United States District Court, E.D. California
FINDINGS AND RECOMMENDATIONS REGARDING
PLAINTIFF'S SOCIAL SECURITY COMPLAINT (ECF NO. 17)
OBJECTIONS DUE WITHIN 21 DAYS
This
matter is before the Court on Plaintiff's complaint for
judicial review of an unfavorable decision by the
Commissioner of the Social Security Administration regarding
her application for Disability Insurance Benefits and
Supplemental Security Income.
At a
hearing on December 3, 2019, the Court heard from the parties
and, having reviewed the record, administrative transcript,
the briefs of the parties, and the applicable law, makes the
following Findings and Recommendations:
I.
Whether the ALJ's Residual Functional Capacity Finding is
Fatally Flawed
Plaintiff
first argues that “The ALJ's Residual Functional
Capacity Finding is Fatally Flawed, ” because it failed
to take into consideration all relevant evidence in the
record and unfairly evaluated the medical opinions of record.
A.
The ALJ's Discussion of the Medical Record
Plaintiff
summarizes various pieces of medical evidence not included in
the ALJ's summary of medical evidence, including
Plaintiff's diagnoses of Chronic Pain Syndrome and
myofascial pain syndrome; clinical findings of
“rigidity and guarding, ” “trigger points,
” “taut bands and jump signs, ” restricted
ranges of motion and radiculopathy (radiated pain) in
Plaintiff's neck and back, positive Gaenslen's and
Patrick's signs; and a cervical MRI showing multilevel
disc bulges from C5 to C7, facet arthrosis from C2 to T1 and
multilevel cervical spondylolysis. (ECF No. 17, at p. 22).
In
response, the Defendant Commissioner summarizes evidence
supportive of the ALJ's RFC, including medical imaging
showing no significant abnormalities; and physical
examinations showing full or nearly full strength, normal
gait, normal reflexes, intact sensation and normal muscle
bulk and tone. Additionally, doctors repeatedly reported that
Plaintiff was well developed, well nourished, not in apparent
distress, and had intact cranial nerves and normal
neurological examinations.
According
to the Ninth Circuit, the decision of the Commissioner must
be upheld if it is supported by substantial evidence and if
the Commissioner applied the correct legal standards.
Pagter v. Massanari, 250 F.3d 1255, 1258 (9th Cir.
2001). Substantial evidence is “more than a mere
scintilla but less than a preponderance; it is such relevant
evidence as a reasonable mind might accept as adequate to
support a conclusion.” Sandgathe v. Chater,
108 F.3d 978, 980 (9th Cir. 1997) (citation omitted). In
making a determination of disability, the ALJ must develop
the record and interpret the medical evidence. See
Crane v. Shalala, 76 F.3d 251, 255 (9th Cir. 1996).
In doing so, the ALJ must consider the “combined
effect” of all the claimant's impairments without
regard to whether any such impairment, if considered
separately, would be of sufficient severity. 20 C.F.R. §
416.923. However, in interpreting the evidence and developing
the record, the ALJ does not need to “discuss every
piece of evidence.” Howard ex rel. Wolff v.
Barnhart, 341 F.3d 1006, 1012 (9th Cir. 2003).
Here,
while the ALJ's summary of the medical evidence does not
include all the evidence cited by Plaintiff, it does not
demonstrate such a bias to render the decision legally
erroneous. The ALJ begins her discussion of the medical
evidence of record by summarizing various pieces of evidence
that show the existence of a medically determinable physical
impairment, as follows:
Over the whole record the claimant has reported experiencing
back pain (6F/6), neck pain (5F/2), and radicular pain
radiating, e.g., over her lower extremities (2F/15). She has
also reported experiencing numbness and tingling over her
upper extremities (6F/4), accompanied by dispersed weakness
(4F/12). She has specifically reported experiencing pain,
numbness, and tingling in her hands and fingers. (4F/11.) She
has also reported experiencing persisting headaches. (1F/2.)
Radiographs have provided a diagnostic basis for at least
some of these reports. For instance, imaging in February 2016
revealed “mild degenerative changes” along the
claimant's cervical spine. (2F/29.) Other imaging on that
occasion also found disc-space narrowing along the
claimant's lumbar spine. (2F/31.) More recent x-rays in
May 2017 also found degenerative changes along the
claimant's lumbar spine. (5F/14.) On clinical examination
sources have objectively noted tenderness along the
claimant's pine (1F/4), and swelling in the
claimant's hands (5F/12). The claimant's straight leg
raise testing has also been positive. (4F/12.) On these bases
sources have diagnosed the claimant with evidence of
degenerative disc disease (4F/2), lumbar radiculopathy
(6F/6), facet arthropathy (6F/4), cervical and lumber
myofascial pain syndrome (4F/9), rheumatoid arthritis
(2F/17), generalized arthritis (2F/4), occipital neuralgia
(4F/13), and migraine headaches (5F/2).
(A.R. 25).
Thus,
while the ALJ did not address certain pieces of medical
evidence that supported Plaintiff's disability claim, the
ALJ addressed evidence both supportive and contrary to
Plaintiff's disability claim. Moreover, substantial
evidence supports the ALJ's determination regarding the
RFC. The Court thus recommends findings that the ALJ's
RFC is not subject to reversal on the basis that the ALJ
unfairly omitted portions of the medical record supportive to
Plaintiff's position.
B.
The ALJ's Rejection of Certain Opinions of
Plaintiff's Treating Physician
Plaintiff
next claims that the ALJ erroneously rejected the opinions of
Dr. Wahid, Plaintiff's treating physician.
In
social security disability cases, “[t]he ALJ must
consider all medical opinion evidence.” Tommasetti
v. Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008).
Generally, the opinion of a treating physician is entitled to
more weight than the opinion of an examining physician, and
more weight is given to the opinion of an examining physician
than a non-examining physician. Ghanim v. Colvin,
763 F.3d 1154, 1160 (9th Cir. 2014). Where a treating
physician's opinion is “well-supported by medically
acceptable clinical and laboratory diagnostic techniques and
is not inconsistent with the other substantial
evidence” in the record, it must be given controlling
weight. 20 C.F.R. § 404.1527(c)(2). The ALJ must provide
clear and convincing reasons, supported by substantial
evidence, for rejecting the uncontradicted opinion of
treating physicians. Ghanim, 763 F.3d at 1160;
see also Thomas v. Barnhart, 278 F.3d 947,
957 (9th Cir. 2002) (holding that ALJ can reject
uncontradicted treating physician's opinion “by
setting out a detailed and thorough summary of the facts and
conflicting medical evidence, stating his own interpretation
thereof, and making findings”) (internal quotation
marks and citation omitted). Where contradicted, the opinion
of treating physicians may be rejected only for
“specific and legitimate reasons that are supported by
substantial evidence.” Ghanim, 763 F.3d at
1160.
Here,
Dr. Wahid's opinions were contradicted by the state
agency medical consultants. (Exhibits 1A, 2A, 5A, 6A). Thus,
this Court looks to whether the ALJ provided specific and
legitimate reasons that are supported ...