Peacock v. Commissioner of Social Security Administration
Filing
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ORDER - The Commissioner's decision is REVERSED and this matter is REMANDED for further proceedings. Signed by Magistrate Judge Bridget S Bade on 6/8/18. (MSA)
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IN THE UNITED STATES DISTRICT COURT
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FOR THE DISTRICT OF ARIZONA
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Kelly Brian Peacock,
Plaintiff,
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ORDER
v.
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No. CV-17-00523-PHX-BSB
Commissioner of Social Security
Administration,
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Defendant.
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Plaintiff Kelly Brian Peacock seeks judicial review of the final decision of the
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Commissioner of Social Security (“the Commissioner”) denying his application for
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benefits under the Social Security Act (“the Act”). The parties have consented to proceed
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before a United States Magistrate Judge pursuant to 28 U.S.C. § 636(b), and have filed
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briefs in accordance with Rule 16.1 of the Local Rules of Civil Procedure. As discussed
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below, the Court reverses the Commissioner’s decision and remands for further
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proceedings.
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I.
Procedural Background
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In July 2013, Plaintiff filed an application for supplemental security income
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benefits (“SSI”). (Tr. 16.)1 After the Social Security Administration denied Plaintiff’s
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initial application and his request for reconsideration, he requested a hearing before an
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administrative law judge (“ALJ”). (Id.) After conducting two hearings, the ALJ issued a
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decision finding Plaintiff not disabled under the Act. (Tr. 16-26.) This decision became
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Citations to Tr. are to the certified administrative transcript of record. (Doc. 8.)
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the final decision of the Commissioner when the Social Security Administration Appeals
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Council denied Plaintiff’s request for review. (Tr. 1-4); see also 20 C.F.R. § 404.981
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(explaining the effect of a disposition by the Appeals Council). Plaintiff now seeks
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judicial review of this decision pursuant to 42 U.S.C. § 405(g).
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II.
Administrative Record
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The administrative record includes medical records pertaining to the history of
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diagnoses and treatment related to Plaintiff’s alleged impairments of degenerative disc
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disease of the lumbar and cervical spine. (Tr. 27.) The record also includes several
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medical opinions. The Court discusses the relevant evidence below.
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A.
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The ALJ noted that Plaintiff had “a significant history of back problems.”
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(Tr. 19.) The record reflects that after experiencing right-sided hand weakness, radicular
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pain, and numbness, Plaintiff had an MRI on October 12, 2012. (Tr. 364, 367, 426-27.)
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The MRI showed large C7-T1 right-sided disc fragments in the neural foramen. (Tr. 364,
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367, 426-27.) Peter Nakaji, M.D., assessed “radiculopathy secondary to herniated disc,
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significant numbness and weakness in dominant hand.”
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assessment, on October 27, 2012, Dr. Nakaji performed an anterior cervical discectomy,
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fusion, and plating at C7-T1 on Plaintiff. (Tr. 364-65.) Plaintiff’s symptoms improved
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after surgery, but returned in February 2013. (Tr. 376-79 (reporting improvement after
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surgery), Tr. 393 (Feb. 12, 2013 cervical spine x-ray showing degenerative disc disease at
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C4-C5 and C5-C6), Tr. 395 (February 2013 MRI report noting “new upper extremity
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pain and numbness”), Tr. 483 (noting sudden onset of pain in February 2013).) On
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February 12, 2013, an MRI of Plaintiff’s cervical spine showed a large C6-C7 central
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disc extrusion with deformity of the spinal cord, but without foraminal compromise.
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(Tr. 395-96.) In July 2013, an MRI of Plaintiff’s lumbar spine showed moderate L5-S1
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degenerative disc disease.
Medical Treatment Evidence
(Tr. at 442-43.)
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(Tr. 367.)
Based on that
Plaintiff consistently reported pain and
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headaches related to these conditions. (Tr. 407-09, 415-17, 434-36, 473-76, 482-83, 486-
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89, 491-92, 494, 496, 500.)2
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B.
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Medical Opinion Evidence
1.
Leo Kahn, M.D., P.C.
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On March 23, 2015, at the request of Plaintiff’s attorney, Dr. Leo Kahn examined
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Plaintiff and offered opinions about Plaintiff’s physical functional limitations. (Tr. 541-
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47.) Dr. Kahn took a medical report from Plaintiff, examined Plaintiff, reviewed his
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medical records, and opined as to Plaintiff’s physical limitations. (Id.) Plaintiff reported
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to Dr. Kahn that he was experiencing headaches three-to-four times a week that were
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primarily triggered by “head positioning” and that lasted about four to six hours.
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(Tr. 541.) Plaintiff stated that maintaining his head in a “position of extension” triggered
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a headache. (Id.) Plaintiff described the headache as “a pressure sensation” that made
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him sensitive to light and noise. (Id.) Plaintiff said the best treatment for his headaches
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was to “be in a quiet dark room” and to “try to sleep.” (Id.)
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With respect to his neck, Plaintiff reported that before undergoing C7-TI fusion,
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he had severe right arm pain and neck pain. (Id.) He stated that after surgery his right
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arm pain mostly subsided, but he had some “residual right hand numbness.”
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Plaintiff reported that surgery initially relieved his neck pain, but intense pain returned
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about two weeks after surgery. (Id.) Plaintiff reported ongoing numbness in his right
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hand, some pain in his trapezius, and that most of his pain was in the “paracervical
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areas.” (Tr. 542.) Plaintiff did not report symptoms in his left upper extremity or in his
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lower extremities. (Id.) Plaintiff stated that he had recently completed a series of
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injections but they did not reduce his “neck discomfort.” (Id.) Plaintiff reported low
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back pain that could be severe. (Id.) Plaintiff stated that he could not work “secondary to
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headaches as well as neck pain.” (Id.)
(Id.)
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Dr. Kahn examined Plaintiff’s neck and noted that “flexion [was] approximately
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three finger breadths above the sternum. Extension [was] to approximately 25 degrees.
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The citation to medical records showing pain and headaches is not exhaustive. The
administrative record includes additional medical records. (Doc. 8.)
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Left lateral rotation [was] to about 70 degrees.” (Tr. 543.) Dr. Kahn noted that Plaintiff
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could rotate his neck to the right laterally about 45 degrees, but reported pain with lateral
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right rotation. (Id.) Plaintiff had a full range of motion in both shoulders and normal
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strength in all four extremities. (Id.) Dr. Kahn observed that Plaintiff was “very slightly
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clumsy with rapid alternating movements involving the upper right extremity as
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compared to the left.” (Id.) Straight-leg raising was negative bilaterally. (Id.) Plaintiff
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had a normal gait. (Id.) Plaintiff reported tenderness to palpation of his lower lumbar
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region.
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(Tr. 547.) He did not consider the headaches “classic migraine headaches, but rather
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(Id.)
Dr. Kahn found that Plaintiff’s reports of headaches were credible.
cervicogenic headache secondary to underlying cervical spine condition.” (Id.)
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Based on Plaintiff’s “persistent cervical spine condition as well as the headaches,”
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Dr. Kahn opined that Plaintiff could lift ten pounds frequently and up to twenty pounds
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occasionally. (Tr. 547.) Dr. Kahn found that Plaintiff “should not work above shoulder
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height, i.e. he should not . . . work with his neck in extension.” (Id.) Dr. Kahn opined
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that Plaintiff should not “be required to maintain his neck in any one fixed position for
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more than a couple of minutes.” (Id.) Additionally, Plaintiff was limited with regard to
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fine motor skills and could only do “crude activity with his right hand.” (Id.) Dr. Kahn
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opined that “[b]ased on the reported severity of [Plaintiff’s] headaches, it would not be
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expected that he could possibly be unable to work anywhere from one to three days per
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month.” (Id.)
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On June 29, 2015, Dr. Kahn offered a supplemental opinion after he reviewed a
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consultative evaluation of Plaintiff performed by Dr. Keith Cunningham.3 (Tr. 569.)
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Dr. Kahn reiterated that he “did not believe that [Plaintiff] should maintain his neck in
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any one fixed position for more than a couple of minutes.” (Id.) He also stated that
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Plaintiff could “only carry out what would be considered non-fine motor skills with the
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right hand.” (Id.) Dr. Kahn opined that there was an “organic basis” for Plaintiff’s
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headaches “related to the previous cervical spine fusion as well as the chronic
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Dr. Cunningham’s consultative evaluation of Plaintiff, performed on May 12, 2015, is
described below in Section II.B.2.
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degenerative spondylosis.” (Id.) He concluded that Plaintiff had consistently reported
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headaches and that it was “reasonable to conclude that [he] would be absent from work
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one to three times per month secondary to headaches.” (Id.)
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2.
Keith Cunningham, M.D.
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After the initial April 1, 2015 administrative hearing, the ALJ referred Plaintiff for
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a consultative examination that Dr. Cunningham performed on May 12, 2015. (Tr. 558-
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567.) The notes from that examination do not indicate that Dr. Cunningham reviewed
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any medical records. (Id.) During the examination, Plaintiff reported that he tried to
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return to work following a cervical discectomy, but he had continued neck pain
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accompanied by stiffness and headaches. (Tr. 558.) Plaintiff reported continuing pain
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and headaches over the previous three years. (Id.) Plaintiff stated that he was treated at
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Maricopa County Hospital and that, after he had an MRI in April 2015, Dr. Feiz-Erfan
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recommended “conservative treatment.” (Id.) Plaintiff said that he experienced “pain
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and grinding” when he turned his neck or did any heavy lifting. (Id.) Plaintiff described
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his other symptoms as numbness of his right palm and groin pain. (Id.) Plaintiff reported
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that he did not use an assistive device and was independent in his activities of daily
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living. (Id.)
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On examination, Dr. Cunningham reported that Plaintiff’s neck had “30 degrees of
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forward flexion, 20 degrees of extension, [and] 70 degrees left and right lateral rotation.”
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(Tr. 559.)
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Dr. Cunningham observed that Plaintiff’s “back otherwise demonstrate[d] normal lumbar
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range of motion.” (Id.) Plaintiff had normal range of motion in his shoulders, elbows,
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wrists, fingers and thumbs. (Id.) Plaintiff’s “hips, knees and ankles moved normally.”
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(Id.) “Strength testing was normal throughout.” (Id.) Plaintiff had “slight decreased
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sensation to touch in the right palm,” but otherwise intact sensation.
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Dr. Cunningham assessed “[s]taus post cervical spine surgery with limited range of
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motion with sensory deficits of the right palm which were minimal on exam[ination].”
“There [was] audible cracking heard when turning the neck.”
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(Id.)
(Id.)
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(Tr. 560.) Dr. Cunningham also assessed “[r]ight groin pain without abnormality noted,”
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and hypertension. (Id.)
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Dr. Cunningham completed a “Medical Source Statement of Ability to do Work-
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Related Activities (Physical).” (Tr. 560-66.) He opined that Plaintiff could lift or carry
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up to ten pounds continually, eleven to twenty pounds frequently, and twenty-one to fifty
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pounds occasionally. (Tr. 561.) He opined that Plaintiff could sit, stand, or walk up to
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two hours at a time for a total of eight hours in an eight-hour workday. (Tr. 561-62.)
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Dr. Cunningham opined that, with either hand, Plaintiff could occasionally reach
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overhead and could reach in all other directions continuously. (Tr. 562.) He opined that
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Plaintiff could continuously handle, finger, feel, push, and pull.
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Dr. Cunningham further found that Plaintiff could use his feet continuously. (Tr. 563.)
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Dr. Cunningham opined that Plaintiff could never climb ladders or scaffolds, could
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occasionally stoop and crawl, could frequently climb ramps and stairs and frequently
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crouch, and could continuously balance and kneel. (Id.) Dr. Cunningham also assessed
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several environmental limitations and found that Plaintiff could perform activities of
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daily living. (Tr. 565.)
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III.
(Tr. 562-63.)
The Administrative Hearings
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Plaintiff was forty-five years old when he applied for SSI. (Tr. 24.) He had a high
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school education. (Tr. 57.) Plaintiff had past relevant work as a janitor, delivery truck
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driver, and a power washer. (Id.) At the first administrative hearing in April 2015,
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Plaintiff testified that following cervical surgery he continued to have numbness and pain
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in his right hand. (Tr. 56.) Plaintiff testified that he experienced pounding headaches
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that made him sensitive to light and sound and that if he got into an “unusual posture”
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such as “look[ing] under the table . . . [he] would get a migraine.” (Id.) Plaintiff stated
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that he had headaches once or twice a week that lasted for four to five hours during which
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time he would lay down in the dark with no sound. (Id. at 56-57.) After Plaintiff
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testified, the ALJ ordered a consultative examination and permitted Plaintiff’s counsel to
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identify up to fifty pages of the medical record, including Dr. Kahn’s report, to be
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reviewed as part of the evaluation. (Id. at 62.) Plaintiff states that there is no evidence
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that his records were provided to the examiner, Dr. Cunningham. (Doc. 11 at 10.)
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At the second administrative hearing in November 2015, Plaintiff testified that he
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still had headaches once or twice a week that lasted for three to four hours. (Tr. 77.)
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Plaintiff testified that if he “look[ed] a certain way, like not straight on or not level, and
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[held his head] there for any amount of time, even just a few seconds,” he could
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“sometimes” get a “migraine.” (Tr. 78.) A vocational expert also testified at the second
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hearing. The vocational expert testified that an individual with the functional limitations
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that Dr. Cunningham identified could not perform Plaintiff’s past relevant work, but
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could perform other jobs such as cashier, routing clerk, office helper, document scanner,
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ticket checker, and call out operator. (Tr. 83-86.) The vocational expert testified that a
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person could not maintain employment in those jobs if that person would regularly miss
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more than one day of work per month. (Tr. 86.) The vocational expert also testified that
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an individual limited to maintaining a fixed head position, a limitation that Dr. Khan
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assessed, would be unable to sustain employment in any of the jobs identified. (Tr. 89.)
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The vocational expert further testified that an inability to perform fine manipulation
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would preclude employment in the identified jobs. (Tr. 87-89.)
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IV.
The ALJ’s Decision
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A claimant is considered disabled under the Act if he is unable “to engage in any
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substantial gainful activity by reason of any medically determinable physical or mental
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impairment which can be expected to result in death or which has lasted or can be
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expected to last for a continuous period of not less than 12 months.”
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42 U.S.C. § 423(d)(1)(A); see also 42 U.S.C. § 1382c(a)(3)(A) (nearly identical standard
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for supplemental security income disability insurance benefits). To determine whether a
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claimant is disabled, the ALJ uses a five-step sequential evaluation process.
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See 20 C.F.R. §§ 404.1520, 416.920.
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A.
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In the first two steps, a claimant seeking disability benefits must demonstrate
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(1) that he is not presently engaged in a substantial gainful activity, and (2) that his
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medically determinable impairment or combinations of impairments is severe.
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20 C.F.R. §§ 404.1520(b) and (c), 416.920(b) and (c). If a claimant meets steps one and
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two, there are two ways in which he may be found disabled at steps three through five.
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At step three, he may prove that his impairment or combination of impairments meets or
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equals an impairment in the Listing of Impairments found in Appendix 1 to Subpart P of
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20 C.F.R. Part 404.
The Five-Step Sequential Evaluation Process
20 C.F.R. §§ 404.1520(a)(4)(iii) and (d), 416.920(d).
If so, the
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claimant is presumptively disabled. If not, the ALJ determines the claimant’s residual
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functional capacity (“RFC”). 20 C.F.R. §§ 404.1520(e), 416.920(e). At step four, the
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ALJ determines whether a claimant’s RFC precludes him from performing his past
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relevant work. 20 C.F.R. §§ 404.1520(f), 416.920(f). If the claimant establishes this
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prima facie case, the burden shifts to the government at step five to establish that the
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claimant can perform other jobs that exist in significant number in the national economy,
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considering
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20 C.F.R. §§ 404.1520(g), 416.920(g). If the government does not meet this burden, then
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the claimant is considered disabled within the meaning of the Act.
the
claimant’s
RFC,
age,
work
experience,
and
education.
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B.
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Applying the five-step sequential evaluation process, the ALJ found that Plaintiff
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had not engaged in substantial gainful activity since the alleged disability onset date.
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(Tr. 18.) At step two, the ALJ found that Plaintiff had the following severe impairments:
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“degenerative disc disease of the lumbar and cervical spine; status post fusion of C7-T1
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vertebrae (20 CFR 416.920(c)).” (Id.) At step three, the ALJ found that Plaintiff did not
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have an impairment or combination of impairments that met or equaled the severity of a
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listed impairment. (Tr. 19.)
The ALJ’s Application of the Five-Step Evaluation Process
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The ALJ found that Plaintiff had the RFC to perform “light work as defined in 20
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CFR 416.967(b)” with numerous qualifiers. (Tr. 20.) Notably, the ALJ concluded that
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Plaintiff could carry up to ten pounds continuously, eleven to twenty pounds frequently,
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and twenty-one to fifty pounds occasionally. (Id.) The ALJ found that Plaintiff could sit,
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stand, or walk up to two hours at a time for a total of eight hours in an eight-hour
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workday. (Id.) The ALJ found that Plaintiff could occasionally reach overhead and
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could reach in all other directions and push and pull continuously. (Id.) The ALJ further
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found that Plaintiff could “continuously handle, finger, or feel.” (Id.)
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The ALJ concluded that Plaintiff could not perform his past relevant work but that,
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considering Plaintiff’s age, education, work experience, and RFC, Plaintiff could perform
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other work that existed in significant numbers in the national economy. (Tr. 24-25.)
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Therefore, the ALJ concluded that Plaintiff was not under a disability as defined in the
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Act since July 12, 2013, the date Plaintiff filed his application, and denied his application
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for SSI. (Tr. 26.)
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V.
Standard of Review
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The district court has the “power to enter, upon the pleadings and transcript of
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record, a judgment affirming, modifying, or reversing the decision of the Commissioner,
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with or without remanding the cause for a rehearing.” 42 U.S.C. § 405(g). The district
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court reviews the Commissioner’s final decision under the substantial evidence standard
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and must affirm the Commissioner’s decision if it is supported by substantial evidence
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and it is free from legal error. Smolen v. Chater, 80 F.3d 1273, 1279 (9th Cir. 1996);
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Ryan v. Comm’r of Soc. Sec. Admin., 528 F.3d 1194, 1198 (9th Cir. 2008). Even if the
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ALJ erred, however, “[a] decision of the ALJ will not be reversed for errors that are
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harmless.” Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005).
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Substantial evidence means more than a mere scintilla, but less than a
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preponderance; it is “such relevant evidence as a reasonable mind might accept as
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adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971)
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(citations omitted); see also Webb v. Barnhart, 433 F.3d 683, 686 (9th Cir. 2005). In
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determining whether substantial evidence supports a decision, the court considers the
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record as a whole and “may not affirm simply by isolating a specific quantum of
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supporting evidence.”
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quotation and citation omitted).
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testimony, determining credibility, and resolving ambiguities. See Andrews v. Shalala,
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53 F.3d 1035, 1039 (9th Cir. 1995). “When the evidence before the ALJ is subject to
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more than one rational interpretation [the court] must defer to the ALJ’s conclusion.”
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Batson v. Comm’r of Soc. Sec. Admin., 359 F.3d 1190, 1198 (9th Cir. 2004) (citing
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Andrews, 53 F.3d at 1041).
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VI.
Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007) (internal
The ALJ is responsible for resolving conflicts in
Plaintiff’s Claims
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Plaintiff raises the following claims: (1) the ALJ erred by assigning little weight to
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the opinion of examining physician Dr. Kahn and instead assigning great weight to the
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opinion of examining physician Dr. Cunningham; and (2) the ALJ erred by failing to
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provide clear and convincing reasons for rejecting Plaintiff’s symptom testimony.
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(Doc. 11 at 1.) The Commissioner asserts that the ALJ’s decision is free from harmful
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error and is supported by substantial evidence.
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addressing Plaintiff’s first claim, the Court concludes that the ALJ erred by failing to
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provide Dr. Cunningham with Plaintiff’s medical records in violation of 20 C.F.R
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§ 416.917. The Court reverses the ALJ’s decision based on that error and does not reach
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Plaintiff’s remaining claims.
(Doc. 17.)
As set forth below, in
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A.
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In the discussion of his first claim, Plaintiff argues that the ALJ’s assessment of
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Plaintiff’s RFC is flawed because it was not based on “careful consideration of the entire
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record,” but instead simply incorporated the limitations Dr. Cunningham assessed.
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(Doc. 11 at 12; compare Tr. 560-66 with Tr. 20.) The ALJ stated that he assigned “great
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weight” to Dr. Cunningham’s opinion and “incorporated it into [Plaintiff’s] residual
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functional capacity.” (Tr. 23.) The regulations provide that an RFC is formulated based
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on consideration of “all the relevant medical and other evidence.”
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§ 416.945(a)(3).
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Dr. Cunningham’s assessment of Plaintiff’s physical limitations into the RFC, the ALJ
The ALJ Considered the Medical Record
20 C.F.R.
Therefore, Plaintiff argues that because the ALJ incorporated
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did not appropriately consider the medical record in determining the RFC. (Doc. 11 at 12
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and n. 10.) Although the ALJ admittedly adopted Dr. Cunningham’s assessed limitation
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(Tr. 23), he also considered other evidence in the record before doing so, including the
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medical records. (Tr. 19 (discussing the medical records).) Therefore, the Court rejects
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Plaintiff’s claim that the ALJ erred by failing to consider the medical record.
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B.
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In the discussion of his first claim, Plaintiff also argues that the ALJ failed to
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comply with 20 C.F.R § 416.917 because the ALJ ordered a consultative examination,
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but the consultative examiner, Dr. Cunningham, was not provided with any of Plaintiff’s
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medical records. (Doc. 11 at 12-14.) The Commissioner does not dispute Plaintiff’s
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assertion that the ALJ did not provide Plaintiff’s medical records to Dr. Cunningham, and
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does not directly address the ALJ’s alleged violation of § 416.917. (Doc. 17 at 6-7.)
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Rather, the Commissioner argues that the Court should reject Plaintiff’s claim because a
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“consultative examiner is not legally obligated to review a claimant’s medical records.”
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(Doc. 17 at 6.) As set forth below, the Court concludes that the ALJ erred by failing to
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provide Plaintiff’s medical records to Dr. Cunningham.
The ALJ Failed to Comply with 20 C.F.R. § 416.917
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Pursuant to 20 C.F.R. § 416.917, consultative examiners must be provided with
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“any necessary background information” concerning a claimant’s condition.4 The phrase
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“necessary background information” has been interpreted to mean medical records. See
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Brantley v. Comm’r of Soc. Sec., 637 F. App’x. 888, 894-95 (6th Cir. 2016) (citing Soc.
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Sec. Admin., POMS Home, https://secure.ssa.gov/apps10 (last visited Oct. 15, 2015)).
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Additionally, the parties’ briefing assumes that “necessary background information”
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includes medical records. (Doc. 11 at 12-14, Doc. 17 at 6-7.) On referral from the ALJ,
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Dr. Cunningham conducted a consultative examination of Plaintiff on May 12, 2105.
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(Tr. 558-566.) The parties do not dispute that Dr. Cunningham was not provided with
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Plaintiff’s medical records. (Doc. 11 at 12-14, Doc. 17 at 6-7.)
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4
20 C.F.R. § 404.1517 contains the same requirement.
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Plaintiff relies on Reed v. Massanari, 270 F.3d 838, 842-43 (9th Cir. 2001), and
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argues that the ALJ’s failure to provide Dr. Cunningham with Plaintiff’s medical records
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violated the ALJ’s obligation to provide “necessary background information” and
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constitutes reversible error. (Doc. 11 at 12-14.) In Reed, the court noted that although a
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claimant has the burden of establishing disability, the “‘ALJ has a duty to assist in
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developing the record.’” Reed, 270 F.3d at 841 (quoting Armstrong v. Comm’r of Soc.
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Sec. Admin., 160 F.3d 587, 589 (9th Cir. 1998)). A consultative examination, which is a
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physical or mental examination at the agency’s request and expense, is “[o]ne of the
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means available to an ALJ to supplement an inadequate medical record . . . .” Reed, 270
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F.3d at 841 (citing 20 C.F.R. §§ 404.1519, 416.919). Although a claimant does not have
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“an affirmative right to have a consultation performed by a chosen specialist . . . , the
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agency’s actions with respect to consultative examinations must be taken in accordance
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with regulatory procedures.” Reed, 270 F.3d at 842-43 (citing Andriassian v. INS, 180
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F.3d 1033, 1046 (9th Cir. 1999)).
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In Reed, the ALJ acknowledged that a consultative examination from a
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rheumatologist would have been appropriate, but chose not to order an examination
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because he believed that both of the available examining physicians with the appropriate
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specialization routinely “conclude that ‘everybody’ is disabled.” Reed, 270 F.3d at 843.
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The claimant argued that the ALJ exhibited bias when he denied her request for an
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additional consultative examination by a rheumatologist. Id. at 840. Because there was
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no evidence to support the ALJ’s conclusion about the available examining physicians,
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the court found that the ALJ’s “ad hoc” disqualification of the only two available
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rheumatologists “exceed[ed] the ALJ’s authority in the disability determination process.”
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Id. at 844 (noting that the record was “barren” of “analysis from other medical
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professionals” and thus lacking the criterion upon which the decision to appoint a
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consultative examiner “turned.”). The court found the ALJ’s “reason for denying [the
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claimant] a consultative examination was not in accordance with law,” and reversed and
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remanded for further proceedings before a different ALJ. Id. at 845.
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The Commissioner does not discuss Reed and does not directly address Plaintiff’s
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assertion that the ALJ erred by failing to provide Dr. Cunningham with Plaintiff’s
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medical records. (Doc. 17 at 6-7.) Rather, the Commissioner argues that the ALJ did not
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err by relying on Dr. Cunningham’s opinion, which he formed without reviewing
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Plaintiff’s medical records, because Dr. Cunningham was not required to review those
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records. (Doc. 17 at 6 (citing Castaneda v. Astrue, 344 F. App’x 396, 398 (9th Cir. 2009)
7
(holding that ALJ did not err in relying on the report of a consultative examiner who did
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not review a previous MRI record because the examiner’s report rested on his own
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independent examination of plaintiff); Anderson v. Astrue, 2009 WL 3297247 (W.D.
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Wash. Oct. 14, 2009); Fortes v. Astrue, 2009 WL 734161, at *3 (S.D. Cal. Mar. 18,
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2009) (ALJ did not err in relying on a report from a consultative examiner who failed to
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review claimant’s medical records because the examiner obtained a medical history from
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plaintiff and performed his own orthopedic examination.)).
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These cases are not persuasive. The Commissioner cites these cases for the
15
proposition that “[a] consultative examiner is not legally obligated to review a claimant’s
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medical records.” (Doc. 17 at 6.) Plaintiff, however, does not assert that § 416.917
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obligates the consultative examiners to actually review the relevant medical records.
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(Doc. 11 at 12.) Instead, Plaintiff argues that the applicable regulation requires the ALJ
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to provide the consultative examiner with the claimant’s medical records. (Id.) None of
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the cases the Commissioner cites addressed whether the ALJ’s failure to provide medical
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records to a consultative examiner, in violation of § 416.917, constitutes reversible error.
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A federal agency is obligated to adhere to the regulations it promulgates. See
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Sameena, Inc. v. U.S. Air Force, 147 F.3d 1148, 1153 (9th Cir. 1998) (citing Vitarelli v.
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Seaton, 359 U.S. 535, 545 (1959)). In this case, the Court concludes that the ALJ
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violated the applicable regulation, § 416.917, by failing to provide Dr. Cunningham with
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Plaintiff’s medical records. See Brantley, 637 F. App’x at 894-97 (concluding that the
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ALJ violated § 416.917 by failing to give a consultative examiner the claimant’s medical
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records and remanding for further proceedings.).
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The Commissioner states that Dr. Cunningham obtained a medical history from
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Plaintiff and “performed his own physical examination.” (Doc. 17 at 7.) Although this
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statement suggests that the ALJ’s failure to comply with § 416.917 was harmless error,
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the Commissioner does not make that argument. (Id.); see Robbins v. Soc. Sec. Admin.,
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466 F.3d 880, 885 (9th Cir. 2006) (stating that the court will not reverse the
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Commissioner’s decision if it is based on harmless error, which exists only when it is
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“clear from the record that an ALJ’s error was ‘inconsequential to the ultimate
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nondisability determination.’”) (quoting Stout v. Comm’r, 454 F.3d 1050, 1055-56 (9th
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Cir. 2006)). Plaintiff asserts that the ALJ’s failure to provide Dr. Cunningham with his
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medical records was reversible error because his medical records include evidence of
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significant findings on testing, including an MRI, after his C7-T1 fusion. (Doc. 11 at 13-
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14 (citing Tr. 452, 539).) Plaintiff’s argument invites the Court to assume that reviewing
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the medical records would have affected Dr. Cunningham’s assessment of Plaintiff’s
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physical limitations.
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Plaintiff’s medical records would have affected Dr. Cunningham’s opinion.
The Court, however, cannot determine whether reviewing
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Nonetheless, courts have found the agency’s failure to comply with its own
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regulations prejudicial. See Reed, 270 F.3d at 843; see also Wilson v. Comm’r of Soc.
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Sec., 378 F.3d 541, 46 (6th Cir. 2004) (concluding that excusing noncompliance with
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agency regulations “simply because there is substantial evidence that a different outcome
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on remand is unlikely . . . would afford the Commissioner the ability [to] violate the
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regulation with impunity and render the protections promised therein illusory” and
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remanding to the Commissioner for further proceedings); Deden v. Colvin, 2013 WL
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6189954, at *5 (C.D. Cal. Nov. 26, 2013) (noting that “background information is
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essential, because consultative exams are utilized ‘to try to resolve a conflict or ambiguity
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if one exists.’”) (quoting 20 C.F.R. §§ 404.1519a(b), 416.919a(b)). Therefore, the Court
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concludes that the ALJ violated § 416.917 by failing to provide Dr. Cunningham with
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Plaintiff’s “necessary background information,” specifically his medical records. The
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Court reverses the ALJ’s decision based on this error.
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1
VII.
Conclusion and Remedy
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Because the Court has decided to reverse the Commissioner’s decision, it has the
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discretion to remand the case for further development of the record or for an award
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benefits. See Reddick v. Chater, 157 F.3d 715, 728 (9th Cir. 1998). When no useful
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purpose would be served by further administrative proceedings, or when the record has
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been fully developed, it is appropriate to exercise this discretion to direct an immediate
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award of benefits. See Harman v. Apfel, 211 F.3d 1172, 1179 (9th Cir. 2000) (“the
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decision of whether to remand for further proceedings turns upon the likely utility of such
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proceedings”).
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However, when there are outstanding issues that must be resolved before a
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determination of disability can be made, and it is not clear from the record that the ALJ
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would be required to find the claimant disabled if all the evidence were properly
13
evaluated, remand is appropriate. Id.; see Garrison v. Colvin, 759 F.3d 995, 1020 (9th
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Cir. 2014) (stating that evidence should be credited as true and an action remanded for an
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immediate award of benefits when each of the following factors are present: “(1) the
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record has been fully developed and further administrative proceedings would serve no
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useful purpose; (2) the ALJ has failed to provide legally sufficient reasons for rejecting
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evidence, whether claimant’s testimony or medical opinion; and (3) if the improperly
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discredited evidence were credited as true, the ALJ would be required to find the
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claimant disabled on remand.”).
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In this case further administrative proceedings to develop the record would be
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helpful because Dr. Cunningham did not have the opportunity to review Plaintiff’s
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medical records when he examined Plaintiff and when he provided an assessment of
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Plaintiff’s physical functional limitations.
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therefore, remands for further proceedings to allow the ALJ to remedy the error identified
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in this Order.
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See 20 C.F.R. § 416.917.
Accordingly,
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The Court,
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IT IS ORDERED that the Commissioner’s decision is REVERSED and this
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matter is REMANDED for further proceedings.
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Dated this 8th day of June, 2018.
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