“An ALJ is 23 not required to take medical opinions at face value, but may take 24 into account the quality of the explanation when determining how 25 much weight to give a medical opinion.”
How later courts described this case
- “An ALJ is 23 not required to take medical opinions at face value, but may take 24 into account the quality of the explanation when determining how 25 much weight to give a medical opinion.”
- as 25 amended Apr. 9, 1996
- “[B]lecause the ALJ 23 gave specific, clear and convincing reasons [for discounting plaintiff’s symptom statements], any error in the additional reasons the ALJ provided . . . was harmless.” (citation 25 omitted)
- factors in assessing physician’s 11 opinion include length of treatment relationship, frequency of 12 examination, and nature and extent of treatment relationship
Written by the judges who cited it.
The opinion
1
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8 UNITED STATES DISTRICT COURT
9 CENTRAL DISTRICT OF CALIFORNIA
10
AMANDIP K.,1 ) Case No. EDCV 19-1346-JPR
11
)
Plaintiff, )
12
) MEMORANDUM DECISION AND ORDER
v. ) AFFIRMING COMMISSIONER
13
)
ANDREW SAUL, Commissioner )
14
of Social Security, )
)
15
Defendant. )
16
I. PROCEEDINGS
17
Plaintiff seeks review of the Commissioner’s final decision
18
denying her application for Social Security disability insurance
19
benefits (“DIB”). The matter is before the Court on the parties’
20
Joint Stipulation, filed June 8, 2020, which the Court has taken
21
under submission without oral argument. For the reasons stated
22
below, the Court recommends that the Commissioner’s decision be
23
affirmed.
24
25
26
1 Plaintiff’s name is partially redacted in line with
27 Federal Rule of Civil Procedure 5.2(c)(2)(B) and the
recommendation of the Committee on Court Administration and Case
28 Management of the Judicial Conference of the United States.
1
1 II. BACKGROUND
2 Plaintiff was born in 1976. (Administrative Record (“AR”)
3 167.) She completed high school (AR 171) and worked as a
4 warehouse supervisor (AR 54, 159). On November 13, 2015, she
5 applied for DIB, alleging that she had been unable to work since
6 September 27, 2013 (AR 186), because of back, leg, feet, and neck
7 pain (AR 170).
8 After her application was denied initially (AR 79-82) and on
9 reconsideration (AR 86-91), she requested a hearing before an
10 Administrative Law Judge (AR 92-97). A hearing was held on
11 August 28, 2018, at which Plaintiff, represented by counsel,
12 testified, as did a vocational expert. (AR 31-58.) In a written
13 decision issued September 14, 2018, the ALJ found her not
14 disabled. (AR 12-30.) On September 19, 2018, she requested that
15 the Appeals Council review the ALJ’s decision. (AR 147-49.) On
16 June 6, 2019, the Appeals Council denied her request for review.
17 (AR 1-6.) This action followed.
18 III. STANDARD OF REVIEW
19 Under 42 U.S.C. § 405(g), a district court may review the
20 Commissioner’s decision to deny benefits. The ALJ’s findings and
21 decision should be upheld if they are free of legal error and
22 supported by substantial evidence based on the record as a whole.
23 See Richardson v. Perales, 402 U.S. 389, 401 (1971); Parra v.
24 Astrue, 481 F.3d 742, 746 (9th Cir. 2007). Substantial evidence
25 means such evidence as a reasonable person might accept as
26 adequate to support a conclusion. Richardson, 402 U.S. at 401;
27 Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007). It
28 is “more than a mere scintilla, but less than a preponderance.”
2
1 Lingenfelter, 504 F.3d at 1035 (citing Robbins v. Soc. Sec.
2 Admin., 466 F.3d 880, 882 (9th Cir. 2006)). “[W]hatever the
3 meaning of ‘substantial’ in other contexts, the threshold for
4 such evidentiary sufficiency is not high.” Biestek v. Berryhill,
5 139 S. Ct. 1148, 1154 (2019). To determine whether substantial
6 evidence supports a finding, the court “must review the
7 administrative record as a whole, weighing both the evidence that
8 supports and the evidence that detracts from the Commissioner’s
9 conclusion.” Reddick v. Chater, 157 F.3d 715, 720 (9th Cir.
10 1998). “If the evidence can reasonably support either affirming
11 or reversing,” the reviewing court “may not substitute its
12 judgment” for the Commissioner’s. Id. at 720-21.
13 IV. THE EVALUATION OF DISABILITY
14 People are “disabled” for purposes of receiving Social
15 Security benefits if they are unable to engage in any substantial
16 gainful activity owing to a physical or mental impairment that is
17 expected to result in death or has lasted, or is expected to
18 last, for a continuous period of at least 12 months. 42 U.S.C.
19 § 423(d)(1)(A); Drouin v. Sullivan, 966 F.2d 1255, 1257 (9th Cir.
20 1992).
21 A. The Five-Step Evaluation Process
22 An ALJ follows a five-step sequential evaluation process to
23 assess whether someone is disabled. 20 C.F.R. § 404.1520(a)(4);
24 Lester v. Chater, 81 F.3d 821, 828 n.5 (9th Cir. 1995) (as
25 amended Apr. 9, 1996). In the first step, the Commissioner must
26 determine whether the claimant is currently engaged in
27 substantial gainful activity; if so, the claimant is not disabled
28 and the claim must be denied. § 404.1520(a)(4)(i).
3
1 If the claimant is not engaged in substantial gainful
2 activity, the second step requires the Commissioner to determine
3 whether the claimant has a “severe” impairment or combination of
4 impairments significantly limiting her ability to do basic work
5 activities; if not, a finding of not disabled is made and the
6 claim must be denied. § 404.1520(a)(4)(ii) & (c).
7 If the claimant has a “severe” impairment or combination of
8 impairments, the third step requires the Commissioner to
9 determine whether the impairment or combination of impairments
10 meets or equals an impairment in the Listing of Impairments
11 (“Listing”) set forth at 20 C.F.R., part 404, subpart P, appendix
12 1; if so, disability is conclusively presumed and benefits are
13 awarded. § 404.1520(a)(4)(iii).
14 If the claimant’s impairment or combination of impairments
15 does not meet or equal one in the Listing, the fourth step
16 requires the Commissioner to determine whether the claimant has
17 sufficient residual functional capacity (“RFC”)2 to perform her
18 past work; if so, she is not disabled and the claim must be
19 denied. § 404.1520(a)(4)(iv). The claimant has the burden of
20 proving she is unable to perform past relevant work. Drouin, 966
21 F.2d at 1257. If the claimant meets that burden, a prima facie
22 case of disability is established. Id.
23 If that happens or if the claimant has no past relevant
24
25 2 RFC is what a claimant can do despite existing exertional
26 and nonexertional limitations. § 404.1545(a)(1); see Cooper v.
Sullivan, 880 F.2d 1152, 1155 n.5 (9th Cir. 1989). The
27 Commissioner assesses the claimant’s RFC between steps three and
four. Laborin v. Berryhill, 867 F.3d 1151, 1153 (9th Cir. 2017)
28 (citing § 416.920(a)(4)).
4
1 work, the Commissioner bears the burden of establishing that the
2 claimant is not disabled because she can perform other
3 substantial gainful work available in the national economy, the
4 fifth and final step of the sequential analysis.
5 §§ 404.1520(a)(4)(v), 404.1560(b).
6 B. The ALJ’s Application of the Five-Step Process
7 At step one, the ALJ found that Plaintiff had not engaged in
8 substantial gainful activity since September 27, 2013, the
9 alleged onset date. (AR 17.) Her date last insured was December
10 31, 2019. (Id.) At step two, she determined that Plaintiff had
11 severe impairments of “degenerative disc disease of the lumbar
12 spine,” “spondylosis with sciatica,” and “bilateral venous
13 insufficiency.” (Id.) She concluded that her depression was not
14 severe because it did “not cause more than minimal limitation in
15 [her] ability to perform basic mental work activities.” (AR 18.)
16 At step three, she found that Plaintiff’s impairments did not
17 meet or equal any of the impairments in the Listing. (AR 18-19.)
18 At step four, she determined that she had the RFC to perform
19 light work except that she could not “push or pull with the right
20 lower extremity”; could “occasionally climb ramps and stairs,”
21 “stoop, kneel, crouch and crawl”; could “never climb ladders,
22 ropes, or scaffolds”; and was “limited to simple tasks due to
23 pain.” (AR 19.) The ALJ concluded that Plaintiff was unable to
24 perform her past relevant work but could work as a hotel
25 housekeeper, cashier II, or fast-food worker, positions that
26 “exist[ed] in significant numbers in the national economy.” (AR
27 25; see AR 24-26.) Accordingly, she found her not disabled. (AR
28 26.)
5
1 V. DISCUSSION
2 Plaintiff alleges that the ALJ erred in assessing her RFC
3 and her symptom statements. (See J. Stip. at 4-9, 15-18.) For
4 the reasons discussed below, remand is not warranted.
5 A. Medical Opinions and Evidence
6 1. Wayne Cheng
7 On April 24, 2013, Plaintiff saw Dr. Wayne Cheng,3
8 complaining of “[r]ight thigh pain.” (AR 283.) Dr. Cheng noted
9 that she had done well “from [a] 3 level” lumbar fusion in 2010
10 but “now ha[d] right hamstring, piriformis4 and lateral thigh
11 pain” (AR 284); “lying down” provided her “[o]nly relief” (id.).
12 He instructed her to “try [C]elebrex”5 and physical therapy.
13 (Id.)
14 Plaintiff reported on June 17, 2013, that “a few sessions”
15 of physical therapy “did not help,” she “did not take the
16 Celebrex due to insurance reasons,” she was in “so much pain she
17 [couldn’t] function, she [was] embarrassed at work” because “she
18
19
3 Dr. Cheng primarily practices spine surgery. See Cal.
20 Dep’t Consumer Aff. License Search, https://search.dca.ca.gov
(search for “Wayne” with “Cheng” under “License Type,”
21
“Physicians and Surgeons”) (last visited Feb. 22, 2021).
22
4 The piriformis muscle is a flat, bandlike muscle located
23 in the buttocks near the top of the hip joint. See Piriformis
Syndrome, WebMD, https://www.webmd.com/pain-management/guide/
24 piriformis-syndrome-causes-symptoms-treatments#1 (last visited
Feb. 22, 2021).
25
26
5 Celebrex is name-brand celecoxib, a nonsteroidal anti-
inflammatory used to relieve pain, tenderness, swelling, and
27 stiffness caused by arthritis and spondylitis. See Celecoxib,
MedlinePlus, https://www.medlineplus.gov/druginfo/meds/
28 a699022.html (last visited Feb. 22, 2021).
6
1 [was] always in pain,” “she [was] in her bed” “[w]hen . . . not
2 at work,” her “leg . . . at times ‘fe[lt] like [it was] broken,’”
3 and she was “sedentary [and did] not exercise due to the pain.”
4 (AR 296.) A new MRI of her lumbar spine and an EMG and bone scan
5 of her right lower leg were ordered. (AR 297.)
6 On July 3, 2013, Plaintiff complained of “right buttock
7 pain, right thigh pain and pain in the middle of her right shin
8 and now starting in her left shin.” (AR 302.) It was “worse
9 with sitting/standing/walking,” but she found “relief with lying
10 down” and with “Norco/[L]ortab.”6 (Id.) Plaintiff had “[n]o
11 pain” with the FABERE test.7 (AR 303.) A physician’s assistant
12 noted that Dr. Cheng had reviewed a June 25 bone scan and MRI and
13 that they showed a “[s]mall posterior disc bulge at L2-3 and
14 right foraminal disc bulge at L3-4.” (Id.) Physical therapy and
15 a Flector patch8 were prescribed. (AR 304.)
16 Plaintiff saw Dr. Cheng’s physician’s assistant on October
17 21, 2013, for “follow up on her bilateral lower extremity pain.”
18
19 6 Norco and Lortab are opioid-based medications for treating
moderate to severe pain, consisting of hydrocodone and
20 acetaminophen. See Norco, WebMD, https://www.webmd.com/drugs/
2/drug-63 /norco-oral/details (last visited Feb. 22, 2021);
21
Hydrocodone-Acetaminophen, WebMD, https://www.webmd.com/drugs/2/
22 drug-251/hydrocodone-acetaminophen-oral/details (last visited
Feb. 22, 2021).
23
7 The Patrick, or FABERE, test measures pain or dysfunction
24 in the hip and sacroiliac joints. Patrick Test, The Free
Dictionary, http://medical-dictionary.thefreedictionary.com/
25
Patrick+test (last visited Feb. 22, 2021).
26
8 Flector is a brand of diclofenac-transdermal patch used to
27 treat pain from minor strains, sprains, and bruises. Diclofenac
Transdermal Patch, MedlinePlus, https://medlineplus.gov/
28 druginfo/meds/a611001.html (last visited Feb. 22, 2021).
7
1 (AR 210.) She “denie[d] any back” pain and reported that “her
2 right lateral thigh pain ha[d] improved” with physical therapy
3 and that “the compression stockings . . . ha[d] really helped her
4 leg pain,” but “[s]he continue[d] to have bilateral shin pain.”
5 (Id.) She was encouraged to follow up with another doctor
6 concerning “possible venous insufficiency,” have an “EMG
7 completed,” and get a “second opinion [about] her back.” (AR
8 211.)
9 On November 27, 2013, Plaintiff saw Dr. Cheng for “follow up
10 on her bilateral lower extremity pain.” (AR 212.) He noted that
11 she had done “fine for a couple of years” following her 2010
12 lumbar fusion. (Id.) She reported that in the “last year her
13 leg pain ha[d] been progressively getting worse” and that she had
14 “not been able to work due to her pain.” (Id.) She “denie[d]
15 any back” pain and reported that “her right lateral thigh pain
16 ha[d] improved” with physical therapy, but she “continue[d] to
17 have bilateral shin pain.” (Id.) She was being treated for
18 “possible venous insufficiency” and had been wearing the
19 recommended compression stockings, which “really helped her leg
20 pain out.” (Id.) Dr. Cheng noted that the June 25, 2013 MRI
21 showed “[i]nterval placement of anterior stabilization hardware
22 and disc spacers at L3-4, L4-5, and L5-S1” and a “[s]mall
23 posterior disc bulge at L2-3 and right foraminal disc bulge at
24 L3-4,” but “[n]o central spinal stenosis or significant neural
25 foraminal narrowing.” (AR 213.) He diagnosed “[n]europathy,”
26 “[l]ow back pain radiating to both legs,” “[l]umbar spondylosis,”
27 “[d]egenerative disc disease,” and “[l]umbago.” (Id.) He opined
28 that her “bilateral leg pain [was] not coming from her back” and
8
1 that “no further surgical intervention [was] warranted.” (AR
2 214.) He encouraged her to follow her treatment for “possible
3 venous insufficiency” and “start on [L]yrica9 . . . for pain.”
4 (Id.) He also “discussed [a] spinal cord stimulator” with her,
5 but she “really [did] not want anything foreign in her body.”
6 (Id.)
7 Plaintiff reported on January 27, 2014, that she
8 “continue[d] to have bilateral shin pain,” the “compression
9 stockings . . . [had] only helped out for a little,” “Lyrica
10 . . . [had] not help[ed],” “she felt depressed and tired,” and
11 “she ha[d] been out of work . . . for 4 months due to her leg
12 pain.” (AR 217.) But she “denie[d] any back” pain. (Id.) The
13 physician’s assistant noted that the EMG “show[ed] neuropathy vs
14 [p]olyneuropathy”; Plaintiff had “min[imum b]ack pain,” and the
15 “[m]ajority of [her] pain [was] from [her] legs.” (AR 218.) The
16 physician’s assistant “suggest[ed that she] start on [L]yrica”
17 and “discussed [a] spinal cord stimulator” with her. (Id.) A
18 new MRI of the lumbar spine was ordered “to rule out spinal
19 stenosis,” and she was referred “to pain management for a spinal
20 stimulator” and instructed to “be off work for another 6 weeks.”
21 (AR 219.)
22 2. Gilbert P. Eng
23 Plaintiff saw Dr. Gilbert P. Eng10 on May 7, 2013, for a
24
9 Lyrica treats pain and certain types of seizures. See
25
Lyrica, WebMD, https://www.webmd.com/drugs/2/drug-93965/
26 lyrica-oral/details (last visited Feb. 22, 2021).
27 10 Dr. Eng primarily practices internal medicine. See Cal.
Dep’t Consumer Aff. License Search, https://search.dca.ca.gov
28 (continued...)
9
1 “[r]outine general medical examination.” (AR 292.) He diagnosed
2 “[e]sophageal reflux,” “[l]umbago,” “[d]egenerative disc
3 disease,” and “[o]besity, unspecified.” (AR 290.) He noted that
4
she was currently prescribed Celebrex, Nexium,11 and Lortab
5 (id.); he ordered a urinalysis and blood work (AR 292).
6 3. Lucas Korcek
7
Plaintiff saw Dr. Lucas Korcek12 on August 26, 2013,
8 complaining of “pain in [her right] buttocks, [right] thigh[,]
9 and [both] shins.” (AR 308.) She reported that her “[p]ain
10 [was] focused mostly over” her bilateral “anterior lower leg” and
11 was “aggravated with standing/walking and relieved with rest.”
12 (Id.) She got “relief with lying down” and with “Norco/[L]ortab”
13 and “denie[d] any associated back pain/leg weakness/decreased leg
14 sensation/edema.” (Id.) An examination that day showed “[n]o
15 pain” with the FABERE test, “[n]o sensory deficits” in the
16 bilateral lower extremities, “[n]o edema,” “2+” foot pulses, and
17 “5/5 hip flexion/knee extension/ankle dorsiflexion/great toe
18 extension/ankle planar flexion” bilaterally. (AR 309.) Dr.
19 Korcek noted that there was “[n]o clear etiology for
20
10 (...continued)
21
(search for “Gilbert P.” with “Eng” under “License Type,”
22 “Physicians and Surgeons”) (last visited Feb. 22, 2021).
23 11 Nexium treats stomach and esophagus problems by
decreasing the amount of acid made by the stomach. See Nexium
24 Capsule, Delayed Release, WebMD, https://www.webmd.com/drugs/
2/drug-20536/nexium-oral/details (last visited Feb. 22, 2021).
25
26
12 Dr. Korcek primarily practices orthopedic surgery. See
Cal. Dep’t Consumer Aff. License Search, https://
27 search.dca.ca.gov (search for “Lucas” with “Korcek” under
“License Type,” “Physicians and Surgeons”) (last visited Feb. 22,
28 2021).
10
1 [Plaintiff’s] pain,” prescribed stretching exercises and
2 swimming, gave her a “temporary 4 hour work restriction,” and
3 referred her to a sports-medicine doctor and a pain-management
4 clinic. (AR 310.)
5 4. Cole W. Robinson
6
On September 5, 2013, Plaintiff saw Dr. Cole W. Robinson,13
7 complaining of “bil[ateral] leg pain” and “left>right anterior
8 shin leg pain” that had started one year before after exercising
9 and “would resolve with rest/massage[] and raising the limb.”
10 (AR 314.) She reported that the pain “always resolve[d] after 1-
11 2 hours” and “seem[ed] to radiate proximally to the lateral
12 portion of her left knee, but . . . the radiating pain was not
13 severe.” (Id.) She had “stopped walking for exercise,” but “the
14 pain [was] now present with the activities associated with her
15 job.” (Id.) Dr. Robinson noted that her “presentation [was]
16 most consistent with chronic anterior compartment syndrome” and
17 instructed her to return “for compartment pressure measurements
18 . . . before and after exercise.” (AR 316.)
19 5. Christopher M. Jobe
20 On September 17, 2013, Plaintiff saw Dr. Christopher M.
21
Jobe,14 who noted that “[a]fter reviewing [her] symptoms and
22
23 13 Dr. Robinson primarily practices pain medicine. See Cal.
Dep’t Consumer Aff. License Search, https://search.dca.ca.gov
24 (search for “Cole W.” with “Robinson” under “License Type,”
“Physicians and Surgeons”) (last visited Feb. 22, 2021).
25
26
14 Dr. Jobe primarily practices orthopedic surgery. See
Cal. Dep’t Consumer Aff. License Search, https://
27 search.dca.ca.gov (search for “Christopher M.” with “Jobe” under
“License Type,” “Physicians and Surgeons”) (last visited Feb. 22,
28 (continued...)
11
1 physical exam, [he] believ[ed] that her problem [was] venous
2 congestion in the legs.” (AR 209; see AR 321.) He instructed
3 her to use compression stockings. (AR 209, 321.)
4 6. Gurvinder Uppal
5 On October 22, 2013, Plaintiff saw othopedist Gurvinder
6 Uppal for low-back pain. (AR 455.) Dr. Uppal noted that an MRI
7 before her fusion surgery showed “a herniated disc at L3-4 [and]
8 L4-5 and collapse of the L5-S1 disc space.” (Id.) An MRI
9 performed after the surgery showed “adequate position of the
10 hardware.” (Id.) A bone scan was “negative for any fractures or
11 infections.” (Id.) Plaintiff reported that she was taking “six+
12 Norco or Lortab a day” when she was working, but since she was no
13 longer working she was “tak[ing] maybe one.” (Id.) She had
14 “normal balance” and “[n]o gross muscle weakness.” (Id.) An
15 examination showed “60 degrees of flexion and 10 degrees of
16 extension,”15 a negative straight-leg-raise test,16 and “5/5”
17 muscle strength of the ankle dorsi, plantar flexors, quadriceps,
18
19
20
14 (...continued)
21
2021).
22
15 Normal lumbar-spine range of motion is 60 degrees of
23 flexion and 25 degrees of extension. See Range of Motion,
Chiro.Org, https://chiro.org/forms/romchiro.html (last visited
24 Feb. 22, 2021).
25 16 A straight-leg-raise test involves mechanical
26 manipulation of the legs, stressing the neurological tissues in
the spine; specific symptoms reported at different degrees of
27 flexion can indicate nerve compression. See The Pain Clinic
Manual 44-45 (Stephen E. Abram & J. David Haddox eds., 2d ed.
28 2000).
12
1 and iliopsoas.17 (AR 456.) Dr. Uppal instructed her to continue
2 stretching exercises and noted that he was “placing her on
3 temporary disability.” (Id.)
4 Dr. Uppal noted at a March 25, 2014 follow-up visit that
5 Plaintiff had “had EMG/NCV studies done” that were “consistent
6 with abnormalities, but not diagnostic.” (AR 457.) He opined
7 that the abnormalities were “consistent with changes from [her]
8 previous surgery.” (Id.) She had “normal balance” and “[n]o
9 gross muscle weakness.” (Id.) She exhibited “spasms” “[o]n
10 examination.” (Id.) But she had “60 degrees flexion and 10
11 extension”; a negative straight-leg-raise test; and “5/5” muscle
12 strength in the ankle dorsi, plantar flexors, quadriceps, and
13 iliopsoas. (Id.) Dr. Uppal noted that he was “giving her a
14 disability note for six months” and that he didn’t “feel she
15 [could] go back to work” because she was “on pain medicine and
16 [was] having significant spasms in her low back.” (AR 458.)
17 On September 23, 2014, Plaintiff saw Dr. Uppal for low-back
18 and “bilateral buttock pain.” (AR 459.) She had “normal
19 balance” and “[n]o gross muscle weakness.” (Id.) She again
20 exhibited “60 degrees flexion and 10 extension”; a negative
21 straight-leg-raise test; and “5/5” muscle strength in the ankle
22 dorsi, plantar flexors, quadriceps, and iliopsoas. (Id.) Dr.
23 Uppal instructed her to “[c]ontinue home stretching exercises”
24 and noted that “[s]he [was] placed on disability.” (AR 460.)
25
26
17 The iliopsoas muscle is part of a group of muscles known
27 as the hip flexors. See Hip Flexor Strain — Aftercare,
MedlinePlus, http://www.nlm.nih.gov/medlineplus/ency/
28 patientinstructions/000682.htm (last visited Feb. 22, 2021).
13
1 During a February 10, 2015 follow-up visit, Plaintiff
2 reported that she was “having more and more back and leg pain” in
3 the “low back, posterior buttock, thigh, calf[, and] all the way
4 to the feet.” (AR 461.) Examination again showed “normal
5 balance,” “[n]o gross muscle weakness,” “60 degrees flexion and
6 10 extension,” a negative straight-leg-raise test, and “5/5”
7 muscle strength in the ankle dorsi, plantar flexors, quadriceps,
8 and iliopsoas. (Id.) Dr. Uppal recommended a “CAT scan to
9 evaluate if there [was] any stenosis and spondylosis.” (AR 462.)
10 He gave “her an off work note for another four weeks,” noting
11 that he did “not feel she [could] do any significant bending,
12 stooping, [or] lifting” and that she was “on Norco which causes
13 further depression and lack of concentration.” (Id.)
14 Dr. Uppal noted during a May 12, 2015 follow-up visit that a
15 report of a recent “myelogram and CAT scan of the lumbar spine”
16 showed “a 3 mm bulging disc at . . . L2-3.” (AR 463.) He opined
17 that “the reason she [was] having pain [was] because of adjacent
18 level degenerative changes because she ha[d] had L3-4, L4-5 and
19 L5-S1 decompression and fusion.” (Id.) Her examination findings
20 were unchanged, except she had a positive straight-leg-raise
21 test. (AR 463-64.) Dr. Uppal noted that he wanted to see the
22 films from the myelogram and CAT scan and that she was “continued
23 on her disability.” (AR 464.)
24 On June 9, 2015, Dr. Uppal found that the “CAT scan
25 myelogram” showed “no significant stenosis.” (AR 465.)
26 Plaintiff’s examination showed “60 degrees of flexion and 10
27 degrees of extension,” a negative straight-leg-raise test, and
28 “5/5” muscle strength in the ankle dorsi, plantar flexors,
14
1 quadriceps, and iliopsoas. (Id.) Dr. Uppal referred her to a
2 pain-management specialist, noting that she had “some thickening
3 of the ligamentum flavum” but “no significant stenosis.” (Id.)
4 He stated that “if her symptoms [got] much worse . . . she
5 [would] be a candidate for posterior decompression and fusion.”
6 (Id.) But the “risk benefit ratio [was] not [yet] in her favor.”
7 (Id.) He “continued [her] on disability” “because she [was] on
8 pain medication,” “it causes too much drowsiness,” and “she
9 [couldn’t] really take” doing “a lot of activities such as
10 bending, stooping, [and] lifting.” (Id.)
11 Dr. Uppal noted during a September 8, 2015 follow-up visit
12 that Plaintiff was “trying to hold off” on back surgery. (AR
13 466.) Her examination findings were unchanged except she had a
14 positive straight-leg-raise test. (Id.) Dr. Uppal recommended
15 that she undergo epidural injections. (AR 467.)
16 Plantiff reported on December 8, 2015, that she had not had
17 the injections because of a communication issue with scheduling
18 them. (AR 468.) Dr. Uppal noted that her “stenosis at L2-3” was
19 “junctional due to stress transference.” (Id.) Her straight-
20 leg-raise test was negative, and the other examination findings
21 were unchanged. (Id.) Dr. Uppal again recommended that she
22 undergo epidural injections and “kept [her] on temporary total
23 disability for another three month[s].” (Id.)
24 On March 8, 2016, Plaintiff reported that she “never
25 underwent her epidurals because she had [a] urinary tract
26 infection.” (AR 470.) Dr. Uppal noted that an “[e]xamination of
27 [her] back reveal[ed] spasms”; she had “40 degrees of flexion and
28 10 degrees of extension”; the straight-leg-raise test was
15
1 positive; muscle strength was “5/5” for the ankle dorsi, plantar
2 flexors, quadriceps, and iliopsoas; and there was “tenderness
3 over the screw tops” hardware from her surgery. (Id.) He
4 recommended “a lumbar corset on an as needed basis” and gave her
5 an “off-work note,” noting that he did “not feel she [was] going
6 to return back to work.” (AR 470-71.)
7 Dr. Uppal noted during a May 24, 2016 follow-up visit that
8 Plaintiff’s “symptoms [were] more due to scarring around the
9 nerves,” “she should get into pain management,” and she “may need
10 to have a switch of her medications.” (AR 472.) Examination
11 showed “tenderness over the screw tops,” “60 degrees of flexion
12 and 10 degrees of extension,” positive right- and negative left-
13 straight-leg-raise test, and a negative FABERE test, “which
14 indicate[d] no hip pathology.” (Id.) Dr. Uppal recommended pain
15 management and physical therapy and noted that he would
16 “recommend . . . remov[ing] the hardware” if those measures
17 failed and she had “unacceptable symptoms.” (Id.) Plaintiff
18 “wish[ed] to hold off at [that] point.” (Id.)
19 7. Ook Kim
20 On December 17, 2013, Plaintiff saw Dr. Ook Kim18 for a
21 medication refill and to reestablish care. (AR 214.) Plaintiff
22 reported her pain as “5 on a scale of 0-10.” (AR 215.) Dr. Kim
23 noted that her “[d]aily physical functioning” was “good,” and her
24 “[e]motional functioning” was “excellent.” (Id.) She was being
25
26
18 Dr. Kim primarily practices internal medicine. See Cal.
27 Dep’t Consumer Aff. License Search, https://search.dca.ca.gov
(search for “Ook” with “Kim” under “License Type,” “Physicians
28 and Surgeons”) (last visited Feb. 22, 2021).
16
1 “maintained on Lortab 7.5/500 3 tab(s) a day” (id.); she “[u]sed
2 to take 5 tabs a day while working” but no longer needed to since
3 being at home (id.). Dr. Kim found her “[l]umbar spondylosis”
4 “[p]ain controlled” with her medication and instructed her to
5 return in three months. (AR 216.)
6 Plaintiff saw Dr. Kim on July 1, 2014, for a medication
7 refill. (AR 222.) She again rated her pain as “5/10,” her daily
8 physical functioning as “good,” and her emotional functioning as
9 “excellent.” (Id.) An examination showed “no low back
10 tenderness” and “normal, atraumatic” extremities with “no
11 cyanosis or edema.” (AR 223.) Dr. Kim noted “[n]o evidence[] of
12 radiculopathy” and found Plaintiff’s lumbar spondylosis
13 “[c]ontrolled.” (AR 225.) She adjusted the dosage of her Norco
14 and started her on nortriptyline.19 (Id.)
15 On October 16, 2014, Plaintiff saw Dr. Kim for a medication
16 refill and leg pain. (AR 232.) She denied any side effects from
17 her medications; reported her pain as “1 on a scale of 0-10”; and
18 said her daily physical functioning and social and emotional
19 functioning were “excellent.” (AR 233.) Dr. Kim found her
20 lumbar spondylosis “[c]ontrolled” and renewed her Norco
21 prescription. (AR 234-35.)
22 Plaintiff returned to Dr. Kim on February 19, 2015, for
23 another medication refill (AR 235) and reported that she had
24
19 Nortriptyline treats depression. See Nortriptyline HCL,
25
WebMD, https://www.webmd.com/drugs/2/drug-10710/
26 nortriptyline-oral/details (last visited Feb. 22, 2021). It is
occasionally used for treating neuropathic pain. See
27 Nortriptyline for Neuropathic Pain in Adults, NCBI, https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC6485407/ (last visited Feb.
28 22, 2021).
17
1 “been well” (AR 236). She rated her pain as “5 on a scale of 0-
2 10” and said her social and emotional functioning was “good” and
3 her daily physical functioning was “fair.” (Id.) Dr. Kim
4 assessed her lumbar spondylosis as “[c]ontrolled,” continued her
5 on her medication regimen, and instructed her to “[f]ollow up
6 with orthopedics.” (AR 237.)
7 On June 15, 2015, Plaintiff denied back pain and rated her
8 right-leg pain as “5-7/10” and her back pain as “1 on a scale of
9 0-10.” (AR 242.) She said her social and emotional functioning
10 was “good” and her daily physical functioning was “fair due to
11 right buttock pain.” (Id.) On examination, Dr. Kim noted that
12 she had “moderate tenderness to palpation of the right buttock
13 around the ischial tuberosity,”20 her straight-leg-raise and
14 FABERE tests were negative, and the neurological findings were
15 normal. (AR 243.) Dr. Kim noted that Kenalog21 injections would
16 be scheduled for her right-buttock pain. (AR 244.)
17 Plaintiff underwent a Kenalog injection on July 15, 2015.
18 (AR 246.) On August 13, 2015, she reported to Dr. Kim that
19 “[h]er pain got better for a week” after the injection, but it
20 had returned. (AR 247.) She rated her right-buttock pain as “5-
21 7/10” (id.) and her back pain as “1 on a scale of 0-10” (AR 248).
22
23 20 The ischial tuberosity is a rounded bone that extends
from the ischium — the curved bone that makes up the bottom of
24 the pelvis. See Everything You Need to Know About Your Ischial
Tuberosity, Healthline, https://www.healthline.com/health/
25
ischial-tuberosity (last visited Feb. 22, 2021).
26
21 Kenalog is name-brand triamcinolone acetonide, a
27 corticosteroid hormone that decreases swelling. See Kenalog-40
Vial, WebMD, https://www.webmd.com/drugs/2/drug-9275/
28 kenalog-injection/details (last visited Feb. 22, 2021).
18
1 An examination showed “moderate tenderness to palpation of the
2 right buttock around the ischial tuberosity” and “moderate
3 tenderness to palpation of both . . . low[er] legs” but “no
4 swelling, erythema, or warmth.” (AR 249.) Straight-leg-raise
5 and FABERE tests were negative, and the neurological examination
6 was normal. (Id.)
7 On September 10, 2015, Plaintiff rated her right buttock,
8 leg, and back pain as “3/10.” (AR 252.) She reported her social
9 and emotional functioning as “good” and her daily physical
10 functioning as “fair.” (Id.) Dr. Kim noted for both Plaintiff’s
11 lumbar spondylosis and her right-leg pain that her “current
12 medical regimen [was] effective.” (AR 254.)
13 During a January 4, 2016 followup, Plaintiff rated her pain
14 as “3 on a scale of 0-10” and denied any side effects from her
15 medication. (AR 262.) Dr. Kim found that her “current medical
16 regimen [was] effective,” instructed her to “continue [the] plan
17 and medications,” and added “axial muscle-strengthening
18 exercises.” (AR 264.)
19 Plaintiff saw Dr. Kim for a medication refill on March 18,
20 2016. (AR 504.) She rated her pain as “3 on a scale of 0-10”
21 and denied any side effects from her medication. (AR 505.) Dr.
22 Kim assessed her “medical regimen” as “effective” and instructed
23 her to “continue [the] plan and medications.” (AR 507.)
24 On April 15, 2016, Plaintiff again rated her pain as “3 on a
25 scale of 0-10.” (AR 514.) She reported that Dr. Uppal had
26 recommended that the hardware from her previous back surgery be
27 removed. (Id.) Dr. Kim again noted that her “current medical
28 regimen” for her lumbar spondylosis was “effective” and
19
1 instructed her to follow up with Dr. Uppal. (AR 516.)
2 Plaintiff saw Dr. Kim for a followup on her back pain and
3 radicular right-leg pain on July 20, 2016. (AR 540.) She rated
4 her pain as “2 on a scale of 0-10.” (AR 541.) Dr. Kim noted
5 that “Dr. Chen[g] . . . [didn’t] recommend surgery.” (Id.) A
6 neurological examination showed normal findings except “0+” on
7 the right-achilles deep-tendon reflexes and “[d]ecreased light
8 touch and vibration to [the] right foot through L4-S1.” (AR
9 542.)
10 On October 19, 2016, Plaintiff rated her pain as “2 on a
11 scale of 0-10” and denied any side effects from her medication.
12 (AR 581.) Her back-pain score was noted as “5.” (AR 581-82.)
13 Neurological examination findings were unchanged from July except
14 her straight-leg-raise test was positive, with the right greater
15 than the left. (AR 583.) Dr. Kim diagnosed “[o]steoarthritis of
16 spine with radiculopathy, lumbar region” and noted that Plaintiff
17 would “taper off Norco” and that it was “[u]nclear if” her leg
18 pain was “radiculopathy or [a] shin splint given [the] normal EMG
19 and positive” straight-leg-raise test. (AR 584.)
20 8. Ranier E. Guiang
21 On January 8, 2014, Plaintiff saw Ranier E. Guiang,22
22 complaining of “back pain radiating down to the legs especially
23 on the right.” (AR 626.) She reported that Gabapentin23 and
24
22 Dr. Guiang primarily practices pain medicine. See Cal.
25
Dep’t Consumer Aff. License Search, https://search.dca.ca.gov
26 (search for “Ranier E.” with “Guiang” under “License Type,”
“Physicians and Surgeons”) (last visited Feb. 22, 2021).
27
23 Gabapentin is an anticonvulsant used sometimes to relieve
28 (continued...)
20
1 Lyrica had been ineffective for her pain (id.), and Dr. Guiang
2 recommended epidural injections (AR 627).
3 Plaintiff returned to Dr. Guiang on July 13, 2017, for
4 “lower back pain radiating to her right thigh” and “bilateral
5 shin pain.” (AR 631.) Dr. Guiang prescribed Nucynta24 and
6 epidural steroid injections. (Id.) She underwent epidural
7 injections on August 15, 2017 (AR 643), and February 27, 2018 (AR
8 674). On February 23, 2018, she reported “adequate pain relief
9 on [her] current pain regimen,” with “[n]o . . . adverse
10 reactions or over sedation.” (AR 669.)
11 9. Frances Batin
12 On November 3, 2015, Plaintiff reported to Dr. Frances
13 Batin25 that she had “been having ‘bruise-like’ lesions on [her]
14 legs above and below [the] knees” “for one year.” (AR 447.) The
15 lesions “ha[d] never been painful” before, but the pain from “a
16 lesion on her right calf for 2 days” was “intolerable and
17 worsened with weight-bearing,” “driving the car, or . . .
18 dorsiflexion at rest.” (Id.) She also reported “right lower leg
19 pain for 3 years that [was] undiagnosed” and for which she took
20
23 (...continued)
21
nerve pain. See Gabapentin, WebMD, https://www.webmd.com/
22 drugs/2/drug-14208-8217/gabapentin-oral/gabapentin-oral/details
(last visited Feb. 22, 2021).
23
24 Nucynta is used to help relieve moderate to severe short-
24 term pain. See Nucynta, WebMD, https://webmd.com/drugs/2/
drug-152563/nucynta-oral/details (last visited Feb. 22, 2021).
25
26
25 Dr. Batin primarily practices internal medicine. See
Cal. Dep’t Consumer Aff. License Search, https://
27 search.dca.ca.gov (search for “Frances” with “Batin” under
“License Type,” “Physicians and Surgeons”) (last visited Feb. 22,
28 2021).
21
1 Norco “every 5 hours.” (Id.) She rated her pain “6/10 in the
2 office”26 and “9/10” “[w]hen driving or when Norco w[ore] off.”
3 (Id.) Dr. Batin diagnosed “[m]yofascial pain in both legs” and
4 “[e]pidermal lesions likely vasculature in nature” (id.) and
5 scheduled a skin biopsy (AR 448), which she performed on November
6 13, 2015 (AR 453). The results do not appear in the record.
7 10. William Wang
8 Plaintiff saw orthopedist William Wang for a complete
9 orthopedic evaluation on May 11, 2016. (AR 266-71.) Dr. Wang
10 noted that she got into and out of a chair “without difficulty”
11 and had “no apparent ataxia or dyspnea.” (AR 267-68.) She had
12 “mild tenderness to palpation in the midline of the lumbar spine”
13 and a “slight loss of lordosis.” (AR 268.) But there was “no
14 CVA27 tenderness,” “evidence of bruits,”28 or “muscle spasm” and
15 no “pain with range of motion,” “axial rotation of the trunk,” or
16 “axial loading of the spine at the head.” (Id.) The straight-
17 leg-raise test was “positive at 40 degrees, both sitting and
18
19
26 Plaintiff apparently stopped working in late 2013,
20 although she had fairly substantial unexplained income in 2014.
(AR 153, 155.) It is unclear what “office” she was referring to
21
in late 2015.
22
27 The costovertebral angle (“CVA”) is located on the back
23 at the bottom of the ribcage. The Costovertebral Angle: What Is
It and Why Can It Be Painful?, Healthline, https://
24 www.healthline.com/ health/costovertebral-angle (last visited
Feb. 22, 2021).
25
26
28 A bruit is a sound heard over an artery or vascular
channel, reflecting turbulence of flow and most commonly caused
27 by abnormal narrowing of an artery. Medical Definition of Bruit,
MedicineNet, https://www.medicinenet.com/bruit/definition.htm
28 (last visited Feb. 22, 2021).
22
1 supine.” (Id.) Her “[r]ange of motion of the back [was] 60/90
2 degrees of forward flexion, 10/25 degrees of extension, 15/25
3 degrees of lateral flexion to the left, and 15/25 degrees of
4 lateral flexion to the right.” (Id.) Dr. Wang noted that the
5 cervical-spine examination revealed “normal curvature without
6 deformity or asymmetry,” “50/50 degrees of forward flexion, 60/60
7 degrees of extension, 45/45 degrees of lateral flexion,
8 bilaterally, and 80/80 rotation bilaterally.” (Id.) He also
9 found “no tenderness to palpation in the midline or paraspinal
10 areas”; “no evidence of swelling, palpable mass, or
11 inflammation”; and “no paracervical or bilateral trapezius muscle
12 spasm.” (Id.) Her “gait [was] antalgic,” but she was “able to
13 perform [a] tandem gait,” “stand on [her] toes with some
14 difficulty,” “stand on [her] heels,” “squat,” “get on and off the
15 examination table without difficulty,” and “walk across the exam
16 room” without “the use of an assistive device.” (AR 269.)
17 A hip examination revealed “no evidence of trochanteric
18 bursal tenderness to palpation” or “joint deformities.” (Id.)
19 Range of motion testing revealed 100/100 degrees of forward
20 flexion, 30/30 degrees of backward extension, 25/25 degrees of
21 abduction, 15/15 degrees of adduction, 30/30 degrees of external
22 rotation bilaterally, and 20/20 degrees of internal rotation
23 bilaterally. (Id.)
24 A neurological examination revealed “good active motion”;
25 “5/5” strength “in the bilateral lower extremities”; “intact”
26 sensation “to light touch, pinprick, and vibration in the upper
27 and lower extremities”; “2+” deep-tendon reflexes in the
28 bilateral biceps and ankles, “3+” bilateral knee reflexes; no
23
1 clonus,29 and a negative Babinski reflex.30 (AR 270.) Finger-to-
2 nose and heel-to-shin tests were normal, and a Romberg test31 was
3 negative. (Id.) Based on the examination, Dr. Wang opined that
4 Plaintiff could lift and carry 20 pounds occasionally and 10
5 pounds frequently, stand and walk for six hours in an eight-hour
6 workday, and sit for six hours in an eight-hour workday. (AR
7 271.) She was “occasionally limited in performing climbing,
8 crouching, stooping, and kneeling activities.” (Id.) He
9 assessed “no manipulative, visual, communicative, or
10 environmental limitations.” (Id.)
11 11. Anita Pai
12 On June 21, 2016, Plaintiff saw Anita Pai, an orthopedist
13 with Dr. Uppal’s practice group. (AR 473.) A back examination
14 showed “normal curvature,” “tenderness to palpation in the low
15 lumbar area,” and “no significant” [sacroiliac] joint
16 tenderness.” (AR 475.) A neurological examination showed “[n]o
17
18
29 Clonus is a neurological condition that creates
19 involuntary muscle contractions, primarily in muscles that
control the knees and ankles. What Is Clonus, Healthline,
20 https://www.healthline.com/health/clonus (last visited Feb. 22,
2021).
21
22 30 “The Babinski reflex occurs after the sole of the foot
has been firmly stroked.” Babinski Reflex, MedlinePlus, https://
23 medlineplus.gov/ency/article/003294.htm (last visited Feb. 22,
2021). “The big toe then moves upward or toward the top surface
24 of the foot.” (Id.) “The other toes fan out.” (Id.) “When the
Babinski reflex is present in a child older than 2 years or in an
25
adult, it is often a sign of a central nervous system disorder.”
26 (Id.)
27 31 The Romberg test measures balance. Romberg Test,
Physiopedia, https://www.physio-pedia.com/Romberg_Test (last
28 visited Feb. 22, 2021).
24
1 abnormal movement” and “grossly normal” “strength in the
2 bilateral lower extremity,” but her “[s]ensation [was] decreased
3 to light touch in the L5 dermatome.” (Id.) Dr. Pai referred her
4 for physical therapy for 12 visits and advised her to continue
5 her pain medication and follow up with Dr. Cheng. (AR 476.) She
6 noted that Plaintiff might benefit from repeat epidural
7 injections if the physical therapy didn’t help. (Id.)
8 12. Garrett Chapman
9 On July 13, 2016, Plaintiff saw Dr. Garrett Chapman,32
10 complaining of “bilateral shin pain and right thigh pain for
11 . . . 3 years.” (AR 531.) She reported that she had “not
12 experienced back pain until just 3 months” before physical
13 therapy, Lyrica had “not provided . . . significant relief,” and
14 a “workup was negative for shin splints.” (Id.) Dr. Chapman
15 noted that an x-ray of the spine showed “[n]o scoliosis” and
16 “[m]ild los[s] of lumbar lordosis.” (AR 532.) He stated that
17 “it d[id] not appear [that] her bilateral shin pain [was] from
18 any spinal pathology,” concluded that “[n]o surgical intervention
19 [was] recommended at [that] time,” and referred “her to neurology
20 for evaluation of neuropathy vs polyneuropathy which was shown on
21 a previous” EMG. (AR 533.)
22 13. Jeffrey Rosenfeld
23 On August 16, 2016, Plaintiff saw neurologist Jeffrey
24 Rosenfeld for an evaluation. (AR 555.) She reported that she
25
26
32 Dr. Chapman primarily practices orthopedic surgery. See
Cal. Dep’t Consumer Aff. License Search, https://
27 search.dca.ca.gov (search for “Garrett” with “Chapman” under
“License Type,” “Physicians and Surgeons”) (last visited Feb. 22,
28 2021).
25
1 had right “buttocks ‘sciatic’ pain with some radiation to the
2 thigh” and “[s]evere pain in the ‘shins’ bilaterally.” (Id.)
3 Dr. Rosenfeld noted that an examination revealed “5/5” muscle
4 strength in all areas; “2+” deep-tendon reflexes bilaterally in
5 the biceps, triceps, brachrad,33 and ankle; and “3+” deep-tendon
6 reflexes bilaterally in the patellar. (AR 558.) Babinski and
7 Hoffman’s34 reflexes were absent bilaterally. (Id.) He opined
8 that the “distribution, myalgia and chronicity implicat[ed]
9 possible myopathy (distal) superimposed on [left-sided]
10 radiculopathy.” (Id.) He ordered several tests, including an
11 EMG. (AR 558-59.)
12 Plaintiff saw Dr. Rosenfeld for a follow-up evaluation on
13 September 20, 2016. (AR 570-72.) She complained that her pain
14 had “started radiating to the bottom of both feet”; it was
15 “exacerbated by palpation of the tibial bone”; and it was reduced
16 by “elevating legs, heat pads, and [N]orco . . . 4-5 times per
17 day.” (AR 570.) She “denie[d] any shooting pain from her back
18 . . . to her shins.” (Id.) Dr. Rosenfeld noted that the EMG of
19 the right lower limb was “mildly abnormal,” with
20 “electrophysiologic evidence of chronic neurogenic changes in two
21 limb muscles of the right L5 myotome that [was] very subtle and
22
23 33 The brachioradialis is a forearm muscle that extends from
the lower part of the humerus to the radius. Brachioradialis
24 Pain, Healthline, https://www.healthline.com/health/
brachioradialis-pain (last visited Feb. 22, 2021).
25
26
34 A Hoffman’s reflex response can indicate spinal-cord
compression or another nerve condition. See What Does a Positive
27 or Negative Hoffman Sign Mean?, Med. News Today, https://
www.medicalnewstoday.com/articles/322106.php (last visited Feb.
28 22, 2021).
26
1 non-diagnostic for a lumbosacral radiculopathy.” (Id.) He
2 concluded that there was “no electrophysiologic evidence of
3 myopathy, polyneuropathy, or mononeuropathy in the extensively
4 tested lower limbs” (id.); the EMG did not “account[] for
5 [Plaintiff’s] pain” (AR 571); and the “[e]xam[ination] and prior
6 imaging [were] also under[]whelming” (id.). He noted “[s]ome
7 signs [of] plantar fascitis” and gave Plaintiff an “[a]mbulatory
8 referral to Orthotics.” (AR 571-72.)
9 B. Plaintiff’s Testimony and Statements
10 In Plaintiff’s December 16, 2015 Disability Report, she
11 stated that she was unable to work because of back, leg, feet,
12 and neck pain. (AR 170.) At the August 28, 2018 hearing, she
13 testified that she had to spend between 75 and 80 percent of the
14 day on her sofa with her feet elevated (AR 46-48) and that on bad
15 days, which she had six days a week (AR 50), she could not “even
16 get up and go to the restroom” (AR 46). She testified that she
17 was able to microwave food, make coffee, grocery shop, and drive
18 short distances to the store, however. (AR 47-50.) She claimed
19 that although she previously got pain relief by elevating her
20 legs, that no longer worked and she now also needed a heating pad
21 and compression socks. (AR 45.) Her medications made her
22 drowsy. (AR 52-53.)
23 C. The ALJ Properly Assessed Plaintiff’s RFC
24 Plaintiff alleges that the ALJ erred in assessing her RFC by
25 failing “to properly consider significant medical evidence of
26 record which is supportive of her claim of disability” (J. Stip.
27 at 4) and improperly assessing physicians’ opinions (id. at 5,
28 9). For the reasons discussed below, remand is not warranted on
27
1 this issue.
2 1. Medical evidence of Plaintiff’s impairments
3 Plaintiff complains that the ALJ failed to properly consider
4 medical evidence documenting “severe impairments which would
5 prevent Plaintiff from persisting at any full time employment.”
6 (J. Stip. at 4.) She notes that the record demonstrates that she
7 had treatment for venous insufficiency in her legs, degenerative
8 disc disease and degenerative joint disease in the spine, lower-
9 extremity neuropathy/polyneuropathy, and decreased reflexes and
10 sensation in the lower extremities. (Id. at 4-5.) But the ALJ
11 recognized and discussed these conditions and the treatment
12 Plaintiff underwent for them — including spine surgery, physical
13 therapy, pain medication, and injections. (AR 20-22.) Plaintiff
14 simply summarizes portions of the record evidencing her treatment
15 for these conditions; she offers no argument, much less evidence,
16 as to what specific treatment the ALJ failed to consider or how
17 any of these conditions caused limitations greater than those
18 included in her RFC. Although she points to her own statements
19 that she needed to elevate her legs, she offers no evidence that
20 any doctor assigned any such limitation. Moreover, as discussed
21 in section V.D., the ALJ properly discounted Plaintiff’s
22 subjective symptom statements. Based on the record and
23 Plaintiff’s failure to identify any flaw in the ALJ’s reasoning,
24 the ALJ adequately considered the medical evidence of Plaintiff’s
25 impairments. See Bayliss v. Barnhart, 427 F.3d 1211, 1217 (9th
26 Cir. 2005) (ALJ not required to include in RFC limitations based
27 on plaintiff’s properly discounted subjective complaints);
28 Figueroa v. Colvin, No. CV 12-067420-OP., 2013 WL 1859073, at *9
28
1 (C.D. Cal. May 2, 2013) (no error in failing to include
2 limitations in RFC when ALJ properly rejected plaintiff’s
3 subjective complaints of impairment).
4 2. Medical opinions
5 Plaintiff argues that the ALJ erred in assessing the
6 physicians’ opinions. (J. Stip. at 5, 9.) For the reasons
7 discussed below, remand is not warranted.
8 a. Applicable law
9 Three types of physicians may offer opinions in Social
10 Security cases: those who directly treated plaintiff, those who
11 examined but did not treat her, and those who did neither. See
12 Lester, 81 F.3d at 830. A treating physician’s opinion is
13 generally entitled to more weight than an examining physician’s,
14 and an examining physician’s opinion is generally entitled to
15 more weight than a nonexamining physician’s. Id.; see
16 § 404.1527(c)(1)-(2).35 But “the findings of a nontreating,
17 nonexamining physician can amount to substantial evidence, so
18 long as other evidence in the record supports those findings.”
19 Saelee v. Chater, 94 F.3d 520, 522 (9th Cir. 1996) (per curiam)
20 (as amended).
21 The ALJ may discount a physician’s opinion regardless of
22 whether it is contradicted. Magallanes v. Bowen, 881 F.2d 747, 751
23 (9th Cir. 1989); see also Carmickle v. Comm’r, Soc. Sec. Admin., 533
24 F.3d 1155, 1164 (9th Cir. 2008). When a doctor’s opinion is not
25
26
35 For claims filed on or after March 27, 2017, the rules in
§ 404.1520c (not § 404.1527) apply. See § 404.1520c (evaluating
27 opinion evidence for claims filed on or after Mar. 27, 2017).
Plaintiff’s claims were filed before March 27, 2017, however, and
28 the Court therefore analyzes them under former § 404.1527.
29
1 contradicted by other medical-opinion evidence, however, it may be
2 rejected only for a “clear and convincing” reason. Magallanes, 881
3 F.2d at 751 (citations omitted); Carmickle, 533 F.3d at 1164 (citing
4 Lester, 81 F.3d at 830-31). When it is contradicted, the ALJ need
5 provide only a “specific and legitimate” reason for discounting it.
6 Carmickle, 533 F.3d at 1164 (citing Lester, 81 F.3d at 830-31). The
7 weight given a doctor’s opinion, moreover, depends on whether it is
8 consistent with the record and accompanied by adequate explanation,
9 among other things. See § 404.1527(c); see also Orn v. Astrue, 495
10 F.3d 625, 631 (9th Cir. 2007) (factors in assessing physician’s
11 opinion include length of treatment relationship, frequency of
12 examination, and nature and extent of treatment relationship).
13 b. Dr. Uppal
14 On March 25, 2014, Dr. Uppal opined that Plaintiff should be
15 on disability for six months. (AR 458.) On February 10, 2015,
16 he said she should be on disability for four weeks and should not
17 “do any significant bending, stooping, [or] lifting” (AR 462); he
18 also noted that she was on Norco, which caused “further
19 depression and lack of concentration” (id.). Finally, on March
20 8, 2016, he stated that he did “not feel she [was] going to
21 return . . . to work.” (AR 471.) The ALJ afforded these
22 opinions “little weight.” (AR 24.)
23 As the ALJ noted, Dr. Uppal did not include any function-by-
24 function limitations that would prevent Plaintiff from working
25 except in the February 2015 opinion. (See id.) And the
26 functional limitations included in that opinion were vague
27 because they restricted only “significant” performance of those
28 activities without defining the term. (AR 462.) This alone was
30
1 sufficient to reject Dr. Uppal’s disability findings. See Ford
2 v. Saul, 950 F.3d 1141, 1156 (9th Cir. 2020) (“ALJ found that
3 [physician’s] descriptions of [plaintiff’s] ability to perform in
4 the workplace as ‘limited’ or ‘fair’ were not useful because they
5 failed to specify [his] functional limits,” and therefore ALJ
6 could “reasonably conclude these characterizations were
7 inadequate for determining RFC”). In any event, the ALJ limited
8 Plaintiff to “occasional” posturals and lifting of up to 20
9 pounds, thereby essentially adopting much of Dr. Uppal’s
10 “significant” restriction.
11 The ALJ also noted that Dr. Uppal’s opinions were “not
12 supported by objective evidence,” were “inconsistent with the
13 record as a whole,” and “demonstrate[d] a lack of understanding
14 of social security disability programs and evidentiary
15 requirements.” (AR 24.) Indeed, Dr. Uppal did not support his
16 opinion that Plaintiff was disabled with any explanation other
17 than to state that she was on pain medication and having back
18 spasms. (See AR 458.) An ALJ “need not accept the opinion of
19 any physician, including a treating physician, if that opinion is
20 brief, conclusory, and inadequately supported by clinical
21 findings.” Thomas v. Barnhart, 278 F.3d 947, 957 (9th Cir. 2002)
22 (citation omitted); see also Ford, 950 F.3d at 1155 (“An ALJ is
23 not required to take medical opinions at face value, but may take
24 into account the quality of the explanation when determining how
25 much weight to give a medical opinion.”).
26 Plaintiff offers no meaningful challenge to the ALJ’s
27 assessment of Dr. Uppal’s opinions. No error occurred.
28
31
1 c. State-agency doctors
2 On May 11, 2016, Plaintiff attended an orthopedic evaluation
3 with Dr. Wang. (AR 266-71.) He opined that she could lift and
4 carry 20 pounds occasionally and 10 pounds frequently; could
5 stand and walk for six hours in an eight-hour workday; could sit
6 for six hours in an eight-hour workday; was occasionally limited
7 in climbing, crouching, stooping, and kneeling activities; and
8 had no manipulative, visual, communicative, or environmental
9 limitations. (AR 271.)
10 On May 26, 2016, D. Haaland, a state-agency reviewing
11 physician,36 evaluated portions of Plaintiff’s medical records,
12 including some of Dr. Kim’s treatment records and Dr. Wang’s May
13 11 report. (AR 60-63.) Dr. Haaland opined that Plaintiff could
14 occasionally lift and/or carry 20 pounds; could frequently lift
15 and/or carry 10 pounds; could stand and/or walk for a total of
16 about six hours in an eight-hour workday; could sit for a total
17 of about six hours in an eight-hour workday; had no pushing,
18 pulling, balancing, manipulative, visual, communicative, or
19 environmental limitations; could occasionally climb ramps or
20 stairs, stoop, kneel, crouch, or crawl; and could never climb
21 ladders, ropes, or scaffolds. (AR 64-65.)
22
23
24
25
26
36 Dr. Haaland used a medical specialty code of 29 (AR 68),
indicating orthopedics, see Soc. Sec. Admin., Program Operations
27 Manual System (POMS) DI 24501.004 (May 5, 2015), https://
secure.ssa.gov/apps10/poms.nsf/lnx/0424501004 (last visited
28 Feb. 22, 2021).
32
1 On July 15, 2016, H.M. Estrin, also a state-agency reviewing
2 physician,37 reviewed the same records as Dr. Haaland and assessed
3 the same limitations. (AR 74-75.)
4 The ALJ gave the assessments of Dr. Wang and the state-
5 agency reviewing physicians “significant weight” (AR 23), finding
6 that they were
7 generally reasonable and consistent with the objective
8 medical evidence, which shows a history of treatment for
9 degenerative disc disease with some evidence of radicular
10 pain, worse in the right lower extremity, with no
11 indication of significant neurological deficits, gait
12 abnormalities, or significant physical limitations caused
13 by these impairments.
14 (AR 24.)
15 Plaintiff again offers no meaningful challenge to the ALJ’s
16 assessment of these opinions. She merely argues that the medical
17 evidence of record does not support the opinion that Plaintiff
18 had the ability to persist at light-work activity. (J. Stip. at
19 9.) But she does not explain what evidence in the record
20 conflicts with that opinion. And Dr. Wang performed and relied
21 on his own objective medical tests, including straight leg raise,
22 range of motion, strength, sensation, and reflex. (AR 268-70.)
23 The state-agency physicians relied on Dr. Wang’s objective
24 medical tests and opinion and reviewed other medical evidence as
25 well. (AR 60, 70.) Those opinions, therefore, constituted
26
27 37 Dr. Estrin used a medical specialty code of 19 (AR 78),
indicating internal medicine, see POMS DI 24501.004,
28 https://secure.ssa.gov/apps10/poms.nsf/lnx/0424501004.
33
1 substantial evidence that the ALJ appropriately credited.
2 Saelee, 94 F.3d at 522. Plaintiff has not pointed to any way in
3 which the ALJ erred. Remand is not required on this issue.
4 D. The ALJ Properly Assessed Plaintiff’s Subjective
5 Symptom Statements
6 Plaintiff asserts that the ALJ failed to properly evaluate
7 her subjective symptom statements. (J. Stip. at 15-18.) For the
8 reasons discussed below, the ALJ did not err.
9 1. Applicable law
10 An ALJ’s assessment of a claimant’s allegations concerning
11 the severity of her symptoms is entitled to “great weight.”
12 Weetman v. Sullivan, 877 F.2d 20, 22 (9th Cir. 1989) (as amended)
13 (citation omitted); Nyman v. Heckler, 779 F.2d 528, 531 (9th Cir.
14 1985) (as amended Feb. 24, 1986). “[T]he ALJ is not ‘required to
15 believe every allegation of disabling pain, or else disability
16 benefits would be available for the asking, a result plainly
17 contrary to 42 U.S.C. § 423(d)(5)(A).’” Molina v. Astrue, 674
18 F.3d 1104, 1112 (9th Cir. 2012) (quoting Fair v. Bowen, 885 F.2d
19 597, 603 (9th Cir. 1989)).
20 In evaluating a claimant’s subjective symptom testimony, the
21 ALJ engages in a two-step analysis. See Lingenfelter, 504 F.3d
22 at 1035-36; see also SSR 16-3p, 2016 WL 1119029, at *3 (Mar. 16,
23 2016). “First, the ALJ must determine whether the claimant has
24 presented objective medical evidence of an underlying impairment
25 ‘[that] could reasonably be expected to produce the pain or other
26 symptoms alleged.’” Lingenfelter, 504 F.3d at 1036 (citation
27 omitted). If such objective medical evidence exists, the ALJ may
28 not reject a claimant’s testimony “simply because there is no
34
1 showing that the impairment can reasonably produce the degree of
2 symptom alleged.” Id. (citation omitted; emphasis in original).
3 If the claimant meets the first test, the ALJ may discount
4 the claimant’s subjective symptom testimony only if she makes
5 specific findings that support the conclusion. See Berry v.
6 Astrue, 622 F.3d 1228, 1234 (9th Cir. 2010). Absent a finding or
7 affirmative evidence of malingering, the ALJ must provide a
8 “clear and convincing” reason for rejecting the claimant’s
9 testimony. Brown-Hunter v. Colvin, 806 F.3d 487, 493 (9th Cir.
10 2015) (as amended) (citing Lingenfelter, 504 F.3d at 1036);
11 Treichler v. Comm’r of Soc. Sec. Admin., 775 F.3d 1090, 1102 (9th
12 Cir. 2014). The ALJ may consider, among other factors, the
13 claimant’s (1) reputation for truthfulness, prior inconsistent
14 statements, and other testimony that appears less than candid;
15 (2) unexplained or inadequately explained failure to seek
16 treatment or to follow a prescribed course of treatment; (3)
17 daily activities; (4) work record; and (5) physicians’ and third
18 parties’ statements. Rounds v. Comm’r Soc. Sec. Admin., 807 F.3d
19 996, 1006 (9th Cir. 2015) (as amended); Thomas, 278 F.3d at 958-
20 59 (citation omitted). If the ALJ’s evaluation of a plaintiff’s
21 alleged symptoms is supported by substantial evidence in the
22 record, the reviewing court “may not engage in second-guessing.”
23 Thomas, 278 F.3d at 959.
24 2. The ALJ’s decision
25 The ALJ reviewed Plaintiff’s claimed limitations and found
26 that her “medically determinable impairments could reasonably be
27 expected to cause some of the alleged symptoms; however, [her]
28 statements concerning the intensity, persistence and limiting
35
1 effects of these symptoms [were] not entirely consistent with the
2 medical evidence and other evidence in the record[.]” (AR 20.)
3 The ALJ discounted Plaintiff’s subjective symptom statements
4 because they were inconsistent with the objective medical
5 evidence (id.); she had received routine, conservative,
6 nonemergency treatment (AR 20, 22-23); her treatment had been
7 “relatively effective” in controlling her symptoms (AR 23); and
8 she had made statements to her doctor regarding her functioning
9 and symptoms that were inconsistent with her allegations of
10 disability (id.).
11 3. Analysis
12 a. Medical and other evidence
13 To start, the ALJ properly concluded that Plaintiff’s
14 subjective symptom statements were inconsistent with the
15 objective medical evidence in the record, a finding Plaintiff has
16 not challenged on appeal other than to point out that that can’t
17 serve as the only reason for an ALJ to discount a plaintiff’s
18 statements and testimony. (AR 20-23; see also J. Stip. at 16);
19 Morgan v. Comm’r of Soc. Sec. Admin., 169 F.3d 595, 600 (9th Cir.
20 1999) (finding “conflict” with “objective medical evidence in the
21 record” to be “specific and substantial reason” undermining
22 plaintiff’s allegations); § 404.1529(c)(2); see also Ruiz v.
23 Comm’r of Soc. Sec., 490 F. App’x 907, 908 (9th Cir. 2012)
24 (plaintiff conceded four of five reasons ALJ gave for rejecting
25 examining doctor’s opinion by not addressing them in briefing).
26 Among other things, the ALJ noted that although Plaintiff claimed
27 she had difficulty walking because of pain (see, e.g., AR 267),
28 she was often noted to ambulate with a normal gait and was never
36
1 prescribed an assistive device (AR 22-23 (citing AR 637)). The
2 ALJ also correctly noted that there was no evidence of loss of
3 motor strength in the lower extremities or muscle atrophy, and
4 examination findings were generally mild to moderate. (AR 22-23;
5 see AR 223, 558.)
6 b. Effective treatment
7 The ALJ also discounted Plaintiff’s subjective symptom
8 statements because they were inconsistent with evidence
9 demonstrating that her treatment and medications had been
10 “relatively effective.” (AR 23.) As the ALJ noted, Plaintiff
11 regularly reported that compression stockings, physical therapy,
12 and medication improved her pain. (AR 20-21 (citing AR 212, 225,
13 254).) On numerous occasions, she rated her pain from none to
14 between one and three out of 10 and denied medication side
15 effects. (AR 21-23 (citing AR 233, 252, 254, 421, 541, 669,
16 682).) And even when she reported more serious pain, she
17 generally said she had fair to excellent functioning. (AR 21-23
18 (citing AR 236-37, 242, 252).)
19 Plaintiff argues that her epidural injections demonstrate
20 that her treatment was not effective. But that she occasionally
21 needed more aggressive treatment does not diminish the numerous
22 times when she acknowledged that her medication was working. At
23 most, the records cited by Plaintiff establish that the medical
24 evidence was susceptible of more than one rational
25 interpretation, which is insufficient to warrant reversal. See
26 Molina, 674 F.3d at 1111; Tommasetti v. Astrue, 533 F.3d 1035,
27 1041 (9th Cir. 2008) (ALJ is “final arbiter with respect to
28 resolving ambiguities in the medical evidence”). The ALJ
37
1 properly considered this evidence in discounting Plaintiff’s
2 symptom statements.
3 c. Plaintiff’s inconsistent statements
4 Finally, the ALJ properly discounted Plaintiff’s subjective
5 symptom statements because some of them were inconsistent with
6 other statements she made to her treatment providers. Rounds,
7 807 F.3d at 1006 (listing prior inconsistent statement as factor
8 ALJ may consider in assessing claimant’s testimony). To start,
9 Plaintiff testified that she had to spend between 75 and 80
10 percent of the day on her sofa with her feet elevated (AR 46-48)
11 and that on bad days — which occurred six days a week (AR 50) —
12 she could not “even get up and go to the restroom” (AR 46), but
13 she often reported fair or good physical functioning to her
14 treatment providers (see AR 215, 222, 236, 242, 252, 541). And
15 although she testified that she got drowsy and slept after taking
16 her pain medication (AR 52-53), which was the same Norco she had
17 been taking for years (AR 45, 455),38 she repeatedly denied to her
18 treatment providers that she had any medication side effects
19 (see, e.g., AR 233, 262, 505, 581).
20 Substantial evidence supported the ALJ’s discounting of
21 Plaintiff’s subjective symptom statements. Remand is not
22 warranted on this basis.39
23
24 38 Indeed, at the time of the hearing Plaintiff was taking
fewer Norco than she had when she was working. (See AR 52, 455.)
25
26
39 The ALJ also discounted Plaintiff’s subjective symptom
statements because they were inconsistent with her “conservative”
27 treatment. (AR 20, 22-23.) Plaintiff’s treatment was likely not
conservative. See, e.g., Lapeirre–Gutt v. Astrue, 382 F. App’x
28 (continued...)
38
1 CONCLUSION
2 Consistent with the foregoing and under sentence four of 42
U.S.C. § 405(g),*° IT IS ORDERED that judgment be entered
4} AFFIRMING the Commissioner’s decision, DENYING Plaintiff’s
5 || request for remand, and DISMISSING this action with prejudice.
fu hronltatl~
7 || DATED: February 23, 2021
JEAN ROSENBLUTH
8 U.S. Magistrate Judge
9
10
11
12
13
14
8? (...continued)
15} 662, 664 (9th Cir. 2010) (treatment with narcotic pain
medication, occipital nerve blocks, trigger-point injections, and
16 | cervical-fusion surgery not conservative); Samaniego v. Astrue,
17 No. EDCV 11-865 JC, 2012 WL 254030, at *4 (C.D. Cal. Jan. 27,
2012) (treatment not conservative when claimant was treated “on a
1g || continuing basis” with steroid and anesthetic “trigger point
injections,” occasional epidural injections, and narcotic
19 medication and doctor recommended surgery); Ruiz v. Berryhill,
No. CV 16-2580-SP, 2017 WL 4570811, at *5-6 (C.D. Cal. Oct. 11,
20 1 2017) (treatment by “narcotic medication, facet joint injections,
and epidural steroid injections” not conservative). Because the
ALJ provided other clear and convincing reasons for discounting
22 her statements, however, remand is not necessary. See Larkins v.
Colvin, 674 F. App’x 632, 633 (9th Cir. 2017) (“[B]lecause the ALJ
23 gave specific, clear and convincing reasons [for discounting
plaintiff’s symptom statements], any error in the additional
reasons the ALJ provided . . . was harmless.” (citation
25 omitted)).
26 9 That sentence provides: “The [district] court shall have
power to enter, upon the pleadings and transcript of the record,
27 a judgment affirming, modifying, or reversing the decision of the
Commissioner of Social Security, with or without remanding the
28 ll cause for a rehearing.”
39