United States District Court, E.D. California
PATRICIA J. MASSEY, Plaintiff,
ANDREW M. SAUL, Commissioner of Social Security, Defendant.
ORDER DIRECTING ENTRY OF JUDGMENT IN FAVOR OF
DEFENDANT, ANDREW M. SAUL, COMMISSIONER OF SOCIAL SECURITY,
AND AGAINST PLAINTIFF PATRICIA J. MASSEY
JENNIFER L. THURSTON UNITED STATES MAGISTRATE JUDGE.
Massey asserts she is entitled to supplemental security
income under Title XVI of the Social Security Act. Plaintiff
argues the administrative law judge erred in evaluating the
medical record and seeks judicial review of the decision to
deny her application for benefits. Because the ALJ applied
the proper legal standards and the decision is supported by
substantial evidence in the record, the administrative
decision is AFFIRMED.
February 2014, Plaintiff filed her application for benefits,
in which she alleged disability beginning September 18, 2010,
due to bipolar disorder, depression, anxiety, migraines,
post-traumatic stress disorder, a learning disability, sleep
apnea, COPD, fibromyalgia, neuropathy, and “back pain
(deteriorating disks).” (Doc. 9-5 at 31; Doc. 9-8 at
2-8) The Social Security Administration denied the
applications at the initial level and upon reconsideration.
(Doc. 9-6 at 2-4, 11-16) Plaintiff requested a hearing and
testified before an ALJ on January 10, 2017. (Doc. 9-3 at 17;
Doc. 9-4 at 84) The ALJ determined Plaintiff was not disabled
under the Social Security Act, and issued an order denying
benefits on May 3, 2017. (Doc. 9-3 at 17-28) Plaintiff filed
a request for review of the decision with the Appeals
Council, which denied the request on May 23, 2018.
(Id. at 2-5) Therefore, the ALJ’s
determination became the final decision of the Commissioner
of Social Security.
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 a
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).
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).
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).
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,
Relevant Medical Evidence
Woodrow Wilson performed a consultative examination on June
28, 2012. (Doc. 9-10 at 9) Plaintiff described a history of
migraine headaches beginning in 2009 and rheumatoid arthritis
that was diagnosed in 2010. (Id.) Dr. Wilson
observed that Plaintiff walked with a normal gait; could
“go up on her toes, back on her heels, [and] balance
weight on each foot independently;” and stood from a
chair without difficulty. (Id. at 10) He noted
Plaintiff reported neck pain when she moved her arms, but she
had a full range of motion in her elbows, wrists, hands,
hips, knees, and ankles. (Id.) Dr. Wilson found
“no obvious rheumatoid changes to her hands or
fingers.” (Id.) Plaintiff’s motor
strength was 5/5. (Id. at 11) Dr. Wilson noted
Plaintiff “complained of decreased sensation in the
left toes as compared to the right side” when testing
her sensation to touch, and he was unable to elicit tendon
reflexes in the patella or Achilles on either leg.
(Id.) Dr. Wilson concluded Plaintiff “could
sit for six to eight hours in an eight-hour day” and
“stand and walk probably four to six hours
each.” (Id.) He indicated Plaintiff still had
limits due to a hysterectomy, which was followed by a staph
wound infection, and opined “[s]he could lift only 10
lbs at this point.” (Id.)
7, 2013, Dr. Victor Isaac evaluated Plaintiff upon a referral
“for conservative management” of her pain. (Doc.
9-10 at 79) Dr. Isaac noted Plaintiff complained of
“neck pain and numbness in the right hand and
feet,” and she described her pain as “6/10, dull
aching, [and] constant.” (Id.) He found
Plaintiff’s coordination was intact and she had a
normal range of motion in her cervical spine and neck.
(Id.) Dr. Isaac determined Plaintiff exhibited
trapezius tenderness and had a paraspinal muscle spasm.
(Id. at 80) Dr. Isaac noted Plaintiff’s
medication included Gabapentin, Hydrocodone, Abilify, and
Celexa; and recommended Plaintiff continue with a home
exercise program. (Id. at 79-80)
had an MRI of her cervical spine done on May 10, 2013. (Doc.
9-10 at 43) Dr. John Ross noted “[o]nly sagittal T2
imaging was acquired, before [Plaintiff] terminated the
procedure.” (Id.) According to Dr. Ross,
“[t]he included portions of the brain parenchyma and
cervical cord signal appear[ed] normal” and there was a
“[m]ild loss of lordosis.” (Id.) He
found “[n]o appreciable high-grade spinal/foraminal
narrowing.” (Id.) On May 20, she had another
MRI of the cervical spine, as well as her lumbar spine.
(Id. at 44-45) Dr. Andrew Brittan opined Plaintiff
had a “reversal of [the] normal cervical lordosis which
may be from muscular spasm” and “[a] tiny disc
herniation … at the C7-T1 level.” (Id.
at 44) He found Plaintiff had fluid in the sphenoid sinus,
which was “likely compatible with sinusitis.”
(Id.) Dr. Brittan opined there were “no
abnormalities” at the C3-3, C3-4, C5-6, and C6-7
levels. (Id.) Dr. Brittan also determined Plaintiff
had a “negative…examination of the lumbar spine
without evidence of central or neural foraminal
stenosis.” (Id. at 45)
2013, Plaintiff continued to report “neck pain with
numbness in the right hand and feet.” (Doc. 9-10 at 77)
She also reported having joint stiffness and “[p]ainful
joints.” (Id.) Dr. Isaac opined Plaintiff had
normal range of motion in her neck and shoulder joints;
normal motor strength; and normal stability. (Id.)
Dr. Isaac determined Plaintiff had a normal sensory exam.
(Id.) He again found Plaintiff had a paraspinal
muscle spasm. (Id.) On June 21, Plaintiff had an MRI
of her thoracic spine, which Dr. Landman determined showed a
“minimal bulge” at the T7-8 level and
“[m]inimal disc space narrowing … at T8-9 and
T9-10.” (Id. at 47)
following month, Plaintiff told Dr. Isaac that she did not
feel her medication was helping but denied having any side
effects. (Doc. 9-10 at 75) Dr. Isaac found Plaintiff
continued to have a normal range of motion in her neck and
shoulder joint, normal sensations, and normal strength.
(Id. at 73, 75) Plaintiff reported she had
“some muscle spasm in her upper back,” and Dr.
Issac found she exhibited both paraspinal muscle spasm and
trapezius tenderness. (Id.) Dr. Isaac discontinued
the prescription for Robaxin and issued a new prescription
for Norflex. (Id. at 76)
reported she continued to have upper back pain that she
described as “6/10, dull aching, constant” in
August 2013. (Doc. 9-10 at 71) Dr. Isaac recommended
Plaintiff receive a trigger point injection for her upper
back, and Plaintiff agreed to the treatment. (Id.)
However, the injection was denied by her insurance.
(Id. at 69)
September 2013, Plaintiff had an “acute
exacerbation” of her obstructive chronic bronchitis.
(Doc. 9-11 at 20) She also reported “the muscle relaxer
norflex [was] not working for her neck and shoulder
spasm,” though her pain was “reduced from 9/10 to
6/10 with [the] current dose of lortab.” (Doc. 9-10 at
69) Dr. Isaac found Plaintiff’s shoulder abduction
range of motion was “slightly limited.”
(Id.) He determined Plaintiff had “no
tenderness with palpation of joints, muscle spasm in neck and
upper back.” (Id.) Dr. Isaac opined Plaintiff
had a normal gait, strength, and tone; but her
“sensation [was] diminished in [her] left toes and left
arm.” (Id.) Dr. Isaac discontinued the
prescriptions for Hydrocodone-Acetaminophen and Norflex, and
prescribed Baclofen. (Id. at 70)
Elizabeth Shultz evaluated Plaintiff at the Vanderbilt
Psychiatric Hospital on October 17, 2013, following
Plaintiff’s voluntary admission to the facility. (Doc.
9-10 at 35) During the physical examination, Dr. Shultz
opined Plaintiff’s muscle strength was “5/5
proximally” in her upper and lower extremities,
“but 4 distally.” (Id. at 38) She
also determined Plaintiff’s “light touch
sensation [was] intact grossly.” (Id.)
December 2013, Plaintiff told Daniel Rasbach, NP, that her
back and neck pain had worsened. (Doc. 9-10 at 65) She
believed she had “a pinched nerve in her heck and
[said] that she [had] ‘excruciating pain’ in
[her] right shoulder.” (Id.) She also reported
“having muscle spasms in [her] low back when standing
to do dishes.” (Id.) Plaintiff stated her
depression was “much improved” with the new
medication she received following her hospitalization.
(Id.) Mr. Rasbach opined Plaintiff continued to have
decreased sensation in her right arm and leg. (Id.)
Plaintiff did not appear in acute distress and had “no
tenderness with palpation of joints.” (Id.)