Kenneth D. Edmond v. Carolyn W. Colvin

Filing 32

MEMORANDUM AND ORDER by Magistrate Judge Kenly Kiya Kato. IT IS ORDERED that judgment be entered REVERSING the decision of the Commissioner and REMANDING this action for further proceedings consistent with this Order. (twdb)

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1 2 3 4 5 6 UNITED STATES DISTRICT COURT 7 CENTRAL DISTRICT OF CALIFORNIA 8 9 KENNETH D. EDMOND, 10 Case No. CV 15-8256-KK Plaintiff, 11 v. 12 13 MEMORANDUM AND ORDER NANCY A. BERRYHILL,1 Acting Commissioner of Social Security, 14 Defendant. 15 16 Plaintiff Kenneth D. Edmond (“Plaintiff”) seeks review of the final decision 17 18 of the Commissioner of the Social Security Administration (“Commissioner” or 19 “Agency”) denying his application for Title II Disability Insurance Benefits 20 (“DIB”) and Title XVI Supplemental Security Income Benefits (“SSI”). The 21 parties have consented to the jurisdiction of the undersigned United States 22 Magistrate Judge, pursuant to 28 U.S.C. § 636(c). For the reasons stated below, 23 the Commissioner’s decision is REVERSED and this action is REMANDED for 24 further proceedings consistent with this Order. 25 /// 26 27 28 Nancy A. Berryhill is now the Acting Commissioner of the Social Security Administration. Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure, the Court substitutes Nancy A. Berryhill as Defendant in the instant case at Plaintiff’s request. 1 1 I. 2 PROCEDURAL HISTORY 3 On September 14, 2012, Plaintiff filed applications for SSI and DIB alleging a 4 disability onset date of December 6, 2011 for both. Administrative Record (“AR”) 5 at 166-73. Plaintiff’s applications were denied initially on January 15, 2013, and 6 upon reconsideration on May 14, 2013. Id. at 98-103, 105-11. 7 On June 11, 2013, Plaintiff requested a hearing before an Administrative Law 8 Judge (“ALJ”). Id. at 112-13. On January 29, 2014, Plaintiff appeared with counsel 9 and testified at a hearing before the assigned ALJ. Id. at 33-53. A vocational expert 10 (“VE”) also testified at the hearing. Id. at 49-52. On February 10, 2014, the ALJ 11 issued a decision denying Plaintiff’s applications for DIB and SSI. Id. at 15-32. On April 9, 2014, Plaintiff filed a request to the Agency’s Appeals Council to 12 13 review the ALJ’s decision. Id. at 10-13. On August 26, 2015, the Appeals Council 14 denied Plaintiff’s request for review. Id. at 1-6. On October 21, 2015, Plaintiff filed the instant action. ECF Docket No. 15 16 (“Dkt.”) 1, Compl. This matter is before the Court on the parties’ Joint 17 Stipulation (“JS”), filed on May 30, 2017, which the Court has taken under 18 submission. Dkt. 31, JS. 19 II. 20 PLAINTIFF’S BACKGROUND Plaintiff was born on January 17, 1961 and his alleged disability onset date is 21 22 December 6, 2011. AR at 166, 168. He was forty-nine years old on the alleged 23 disability onset date and fifty-two at the time of the hearing before the ALJ. Id. at 24 53, 166, 168. Plaintiff has completed two years of college and has prior work 25 experience as an auditor. Id. at 193. Plaintiff alleges disability based on numbness 26 in both arms and hand; stiffness in his neck and back; stomach pain and cramps; 27 swelling and pain in both legs. Id. at 192. 28 /// 2 1 III. 2 STANDARD FOR EVALUATING DISABILITY 3 To qualify for DIB and SSI, a claimant must demonstrate a medically 4 determinable physical or mental impairment that prevents him from engaging in 5 substantial gainful activity, and that is expected to result in death or to last for a 6 continuous period of at least twelve months. Reddick v. Chater, 157 F.3d 715, 721 7 (9th Cir. 1998). The impairment must render the claimant incapable of performing 8 the work he previously performed and incapable of performing any other 9 substantial gainful employment that exists in the national economy. Tackett v. 10 11 12 13 14 15 16 17 Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). To decide if a claimant is disabled, and therefore entitled to benefits, an ALJ conducts a five-step inquiry. 20 C.F.R. §§ 404.1520, 416.920. The steps are: 1. Is the claimant presently engaged in substantial gainful activity? If so, the claimant is found not disabled. If not, proceed to step two. 2. Is the claimant’s impairment severe? If not, the claimant is found not disabled. If so, proceed to step three. 3. Does the claimant’s impairment meet or equal one of the specific 18 impairments described in 20 C.F.R. Part 404, Subpart P, Appendix 1? If so, 19 the claimant is found disabled. If not, proceed to step four.2 20 21 22 23 4. Is the claimant capable of performing work he has done in the past? If so, the claimant is found not disabled. If not, proceed to step five. 5. Is the claimant able to do any other work? If not, the claimant is found disabled. If so, the claimant is found not disabled. 24 25 26 27 28 2 “Between steps three and four, the ALJ must, as an intermediate step, assess the claimant’s [residual functional capacity],” or ability to work after accounting for her verifiable impairments. Bray v. Comm’r of Soc. Sec. Admin., 554 F.3d 1219, 1222-23 (9th Cir. 2009) (citing 20 C.F.R. § 416.920(e)). In determining a claimant’s residual functional capacity, an ALJ must consider all relevant evidence in the record. Robbins v. Soc. Sec. Admin., 466 F.3d 880, 883 (9th Cir. 2006). 3 1 See Tackett, 180 F.3d at 1098-99; see also Bustamante v. Massanari, 262 F.3d 949, 2 953-54 (9th Cir. 2001); 20 C.F.R. §§ 404.1520(b)-(g)(1), 416.920(b)-(g)(1). The claimant has the burden of proof at steps one through four, and the 3 4 Commissioner has the burden of proof at step five. Bustamante, 262 F.3d at 953- 5 54. Additionally, the ALJ has an affirmative duty to assist the claimant in 6 developing the record at every step of the inquiry. Id. at 954. If, at step four, the 7 claimant meets his burden of establishing an inability to perform past work, the 8 Commissioner must show that the claimant can perform some other work that 9 exists in “significant numbers” in the national economy, taking into account the 10 claimant’s residual functional capacity (“RFC”), age, education, and work 11 experience. Tackett, 180 F.3d at 1098, 1100; Reddick, 157 F.3d at 721; 20 C.F.R. 12 §§ 404.1520(g)(1), 416.920(g)(1). 13 IV. 14 THE ALJ’S DECISION 15 A. STEP ONE At step one, the ALJ found Plaintiff “engaged in substantial gainful activity 16 17 during the following periods: December 2011 through March 2012 . . . However, 18 there has been a continuous 12-month period(s) during which [Plaintiff] did not 19 engage in substantial gainful activity. The remaining findings address the period(s) 20 [Plaintiff] did not engage in substantial gainful activity . . . from April 1, 2012, 21 through the date of this decision.” AR at 20-21. 22 B. STEP TWO 23 At step two, the ALJ found Plaintiff “ha[d] the following severe 24 impairments: degenerative joint disease and degenerative disc disease of the 25 cervical spine; status-post cervical fusion in June 2013; cervical radiculopathy; 26 hypertension; lumbago; degenerative narrowing at the lateral joint compartment of 27 the left knee; and mild osteopenia in the right knee.” Id. at 21. 28 /// 4 1 C. STEP THREE At step three, the ALJ found Plaintiff “does not have an impairment or 2 3 combination of impairments that meets or medically equals the severity of one of 4 the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1.” Id. 5 D. RFC DETERMINATION 6 The ALJ found Plaintiff had the following RFC: 7 to perform light work as defined in 20 CFR 404.1567(b) and 416.97(b) 8 except [Plaintiff] can lift and/or carry 20 pounds occasionally and 10 9 pounds frequently: he can stand and/or walk for six hours out of an 10 eight-hour workday but no more than 15-20 minutes at a time; he can 11 sit for six hours out of an eight-hour workday but with brief position 12 changes after 1-2 hours; he can occasionally perform postural 13 activities; he cannot climb ladders, ropes, or scaffolds; he cannot work 14 at unprotected heights, around moving machinery, or other hazards; 15 he cannot do overhead reaching or lifting bilaterally; he cannot do 16 repetitive or constant pushing and/or pulling with the lower 17 extremities, such as operating foot pedals; he cannot do repetitive or 18 constant fine manipulation bilaterally, but frequent use is permissible; 19 he cannot perform jobs that require fast paced production or assembly 20 line type work; and he needs ready access to a restroom, meaning it 21 needs to be in the same building. 22 Id. at 22. 23 E. STEP FOUR At step four, the ALJ found Plaintiff “is capable of performing past relevant 24 25 work as an auditor.” Id. at 28. The ALJ, therefore, found Plaintiff not disabled and 26 did not proceed to step five. Id. 27 /// 28 /// 5 1 V. 2 PLAINTIFF’S CLAIMS Plaintiff presents one disputed issue: whether the ALJ failed to articulate 3 4 specific and legitimate reasons for rejecting Plaintiff’s testimony as not credible. JS 5 at 5. 6 VI. 7 STANDARD OF REVIEW 8 Pursuant to 42 U.S.C. § 405(g), a district court may review the 9 Commissioner’s decision to deny benefits. The ALJ’s findings and decision should 10 be upheld if they are free of legal error and supported by substantial evidence based 11 on the record as a whole. Richardson v. Perales, 402 U.S. 389, 401, 91 S. Ct. 1420, 12 28 L. Ed. 2d 842 (1971); Parra v. Astrue, 481 F.3d 742, 746 (9th Cir. 2007). 13 “Substantial evidence” is evidence that a reasonable person might accept as 14 adequate to support a conclusion. Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th 15 Cir. 2007). It is more than a scintilla but less than a preponderance. Id. To 16 determine whether substantial evidence supports a finding, the reviewing court 17 “must review the administrative record as a whole, weighing both the evidence that 18 supports and the evidence that detracts from the Commissioner’s conclusion.” 19 Reddick, 157 F.3d at 720 (citation omitted); see also Hill v. Astrue, 698 F.3d 1153, 20 1159 (9th Cir. 2012) (stating that a reviewing court “may not affirm simply by 21 isolating a ‘specific quantum of supporting evidence’”) (citation omitted). “If the 22 evidence can reasonably support either affirming or reversing,” the reviewing court 23 “may not substitute its judgment” for that of the Commissioner. Reddick, 157 24 F.3d at 720-21; see also Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012) 25 (“Even when the evidence is susceptible to more than one rational interpretation, 26 we must uphold the ALJ’s findings if they are supported by inferences reasonably 27 drawn from the record.”). 28 6 1 The Court may review only the reasons stated by the ALJ in his decision 2 “and may not affirm the ALJ on a ground upon which he did not rely.” Orn v. 3 Astrue, 495 F.3d 625, 630 (9th Cir. 2007). If the ALJ erred, the error may only be 4 considered harmless if it is “clear from the record” that the error was 5 “inconsequential to the ultimate nondisability determination.” Robbins, 466 F.3d 6 at 885 (citation omitted). 7 VII. 8 RELEVANT FACTS 9 10 A. Plaintiff’s Testimony Plaintiff testified he has “consistent pain in [his] neck” and that the daily 11 level of pain ranges from a nine or a ten without medication, and an eight or a nine 12 with medication. AR at 39-40. Plaintiff additionally testified he suffers from 13 “nerve damage in [his] hands which results [in] them always being cold and 14 numb.” Id. at 39. Plaintiff claims that because of the nerve damage, he has 15 difficulty lifting his arms above his head. Id. at 40. In addition to the nerve damage 16 and neck pain, Plaintiff testified he suffers from arthritis in both of his knees, which 17 limits the length of time he is able to sit or stand. Id. at 42. Plaintiff testified he 18 often loses his balance while walking, and occasionally uses an assistive device for 19 balance. Id. at 43. 20 To manage the pain, Plaintiff testified he is currently taking muscle relaxers, 21 blood pressure medication, and prescription Ibuprofen. Id. at 40-41. Depending 22 on the pain, Plaintiff will take three or four 800-miligram Ibuprofen pills per day. 23 Id. at 41. Plaintiff testified he received surgery on his neck, which only slightly 24 improved the pain. Id. at 39. He did not go through physical therapy following his 25 surgery. Id. at 41. 26 Because of the pain, Plaintiff testified he spends about half the day lying 27 down. Id. at 48. He often takes two to three naps a day for a total of about two to 28 three hours. Id. at 49. He has difficulties engaging in simple daily tasks like getting 7 1 dressed and putting shoes on. Id. As of the date of the hearing, Plaintiff stated he 2 had not had any recent visits to the hospital or emergency room because of his pain. 3 Id. at 40. 4 B. 5 The ALJ’s Adverse Credibility Determination In evaluating Plaintiff’s allegations of pain, the ALJ found Plaintiff’s claims 6 were “less than fully credible.” Id. at 23. First, the ALJ questioned Plaintiff’s 7 descriptions of his limited daily activities, which generally involved hours spent 8 immobile and in bed, finding it difficult to reconcile Plaintiff’s severe limitations 9 with the “relatively benign medical evidence . . . .” Id. As to Plaintiff’s allegations 10 of difficulty sleeping through the night, the ALJ noted, “Perhaps his poor sleep is 11 caused by his diurnal sleeping pattern, allegedly consisting of 2-3 naps daily, each 2 12 to 3 hours in duration, coupled with lying down for up to 12 hours per day.” Id. 13 Additionally, the ALJ considered Plaintiff’s receipt of unemployment 14 benefits from 2012 to 2013 as a factor affecting the credibility and weight of the 15 evidence. Id. at 24. The ALJ noted Plaintiff’s earning records reveal Plaintiff 16 “received unemployment benefits from the second quarter of 2012 through the 17 second quarter of 2013.” Id. The ALJ highlighted the fact that “[i]n order to 18 receive unemployment benefits, [Plaintiff] was required to certify he was willing 19 and able to engage in work activity, which is inconsistent with a claim for 20 disability.” Id. 21 Furthermore, the ALJ noted Plaintiff “has not received the type of treatment 22 one would expect from a completely disabled individual, as evidenced by gaps in 23 the claimant’s history of treatment and generally conservative treatment.” Id. at 24 24. The ALJ specifically found the “treatment records reveal [Plaintiff] received 25 routine, conservative, and non-emergency treatment since the alleged onset date.” 26 Id. While conceding Plaintiff underwent surgery on his cervical spine, the ALJ 27 noted “the medical record indicates that this greatly improved his condition.” Id. 28 Specifically, the ALJ noted “[i]t appears [Plaintiff’s] symptoms were greatly 8 1 relieved after surgery, as there are no medical recording showing that he attended 2 physical therapy or presented for treatment of this condition again for nearly a 3 year.” Id. at 25. Moreover, the ALJ stated “the medical records show that [Plaintiff] failed to 4 5 follow up on several referrals to specialist[s], indicating that his symptoms are not 6 as severe as alleged . . . [and] demonstrate[ing] a possible unwillingness to do what 7 is necessary to improve his symptoms.” Id. at 26. For example, the ALJ noted 8 “the medical records indicate that [Plaintiff] did not follow up on [a referral he 9 received on February 24, 2012].” Id. at 25; see also id. at 693. Additionally, the 10 ALJ noted in August 2013, Plaintiff was referred to a neurologist for evaluation, but 11 “[i]t is unclear if [Plaintiff] followed up on this referral.” Id. at 26. 12 Ultimately, the ALJ concluded that after reviewing and considering 13 Plaintiff’s complete medical history, “[t]he treatment records reveal [Plaintiff] 14 received routine, conservative, and non-emergency treatment since the alleged 15 onset date” and “[t]he positive objective clinical and diagnostic findings since the 16 alleged onset date detailed below do not support more restrictive functional 17 limitations than those assessed herein.” Id. 18 VIII. 19 DISCUSSION 20 THE ALJ FAILED TO CONSIDER THE OVERALL DIAGNOSTIC 21 RECORD WHEN REJECTING PLAINTIFF’S TESTIMONY 22 A. PLAINTIFF’S RELEVANT MEDICAL HISTORY 23 1. Plaintiff’s Symptoms and Treatment Before Surgery 24 On December 6, 2011, Plaintiff visited Kaiser Permanente’s Department of 25 Emergency Medicine with complaints of pain on the left side of his neck and 26 shoulder. AR at 408-13. Plaintiff was prescribed Norco and Robaxin, to take as 27 needed, and instructed to follow up with his primary treating physician. Id. 28 9 On December 12, 2011, Plaintiff was examined by his treating physician, Dr. 1 2 Kenneth Van Williams (“Dr. Kenneth Williams”), a family medicine doctor of 3 osteopathy. Id. at 425-26. Dr. Kenneth Williams noted Plaintiff claimed to be 4 suffering from moderately severe left shoulder pain, which had persisted for more 5 than two weeks. Id. at 426. Additionally, Dr. Kenneth Williams noted Plaintiff’s 6 pain is “aggravated by abduction and rotation, and overhead motions,” and not 7 relieved by Plaintiff’s current medication. Id. Dr. Kenneth Williams diagnosed 8 Plaintiff with “bursitis of shoulder region,” specifically “rotator cuff tendinitis.” 9 Id. at 428. Dr. Kenneth Williams ordered an x-ray, referred Plaintiff to physical 10 therapy, and prescribed Naproxen and Norco to manage the pain. Id. X-rays 11 revealed normal alignment, no acute fractures, no significant soft tissue 12 abnormality, but a mild degenerative change of the acromioclavicular joint. Id. at 13 437. 14 On December 20, 2011, Plaintiff returned to Dr. Kenneth Williams because 15 the pain in his neck and shoulder continued to worsen despite the prior week’s 16 treatment. Id. at 449. Dr. Kenneth Williams noted that, in addition to pain, 17 Plaintiff now complained of a numbing sensation radiating down into his left arm 18 and hand. Id. According to Plaintiff, the pain in his shoulder worsened when he 19 lifted his arm. Id. Dr. Kenneth Williams diagnosed Plaintiff with cervical 20 radiculopathy and treated him with a steroid cortisone shot. Id. at 451. 21 On December 27, 2011, Plaintiff returned to Dr. Kenneth Williams 22 complaining of “left arm pain, numbness, and weakness, feels cold.” Id. at 459. 23 Dr. Kenneth Williams noted Plaintiff received a cortisone injection in his left 24 shoulder the week before, but relief lasted for less than 24 hours. Id. Dr. Kenneth 25 Williams ordered additional x-rays, prescribed Prednisone, and referred Plaintiff to 26 an orthopedist. Id. at 460. 27 28 On January 4, 2012, Plaintiff was examined by Dr. Shane K. Williams, an orthopedic surgeon (“Dr. Shane Williams”). Id. at 478. Following an initial 10 1 observation, Dr. Shane Williams ordered an MRI of Plaintiff’s left shoulder. Id. at 2 480. 3 On January 6, 2012, Plaintiff began his first session of physical therapy. Id. at 4 487-88. The physical therapist noted Plaintiff suffered from the following 5 functional limitations / aggravating factors: coughing, driving, looking over 6 shoulder, lying on left side, bathing, dressing and grooming activities, reaching 7 overhead, lifting objects with work activities. Id. at 489. The physical therapist 8 also noted Plaintiff’s current level of pain was a 3 out of 10 at rest, and a 10 out of 9 10 with activity. Id. The physical therapist additionally noted Plaintiff’s symptoms 10 as “insidious onset aching, constant, sharp, and radiating numbness, tingling and 11 ‘cold’ sensation in left upper extremity to hand.” Id. at 490. Plaintiff was 12 scheduled to have eight sessions of physical therapy over the course of eight weeks. 13 Id. at 488. The goals for Plaintiff, as established by the physical therapist, were to: 14 be compliant with home exercise program within four weeks, improve posture with 15 daily and work activities within six weeks, be able to manage radicular symptoms 16 with posture and exercise within eight weeks, improve left grip strength to 90% of 17 right within eight weeks to perform lifting activities at work, and be able to perform 18 dressing, bathing and grooming activities without limitation within eight weeks. Id. 19 On January 7, 2012, Plaintiff received his x-rays ordered by Dr. Kenneth 20 Williams on December 27, 2011. Id. at 461. The x-rays revealed “[m]ild degree of 21 degenerative joint disease . . . with spurring at multiple vertebrae and presence of 22 narrowing of some intervertebral spaces.” Id. 23 On January 12, 2012, Plaintiff received the results from his MRI ordered by 24 Dr. Shane Williams on January 4, 2012. Id. at 482. According to the radiologist’s 25 report, the MRI revealed abnormal findings, including “hypetrophic degenerative 26 changes of the acromioclavicular joint with lateral downsloping of the acromion 27 process with undersurface spurring”; “mild increased intrasubstance signal along 28 the superior fibers of the underlying supraspinatus tendon”; “a small rim rent tear 11 1 of the supraspinatus tendon at the footplate”; “prominent subcortical cystic 2 changes at the greater tuberosity.” Id. 3 On January 13, 2012, Plaintiff completed his second session of physical 4 therapy. Id. at 524. The physical therapist noted Plaintiff reported “no change in 5 neck and shoulder pain,” “difficulty using left hand for writing,” and a four out of 6 ten pain level. Id. 7 On January 19, 2012, Dr. Shane Williams reviewed Plaintiff’s January 12, 8 2012 MRI results, including the radiologist’s report, and determined that there was 9 “no evidence of full-thickness rotator cuff tear, but supraspinatus tendinopathy.” 10 Id. at 574. Dr. Shane Williams treated Plaintiff with a Depo-Medrol injection into 11 the left shoulder and advised Plaintiff to continue to take his prescription pain- 12 relievers and to attend physical therapy. Id. at 575. 13 On January 24, 2012, Plaintiff returned to Dr. Kenneth Williams, 14 “complaining of left shoulder pain with radiation of numbness sensation down into 15 right arm” and claiming his “whole left arm seems weaker and numb.” Id. at 585. 16 Dr. Kenneth Williams encouraged Plaintiff to continue physical therapy and taking 17 medications as directed. Id. at 587. 18 On February 3, 2012, Plaintiff completed his third session of physical 19 therapy. Id. at 601. The physical therapist noted Plaintiff reported “no significant 20 relief at this time, numbness in left hand/fingers continues,” and a continuous pain 21 level. Id. 22 On February 8, 2012, Plaintiff returned to Dr. Kenneth Williams 23 complaining of numbness in his left arm and hand, as well as constipation. Id. at 24 607. Plaintiff requested an “intra-articular injection to left shoulder.” Id. at 608. 25 Dr. Kenneth Williams noted he declined to fulfill Plaintiff’s request and instead 26 directed him to Orthopedics. Id. He further noted Plaintiff appeared “noticeably 27 disappointed.” Id. According to Dr. Kenneth Williams, Plaintiff had missed two 28 of his physical therapy appointments. Id. at 607. 12 1 On February 14, 2012, Plaintiff completed his fourth session of physical 2 therapy. Id. at 616. The physical therapist noted Plaintiff reported “continued and 3 persistent numbness and tingling in bilateral hands and weakness in left shoulder.” 4 Id. According to Plaintiff, the pain level in his neck was at a four to five out of ten. 5 Id. 6 On February 23, 2012, Plaintiff completed his fifth session of physical 7 therapy. Id. at 683. The physical therapist noted Plaintiff reported “continued and 8 persistent numbness and tingling in bilateral hands and weakness in left shoulder”; 9 “his greatest concern is the numbness and tingling in hands”; and “he is having 10 difficulty with dressing (buttons) and tying his shoes.” Id. According to the 11 physical therapist’s assessment, Plaintiff “notes relief of neck pain during 12 treatment, but no change in upper extremity symptoms. No change in overall neck 13 and shoulder range of motion actively.” Id. The physical therapist also noted 14 Plaintiff presented with “[d]ecreased grip strength bilateral upper extremities . . . 15 compared to initial evaluation with [Plaintiff] demonstrating good effort during 16 testing,” and that he “requir[es] verbal cueing with posture and he is attempting to 17 be more aware.” Id. Lastly, the physical therapist noted Plaintiff is “not 18 responding to conservative treatments,” but recommended Plaintiff continue 19 physical therapy. Id. at 683, 686. 20 On February 27, 2012, Dr. Shane Williams saw Plaintiff for a follow-up 21 evaluation of Plaintiff’s left shoulder. Id. at 719-20. Dr. Shane Williams noted 22 Plaintiff has been suffering from “moderate aching pain in his left shoulder” for the 23 last four months and specifically “has pain with overhead use of his left arm.” Id. 24 at 720. Dr. Shane Williams observed Plaintiff has seen “small signs of 25 improvement” through physical therapy and “only mild improvement in his 26 symptoms” from the last cortisone injection he received. Id. Dr. Shane Williams 27 ordered a nerve conduction study “to evaluate diffuse bilateral upper extremity 28 paresthesias.” Id. at 721. 13 1 On March 5, 2012, Dr. Ambika Bhat, a doctor of Physical Medicine and 2 Rehabilitation, performed a nerve conduction study on Plaintiff. Id. at 735. During 3 the appointment, Dr. Bhat noted Plaintiff has a history of “peripheral edema,” and 4 presents with “complaints of entire [left] arm numbness and [right] hand 5 numbness” for over a month, as well as “feelings of coldness in [left] hand.” Id. 6 Additionally, Dr. Bhat noted Plaintiff reported “[bilateral] hand weakness/loss of 7 control with fine motor activities such as putting on shoes . . . [and] weakness with 8 lifting.” Id. Lastly, Dr. Bhat noted Plaintiff “[o]riginally had pain in neck and left 9 shoulder which has improved.” Id. Following the study, Dr. Bhat found Plaintiff 10 presented with “findings of sensorimotor polyneuropathy,” and had “[a]bnormal 11 electrodiagnostic” results. Id. at 737. Thus, Dr. Bhat referred Plaintiff to a 12 neurologist “for abnormal findings on [the nerve conduction study] not consistent 13 with cervical radiculitis or carpal tunnel syndrome,” and noting Plaintiff had “[left] 14 finger abduction weakness, normal reflexes, impaired tandem gait.” Id. at 738. On March 6, 2012, Plaintiff completed his sixth session of physical therapy. 15 16 Id. at 743-44, 749-52. The physical therapist noted Plaintiff rated his neck pain at a 17 five out of ten and reported “continued and persistent numbness and tingling in 18 bilateral hands and weakness in left shoulder.” Id. at 750. Plaintiff stated he 19 “continue[d] to have difficulty with dressing (buttons) and tying his shoes.” Id. 20 The physical therapist noted Plaintiff reports “relief of neck pain during treatment 21 but no change in upper extremity symptoms,” and “[n]o change in overall neck 22 and shoulder range of motion actively.” Id. at 745. The physical therapist 23 concluded Plaintiff “has not responded to conservative treatment at this time,” 24 and thus, discharged Plaintiff to an independent home exercise program. Id. at 745, 25 751. 26 On March 26, 2012, Plaintiff had a consultation with Dr. Sameh Samir 27 Labib, a neurologist, based on Dr. Bhat’s referral regarding the results of Plaintiff’s 28 nerve conduction study. Id. at 762. Dr. Labib noted that, beginning in December 14 1 2011, Plaintiff suffered from pain in his shoulder caused by shoulder bursitis. Id. at 2 763. Although Plaintiff was prescribed medication and underwent physical 3 therapy, there was little improvement. Id. In addition to the shoulder pain, Dr. 4 Labib noted Plaintiff had recently started feeling numbness in his left hand, which 5 got progressively worse, before developing in his right hand as well. Id. Dr. Labib 6 additionally noted Plaintiff’s hand numbness has continued to get worse. Id. He 7 noted Plaintiff’s numbness prevents him from feeling his hands even when he puts 8 them into his pockets, hinders his ability to button his shirt, and causes his “hands 9 [to] get extremely cold.” Id. After examining Plaintiff, Dr. Labib concluded “Easy 10 giveway/poor effort L shoulder”; “inconsistent effort of hand muscles, mostly in L 11 hand . . . but doubt true weakness.” Id. at 764. After reviewing the abnormal 12 results from Plaintiff’s nerve conduction study, Dr. Labib concluded Plaintiff’s 13 “presentation is atypical.” Id. at 767. Dr. Labib found “[r]eported progression is 14 too rapid for polyneuropathy”; “[e]xam is not highly suggestive of such 15 ‘aggressive’ polyneuropathy”; and Plaintiff “has no other obvious risk factors for 16 polyneuropathy.” Id. Dr. Labib ordered an MRI of Plaintiff’s cervical spine and a 17 repeat nerve conduction study. Id. 18 On April 10, 2012, Plaintiff had the MRI ordered by Dr. Labib, which 19 revealed “multilevel degenerative stenosis, most significant at C3-4 and C4-5.” Id. 20 at 768. As a result, Dr. Labib referred Plaintiff to Dr. Vikas Mehta, a neurologist, 21 noting Plaintiff’s “[c]ervical MRI show[ed] severe spinal stenosis at C3-4 and C4-5 22 with cord compression and myelomalcia.” Id. at 225, 226. 23 On April 27, 2012, following the referral from Dr. Labib, Dr. Mehta met with 24 Plaintiff. Id. at 227. Dr. Mehta noted Plaintiff complained of: balance difficulties 25 while walking, dropping objects from hand, difficulty handwriting, buttoning 26 clothing, difficulty opening jars, hand clumsiness, hand numbness, and hand 27 weakness. Id. Dr. Mehta observed Plaintiff “has normal reflexes and intact cranial 28 nerves,” but he “displays weakness,” presents with a “sensory deficit,” “has an 15 1 abnormal Tandem Gait Test,” and has “[n]umbness to LT grossly [in] bilateral 2 hands and fingers.” Id. at 229. Dr. Mehta further noted Plaintiff has “hand 3 weakness, numbness[,] and clumsiness consistent with cervical myelopathy and T2 4 signal change in spinal cord most likely secondary to cervical stenosis impinging 5 upon the spinal cord.” Id. 6 Dr. Mehta advised Plaintiff that his “cervical degenerative disease may 7 progress and cause more spinal cord compression and resultant neurological 8 deficits and progression of symptoms.” Id. Dr. Mehta suggested surgery as a 9 treatment option, but cautioned that “surgery would not necessarily help with 10 [Plaintiff’s] pain in the back of the head, neck, shoulder, arm, and chest and may 11 even make his pain worse or his neck range of motion worse and he would need to 12 wear a cervical collar for a few months after surgery.” Id. 13 On June 4, 2012, Plaintiff underwent cervical laminoplasty surgery for 14 cervical stenosis with myelopathy. Id. at 332. Following the surgery, Plaintiff was 15 prescribed medications including Valium, Norco, and Robaxin to manage the pain. 16 Id. at 334. 17 2. Plaintiff’s Symptoms and Treatment After Surgery 18 On June 15, 2012, Dr. Mehta saw Plaintiff for a follow-up appointment. Id. 19 at 300-01. Dr. Mehta noted Plaintiff was “doing very well post-op” and was “very 20 satisfied with the surgical outcome.” Id. at 301. Dr. Mehta further noted Plaintiff 21 stated his “right hand symptoms are improved after surgery.” Id. at 300. Dr. 22 Mehta advised against physical therapy at that time. Id. at 811. Dr. Mehta referred 23 Plaintiff to Dr. Matthew Thomas Huey to “evaluate and treat for rehab and 24 residual symptoms.” Id. 25 On July 5, 2012, Plaintiff visited Dr. Huey. Id. Dr. Huey noted Plaintiff 26 complained of neck pain and numbness and tingling of the finger tips. Id. Dr. 27 Huey noted Plaintiff had been on unemployment since March 2012 and advised 28 Plaintiff remain off work until August 15, 2012. Id. at 814. Dr. Huey further 16 1 advised Plaintiff to return for a follow up in five weeks, around August 9, 2012. Id. 2 Dr. Huey advised against physical therapy at that time. Id. On August 9, 2012, Plaintiff returned to see Dr. Mehta. Id. at 309. Plaintiff 3 4 complained of “abdominal pain and discomfort and back and leg pain.” Id. Dr. 5 Mehta advised Plaintiff to follow up with his primary care physician and also 6 ordered cervical x-rays as part of his routine follow up. Id. The x-rays revealed 7 “[m]oderate to severe degenerative disk disease . . . from C3-C4 through C6-C7, 8 as before.” Id. at 823. Plaintiff was still taking Valium, Norco, and Robaxin to 9 manage his pain at this time. Id. at 311. In September 2012, Plaintiff lost his Kaiser health insurance. Id. at 884. 10 11 The record does not indicate whether Plaintiff was able to obtain any other health 12 insurance. On December 17, 2012, Plaintiff saw Dr. Vicente R. Bernabe, an orthopedic 13 14 surgeon, for an orthopedic consultation. Id. at 356-61. Dr. Bernabe diagnosed 15 Plaintiff with “status post posterior cervical fusion per history from C3 to C7,” 16 cervical radiculopathy, degenerative disc disease of the cervical spine, and cervical 17 musculoligamentous strain. Id. at 360. However, Dr. Bernabe noted Plaintiff’s 18 range of motion in the upper and lower extremities was within normal limits. Id. at 19 359. 20 On August 29, 2013, Plaintiff visited Wesley Health Centers complaining of 21 pain in neck and both knees, as well as numbness and tingling in both legs and 22 hands. Id. at 884. According to notes from the visit, Plaintiff’s cervical surgery 23 originally eased his symptoms; but about six to seven months later, he began to 24 have a stiff neck and bilateral knee pain. Id. Plaintiff was advised to return to 25 urgent care if the pain became intolerable. Id. 26 On August 30, 2013, Plaintiff had x-rays taken of his knees and spine. Id. at 27 895-98. The x-rays of his knees revealed mild osteopenia in both knees and 28 degenerative narrowing of the lateral joint compartment in the left knee. Id. at 89517 1 96. The x-ray of his spine revealed “multilevel degenerative spurring of vertebral 2 endplates C4 through T1”; “degenerative disc disease C4 through T1”; 3 “multilevel left lateral fusion from C3 through C6.” Id. at 897. On September 5, 2013, Plaintiff underwent a disability assessment by a 4 5 physician with the Department of Public Social Services. Id. at 890. Plaintiff was 6 found temporarily disabled from September 5, 2013 to November 11, 2013 due to 7 neck and knee pain. Id. 8 On November 22, 2013, Plaintiff underwent a second disability assessment 9 by a physician with the Department of Public Social Services. Id. at 887. Plaintiff 10 was found temporarily disabled from November 22, 2013 to January 30, 2014 as a 11 result of his neck problems. Id. at 888. On January 23, 2014, Plaintiff underwent a third disability assessment. Id. at 12 13 926-31. As a result of his neck pain, Plaintiff was found temporarily disabled until 14 February 22, 2014. Id. On February 14, 2014, Plaintiff underwent a fourth disability assessment. Id. 15 16 at 936-41. Due to Plaintiff’s knee pain and hand numbness, Plaintiff was found 17 temporarily disabled until August 14, 2014. Id. 18 B. 19 APPLICABLE LAW If “the record establishes the existence of a medically determinable 20 impairment that could reasonably give rise to the reported symptoms, an ALJ must 21 make a finding as to the credibility of the claimant’s statements about the 22 symptoms and their functional effect.” Robbins, 466 F.3d at 883 (citations 23 omitted). The ALJ’s credibility determination must be supported by “findings 24 sufficiently specific to permit the court to conclude that the ALJ did not arbitrarily 25 discredit claimant’s testimony.” Tommasetti v. Astrue, 533 F.3d 1035, 1039 (9th 26 Cir. 2008) (citation and internal quotation marks omitted). 27 28 The ALJ is required to engage in a two-step analysis. “First, the ALJ must determine whether there is objective medical evidence of an underlying impairment 18 1 which could reasonably be expected to produce the pain or other symptoms 2 alleged.” Molina, 674 F.3d at 1112 (citations and internal quotation marks 3 omitted). “If the claimant has presented such evidence, and there is no evidence of 4 malingering, then the ALJ must give specific, clear and convincing reasons in order 5 to reject the claimant’s testimony about the severity of the symptoms.” Id. 6 (citations and internal quotation marks omitted). “The ALJ must state specifically 7 which symptom testimony is not credible and what facts in the record lead to that 8 conclusion.” Smolen v. Chater, 80 F.3d 1273, 1284 (9th Cir. 1996); see also 9 Brown-Hunter v. Colvin, 806 F.3d 487, 489 (9th Cir. 2015) (holding “an ALJ does 10 not provide specific, clear, and convincing reasons for rejecting a claimant’s 11 testimony by simply reciting the medical evidence in support of his or her residual 12 functional capacity determination”). “If the ALJ’s credibility finding is supported by substantial evidence, [a 13 14 court] may not engage in second-guessing.” Thomas v. Barnhart, 278 F.3d 947, 15 959 (9th Cir. 2002). However, an ALJ’s failure to give specific, clear, and 16 convincing reasons to reject the claimant’s testimony regarding the severity of the 17 symptoms is not harmless, because it precludes the Court from conducting a 18 meaningful review of the ALJ’s reasoning. Brown-Hunter, 806 F.3d at 489. 19 C. ANALYSIS 20 Here, the ALJ failed to consider the overall diagnostic record when he 21 erroneously relied upon (1) Plaintiff’s purported conservative treatment; (2) 22 instances of temporary improvement in Plaintiff’s symptoms; and (3) Plaintiff’s 23 purported exaggeration of his symptoms and receipt of unemployment benefits, in 24 determining Plaintiff’s claims were less than fully credible. See Ghanim v. Colvin, 25 763 F.3d 1154, 1164 (9th Cir. 2013) (holding an ALJ must view a claimant’s 26 treatment records “in light of the overall diagnostic record” to determine whether 27 certain factors undermine Plaintiff’s testimony). 28 19 1 2 3 1. The ALJ Erroneously Relied on Plaintiff’s Purportedly Conservative Treatment In coming to his adverse credibility determination, the ALJ found Plaintiff 4 “has not received the type of treatment one would expect from a completely 5 disabled individual” as evidenced by Plaintiff’s (1) gaps in history of treatment, (2) 6 failure to follow up on referrals for specialists, and (3) routine, non-emergency 7 treatment. AR at 24, 25. The ALJ erred, however, by failing to consider the overall 8 diagnostic record. 9 First, in relying on Plaintiff’s “gaps in history of treatment,” the ALJ failed 10 to address the fact that Plaintiff consistently and regularly saw doctors from 11 December 2011 to August 2012 – oftentimes more than once in a single month – 12 and August 2013 to February 2014. While there is a gap in Plaintiff’s treatment 13 history from August 2012 to August 2013, the medical records establish Plaintiff 14 lost his health insurance in September 2012 and do not indicate Plaintiff ever 15 obtained health insurance following this loss. See id. at 884. Plaintiff’s “failure to 16 seek treatment during the period that he had no medical insurance cannot support 17 an adverse credibility finding.” Orn v. Astrue, 495 F.3d 625, 638 (9th Cir. 2007); 18 Gamble v. Chater, 68 F.3d 319, 321 (9th Cir. 1995); see also Fair v. Bowen, 885 19 F.2d 597, 603 (9th Cir. 1989) (holding “unexplained, or inadequately explained, 20 failure to seek treatment” may be the basis for an adverse credibility finding unless 21 one of a “number of good reasons for not doing so” applies). Looking at the 22 “overall diagnostic record,” it appears Plaintiff regularly and consistently sought 23 treatment when he had medical insurance. Thus, relying on the gap in medical 24 treatment, during a time where Plaintiff did not have medical insurance, ignores the 25 overwhelming evidence establishing regular treatment and does not support an 26 adverse credibility finding. See Ghanim, 763 F.3d at 1164. 27 28 Second, the ALJ’s reliance on the conclusion that Plaintiff failed to follow up on referrals to specialists is erroneous because this conclusion is not supported by 20 1 the overall diagnostic record. AR at 25-26. The ALJ cited two instances in which 2 Plaintiff appeared not to have followed up on his doctors’ referrals: (1) a referral to 3 an orthopedic specialist on February 24, 2012; and (2) a referral to a neurologist in 4 August 2013. Id. As to Plaintiff’s February 24, 2012 visit, although it appeared Dr. 5 Kenneth Williams placed an orthopedic referral for Plaintiff’s knee, it is unclear 6 whether Dr. Kenneth Williams actually ordered the referral as there is nothing 7 under “Patient Instructions” directing Plaintiff to make an appointment with an 8 orthopedist. Id. at 693-94; see id. at 695-701. As to Plaintiff’s August 2013 9 neurologist referral, the ALJ himself notes it is unclear if Plaintiff followed up on 10 this referral. See id. at 26. To the extent the ALJ found the record ambiguous, the 11 ALJ had a duty to conduct an appropriate inquiry. See Tonapetyan v. Halter, 242 12 F.3d 1144, 1150 (9th Cir. 2001) (“Ambiguous evidence, or the ALJ’s own finding 13 that the record is inadequate to allow for proper evaluation of the evidence, triggers 14 the ALJ’s duty to conduct an appropriate inquiry.” (citing Smolen, 80 F.3d at 15 1288). 16 Additionally, even assuming Plaintiff failed to follow up on these two 17 referrals, looking at the “overall diagnostic record,” it appears Plaintiff regularly 18 followed up on his doctors’ referrals. For example, on January 24, 2012, Plaintiff 19 saw orthopedist Dr. Shane Williams, as a result of his primary care physician’s 20 referral; on March 5, 2012, Plaintiff saw Dr. Bhat as a result of Dr. Shane William’s 21 order to obtain a nerve conduction study; on March 26, 2012, Plaintiff saw Dr. 22 Labib as a result of Dr. Bhat’s referral to see a neurologist; and on July 5, 2012, 23 Plaintiff saw Dr. Huey as a result of Dr. Mehta’s referral for a rehab specialist. AR 24 at 478, 735, 762, 811. Thus, the ALJ’s (1) reliance on Plaintiff’s two alleged failures 25 to follow up on referrals as grounds for his adverse credibility determination, and 26 (2) failure to consider the other referrals upon which Plaintiff did follow up, was 27 erroneous. See Ghanim, 763 F.3d at 1164. 28 21 1 Third, the ALJ’s reliance on the finding that Plaintiff received routine, non- 2 emergency treatment only is erroneous because the overall diagnostic record does 3 not support such a finding. AR at 25. As a preliminary matter, Plaintiff’s neck and 4 back pain was severe enough to warrant invasive surgery by Plaintiff’s neurologist, 5 Dr. Mehta, on June 4, 2012. Id. at 332. Moreover, although Plaintiff showed 6 improvement following surgery, his symptoms returned causing him to pursue 7 treatment in July and August 2012 - prior to losing his health insurance - and later 8 again in August 2013. See id. at 309, 811, 884. While there may not be any 9 evidence of emergency treatment related to Plaintiff’s knee, neck, and back pain, 10 there is evidence of Plaintiff’s consistent and repeated efforts to seek out treatment 11 for symptoms that evidently continued to affect him. Notably, the medical record 12 indicates Plaintiff was not responding to conservative treatment. See id. at 684, 13 686, 745, 751. Ultimately, nothing in the medical record suggests Plaintiff ever 14 received treatment that sufficiently addressed his symptoms, or that other 15 treatment options were available for Plaintiff to pursue. Lapeirre-Gutt v. Astrue, 16 382 F. App’x 662, 664 (9th Cir. 2010)3 (“A claimant cannot be discredited for 17 failing to pursue non-conservative treatment options where none exist.”). Accordingly, reliance on Plaintiff’s purportedly conservative treatment 18 19 based on alleged gaps in Plaintiff’s treatment history, failure to follow up on 20 referrals for specialists, and overall non-emergency treatment fails to constitute 21 specific, clear, and convincing reasons to reject Plaintiff’s testimony. See Brown- 22 Hunter, 806 F.3d at 489. 23 /// 24 /// 25 /// 26 27 28 The Court may cite to unpublished Ninth Circuit opinions issued on or after January 1, 2007. U.S. Ct. App. 9th Cir. R. 36-3(b); Fed. R. App. P. 32.1(a). 3 22 1 2. Plaintiff’s Symptoms 2 3 The ALJ Erroneously Relied on Temporary Improvements in The ALJ also cited instances of temporary improvement in Plaintiff’s 4 symptoms in coming to his adverse credibility determination. The ALJ found 5 Plaintiff underwent cervical spine surgery, which “greatly improved [Plaintiff’s] 6 condition” and relieved many of his symptoms. AR at 24-25. Specifically, the ALJ 7 noted Plaintiff did not attend physical therapy following his surgery, nor did he 8 “present[] for treatment of this condition again for a year.” Id. at 25. 9 In concluding that the surgery greatly improved Plaintiff’s condition, the 10 ALJ failed to address the fact that many of Plaintiff’s symptoms associated with his 11 cervical spine condition returned shortly after the surgery. For example, on July 5, 12 2012, just one month after Plaintiff’s surgery, Plaintiff visited Dr. Huey 13 complaining of neck pain and numbness and tingling of the finger tips. Id. at 811. 14 Additionally, on August 9, 2012, Plaintiff visited Dr. Mehta complaining of back 15 and leg pain. Id. at 309. X-rays ordered by Dr. Mehta at that time revealed Plaintiff 16 suffered from “[m]oderate to severe degenerative disk disease . . . from C3-C4 17 through C6-C7, as before.” Id. at 823. Furthermore, on August 29, 2013, Plaintiff 18 visited Wesley Health Centers complaining of pain in the neck and knees and 19 numbness and tingling in both his legs and hands. Id. at 884. A note from the 20 physician indicated that while the surgery originally eased Plaintiff’s symptoms, 21 they eventually began to return months after the surgery. Id. Notably, the return 22 of Plaintiff’s pain is consistent with the warning given by Dr. Mehta, who, prior to 23 conducting Plaintiff’s surgery cautioned Plaintiff that “surgery would not 24 necessarily help with [Plaintiff’s] pain in the back of the head, neck, shoulder, arm, 25 and chest and may even make his pain worse or his neck range of motion worse.” 26 Id. at 229. 27 28 Moreover, while Dr. Mehta and Dr. Huey noted physical therapy as an option for part of Plaintiff’s treatment plan following surgery, they both stated 23 1 Plaintiff should not begin physical therapy until two to three months after surgery. 2 See id. at 811, 814. Despite these notes, however, the record does not show either 3 doctor ever prescribed Plaintiff a course of physical therapy4. While the Court 4 realizes this could have been due to the fact that Plaintiff lost his health insurance 5 and thus was unable to return to see either doctor, the record does not contain any 6 explanation, nor did the ALJ inquire into this possibility. See Tonapetyan, 242 7 F.3d at 1150. Thus, the ALJ’s conclusion, absent further investigation, that 8 Plaintiff “fail[ed] to undergo physical therapy that could have improved the alleged 9 pain” following his surgery as part of the reason for questioning Plaintiff’s 10 11 credibility was erroneous. Lastly, from November 11, 2013 to August 14, 2014, Plaintiff was found 12 “temporarily disabled” due to his neck and back pain according to the findings of 13 four disability assessments conducted by the Department of Public Social Services. 14 Id. at 890-941. While the ALJ ultimately gave little weight to these opinions - 15 finding them “brief, conclusory, and inadequately supported by clinical findings” - 16 the assessments, at a minimum, show that Plaintiff’s improvements following his 17 surgery were only temporary. Id. at 27. 18 Thus, the ALJ’s reliance on Plaintiff’s reported improvement in his 19 symptoms immediately following his surgery, without considering evidence that 20 Plaintiff’s pain symptoms returned, erroneously fails to consider the diagnostic 21 record as a whole. See Ghanim, 763 F.3d at 1164. 22 23 24 25 26 27 28 4 Additionally, to the extent the ALJ believed Plaintiff chose to discontinue the physical therapy he was engaged in prior to surgery, this belief is not supported by the evidence. See AR at 25 (“[T]he claimant decided to discontinue physical therapy after only a few visits.”). While Plaintiff missed two physical therapy sessions, it appears from the record he was ultimately discharged by the therapist because Plaintiff had “not responded to conservative treatment” and, therefore, was being discharged to an independent home exercise program. Id. at 745, 751. 24 3. 1 The ALJ Erroneously Relied on Plaintiff’s Purported 2 Exaggeration of His Symptoms and Receipt of Unemployment 3 Benefits to Evaluate Plaintiff’s Credibility Finally, the ALJ improperly based his credibility determination on Plaintiff’s 4 5 (1) description of his daily activities; and (2) receipt of unemployment benefits.5 As to Plaintiff’s daily activities, the ALJ questioned Plaintiff’s claims that his 6 7 days were limited to hours spent immobile and in bed, finding it difficult to 8 reconcile Plaintiff’s severe limitations with the “relatively benign medical evidence 9 . . . .” AR at 23. However, claims of immobility and fatigue are not necessarily 10 inconsistent with symptoms caused by back, neck, and knee problems, as well as 11 daily consumption of prescription painkillers. More importantly, focusing on 12 Plaintiff’s allegedly exaggerated claims of immobility in assessing his credibility 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 5 On March 28, 2016, after the ALJ’s assessment in this case, SSR 16–3p went into effect. See SSR 16–3p, 2016 WL 1119029 (Mar. 16, 2016). SSR 16–3p supersedes SSR 96–7p, the previous policy governing the evaluation of subjective symptoms. Id. at *1. SSR 16–3p indicates that “we are eliminating the use of the term ‘credibility’ from our sub-regulatory policy, as our regulations do not use this term.” Id. Moreover, “[i]n doing so, we clarify that subjective symptom evaluation is not an examination of an individual’s character[;] [i]nstead, we will more closely follow our regulatory language regarding symptom evaluation.” Id. Thus, the adjudicator “will not assess an individual’s overall character or truthfulness in the manner typically used during an adversarial court litigation. The focus of the evaluation of an individual’s symptoms should not be to determine whether he or she is a truthful person.” Id. at *10. The ALJ is instructed to “consider all of the evidence in an individual’s record,” “to determine how symptoms limit ability to perform work-related activities.” Id. at *2. The ALJ’s February 10, 2014 decision was issued before March 28, 2016, when SSR 16–3p became effective, and there is no binding precedent interpreting this new ruling including whether it applies retroactively. Compare Ashlock v. Colvin, 2016 WL 3438490, at *5 n.1 (W.D. Wash. June 22, 2016) (declining to apply SSR 16–3p to an ALJ decision issued prior to the effective date), with Lockwood v. Colvin, 2016 WL 2622325, at *3 n.1 (N.D. Ill. May 9, 2016) (applying SSR 16–3p retroactively to a 2013 ALJ decision); see also Smolen, 80 F.3d at 1281 n.1 (“We need not decide the issue of retroactivity [as to revised regulations] because the new regulations are consistent with the Commissioner’s prior policies and with prior Ninth Circuit case law”) (citing Pope v. Shalala, 998 F.2d 473, 483 (7th Cir. 1993) (because regulations were intended to incorporate prior Social Security Administration policy, they should be applied retroactively)). Further, SSR 16–3p on its face states that it is intended only to “clarify” the existing regulations. Nevertheless, because the ALJ’s findings are insufficient under either standard, the Court need not resolve the retroactivity issue. Notwithstanding the foregoing, SSR 16–3p shall apply on remand. 25 1 overlooks Plaintiff’s descriptions of pain in his hands, neck, and knees - all of which 2 were documented and supported throughout Plaintiff’s medical history. See id. at 3 39-43; Ghanim, 763 F.3d at 1164. 4 Additionally, the ALJ noted Plaintiff “received unemployment 5 compensation during the relevant period at issue,” which would have required 6 Plaintiff “to certify he was willing and able to engage in work activity.” AR at 24. 7 The ALJ reasoned this fact impacted Plaintiff’s “credibility and weight of the 8 evidence as a whole.” Id. However, while receipt of unemployment benefits can 9 be a legally sufficient reason to find a plaintiff not credible under certain 10 circumstances, receipt of benefits does not necessarily constitute a legally sufficient 11 reason for an adverse credibility determination. See Mulanax v. Commissioner of 12 Social Sec., 293 Fed. Appx. 522, 523 (9th Cir. 2008) (holding receipt of 13 unemployment benefits that were payable to applicants available for temporary or 14 part-time jobs was not necessarily inconsistent with a claim of disability under the 15 Social Security Act); Carmickle v. Comm’r, Soc. Sec. Admin., 533 F.3d 1155, 1162 16 (9th Cir. 2008) (finding that receipt of unemployment benefits can undermine a 17 plaintiff’s alleged inability to work full-time, but a court’s reliance on receipt of 18 benefits alone without determining whether plaintiff held himself out as available 19 for full-time or part-time work is erroneous). 20 Here, while the record establishes Plaintiff received unemployment benefits, 21 the ALJ failed to determine whether Plaintiff held himself out as available for full- 22 time or part-time work during the time he received these benefits. See id. at 42; 23 Lind v. Colvin, No. EDCV 14-1474 RNB, 2015 WL 1863313, at *3 (C.D. Cal. Apr. 24 23, 2015) (noting a person may receive both unemployment benefits and social 25 security benefits if he is capable of only part-time work). In fact, during the hearing, 26 the ALJ simply asked Plaintiff whether he was “trying to find a job at [the time he 27 received unemployment benefits];” to which Plaintiff responded that he was not. 28 Id. Thus, without determining whether Plaintiff held himself out as available for 26 1 full-time or part-time work, the fact that Plaintiff received unemployment 2 compensation during the relevant period at issue is not a specific, clear, and 3 convincing reason to reject Plaintiff’s testimony. See Brown-Hunter, 806 F.3d at 4 489. Lastly, the ALJ inexplicably cites Plaintiff’s criminal history in his credibility 5 6 discussion. See AR at 23. To the extent Plaintiff’s “history of imprisonment in 7 1991, 1992, and 2005 for sale of a controlled substance” was a factor affecting the 8 ALJ’s credibility determination, such evidence is not relevant because the 9 convictions do not involve crimes of dishonesty. Fair, 885 F.2d at 603; Nicklas v. 10 Halter, No. C 00-1904 CRB, 2001 WL 492461, at *5 (N.D. Cal. Apr. 25, 2001). Thus, the ALJ’s reasons for finding Plaintiff not credible are insufficient to 11 12 reject Plaintiff’s testimony regarding the intensity, persistence, and functionally 13 limiting effects of his medical symptoms. 14 VIII. 15 RELIEF 16 17 A. APPLICABLE LAW “When an ALJ’s denial of benefits is not supported by the record, the 18 proper course, except in rare circumstances, is to remand to the agency for 19 additional investigation or explanation.” Hill, 698 F.3d at 1162 (citation omitted). 20 “We may exercise our discretion and direct an award of benefits where no useful 21 purpose would be served by further administrative proceedings and the record has 22 been thoroughly developed.” Id. (citation omitted). “Remand for further 23 proceedings is appropriate where there are outstanding issues that must be resolved 24 before a determination can be made, and it is not clear from the record that the ALJ 25 would be required to find the claimant disabled if all the evidence were properly 26 evaluated.” Id. (citations omitted); see also Reddick, 157 F.3d at 729 (“We do not 27 remand this case for further proceedings because it is clear from the administrative 28 record that Claimant is entitled to benefits.”). 27 1 B. ANALYSIS 2 In this case, the record has not been fully developed. The ALJ must reassess 3 Plaintiff’s credibility and allegations of pain in light of the overall diagnostic record. 4 Accordingly, remand for further proceedings is appropriate. 5 IX. 6 CONCLUSION 7 For the foregoing reasons, IT IS ORDERED that judgment be entered 8 REVERSING the decision of the Commissioner and REMANDING this action for 9 further proceedings consistent with this Order. IT IS FURTHER ORDERED that 10 the Clerk of the Court serve copies of this Order and the Judgment on counsel for 11 both parties. 12 13 14 Dated: July 06, 2017 HONORABLE KENLY KIYA KATO United States Magistrate Judge 15 16 17 18 19 20 21 22 23 24 25 26 27 28 28

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