United States District Court, E.D. California
ORDER REGARDING PLAINTIFF’S SOCIAL SECURITY
Mona Lee Scotia (“Plaintiff”) seeks judicial
review of the final decision of the Commissioner of Social
Security (“Commissioner” or
“Defendant”) denying her application for
Supplemental Security Income (“SSI”) benefits
pursuant to Title 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
Erica P. Grosjean, United States Magistrate
Judge. After a review of the administrative
record, the Court finds the ALJ’s decision is proper
and is supported by substantial evidence in the record as a
whole. Accordingly, this Court affirms the agency’s
determination to deny benefits and denies Plaintiff’s
BACKGROUND AND PRIOR PROCEEDINGS
filed an application for SSI on November 30, 2012, alleging a
disability onset date of January 31, 2011. AR
Her application was denied initially on April 15, 2013 and on
reconsideration on October 1, 2013. AR 92-95; 99-102. A
hearing was conducted before Administrative Law Judge
(“ALJ”) Thomas Cheffins on July 10, 2014. AR
40-65. On October 17, 2014, the ALJ issued a decision finding
that Plaintiff was not disabled. AR 22-35. Plaintiff filed an
appeal of the decision with the Appeals Council. AR 20. The
Appeals Council denied her appeal, rendering the order the
final decision of the Commissioner. AR 1-6.
now challenges that decision, arguing that the ALJ’s
decision is not based on substantial evidence in the record
and that the ALJ erred when he found Plaintiff’s
testimony not credible. (Doc. 18, pgs. 5-9). As a result of
this error, Plaintiff argues that the Court should reverse
the ALJ’s decision and remand the case to the Social
Security Administration with instructions to award benefits.
In opposition, Defendant argues that the ALJ’s adverse
credibility findings are supported by substantial evidence.
(Doc. 21, pgs. 4-8).
was 59 years old at the time of the hearing. AR 45. Plaintiff
is 5’6 ½” and weighs about 180 pounds. AR
47. She graduated college in 2010 and has a cosmetology
license. AR 47. Plaintiff most recently worked as a
hairdresser in 2010. AR 48. Plaintiff also worked briefly as
a telemarketer. AR 50-51.
testified that the pain in her lower back, neck, leg/knee,
and feet limits her ability to work. AR 49-54. Plaintiff has
received shots to alleviate the pain in her back and feet. AR
52-53. Plaintiff takes Vicodin when the pain is severe and
Tramadol when the pain is moderate. AR 55. The medication
makes Plaintiff dizzy. AR 55. Plaintiff uses a cane, although
it was not prescribed by a doctor. AR 54-55.
lives with her boyfriend. AR 46. Plaintiff reports that she
has trouble standing, sitting, driving, and lifting objects.
AR 54-55. Plaintiff reports spending most of the day lying
down. AR 55. Plaintiff occasionally reads and uses a
computer. AR 56. Plaintiff asserts that she is unable to do
housework and that her boyfriend does all of the shopping and
chores around the home. AR 55-56. Plaintiff does not drive,
except for emergencies. AR 56.
entire medical record was reviewed by the Court, however,
only evidence that relates to the issues raised in this
appeal is summarized below.
Treating Physician - Thomas Mertins, M.D.
Mertins has been Plaintiff’s primary care physician
since 2010. AR 56-57. Dr. Mertins examined Plaintiff on July
2, 2014 and opined that Plaintiff’s chronic back and
knee pain prevent her from being able to stand or sit for six
to eight hours at a time. AR 310-11. Dr. Mertins noted that
Plaintiff could stand for only ten minutes, walk for 100 feet
without rest, and that Plaintiff’s impairments require
her to lie down during the day. AR 312. Additionally, Dr.
Mertins noted that Plaintiff was rarely able to reach up
above her shoulders, down to her waist, or towards the floor.
AR 312. Lastly, Dr. Mertins opined that Plaintiff was only
able to lift and carry less than five pounds regularly. AR
312. Based on these findings, Dr. Mertins concluded that
Plaintiff was unable to work. AR 313.
of Plaintiff’s cervical spine, taken on June 25, 2014,
showed a slight reversal of cervical lordosis centered at the
C4 to C5 level, moderate narrowing of disc spaces at C3 to C4
and C6 to C7, and some facet arthropathy at C6 to C7. AR 331.
An MRI scan, performed on July 14, 2014, showed multilevel
degenerative disc disease, severe left-sided intervertebral
neural foramina stenosis and impingement on the crossing left
C4 nerve root at C3 to C4, mild to moderate right-sided
intervertebral neural foramina stenosis, and moderate
left-sided intervertebral neural foramina stenosis with
probable impingement on the crossing left C7 nerve root at C6
to C7. AR 387-88.
Treating Physician - Mark Zachary, M.D.
was examined by Dr. Zachary on November 14, 2012. AR 236. Dr.
Zachary found that Plaintiff had a mild decrease in range of
motion of the right knee with pain as well as crepitus and
tenderness in the lateral aspect. AR 237. Dr. Zachary found
Plaintiff’s right knee quadriceps strength to be
decreased, but that she had an intact anterior cruciate
ligament (“ACL”), as well as medial collateral
ligament stability. AR 237. Plaintiff had no effusion,
posterior knee swelling, calf tenderness, or distal edema. AR
237. Dr. Zachary diagnosed Plaintiff with right medial knee
pain with lateral knee degenerative arthritis and lateral
meniscal tear and obesity. AR 238. Dr. Zachary reviewed an
MRI scan of Plaintiff’s right knee, performed on
November 10, 2012, which showed advanced degenerative
changes, displacement of the lateral meniscus from the joint
line, and a complex tear and degeneration of the anterior
horn of the lateral meniscus. AR 237; 280. Dr. Zachary found
that Plaintiff’s symptoms did not seem to correspond
with the MRI’s findings, and as such, Plaintiff was not
a candidate for surgical intervention. AR 238. At the
examination, Plaintiff denied experiencing paranoia,
depression, anxiety or any sleep disturbances. AR 237.
February 7, 2013, Dr. Zachary noted that Plaintiff
“continued to complain of pain on the medial aspect of
the knee, although she is somewhat improved.” AR 296.
Dr. Zachary opined that Plaintiff should “continue knee
strengthening exercises” and “avoid aggravating
factors.” AR 296. On May 29, 2013, Plaintiff presented
as having recurring pain in her knee with difficulty walking.
AR 290. Plaintiff denied any locking, catching, or giving
way. AR 290. On April 10, 2013, Dr. Zachary recommended that
Plaintiff continue with knee exercises and that if symptoms
recurred, Plaintiff should consider Orthovisc injections. AR
294. On September 20, 2013, Dr. Zachary noted that
Plaintiff’s symptoms in her knee were improving after
receiving Orthovisc injections. AR 283. At the examination,
Plaintiff stated that she felt her leg was getting stronger,
and denied any locking, catching, or giving away. AR 283.
However, on March 17, 2014, Dr. Zachary noted that Plaintiff
continued to complain of severe pain in her knee and that
prior steroid and Orthovisc injections were not providing her
relief. AR 277. Dr. Zachary opined that Plaintiff's
choices were to try additional steroid injections or proceed
with arthroscopic surgery. AR 277. Dr. Zachary informed
Plaintiff that there was no guarantee that arthroscopic
surgery of her right knee would provide the pain relief she
was looking for. AR 277. Dr. Zachary explained that
Plaintiff had underlying severe arthritis and would
eventually need a total knee arthroplasty. AR 277. Plaintiff
did not elect to proceed with surgery, preferring instead to
have a less invasive procedure. AR 277. On March 21, 2014,
Dr. Zachary noted that an x-ray showed narrowing of the
lateral joint line and osteophyte formation. AR 275. Dr.
Zachary opined that Plaintiff was a candidate for partial
knee replacement surgery of the lateral compartment. AR 275.
Treating Physician - Jonathan D. Carlson, M.D.
visited Dr. Carlson on March 5, 2013, and again on September
6, 2013, to be evaluated for pain in her left side and back.
AR 262-73. At both examinations, Dr. Carlson observed that
Plaintiff had joint pain, stiffness, muscle weakness, joint
swelling, back pain, muscle aches, and had experienced weight
gain. AR 263; 270. Dr. Carlson noted that Plaintiff had focal
tenderness at the bilateral lumbar paraspinous and pain with
lumbar facet loading maneuvering. AR 264; 269. Dr. Carlson
found Plaintiff to have normal tone and strength at her neck,
spine, and upper and lower extremities. AR 264-65; 269-70.
Dr. Carlson found Plaintiff’s gait and station to be
normal and found that she could undergo exercise testing and
participate in an exercise program. AR 264; 269. Dr. Carlson
performed a mental status exam and determined that Plaintiff
did not suffer from depression or anxiety. AR 265; 270.
denied “tingling, numbness, or weakness” at the
March 5, 2013 examination. AR 270. Dr. Carlson prescribed
Plaintiff a trial period of tramadol. AR 270. An MRI, taken
on September 4, 2013, showed severe disc desiccation, mild
facet arthropathy, mild central canal stenosis, and moderate
neural foramen narrowing at L2 to L3. AR 272. Plaintiff had a
mild symmetrical disc bulge, facet arthropathy, and neural
foramen narrowing at L3 to L4. AR 272. At L4 to L5, Plaintiff
had severe facet arthropathy, moderate central canal
stenosis, and left neural foramen narrowing. AR 272-73. At
the September 6, 2013 examination, Dr. Carlson noted that
Plaintiff stated that she “feels the pain medication
regimen helps to improve activities of daily living.”
AR 266. Dr. Carlson prescribed Plaintiff a trial period of
ketoprofen, hydrocodone, and bilateral L3-S1 facet joint
injections. AR 266. Additionally, Dr. Carlson noted a plan
for Plaintiff to participate in a weight loss regimen and
exercise therapy program. AR 266.
Examining Physician - Mark Dekutoski, M.D.
Dekutoski met with Plaintiff on June 19, 2013 in regards to
Plaintiff’s complaints of constant lower back pain. AR
255-61. Dr. Dekutoski observed that Plaintiff was in no
obvious distress. AR 258. Dr. Dekutoski noted that Plaintiff
was moderately obese, had a significantly deconditioned
forward soft posture, and moved with a myofascial pain
pattern. AR 258. Dr. Dekutoski found Plaintiff to have a
limited range of motion of the lumbar spine, but noted that
Plaintiff did not have pain with facet loading and had no
issues with straight leg raises. AR 258-59. Dr. Dekutoski
found Plaintiff to have full motor strength of the upper and
lower extremities, and that Plaintiff had a normal range of
motion of the thoracic and cervical spine. AR 259-60. Dr.
Dekutoski noted that Plaintiff had a normal gait and station,