Villapudua v. Commissioner of Social Security

          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 ...