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Massey v. Saul

United States District Court, E.D. California

September 17, 2019

ANDREW M. SAUL[1], Commissioner of Social Security, Defendant.



         Patricia 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.


         In 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.


         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 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).

         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[2]

         Dr. 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.)

         On May 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)

         Plaintiff 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)

         In June 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)

         The 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)

         Plaintiff 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)

         In 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)

         Dr. 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.)

         In 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.) Dr. ...

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