United States District Court, C.D. California
MEMORANDUM DECISION AND ORDER
SUZANNE H. SEGAL UNITED STATES MAGISTRATE JUDGE
Campos Bravo (“Plaintiff”) brings this action
seeking to overturn the decision by the Commissioner of the
Social Security Administration (hereinafter the
“Commissioner” or the “Agency”)
denying her application for Supplemental Security Income
(“SSI”). The parties consented, pursuant to 28
U.S.C. § 636, to the jurisdiction of the undersigned
United States Magistrate Judge.
reasons stated below, the decision of the Commissioner is
AND FACTUAL BACKGROUND
filed for Supplemental Security Income (“SSI”)
benefits on April 3, 2013. (AR 140-48). After the application
was denied, (AR 66-71), Plaintiff requested a hearing before
an Administrative Law Judge (“ALJ”). (AR 75). The
ALJ held hearings on October 21, 2014, (AR 41-53), and
February 18, 2015. (AR 22-40). On March 19, 2015, the ALJ
issued an unfavorable decision. (AR 7-21). The Appeals
Council denied review on June 29, 2016. (AR 1-4). This action
followed on August 2, 2016.
Plaintiff's History And Adult Function Report
was born on August 11, 1953. (AR 54). She was slightly more
than fifty-seven and a half years old at the time of her
alleged disability onset date of April 18, 2011.
(Id.). At the time she filed for disability
benefits, Plaintiff lived with her children in an apartment
where she cooked, shopped and did house chores. (AR 58, 141,
172-73). Plaintiff previously worked as a cashier, (AR 48),
and as a yard supervisor “watching kids.” (AR 49,
191-93). She is clinically obese. (AR 14). Plaintiff alleges
that she suffers from back pain, sciatica, arthritis, and
depression. (AR 46, 54, 188).
Adult Function Report dated May 29, 2013, Plaintiff states
that she suffers pain in her back, legs and hands. (AR 179).
According to Plaintiff, she experiences “very painful
spasms in [her] lower back” and pain in her
“knees, hips, hands, [and] ankles.”
(Id.). Plaintiff admits that gets up to feed her
dog. (AR 180). She also does “a little cleaning,
” her “own laundry, ” and waters the grass
and plants. (Id.). Plaintiff further states that she
goes shopping “once or twice a week as needed” to
purchase “food, shampoo, toilet paper, dish soap,
toothpaste.” (AR 182). Plaintiff reported that she
takes the following prescription medication: Ibuprofen
(pain), Pravastatin (cholesterol), Bupropion (depression),
Hydrochlorothiazide (hypertension), and Atenolol
(hypertension). (AR 186).
testified that she suffers constant pain “everywhere,
” but mostly in her back and down through her legs. (AR
46). The pain prevents her from being able to stand or sit
for long periods. (Id.). “Standing hurts too,
” so Plaintiff has to keep “moving a little
bit.” (AR 47). She can stand or walk for fifteen
minutes before she needs to lie down again. (AR 48).
testified at the October 21, 2014 hearing that after filing
for benefits, she moved in with her brother “for
financial reasons, ” where she continues to do
“housework, ” although it may take her a full day
to clean “one little room.” (AR 51-52). At the
February 18, 2015 hearing, Plaintiff stated that she
“just had to move out of Lancaster[, ] so on cold days,
[she's] hurting, ” and on hot days,
“there's more inflammation” and “more
aching.” (AR 33).
Third Party Adult Function Report
29, 2013, Plaintiff's daughter completed a Third Party
Adult Function Report that closely mirrors the Report
completed by her mother on the same date. The Report states
that Plaintiff “is in constant pain[, ] which keeps her
from getting things done” and from sleeping. (AR
170-71). Plaintiff “can't do lifting, bending over,
or a lot of standing.” (AR 171). Plaintiff's
daughter states that she must help her mother get dressed.
(Id.). However, Plaintiff can cook meals “that
can be cooked in the oven or microwave, ” and is able
to do “laundry & washing dishes.” (AR 172).
Plaintiff also goes shopping for food and toiletries,
typically for two hours every couple of weeks. (AR 173).
medical records from Plaintiff's primary care provider,
the Venice Family Clinic (“VFC”), reflect that
Plaintiff sought treatment for various ailments between July
23, 2012 and August 29, 2014 on twelve
occasions. The first three of these visits pre-date
the filing of Plaintiff's SSI Application in April 2013.
Dr. Tarin Molly Koehler, D.O. is listed as Plaintiff's
treating physician for each of these visits, with the
exceptions of the June 25, 2013 and July 29, 2013 consults,
which identify Dr. Analiza Sanchez, M.D. as the provider. (AR
records for the three visits before Plaintiff filed for SSI
benefits -- for July 23, 2012, February 21, 2013, and March
21, 2013 -- reflect that Plaintiff presented with complaints
of hypertension, (AR 242, 245 and 248), but do not reflect
any complaints of back pain. (AR 242-51). Each of these
pre-SSI filing medical records lists Plaintiff's four
“chronic problems” as hypertension,
hyperlipidemia,  depression, and GERD, again without
mention of back pain. (AR 242, 245 and 248). During the July
2012 visit, Plaintiff complained of “pain in joint
involving ankle and foot, ” for which Dr. Koehler
prescribed Ibuprofen. (AR 250). However, that complaint was
not renewed in the February or March 2013 visits.
record for May 13, 2013, the first visit after Plaintiff
filed for SSI benefits, reflects that Plaintiff for the first
time presented with complaints of “persistent”
back pain, which she claimed had begun two years earlier. (AR
239). The May 2013 visit is also the first of only two times
out of all twelve recorded VFC visits that Plaintiff is
documented as presenting with an “antalgic”
gait. However, the May 2013 record further notes
that Plaintiff's “straight leg raise” test,
which determines whether a patient with low back pain has an
underlying herniated disk, was negative. According to
Plaintiff, the pain in her back was a sharp ache, and was
relieved by movement and stretching. (Id.). The
records for this visit reflect that Plaintiff declined a
“PT [physical therapist] or Ortho referral at this
time.” (AR 241). Dr. Koehler “encourage[d] gentle
ROM exercises and conservative therapy.”
(Id.). As with the prior records, the May 2013
record identifies Plaintiff's four “chronic
problems” as hypertension, hyperlipidemia, depression,
and GERD. (AR 239).
11, 2013, an x-ray revealed that Plaintiff had “mild
anterolisthesis of L4 on L5 by approximately 10% of the
vertebral body length and likely bilateral spondylolysis.
L4-5 and L5-S1 facet arthrosis is likely. There is loss of
disc height at the L5-S1 level which is mild. There is mild
generalized osteopenia.” (AR 337).
with the June 25, 2013 visit and consistently thereafter, the
VFC records add “lumbago” to the list of
Plaintiff's “chronic problems.” (AR 283, 287,
292, 302, 308, 315, 319, 323). However, with the sole
exception of the July 29, 2013 visit, (AR 319), none of the
post-May 2013 records reflect that Plaintiff “presented
with” back pain, although she may have discussed back
pain with her provider during the visit. (See AR 323 (6/25/13
visit, presented with depression and for follow up on lab
tests); AR 315 (10/21/13 visit, follow up on lab tests and
hyptertension); AR 308 (11/4/13 visit, cough and
hypertension); AR 302 (11/20/13 visit, hypertension); AR 292
(1/22/14 visit, hypertension); AR 287 (2/24/14 visit, women
progress note and hypertension); and AR 283 (8/29/14 visit,
hyperlipidemia and hypertension)).
25, 2013, Dr. Sanchez discussed treatment options with
Plaintiff for her lumbago, including acupuncture, physical
therapy and “ortho.” (AR 325). Dr. Sanchez
referred Plaintiff to acupuncture after Plaintiff indicated
that that was her preference among the options.
(Id.). Plaintiff was also advised to continue NSAIDs
(nonsteroidal anti-inflammatory drugs, such as Ibuprofen).
(Id.). On July 29, 2013, Dr. Sanchez noted that
although Plaintiff had been referred to acupuncture, she had
not yet heard about the status of the referral. (AR 319).
Treatment for lumbago continued to be a follow-up on the
referral to acupuncture, and “NSAIDs or tylenol for
pain.” (AR 321). On October 21, 2013, Dr. Koehler noted
that a VFC coordinator needed to “help
reschedule” Plaintiff's acupuncture appointments
because Plaintiff had missed the initial appointments. (AR
317). Dr. Koehler prescribed “home exercises” and
“weight loss” to treat the lumbago.
does not appear to be any reference to treatment for
Plaintiff's lumbago in the records for her November 3,
2013 VFC visit. (AR 308-11). However, an attached record
reflects that Plaintiff visited an acupuncture clinic on
October 22, 2013, the day after her prior VFC visit. (AR
314). On November 20, 2013, Dr. Koehler noted that Plaintiff
was “getting some relief w/acupuncture, ” and
consequently, Dr. Koehler elected to “defer Cpain
referral for now.” (AR 304). On January 22, 2014, Dr.
Koehler noted that Plaintiff continued to experience
“some relief w/acupunture.” (AR 294). However,
Dr. Koehler also noted that VFC should refer Plaintiff to
“Cpain clinic via insurance once insurance status
confirmed.” (Id.). On February 24, 2014, Dr.
Koehler elected to “hold [off] on Cpain referral until
[Plaintiff] has reliable transportation (per
[Plaintiff's] request).” (AR 289). Although the
precise dates of the acupuncture sessions are somewhat
obscured as presented in the Administrative Record, it
appears that between October 22, 2013 and January 28, 2014,
inclusive, Plaintiff received acupuncture treatment
approximately eleven times. (AR 291, 296-301, 305-07, 314).
on August 29, 2014, Dr. Koehler specifically noted that
Plaintiff was “applying for SSI” but continued to
experience “improvement w/conservative therapy [for her
lumbago], will cont[inue] w/new clinic.” (AR 285). Dr.
Koehler also observed, for only the second time in the
record, that Plaintiff's gait was antalgic.
(Id.). Also on August 29, 2014, Dr. Koehler
completed a Medical Opinion form in connection with
Plaintiff's SSI claim in which she stated that Plaintiff
had chronic low back pain and opined that Plaintiff could
lift and carry 10 pounds occasionally; less than 10 pounds
frequently; sit for 15 minutes at a time and for about four
hours in an eight-hour day; stand and walk for 15 minutes
each and for less than two hours in an eight-hour day; had to
alternate at will between sitting and standing/walking; had
to lie down at unpredictable times but as often as every
hour; could occasionally twist, crouch, and climb stairs;
could never stoop or climb ladders; had environmental
limitations; and would miss more than three days of work a
month (AR 339-41). Dr. Koehler further stated that the
assessed limitations on Plaintiff's ability to do
work-related activities were supported by Plaintiff's
back spasms, her limited back range of motion, and her June
2013 lumbar spine x-ray, which revealed anterolisthesis at
¶ 4-5 and facet arthrosis with a loss of disc height at
¶ 5-S1. (AR 340). Dr. Koehler noted, however, that
Plaintiff did not use an ambulatory device and reported some
relief with acupuncture. (AR 341).
September 6, 2013, Board-certified internist Dr. Soheila
Benrazavi, M.D., conducted a consultative examination. (AR
15, 271-76). Accordingly to Dr. Benrazavi, Plaintiff stated
that “she thinks that maybe she has arthritis, ”
that the “pain radiates everywhere to the body, ”
and is “worse with walking, standing and
sitting.” (AR 272). Plaintiff listed the drugs she was
taking as “Ibuprofen, ranitidine, hydrochlorothiazide,
lisinopril, atenolol, pravastatin, and
bupropion.” (Id.). Dr. Benrazavi recorded
Plaintiff's height as 5'1” and her weight as
187 pounds without shoes. (Id.).
Benrazavi performed a straight leg raise test, which was
“negative at 90 degrees.” (AR 273). Dr. Benrazavi
also noted that Plaintiff had “[f]orward flexion
45º with pain otherwise normal.” (Id.).
With respect to Plaintiff's hands, Dr. Benrazavi observed
“[v]ery mild osteoarthritic changes . . . in the area
of the right and left fifth digit DIP joints and very small
ones on the right hand at the DIP joint of the middle
finger.” (AR 274). However, Plaintiff was “able
to make a full fist bilaterally” and there was no
swelling or any other joint deformity. (Id.). The
range of motion was normal bilaterally in Plaintiff's
knees, without any swelling, heat, redness or effusion.
(Id.). Plaintiff's ankles also had a normal
bilateral range of motion. (Id.). Dr.