worked since September 18, 1997. See AR

at 717-18. She reported that her last job was as a seamer operator in a cannery. Id. at 720. She

worked in this job for about four years. Id. The job required that she stand for 71⁄2 hours a day and

put lids into a machine which then were attached to cans. Id. at 722. Part of this job required that

she lift boxes of lids, which she estimated at approximately 35 pounds. Prior to this job, she worked

in the cannery as a caser. Id. at 720. This job required her to load empty cardboard boxes into

machines, which in turn loaded cans into the boxes. Id. Sometimes the cans would fall out of the

boxes and she would have to pick them up and put them in the boxes. Id. She was required to stand

to perform this job as well. Id. Altogether she worked at the cannery for 15 years. Id. The work

was seasonal, lasting from early July until the end of September. Id. at 723. During this time she

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worked 7 days a week for about 7 1⁄2 hours a day. Id. 

Plaintiff testified that she injured her left shoulder and sprained her neck while working. AR

at 723. She reported that she has pain throughout her entire body. Id. at 724. She reported that she

saw only her treating physician, Dr. Suzanne Meyer and that she saw her every month for her chronic

pain and fibromyalgia. Id. Her treatment consisted of physical therapy and Advil. Id. Also, she

reported that she took two hot showers a day to help with the pain. Id. at 725. About two years prior

to the hearing, she testified that she sought surgery for a herniated disc but the doctor she saw refused

to perform an operation. Id.

Plaintiff stated she had been seen in the past by Dr. Mattice Harris for anxiety and panic

attacks. AR at 728. Dr. Harris prescribed Zoloft but interfered with her ability to sleep. Id. At the

time of the hearing, Plaintiff testified that she was not receiving any treatment for mental or

emotional problems. Id.

Plaintiff reported that she didn’t do heavy housework. AR at 725. She reported that she

cleaned the counter tops and on a “good day” was able to sweep and mop. Id. She stated that she

didn’t cook very much because the repetitive motion required “upsets” her arms. Id. She testified

that she went to church and could go grocery shopping if someone else accompanied her. Id. at 727. 

She reported that she tried to shop on her own but sometimes just couldn’t do it. Id. at 727-28.

She testified that she was able to lift and move a gallon of milk occasionally, but if she was

having a lot of pain, she couldn’t lift a glass of milk. AR at 729. She reported that she was in a lot

of pain three to four times per month. Id. These periods lasted between three and seven days. Id. 

She testified that she had difficulty walking due to pain in her pelvis and hips, especially in cold

weather, but could walk about a block. Id. at 726. She stated that she could stand 8-10 minutes at a

time, possibly even 15 minutes. Id. She reported that sometimes she had difficulty sitting because

her legs got numb after about five minutes. Id. At other times, she was able to sit for about 45

minutes at a time. Id. 

Vocational Expert Susan Cleval (“VE”) also testified. She described Plaintiff’s previous

work as a seamer operator as heavy work under the guidelines and as “medium” work as described

by Plaintiff. AR at 732. She described Plaintiff’s prior work as a caser as light work. Id.

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The ALJ asked the VE two hypothetical questions. In the first, he described the following

functional restrictions: (1) lifting 20 pounds occasionally and 10 pounds frequently; (2)

standing/walking for 6 hours in a workday; (3) sitting without restriction; (4) occasionally bending,

stooping, twisting, squatting, kneeling, crawling and climbing stairs, but no climbing ladders or

scaffolding; (5) being unable to work at heights or around hazardous machinery; and (6) being

restricted from overhead reaching with the left upper extremity and to no more than frequent fine

manipulation with the left upper extremity. AR at 732. Under this hypothetical, the VE opined that

Plaintiff couldn’t do her past work, but could do other light work such as that of caser operator, small

parts assembly, sewing machine operator and counter clerk. AR at 733.

Under the second hypothetical, the ALJ further restricted Plaintiff to lifting 10 pounds

occasionally and the ability to move small objects throughout the work day, standing/walking for no

more than 30 minutes at a time and no more than two to four hours a day, sitting without limit and

the same non-exertional limits propounded in the first hypothetical. AR at 733. Here, the VE opined

that Plaintiff could do no “light” work but could do “sedentary” work such as table operator,

pharmaceutical laborer and charge account clerk. Id. at 733-34.

Finally, under a hypothetical propounded by Plaintiff’s attorney incorporating the findings of

Plaintiff’s treating doctor, Dr. Meyer, the VE opined that Plaintiff could not perform the jobs of table

operator or pharmaceutical clerk, but was not clear about whether Plaintiff could perform the job of

charge account clerk. AR at 737.

Medical Record

Plaintiff was examined by Dr. Harish Porecha in November, 1998. Dr. Porecha noted intense

myofascial pain, in particular painful myofascial trigger points in the cervical, upper thoracic

musculature and between the shoulder blades. AR 98. He also noted limited flexion in the neck and

tenderness to palpation of the left scapula and left trapezius. Id. He diagnosed fibromyalgia of the

left scapula region, primarily the serratus anterior muscle and cervical and trapezius tightness, left

side. Id. at 97. He attributed her condition to her injury at the cannery. Id. at 99.

Dr. Porecha opined that Plaintiff should be precluded from heavy lifting or working with her

neck flexed or extended for prolonged periods of time and from repetitive pushing and pulling. AR

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98. He further opined that she could no longer perform her past work and recommended vocational

rehabilitation. Id. at 99.

Progress notes from examinations of Plaintiff by Dr. Mattice Harris in 1998 and 1999, show

Plaintiff was treated for anxiety/depression and insomnia. AR 116, 121, 126, 296, 298. Plaintiff

also complained of back, neck and abdominal pain, but Harris noted in a November 1999 progress

note that Plaintiff had a good range of motion in her shoulders with no tenderness or spasm in those

areas. Id. at 116.

Plaintiff was examined by Dr. Frank Fine, M.D., D.C., in November 2002. Dr. Fine

characterized her range of motion in her cervical spine as “pretty much full.” AR 197. However, he

noted that the range of motion in her left shoulder joint was decreased in all areas and further noted

tenderness in her left cervical paraspinal musculature to trapezius, her left periscapular region and

shoulder blade, and subacromium and left bicipital tendon. Id. Her right shoulder had a full range of

motion and her right subacromium was minimally tender. Id. A motor exam showed her at 5/5 in

her upper extremities. Id. 

Dr. Fine diagnosed bursitis/tendinitis in Plaintiff’s left shoulder, myofascial dysfunction in

her left neck and shoulder girdle area with myospasm in the left cervical trapezius area, left

periscapular strain, cervical tension cephalagia type headaches, neck strain and right shoulder

tendinitis. AR at 197. He recommended that Plaintiff’s undergo a corticosteroid injection in her left

shoulder and a MRI of her right shoulder. Id. at 198. He opined she could no longer do her

previous work and recommended vocational rehabilitation. Id.

In January 2003, Petitioner was examined by Dr. Steven Abelow, M.D., an orthopedic

surgeon. AR at 182. He noted that impingement sign on the right was negative but on the left was

positive. Id. He found no paracervical muscle spasm, no trigger points, no complaints of lower back

pain and a normal Electromyographic Study (“EMG”) and nerve conduction velocity in the left upper

extremity and back. Id. He diagnosed cervicothoracic strain. Id. He opined she could not return to

her previous work and recommended vocational rehabilitation. Id.

Plaintiff was examined again by Dr. Porecha in March 2003. AR 181. He noted her

description of her symptoms, telling him her legs were fine but that she had swelling in her left neck

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up to her head and down to her bra area in the posterior aspect of her body and shoulder near her

pectoral region and into her left hand. Id. at 183. She indicated that the left side of her body,

primarily the torso “numbs up.” Id. She reported that she had trouble washing her hair, and that her

neck felt very tight which prevented her from looking down. Id. Also, she stated that she can’t go

back to work. Id. 

When he assessed her subjective factors, Dr. Porecha noted: (1) her neck pain is “constant

and minimal which intermittently becomes slight to moderate in intensity; (2) she has constant

minimal to slight pain in the left shoulder which frequently becomes slight and intermittently

moderate; and (3) her headaches are occasional with slight to moderate pain. AR at 189. 

Objectively, he found “some increased symptoms with motion of the left shoulder and cervical

spine” and noted positive impingement sign as outlined in Dr. Abelow’s examination. Id. Dr.

Porecha further stated his belief that “[h]er condition has taken a turn for the worse since she was last

seen” particularly regarding her left shoulder and neck. Id. He opined that she should be precluded

from heavy lifting and from working with her neck flexed or extended for long periods of time, and

that she was precluded from pushing and pulling, as well as prolonged reaching and rapid rotation of

her neck. He reiterated his opinion that she should receive vocational rehabilitation as he had

previously recommended. Id. at 190. In a follow-up report dated November 19, 1983, Dr. Porecha

noted that an MRI of her cervical spine revealed a disc herniation at T3-4. Id. at 180. 

After being referred by her treating physician, in December 2003, Plaintiff was examined by

neurosurgeon, Dr. Dikran Bairanmian. AR at 237. Dr. Bairanmian noted that her neck was supple

with minimal tenderness on the left side. Id. at 238. He stated her extremities had a full range of

motion with no clubbing, cyanosis or edema. Id. He noted some tenderness in the left shoulder. Id. 

He also noted her cranial nerves were normal, her motor function was at 5/5 and her sensory function

was normal to light touch and pinprick. Id. He diagnosed neck/left upper extremity pain. Id.

In a December 23, 2003 follow-up, Dr. Bairanmian noted that Plaintiff ambulated without

difficulty. AR at 235. He interpreted an X-ray as showing only minimal degenerative change, noting

a “small thoracic disc protrusion at T3-4 which is of no clinical significance.” Id. He recommended

referral to a pain management specialist and discharged her from routine neurosurgical follow-up. 

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Id.

In a March 25, 2004 exam, Dr. Fine also noted that Plaintiff’s MRI revealed a disc herniation

at T3-4 causing some cord compression. AR at 192. He indicated he wanted to get a consultation

from another doctor concerning the herniation, stating his belief that this may be causing many of her

symptoms. Id.

In January 2005, Plaintiff was examined by Dr. S.K. Madireddi on behalf of the Social

Security Administration. In her report, Dr. Madireddi noted Plaintiff’s neck was positive for

Spurling’s sign on the left side with pain as well a paresthesias over the left shoulder and outer

border of her left upper extremity. AR at 200. Dr. Madireddi noted tenderness in Plaintiff’s

shoulder girdle muscles, levator scapular, rhomboidius major and minor and trapezius. Id. She

stated the entire area was difusely tender, consistent with fibromyalgia. Id. She noted tender areas

on the right side as well and diagnosed limited fibromyalgia. Id.

Dr. Madireddi found further that Plaintiff’s left shoulder strength was 4/5, her left elbow and

her hand were normal and that her right upper extremity was normal also. AR at 200. She noted

normal fist formation and grip on the right hand but decreased 25% on the left with slightly

decreased fine finger movements. Id. She noted tenderness in the spine from T3-7 but noted that

Plaintiff had a normal gait. Id. She attributed Plaintiff’s fibromyalgia to her work injury and also

diagnosed cervical spine strain. Id. at 201. She concluded that Plaintiff had the residual functional

capacity to sit six hours in an eight-hour workday with appropriate breaks, that she could stand/walk

six hours in a day, lift 10 pounds frequently and 15 pounds occasionally and that she could bend,

stoop, kneel, crouch and crawl occasionally. Id. 

Dr. David Pong reviewed Plaintiff’s medical records in February 2005. AR at 211. He found

the same RFC as Dr. Madireddi but also noted a limitation to frequent fingering. Id. at 203-05. A

second agency consultant reviewed Plaintiff’s records in July 2005, and affirmed these findings. Id.

at 711.

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 The name of the consultant is not evident on the report. The Court notes that Dr. Pong made his findings at 2

this time but the Court cannot discern whether this is his report.

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A non-examining medical consultant filed a report in February 2005. AR at 255-58. After a 2

thorough recounting of Plaintiff’s medical history, the consultant concluded Plaintiff had a “limited”

form of fibromyalgia and suggested “light-sed” RFC with occasional postural limitations and some

“slight” limits to her left upper extremity. Id. at 257.

Plaintiff underwent a mental examination in February 2005 by psychiatrist, Dr. Stephane

Lampe. AR at 211. In his report, Dr. Lampe determined that Plaintiff had no psychiatric illness. Id. 

Further he opined that Plaintiff could relate and interact with supervisors, co-workers and the public,

that she could maintain concentration and attention in two hour increments and that depending on the

job, she could withstand the stress and pressure of an 8-hour workday on an ongoing basis. Id.

Finally, notes from Plaintiff’s treating physician, Dr. Meyer, documented ongoing treatment

in 2005 for anxiety, depression and her physical maladies. AR at 232, 234, 241, 242 and 243. At

various examinations, Dr. Meyer noted complaints of back and shoulder pain, as well as anxiety and

depression. Id. at 232, 234. Plaintiff was treated with medication, in particular Restoril, but declined

other medications. Id. at 232. 

Dr. Meyer filled out a Physical Capacity Form in July 2005. Recounting Plaintiff’s

statements to her, she stated that Plaintiff needed frequent rest periods during the day, that she could

sit for no more than 30 minutes at a time, that she could stand and/or walk for only 0-2 hours at a

time and for no more that 2-4 hours in a day, and that she was restricted in the use of her hand and

fingers in repetitive motion. AR at 242. She stated that Plaintiff could lift 10 pounds occasionally,

and could never climb, stoop, kneel, or crawl. Id. at 243. She stated that Plaintiff had difficulty

concentrating, needed help from family to take care of her home and had trouble with everyday tasks

due to her inability to focus because of pain. Id. at 241. Also, Dr. Meyer noted an inability to adapt

to stress. Id. 

ALJ Findings

First, the ALJ determined that Plaintiff met her insured status requirements through June 30,

2001. AR at 23. Then the ALJ evaluated Plaintiff pursuant to the customary 5-step sequential

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evaluation. After determining that Plaintiff had not engaged in substantial gainful activity since

September 17, 1999 (Step 1), he noted at Step 2 that Plaintiff’s “slight herniated cervical spine disc”

and “possible fibromyalgia” were “severe” impairments within Agency regulations. AR at 23. 

However, they did not meet or exceed the level required under Agency guidelines for presumed

disability (Step 3). Id. at 24.

In the fourth step of his analysis, the ALJ determined that Plaintiff retained the residual

functional capacity (“RFC”) to perform work requiring her to lift 20 pounds occasionally and 10

pounds frequently; occasionally climb, balance, stoop, kneel, crouch and crawl; no more than

frequent fine manipulation with the left hand; and no left-sided overhead reaching. AR at 24. Based

on these findings, and the testimony of the VE, the ALJ concluded that Plaintiff could not perform

her past relevant work. Id. at 27. However, the ALJ concluded at Step 5 that significant other

“light” work exists in the national economy that Plaintiff could perform and, therefore, she was not

disabled. Id. at 27, 29.

SCOPE 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, the

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

evidence. 42 U.S.C. 405 (g). Substantial evidence means “more than a mere scintilla,” Richardson

v. Perales, 402 U.S. 389, 402 (1971), but less than a preponderance. Sorenson v. Weinberger, 514

F.2d 1112, 1119, n. 10 (9th Cir. 1975). It is “such relevant evidence as a reasonable mind might

accept as adequate to support a conclusion.” Richardson, 402 U.S. at 401. The record as a whole

must be considered, weighing both the evidence that supports and the evidence that detracts from the

Commissioner’s conclusion. Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). In weighing the

evidence and making findings, the Commissioner must apply the proper legal standards. E.g.,

Burkhart v. Bowen, 856 F.2d 1335, 1338 (9th Cir. 1988). This Court must uphold the

Commissioner’s determination that the claimant is not disabled if the Secretary applied the proper

legal standards, and if the Commissioner’s findings are supported by substantial evidence. See

Sanchez v. Sec’y of Health and Human Serv., 812 F.2d 509, 510 (9th Cir. 1987). 

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 All references are to the 2000 version of the Code of Federal Regulations unless otherwise noted. 3

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REVIEW

In order to qualify for benefits, a claimant must establish that she is unable to engage in

substantial gainful activity due to a medically determinable physical or mental impairment which has

lasted or can be expected to last for a continuous period of not less than 12 months. 42 U.S.C. §

1382c (a)(3)(A). A claimant must show that she has a physical or mental impairment of such

severity that she 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 which exists in

the national economy. Quang Van Han v. Bowen, 882 F.2d 1453, 1456 (9th Cir. 1989). The burden

is on the claimant to establish disability. Terry v. Sullivan, 903 F.2d 1273, 1275 (9th Cir. 1990).

In an effort to achieve uniformity of decisions, the Commissioner has promulgated

regulations which contain, inter alia, a five-step sequential disability evaluation process. 20 C.F.R.

§§ 404.1520 (a)-(f), 416.920 (a)-(f) (1994). Applying this process in this case, the ALJ found that 3

Plaintiff: (1) had not engaged in substantial gainful activity since the alleged onset of her disability;

(2) has a medically determinable and severe physical impairment (a slight herniated disc and possible

fibromyalgia); (3) does not have an impairment which meets or is equal to one of the impairments set

forth in Appendix 1, Subpart P, Regulations No. 4; (4) could not perform her past work as a seamer

operator and caser as that job is performed in the national economy; but (5) retains the RFC to

perform work related activities that would require her to lift and carry 20 pounds occasionally and 10

pounds frequently; with occasional climbing, balancing, stooping, kneeling, crouching and crawling;

and that would require no more than frequent fine manipulation with the left and no left sided

overhead reaching. AR at 24-25. The ALJ then determined that Plaintiff was not under a

“disability” as defined in the Act. Id. at 29. 

Plaintiff challenges the ALJ’s determination at Step 5 of the sequential evaluation process,

where an individual’s ability to perform other work is assessed based on her RFC. Plaintiff raises

two claims of error. First, she alleges the ALJ improperly discounted the opinion of her treating

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 The ALJ also discounted the same diagnosis and functional capacity assessment rendered by Dr. David Pong,

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M.D., a non-examining consultant, for the same reason. AR at 27, 203-05. 

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physician. She also asserts the ALJ improperly discounted the opinions of an examining physician

and a consulting physician in finding that she retained the RFC to perform light work in the national

economy.

DISCUSSION

Plaintiff challenges the ALJ’s failure to give deference to the opinions and findings of her

treating physician, Dr. Meyer, in determining her RFC. In addition, she notes that although an

examining physician, Dr. Madireddi, diagnosed fibromyalgia, the ALJ discounted her diagnosis

simply because he was not convinced it was supported by the criteria of the American College of

Rheumatology. (Doc. 21. at 5; AR at 27.) 4

A The ALJ Properly Discounted the Opinion of Treating Physician Dr. Meyer

The opinions of treating doctors are given more weight than the opinion of non-treating

doctors. If a treating doctor’s opinion is not contradicted by another doctor, it may be rejected only

for “clear and convincing” reasons supported by substantial evidence in the record. Lester v. Chater,

81 F.3d 821, 830 (9 Cir. 1995); see also Reddick v. Chater, 157 F.3d 715, 725 (9 Cir. 1998). Even th th

if contradicted by another doctor, the Commissioner may not reject the opinion without providing

specific and legitimate reasons supported by substantial evidence in the record. Lester, 81 F.3d at

830. 

As noted above, in July 2005, Dr. Meyer filed a form concluding that Plaintiff needed

frequent rest periods during the day, could sit less than 30 minutes at a time and for no more than

two to four hours in a day, could stand/walk no more than two to four hours in a day, and that she is

restricted from repetitive hand motion because of pain. AR at 242. Dr. Meyer indicated also that

Plaintiff could only lift 10 pounds occasionally and could never climb, stoop, kneel, crouch or crawl,

and, at best, could reach only occasionally. Id. at 243. 

In according no weight to Dr. Meyer’s opinion, the ALJ stated that her conclusions were

based upon the claimant’s subjective and self-serving allegations. AR at 27. He found her report to

be internally inconsistent, noting that although Dr. Meyer stated that Plaintiff could perform limited

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 Plaintiff does not challenge the ALJ’s credibility finding. As a result, the Court has not addressed this issue

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on appeal. See Sandgathe v. Chater, 108 F.3d 978, 980 (9 Cir. 1997) (per curiam) (holding that when an issue is not th

raised before the district court, it has been waived on appeal to this court). However, if the matter is remanded, new

issues may be raised before the ALJ. See Gonzalez v. Sullivan, 914 F.2d 1197, 1202 (9 Cir. 1990); 20 C.F.R. ss th

404.946(b)(1), 416.1446(b)(1).

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sedentary work, she also stated that she was unable to sit for more than 30 minutes. See id. at 242,

244. 

In Bray v. Commissioner of Social Security Administration, 554 F.3d 1219 (9 Cir. 2009), th

the court held that the opinion of a treating physician was properly discounted where it was based on

the subjective complaints of the Plaintiff and the ALJ determined that those complaints were not

fully credible. See id. at 1228; see also Ukolov v. Barnhart, 420 F.3d 1002, 1005-06 (9 Cir. 2005) th

(rejecting physicians opinion where it is based “solely on [the claimant’s] own ‘perception or

description’ of his problems”);

Here, Dr. Meyer’s report is predicated on the complaints voiced to her by Plaintiff. In regard

to almost each finding, Dr. Meyer prefaces her conclusion by stating it is based on what Plaintiff told

her. See AR at 241-43. She does not cite clinical findings or independent evidence to support her

conclusions. Magallanes v. Bowen, 881 F.2d 747, 751 (9 Cir. 1989) (finding that a brief and th

conclusionary form opinion which lacks supporting clinical findings is a legitimate reason to reject a

treating physician’s conclusion). Nyman v. Heckler, 779 F.2d 528 (9 Cir. 1985) (“Conclusory th

opinions by medical experts regarding the ultimate question of disability are not binding on the

ALJ.”) This fact, along with the ALJ’s determination that Plaintiff’s statements concerning “the

intensity, persistence and limiting effects of these symptoms” were not entirely credible, see AR at 5

25, provide specific and legitimate reasons for discounting Dr. Meyer’s conclusions that are based

upon substantial evidence in the record. 

B. The ALJ Improperly Discounted the Opinions of Dr. Madireddi and Other Physicians

Plaintiff also notes that the ALJ’s RFC assessment is less restrictive than examining

physician Dr. Madireddi. Dr. Madireddi examined Plaintiff in January 2005. She chronicled a series

of maladies to Plaintiff’s neck, left shoulder, upper back, et al., primarily on the left side of her torso

and upper extremity and diagnosed a number of conditions including fibromyalgia, cervical spine

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The name of the author is not clear from the document however the Court notes that this report is contemporaneous to the

functional capacity assessment made by Dr. Pong in February, 2005. The Court cannot discern but believes this report

may be Dr. Pong’s. If so, the ALJ appears to give great weight to Dr. Pong’s conclusion that Plaintiff retains the ability

to perform “light/sed” work but discounts his specific functional capacity findings as well as his diagnosis of

fibromyalgia. See id. at 203-05, 257.

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sprain, positive Spurling’s sign in the neck and possible C5-6 radiculopathy. AR at 201. Based on

these findings, she opined that Plaintiff could sit for six hours in a day, stand/walk six hours in a day,

lift and carry 10 pounds frequently and 15 pounds occasionally, and perform activities such as

bending, stooping, kneeling, crouching and crawling occasionally. Id. These RFC findings were

echoed by a non-examining consultant, Dr. Pong, after his review of the medical records. See id. at

203-05.

As with a treating physician, the opinion of an examining physician is entitled to greater

weight than that of a non-examining physician. Lester, 81 F.3d at 830. The Commissioner must

provide “clear and convincing” reasons for discounting the uncontroverted opinion of an examining

physician and “specific and legitimate” reasons supported by substantial evidence in the record for

discounting the opinion if contradicted by another doctor. Id. at 830-31. To satisfy this burden, the

ALJ must set out “a detailed and thorough summary of the facts and conflicting clinical evidence,

stating his interpretation thereof, and making findings.” Magallanes, 881 F.2d at 751.

Here, the ALJ gave Dr. Madireddi’s diagnosis and functional capacity findings, as well as

those of Dr. Pong, only “limited weight” because he believed their diagnosis of fibromyalgia did not

satisfy the standards of the American College of Rheumatology. AR at 27. The ALJ then stated,

based on his assessment of the medical record in general , that Plaintiff had the ability to lift and 6

carry up to 20 pounds occasionally and, thus, could perform “light” work under the Agency

guidelines. Id.; see 20 C.F.R. § 404.1567(b). 

In Sarchet v. Chater, 78 F.3d 305 (7 Cir. 1996), the Seventh Circuit Court of Appeals, citing th

the American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia: Report

of the Multicenter Criteria Committee, noted that the cause or causes of fibromyalgia are unknown,

that there is no cure and that the symptoms are entirely subjective. Id. at 306. The principle

symptoms are “pain all over,’ fatigue, disturbed sleep, stiffness, and tender spots, more precisely, 18

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fixed locations on the body, of which a patient must have 11 to be diagnosed with the condition. Id. 

To establish a positive trigger point, a patient should flinch when a particular point is pressed firmly. 

Id. The court noted that these symptoms are easy to fake, and further stated that although some

claimants may have such a severe case of fibromyalgia as to be totally disabled from work, “most do

not and the question is whether [this claimant] is one of the minority.” Id. at 307.

The record indicates that Plaintiff was first diagnosed with fibromyalgia by another

examining physician, Dr. Porecha, in his November 1998 record. AR at 97. Although he did not

delineate the 18 trigger points specifically in his report, Dr. Porecha did opine that Plaintiff had

painful myofascial trigger points in the cervical, upper thoracic musculature, greater between the

shoulder blades. Id. at 98. In making this finding, Dr. Porecha cited a work by Dr. Janet Travell,

M.D. entitled “Myofascial Pain and Dysfunction” which describes the trigger points “in specific

patterns characteristic of each muscle.” Id. 

Likewise, in her report Dr. Madireddi noted numerous areas of painful tenderness, including

“the shoulder girdle muscles . . ., the levator scapular, rhomboidius major and minor and the

trapezius” and noted that “the entire area appears to be diffusely tender, consistent with

fibromyalgia.” Id. at 200. Dr. Madireddi also found “tender spots in the lumbar areas L1 to L5 in

the paraspinous region as well as tender areas over the sacroiliac crests, the greater trochanters and

the medial and lateral condyles of the lower extremities.” She stated that”[t]he distributions of these

tender areas along with [Plaintiff’s] depression and insomnia would be consistent with

fibromyalgia.” Id. 

Without more detail, the ALJ’s discounting of these opinions simply because the doctors

failed to checkoff or delineate the 18 trigger points identified by the American College of

Rheumatology, does not satisfy the requirement of citing specific and legitimate reasons supported

by substantial evidence in the record. Here, the ALJ failed to address Dr. Porecha’s diagnosis of

fibromyalgia while discounting the opinions of Drs. Madireddi and Pong. Moreover, the nonexamining consultant’s report relied upon by the ALJ to support his finding that Plaintiff had the

RFC to perform “light” work in the national economy specifically, accepts the fact that Plaintiff has

fibromyalgia. AR at 257. In addition, the ALJ’s general citation to record evidence “between 1999

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and 2003" is also lacking. See Regenniter v. Commissioner of Social Security Administration, 166

F.3d 1294, 1299 (9 Cir. 1999) (“To say that medical opinions are not supported by sufficient th

objective findings or are contrary to the preponderant conclusions mandated by the objective findings

does not achieve the level of specificity our prior cases have required, even when the objective

factors are listed seriatim. The ALJ must do more than offer his own conclusions. He must set forth

his own interpretations and explain why they, rather than the doctors’, are correct.”) 

As a result, the ALJ improperly discounted the RFC assessments of Dr. Madireddi and Dr.

Pong and failed to address Dr. Porecha’s diagnosis. In addition, the Court concludes that his RFC

finding that Plaintiff could perform “light” work under the Agency guidelines is not based on

substantial evidence. See 20 C.F.R. § 404.1567(b). On a more technical point, the Court notes also

that the ALJ’s RFC assessment for “light” work is facially deficient because he included no

assessment as to whether Plaintiff is capable of sitting for six hours in an eight-hour day or whether

she is capable of standing/walking for six hours in an eight-hour day. AR at 24. These findings are

required for application of the guidelines. 

For these reasons, the Court finds that remand to the Commissioner is appropriate. 

McAllister v. Sullivan, 888 F.2d 599, 603 (9 Cir. 1989) [The decision to remand for further th

proceedings or simply to award benefits is within the discretion of the court.] If additional

proceedings can remedy defects in the original administrative proceedings, a social security case

should be remanded. Here, the Court finds that additional proceedings can remedy the defects noted

and therefore remand is appropriate.

As noted, the ALJ has failed to support his RFC finding that Plaintiff could perform “light”

work with substantial evidence. Although, his RFC finding is lacking and insufficient under the

guidelines, the Court notes that most examining physicians, including Drs. Porecha and Madireddi,

and a non-examining consultant, Dr. Pong, indicated that Plaintiff could perform work. In fact, the

RFC findings of both Dr. Madireddi and Dr. Pong are potentially consistent with the ability to

perform “sedentary” work under the guidelines. See 20 C.F.R. § 404.1567(a). For instance, in a

hypothetical propounded by the ALJ based on findings consistent with the opinions of these doctors,

the VE opined that although Plaintiff would be precluded from “light” work, there was other

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“sedentary” work she could perform. See AR at 733-34. Therefore, remand for rehearing is

appropriate. On remand, the ALJ should consider whether further development of the medical

record is appropriate with regard to the findings of Drs. Porecha and Madireddi on the issue of

fibromyalgia. See Mayes v. Massanari, 276 F.3d 453, 459-60 (9 Cir. 2001) (stating that the ALJ th

has a duty to develop the record when there is ambiguous evidence or the record is inadequate to

allow proper evaluation of the evidence).

By remanding this case, the Court does not comment on the propriety of the ALJ’s ultimate

conclusion that Plaintiff was not disabled. However, because the ALJ improperly discounted the

findings of Dr. Madireddi and Dr. Pong and failed to support his RFC findings by specifically

recounting substantial evidence in the record, remand is necessary.

CONCLUSION

Based on the foregoing, this case is HEREBY REMANDED to the Secretary pursuant to 42

U.S.C. § 405(g) for further proceedings consistent with this decision. The Clerk of Court IS

DIRECTED to enter judgment in favor of Plaintiff.

IT IS SO ORDERED.

Dated: February 8, 2010 /s/ Jennifer L. Thurston 

9j7khi UNITED STATES MAGISTRATE JUDGE 

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