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Cook v. Berryhill

United States District Court, E.D. California

July 24, 2017

NANCY A. BERRYHILL[1], Acting Commissioner of Social Security, Defendant.



         Jennifer Elizabeth Cook asserts she is entitled to disability insurance benefits and supplemental security income under Titles II and XVI of the Social Security Act. Plaintiff seeks judicial review of the decision denying her applications for benefits, asserting the administrative law judge erred in evaluating the medical record. Because the ALJ applied the proper legal standards and the decision is supported by substantial evidence in the record, the administrative decision is AFFIRMED.


         Plaintiff filed applications for benefits on July 15, 2013, in which she alleged disability beginning March 1, 2013. (Doc. 11-3 at 17) The Social Security Administration denied the applications at the initial level and upon reconsideration. (Id.; Doc. 11-5 at 2-6, 14-19) Plaintiff requested a hearing and testified before an ALJ on November 6, 2014. (Doc. 11-3 at 17) The ALJ determined Plaintiff was not disabled under the Social Security Act, and issued an order denying benefits on January 30, 2015. (Id. at 14-29) Plaintiff filed a request for review of the decision with the Appeals Council, which denied the request on January 22, 2016. (Id. at 2-5) Therefore, the ALJ's determination became the final decision of the Commissioner of Social Security.


         District courts have a limited scope of judicial review for disability claims after a decision by the Commissioner to deny benefits under the Social Security Act. When reviewing findings of fact, such as whether a claimant was disabled, the Court must determine whether the Commissioner's decision is supported by substantial evidence or is based on legal error. 42 U.S.C. § 405(g). The ALJ's determination that the claimant is not disabled must be upheld by the Court if the proper legal standards were applied and the findings are supported by substantial evidence. See Sanchez v. Sec'y of Health & Human Serv., 812 F.2d 509, 510 (9th Cir. 1987).

         Substantial evidence is “more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197 (1938)). The record as a whole must be considered, because “[t]he court must consider both evidence that supports and evidence that detracts from the ALJ's conclusion.” Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985).


         To qualify for benefits under the Social Security Act, Plaintiff must establish 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 12 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). The burden of proof is on a claimant to establish disability. Terry v. Sullivan, 903 F.2d 1273, 1275 (9th Cir. 1990). If a claimant establishes a prima facie case of disability, the burden shifts to the Commissioner to prove the claimant is able to engage in other substantial gainful employment. Maounis v. Heckler, 738 F.2d 1032, 1034 (9th Cir. 1984).


         To achieve uniform decisions, the Commissioner established a sequential five-step process for evaluating a claimant's alleged disability. 20 C.F.R. §§ 404.1520, 416.920(a)-(f). The process requires the ALJ to determine whether Plaintiff (1) engaged in substantial gainful activity during the period of alleged disability, (2) had medically determinable severe impairments (3) that met or equaled one of the listed impairments set forth in 20 C.F.R. § 404, Subpart P, Appendix 1; and whether Plaintiff (4) had the residual functional capacity to perform to past relevant work or (5) the ability to perform other work existing in significant numbers at the state and national level. Id. The ALJ must consider testimonial and objective medical evidence. 20 C.F.R. §§ 404.1527, 416.927.

         A. Relevant Medical Evidence

         In June 2010, Plaintiff underwent an x-ray of her lumbar spine, which Dr. Dale Van Kirk opined showed “degenerative arthritis of the lumbar spine with degenerative disc disease” at the L4-S1 level. (Doc. 11-9 at 2)

         In May 2012, Plaintiff went to the office of Dr. Narwhals Mating to request a refill of prescription pain medications, reporting the “pills help[ed] her move and do her job.” (Doc. 11-8 at 11) Dr. Mating noted that in the past, Plaintiff had been diagnosed with back pain, chronic pain syndrome, and anxiety. (Id.) Upon examination, Dr. Mating found Plaintiff's “lower back exhibited swelling and tenderness on palpation.” (Id. at 12) Plaintiff also “demonstrated tenderness on palpation” in the thoracolumbar spine, and her “motion was abnormal.” (Id.) Dr. Mating prescribed Plaintiff with Norco, Soma, and Xanax. (Id. at 13)

         In June 2012, Plaintiff continued to have pain, which she described it as “9” on the pain scale. (Doc. 11-8 at 6-7) Dr. Mating noted that Plaintiff had “tenderness on palpation” in her lower back and thoracolumbar spine. (Id. at 7) Dr. Mating again found Plaintiff had abnormal motion in the spine. (Id.)

         In August and September 2012, Plaintiff went to Dr. Mating seeking prescription refills. (Doc. 11-8 at 121, 125) Plaintiff reported that she was worried her insurance would not give her a month's worth of medication. (Id. at 121) She continued to describe her pain level as “9.” (Id. at 126)

         The following month, Plaintiff requested a “jury excuse” from Dr. Mating, who noted Plaintiff was taking “multiple mind altering meds.” (Doc. 11-8 at 118) Dr. Mating observed that Plaintiff's “lower back exhibited swelling, tenderness on palpation of the lower back, and muscle spasm of the back.” (Id. at 119) In addition, her “thoracolumbar spine demonstrated tenderness on palpation and motion was abnormal.” (Id.) Plaintiff described her pain as a “10” to Dr. Mating. (Id.)

         In January 2013, Plaintiff again said the medication helped her to “move and do her job.” (Doc. 11-8 at 110) She said her pain remained a “10.” (Id.) In March 2013, she continued to describe her pain as a “10, ” stating she had “[i]ncreased pain from having to take care of multiple family members.” (Id. at 104) Dr. Mating continued to prescribe Norco, Soma, and Xanax. (Id. at 105)

         Plaintiff told Dr. Mating that she was “[l]ooking for a job” in April 2013. (Doc. 11-8 at 100) She reported the medication continued to help her move. (Id.) Dr. Mating found Plaintiff had a positive Tinel's test on the left side. (Id. at 102)

         On May 7, 2013, Dr. Mating made an addendum to his treatment notes, in which he indicated: “Both father and aunt have seen me on separate occasions and told me that Jennifer is heavily using methamphetamine.” (Doc. 11-8 at 100) In addition, Dr. Mating noted that Plaintiff “had problems with controlled substances at least twice since being under [his] care.” (Id.) On May 8, Dr. Mating noted that Plaintiff tested “positive for methamphetamine and for dilaudid that she [was] not prescribed.” (Id., emphasis omitted) He noted that Plaintiff was “given multiple chances in the past” and opined that Plaintiff “demonstrate[d] no intention to stop her pattern of polysubstance abuse.” (Id., emphasis omitted) As a result, Dr. Mating cancelled Plaintiff's “pain contract” and referred Plaintiff to pain management and psychiatry. (Id.)

         On May 9, 2013, Plaintiff visited Dr. Mating for a prescription refill, and her aunt was also present. (Doc. 11-8 at 94) Plaintiff “denie[d] any problem with drug abuse, ” though she admitted to using meth “three times in the last couple of months.” (Id., emphasis added) Dr. Mating noted that Plaintiff's aunt “strongly contradict[ed]” her, and said Plaintiff was “heavily abusing meth.” (Id., emphasis omitted) Dr. Mating opined the drug test results supported the assertion that Plaintiff was heavily abusing the drugs. (Id.)

         On May 13, 2013, Plaintiff “self admitted cocaine abuse.” (Doc. 11-8 at 91) Dr. Mating opined Plaintiff was “out of control” and recommended daily pickups for her medication “until titrated to zero.” (Id.) On May 17, Dr. Mating noted he discussed Plaintiff with a psychiatrist, who supported the decision to titrate Plaintiff off all controlled substances. (Id. at 61) Plaintiff denied drug abuse and said her problems were “caused by everyone else, ” including Dr. Mating. (Id.) She requested that she be able to transfer the care of the medical director. (Id.)

         In June 2013, Plaintiff was treated by physicians' assistants, to whom she complained of “chronic pain” that was “not controlled on current medications.” (Doc. 11-8 at 71, 78) In addition, Plaintiff complained of pain in her wrists, and had x-rays taken on June 27. (Id. at 43-44) Dr. Narin Siribhadra determined Plaintiff had “[d]egenerative arthritis of both hands especially of the thumbs.” (Id. at 43) In addition, Dr. Siribhadra found Plaintiff's right wrist was normal. (Id. at 44) Dr. Mating continued the titration of her medications and directed that Plaintiff be seen on a weekly basis until the medications were titrated to zero. (Id. at 56) Plaintiff told Dr. Mating that she “may establish care elsewhere.” (Id.)

         On July 1, 2013, Plaintiff exhibited “no interest in medications … that were not addictive.” (Doc. 11-8 at 50) Dr. Mating noted that “[t]he last time [he] stopped her ambien, a Porterville provider immediately restarted it.” (Id.) Dr. Mating stated he would “not collaborate in the inappropriate prescribing of controlled substances, ” and referred Plaintiff to pain management. (Id.) Two days later, Plaintiff went to Sequoia Family Medical Center, seeking “to change providers and establish care” with Dr. Sidhu. (Id. at 131) Dr. Sidhu noted Plaintiff complained of “severe pain to hands” that inferred with her activities daily living. (Id.) Plaintiff also demonstrated tenderness in her back. (Id.) Further, Plaintiff requested refills of her pain medication and ambien, and Dr. Sidhu noted that Dr. Mating had been titrating Plaintiff's medication. (Id.)

         In August 2013, Plaintiff told Dr. Sidhu that she had knee pain. (Doc. 11-9 at 44) The following month, she reported she had pain in both hands, but was “otherwise doing well.” (Id. at 43)

         Plaintiff reported she continued to have pain in her hands on October 4, 2013. (Doc. 11-9 at 40) In addition, Plaintiff described having “major anxiety recently” and an increase in her back pain. (Id.) Dr. Sidhu “okayed” an increase in her prescription for Xanax and a refill of Norco. (Id.) Plaintiff returned to the medical center on October 21 for treatment of a rash, but also reporting that she needed ...

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