Rosales v. Commissioner of Social Security Administration

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WO
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
Marisol Rosales,
Plaintiff,
v.
Commissioner of Social Security
Administration,
Defendant.
No. CV-25-03244-PHX-JAT
ORDER
Pending before the Court is Plaintiff Marisol Rosales’s appeal from the
Commissioner of the Social Security Administration’s (“SSA,” “Commissioner,” or
“Defendant”) denial of Social Security benefits. (Doc. 8-3). The appeal is fully briefed
(Docs. 11–13), and the Court now rules.
I. BACKGROUND
A. Factual Overview
Plaintiff was 44 years old on her alleged disability onset date of November 13, 2021.
(Doc. 8-3 at 40, 53). She has at least a high school education and a history of past relevant
work as an order filler. (Doc. 8-3 at 53). On November 21, 2021, Plaintiff filed a Title II
application for a period of disability and disability insurance benefits, alleging disability
beginning November 13, 2021. (Doc. 8-3 at 40). On October 3, 2023, Plaintiff testified
with the assistance of an interpreter at a telephonic hearing held before an Administrative
Law Judge (“ALJ”). (Doc. 8-3 at 40). The hearing was continued to allow the claimant to
attend a consultive examination. (Doc. 8-3 at 40). On July 16, 2024, Plaintiff again testified
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with the assistance of an interpreter at a supplemental telephonic hearing. (Doc. 8-3 at 40).
On August 16, 2024, the ALJ denied Plaintiff’s claim. (Doc. 8-3 at 55). The Appeals
Council denied Plaintiff’s request for review and adopted the ALJ’s decision as the
agency’s final decision. (Doc. 8-3 at 2). Plaintiff filed the present appeal following this
unfavorable decision. (Doc. 1).
B. The SSA’s Five-Step Evaluation Process
To qualify for social security disability insurance benefits, a claimant must show
that he “is under a disability.” 42 U.S.C. § 423(a)(1)(E). To be “under a disability,” the
claimant must be unable to engage in “substantial gainful activity” due to any medically
determinable physical or mental impairment. Id. § 423(d)(1). The impairment must be of
such severity that the claimant cannot do his previous work or any other substantial gainful
work within the national economy. Id. § 423(d)(2). The SSA has created a five-step
sequential evaluation process for determining whether an individual is disabled. See 20
C.F.R. § 404.1520(a)(1). The steps are followed in order, and each step is potentially
dispositive. See id. § 404.1520(a)(4).
At Step One, the ALJ determines whether the claimant is engaging in “substantial
gainful activity.” Id. § 404.1520(a)(4)(i). “Substantial gainful activity” is work activity that
is (1) “substantial,” i.e., doing “significant physical or mental activities,” and (2) “gainful,”
i.e., usually done “for pay or profit.” 20 C.F.R. § 416.972(a)–(b). If the claimant is
engaging in substantial gainful work activity, the ALJ will find the claimant is not disabled.
Id. § 404.1520(a)(4)(i).
At Step Two, the ALJ determines whether the claimant has “a severe medically
determinable physical or mental impairment” or severe “combination of impairments.” Id.
§ 404.1520(a)(4)(ii). To be “severe,” the claimant’s impairment must “significantly limit”
the claimant’s “physical or mental ability to do basic work activities.” Id. § 404.1520(c).
If the claimant does not have a severe impairment or combination of impairments, the ALJ
will find the claimant is not disabled. Id. § 404.1520(a)(4)(ii).
At Step Three, the ALJ determines whether the claimant’s impairment(s) “meets or
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equals” an impairment listed in Appendix 1 to Subpart P of 20 C.F.R. Part 404. Id.
§ 404.1520(a)(4)(iii). If so, the ALJ will find the claimant is disabled, but if not, the ALJ
must assess the claimant’s “residual functional capacity” (“RFC”) before proceeding to
Step Four. Id. §§ 404.1520(a)(4)(iii), 404.1520(e). The claimant’s RFC is his ability
perform physical and mental work activities “despite [his] limitations,” based on all
relevant evidence in the case record. Id. § 404.1545(a)(1). To determine RFC, the ALJ
must consider all the claimant’s impairments, including those that are not “severe,” and
any related symptoms that “affect what [the claimant] can do in a work setting.” Id.
§ 404.1545(a)(1)–(2).
At Step Four, the ALJ determines whether the claimant has the RFC to perform the
physical and mental demands of “his past relevant work.” Id. §§ 404.1520(a)(4)(iv),
404.1520(e). “Past relevant work” is work the claimant has “done within the past five years
that was substantial gainful activity and that lasted long enough for [the claimant] to learn
to do it.” Id. § 404.1560(b)(1)(i). If the claimant has the RFC to perform his past relevant
work, the ALJ will find the claimant is not disabled. Id. § 404.1520(a)(4)(iv). If the
claimant cannot perform his past relevant work, the ALJ will proceed to Step Five in the
sequential evaluation process.
At Step Five, the final step, the ALJ considers whether the claimant “can make an
adjustment to other work,” considering his RFC, age, education, and work experience. Id.
§ 404.1520(a)(v). If so, the ALJ will find the claimant not disabled. Id. If the claimant
cannot make this adjustment, the ALJ will find the claimant is disabled. Id.
C. The ALJ’s Application of the Factors
Here, at Step One, the ALJ concluded that Plaintiff did not engage in substantial
gainful activity since her alleged onset date of November 13, 2021. (Doc. 8-3 at 43).
At Step Two, the ALJ determined that Plaintiff had the following severe
impairments: “fibromyalgia, obesity, status post lumbar laminectomy and fusion, lumbar
and cervical degenerative disc disease, cervical spondylosis, sacroiliac joint arthropathy,
Sjogren’s syndrome with inflammatory arthritis, lateral epicondylitis, sacroiliac joint
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arthropathy, and chronic pain syndrome.” (Doc. 8-3 at 43).
At Step Three, the ALJ found that Plaintiff did not have an impairment or
combination of impairments that met or medically equaled the severity of one of the listed
impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Doc. 8-3 at 44). The ALJ then
found that Plaintiff had the RFC
to perform light work as defined in 20 CFR 404.1567(b) except
from November 13, 2021, to December 27, 2023, the claimant
could lift and carry 20 pounds occasionally, 10 pounds
frequently, stand and/or walk with normal breaks 6 hours and
sit 6 hours with normal breaks in an 8-hour day. She could
occasionally climb ramps and stairs, never climb ladders,
ropes, and scaffolds. She could frequently balance, and
occasionally stoop, kneel, crouch, and crawl. Beginning on
December 27, 2023, the claimant can lift and carry 11 to 20
pounds frequently and carry up to 10 continuously, sit 7 hours
(6 hours at a time), stand 4 hours (3 hours at a time), walk 5
hours (3 hours at a time), frequently reach, handle, push and
pull, occasionally climb ladders or scaffolds, stoop, crouch,
and crawl. She can frequently climb ramps and stairs and kneel.
(Doc. 8-3 at 44).
At Step Four, the ALJ established that Plaintiff was unable to perform any past
relevant work. (Doc. 8-3 at 52). At Step Five, considering Plaintiff’s age education, work
experience, and RFC, the ALJ found that there were jobs that exist in significant numbers
in the national economy that Plaintiff could perform.
II. LEGALS STANDARD
This Court may not set aside a final denial of disability benefits unless the ALJ
decision is “based on legal error or not supported by substantial evidence in the record.”
Revels v. Berryhill, 874 F.3d 648, 654 (9th Cir. 2017) (quoting Benton ex rel. Benton v.
Barnhart, 331 F.3d 1030, 1035 (9th Cir. 2003)). “Substantial evidence” is relevant
evidence that “a reasonable mind might accept as adequate to support a conclusion.” Id.
(quoting Desrosiers v. Sec’y of Health & Human Servs., 846 F.2d 573, 576 (9th Cir. 1988)).
It involves “more than a scintilla but less than a preponderance.” Thomas v. Barnhart, 278
F.3d 947, 954 (9th Cir. 2002) (quoting Jamerson v. Chater, 112 F.3d 1064, 1066 (9th Cir.
1997)). This Court must consider the record in its entirety, “weighing both the evidence
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that supports and evidence that detracts from the [ALJ’s] conclusion.” Id. (quoting
Garrison v. Colvin, 759 F.3d 995, 1009 (9th Cir. 2007)).
The ALJ—not this Court—is responsible for resolving ambiguities, resolving
conflicts in medical testimony, determining credibility, and drawing logical inferences
from the medical record. See Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995)
(citing Magallanes v. Bowen, 881 F.2d 747, 750 (9th Cir. 1989); Gallant v. Heckler, 753
F.2d 1450, 1453 (9th Cir. 1984)). Therefore, when the evidence of record could result in
more than one rational interpretation, “the ALJ’s decision should be upheld.” Orn v. Astrue,
495 F.3d 625, 630 (9th Cir. 2007); Batson v. Comm’r of Soc. Sec. Admin., 359 F.3d 1190,
1198 (9th Cir. 2004) (“When the evidence before the ALJ is subject to more than one
rational interpretation, [courts] must defer to the ALJ’s conclusion.”). Further, this Court
may only review the reasons the ALJ provides in the disability determination; it “may not
affirm the ALJ on a ground upon which he did not rely.” Garrison, 759 F.3d at 1010.
III. DISCUSSION
Plaintiff argues that the ALJ committed harmful error by (1) rejecting Plaintiff’s
symptom testimony, and (2) rejecting the medical opinion of treating providers Dr. Ravi
Bhalla and PA-C Paige Nelson. (Doc. 11 at 1).
A. Plaintiff’s Symptom Testimony
Plaintiff argues that the ALJ erred in failing to provide specific, clear and
convincing reasons for rejecting Plaintiff’s subjective symptom testimony. (Doc. 11 at 14).
Conversely, Defendant argues the ALJ’s assessment of Plaintiff’s subjective symptom
testimony was reasonable and supported by substantial evidence. (Doc. 12 at 4–5).
1. Legal Standard for Evaluating Symptom Testimony
In assessing the credibility of a claimant’s subjective symptom testimony, an ALJ
must engage in a two-step analysis. Molina v. Astrue, 674 F.3d 1104, 1112 (9th Cir. 2012).
“First, the ALJ must determine whether the claimant has presented objective medical
evidence of an underlying impairment which could reasonably be expected to produce the
pain or other symptoms alleged.” Lingenfelter v. Astrue, 504 F.3d 1028, 1036 (9th Cir.
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2007) (internal citation and quotation marks omitted). “Second, if the claimant meets the
first test, and there is no evidence of malingering, ‘the ALJ can reject the claimant’s
testimony about the severity of her symptoms only by offering specific, clear and
convincing reasons for doing so.’” Id. (quoting Smolen, 80 F.3d at 1281).
The “specific, clear, and convincing” standard is satisfied where the “ALJ’s
rationale is clear enough that it has the power to convince.” Smartt v. Kijakazi, 53 F.4th
489, 499 (9th Cir. 2022). To be sufficiently specific, the ALJ must identify “what testimony
is not credible and what evidence undermines the claimant’s complaints.” Ghanim v.
Colvin, 763 F.3d 1154, 1163 (9th Cir. 2014) (citation omitted). Moreover, “[t]he evidence
upon which the ALJ relies must be substantial.” Holohan v. Massanari, 246 F.3d 1195,
1208 (9th Cir. 2001). “If the ALJ’s credibility finding is supported by substantial evidence
in the record, [courts] may not engage in second-guessing.” Thomas, 278 F.3d at 959.
Factors an ALJ may consider when determining credibility include: “(1) ordinary
techniques of credibility evaluation, such as the claimant’s reputation for lying, prior
inconsistent statements concerning the symptoms, and other testimony by the claimant that
appears less than candid; (2) unexplained or inadequately explained failure to seek
treatment or to follow a prescribed course of treatment; and (3) the claimant’s daily
activities.” Id. at 1163 (quoting Smolen, 80 F.3d at 1284).
2. The ALJ’s Evaluation of Plaintiff’s Symptom Testimony
The ALJ summarized Plaintiff’s testimony at the initial hearing as follows:
The claimant reported she is single with three adult children,
and currently lives with her brother and her children. Her
daughter receives SSI benefits. She stated she has no income
of her own. The claimant reported she completed the 12th
grade (high school). She has no vocational training. She
reported she has a driver’s license and drives probably two
times a week. She stated she has not worked since November
13, 2021. She stopped work because she could no longer take
her back pain. Her back pain was too great, she was diagnosed
with spinal stenosis and was going to have surgery because her
back pain was unbearable. She was working at PetSmart
warehouse as an order filler and selector. Her job involved
walking all day long. She had to lift about 10 pounds. She has
fibromyalgia and spinal stenosis. She has seen doctors
regularly since the alleged onset date. To this day, she is being
seen and receiving injections in her lower back and she has
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pain in her neck. She has not been hospitalized since the
alleged onset date, other than when she had spine surgery. She
had surgery on December 17, 2021. She was treated with
physical therapy twice after surgery. She does not use a cane
or other assistive device but uses a back brace. She takes pain
medications regularly. The claimant reported she was able to
sit for only 10 minutes at a time, but then has to walk or lie
down, walk about 15 minutes at a time. For example, if she
goes to the mall, she gets very tired and has to sit down. She
reported she [is] able to stand between 10 to 20 minutes at a
time and that she struggles to lift a gallon of milk. The claimant
stated she had not been treated for any mental health problems.
She does not use alcohol or non-prescription drugs. She is
seeing a doctor for migraines. The claimant further testified she
has migraines two to three times a week sometimes four days
a week lasting half a day.
(Doc. 8-3 at 45).
The ALJ summarized Plaintiff’s testimony at the supplemental hearing as follows:
Since the last hearing, she has not been hospitalized or had any
surgical procedures. She has been seeing doctors regularly.
Since the last hearing, she has received three to four injections.
She takes medications regularly. She had not been using a cane
or other assistive device since the last hearing. She is still
taking methotrexate. Her methotrexate dosage increased from
25 mg to 50 mg because [] her migraine headaches are
continuing. She experiences headaches sometimes three times
a week and sometimes four times a week.
(Doc. 8-3 at 46).
Plaintiff alleged that spinal stenosis and fibromyalgia limit her ability to work, and
that she stopped working because of her back pain. (Doc. 8-3 at 45, 103). The ALJ found
that Plaintiff’s medically determinable impairments could reasonably be expected to cause
her symptoms. (Doc. 8-3 at 46). However, the ALJ concluded that Plaintiff’s statements
concerning the intensity, persistence, and limiting effects of her symptoms were not
consistent with the medical evidence and other evidence in the record. (Doc. 8-3 at 46).
The Court finds that the ALJ gave specific, clear and convincing reasons for
discounting Plaintiff’s testimony. Furthermore, the ALJ identified the testimony she found
not credible and explained what evidence undermined the testimony. Holohan, 246 F.3d at
1208. Specifically, the ALJ found that Plaintiff’s statements regarding the severity and
limiting effects of her pain were inconsistent with the medical records, explaining:
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[T]he balance of treatment records . . . generally show the
claimant obtained benefit from lumbar spine surgery and the
medication regimen does help keep the pain symptoms more
tolerable and improve functional ability/capacity with no side
effect. (Exhibits 6F/3, 5; 7F/8; 10F/12, 18, 24, 32, 38, 44, 50,
61; 13F/12, 19, 25, 31, 37; 15F/353, 368, 378, 388, 408, 418;
23F/23F/2, 11, 20, 29, 38, 47, 58, 67, 76, 85, 96, 105, 116).
(Doc. 8-3 at 48). “Contradiction with the medical record is a sufficient basis for rejecting
the claimant’s subjective testimony.” Smartt, 53 F.4th at 499 (quoting Carmickle v.
Comm’r, Soc. Sec. Admin., 533 F.3d 1155, 1161 (9th Cir. 2008)). Additionally, an ALJ
may discount a claimant’s testimony based on effective treatment. Warre v. Comm’r of
Soc. Sec. Admin., 439 F.3d 1001, 1006 (9th Cir. 2006) (“Impairments that can be controlled
effectively with medication are not disabling for the purpose of determining eligibility for
SSI benefits.”).
Regarding the improvements after Plaintiff’s lumbar spine surgery, the ALJ cited to
treatment records from after Plaintiff’s spinal surgery that showed gradual improvement
after the surgery. (Doc. 8-3 at 46–47). The ALJ noted that six months after the surgery,
Plaintiff reported intermittent stiffness but “overall she is extremely pleased with the
outcome of her surgery. She denies bilateral lower extremity pain. She has completed
physical therapy as prescribed. She is beginning to resume her regular activities without
restrictions.” (Doc. 8-3 at 47; Doc. 8-8 at 66).
Regarding the effectiveness of Plaintiff’s medications, the ALJ noted that Plaintiff
testified that medication helps with her pain but makes her very sleepy. (Doc. 8-3 at 46).
The ALJ found that “this is not corroborated by the medical record,” which shows that
Plaintiff “generally tolerates medication with no side effects” and was typically “alert and
oriented with no narcotic intoxication noted.” (Doc. 8-3 at 46). The ALJ provided record
citations to specific pain management records that contradicted Plaintiff’s statements:
Pain management records dated November 22, 2021, to August
16, 2023, generally indicate that the medication regimen does
help keep the pain symptoms more tolerable and improve
functional ability/capacity and she denies any side effects to
the medications and is tolerating them well. (Exhibits 10F/12,
18, 24, 32, 38, 44, 50, 61; 13F/12, 19, 25, 31, 37; 15F/353, 368,
378, 388, 408, 418; 23F/127) Similarly, pain management
records dated September 11, 2023, to May 29, 2024, generally
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reveal that the claimant reported improvement in functional
capacity, and/or activity tolerance, and/or less medication
requirement or otherwise indicate that medication regimen
does help keep the pain symptoms more tolerable and improve
functional capacity and she generally denied side effects to the
medications. (Exhibit 23F/2, 11, 20, 29, 38, 47, 58, 67, 76, 85,
96, 105, 116).
(Doc. 8-3 at 47).
Additionally, an ALJ may consider “whether the claimant engages in daily activities
inconsistent with the alleged symptoms.” Lingenfelter, 504 F.3d at 1040. “Even if the
claimant experiences some difficulty or pain, her daily activities ‘may be grounds for
discrediting the claimant’s testimony to the extent that they contradict claims of a totally
debilitating impairment.’” Smartt, 53 F.4th at 499 (quoting Molina, 674 F.3d at 1113).
Here, the ALJ explained that Plaintiff’s activities of daily living were not “as limited as
would be expected given her complaints of disabling symptoms and limitations.” (Doc. 8-
3 at 48). The ALJ acknowledged that “travel and disability are not necessarily
inconsistent,” but concluded that “in this case, the claimant’s ability to travel to Mexico
regularly strongly suggests she is not as limited as alleged.” (Doc. 8-3 at 48).
Moreover, the ALJ found the medical opinions of Dr. Hunter and Dr. Braverman
persuasive because those medical opinions were consistent with and supported by the
record. (Doc. 8-3 at 52). The ALJ adopted Dr. Braverman’s opined limitations in
formulating Plaintiff’s RFC from November 13, 2021 to December 27, 2023. (Doc. 8-3 at
44, 52). The ALJ adopted Dr. Hunter’s opined limitations in formulating Plaintiff’s RFC
beginning on December 27, 2023. (Doc. 8-3 at 44, 52). Therefore, the Court finds that in
discounting Plaintiff’s testimony, the ALJ gave specific, clear and convincing reasons that
were supported by substantial evidence.
Plaintiff argues that the ALJ “provided a general medical summary, but failed to
connect anything specific in the medical record to a specific inconsistency” with Plaintiff’s
testimony. (Doc. 11 at 14). Plaintiff’s argument fails because, as explained above, the ALJ
found Plaintiff’s testimony regarding the severity of her pain and limitations were
inconsistent with and not supported by medical treatment records, which indicate that
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Plaintiff’s symptoms were improved by her surgery and medications.
Plaintiff additionally argues that the ALJ “failed to provide a specific, clear and
convincing reason supported by substantial evidence to reject Rosales’s chronic pain
testimony” related to her fibromyalgia. (Doc. 11 at 15). However, as explained above, the
ALJ found that Plaintiff’s “ability to travel to Mexico regularly strongly suggests she is not
as limited as alleged.” (Doc. 8-3 at 48). The ALJ pointed to a medical treatment note that
indicated Plaintiff had not started physical therapy “due to recent travel to Mexico.” (Doc.
8-3 at 48; Doc. 8-12 at 197). The ALJ also noted that a consultative examination “was
rescheduled because she was reportedly out of town.” (Doc. 8-3 at 48; Doc. 8-7 at 101).
The ALJ reasonably found that Plaintiff’s frequent travels are inconsistent with her
testimony regarding the severity and limiting effects of her chronic pain.
Plaintiff also argues that the ALJ cherry-picked the medical record with regards to
Plaintiff’s improvement with medication and surgery. (Doc. 11 at 15–18). However, the
ALJ discussed medical reports of ongoing pain and took those into account in formulating
Plaintiff’s RFC. (Doc. 8-3 at 47). Moreover, as previously mentioned, in addition to
medical records indicating improvement with treatment, the ALJ relied on Plaintiff’s
activities of daily living and the medical opinions of Dr. Hunter and Dr. Braverman in
discounting Plaintiff’s testimony regarding the severity of her pain and limitations.
Therefore, the ALJ provided specific, clear and convincing reasons for discrediting
Plaintiff’s testimony.
Finally, Plaintiff argues that her testimony is not inconsistent with her activities of
daily living. (Doc. 11 at 18–19). Specifically, Plaintiff argues that the ALJ failed to explain
how travel was inconsistent with Plaintiff’s testimony considering Plaintiff may have
gotten accommodations. (Doc. 11 at 19). However, Plaintiff did not testify that she received
an accommodation. The ALJ reasonably found that Plaintiff’s frequent travels contradict
her testimony that she could only sit for ten minutes at a time due to pain and that she was
too tired to complete simple tasks.
Therefore, the Court finds that the ALJ provided specific, clear and convincing
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reasons supported by substantial evidence for rejecting Plaintiff’s testimony regarding the
severity and limiting effects of her symptoms.
B. Medical Opinions
Plaintiff argues that substantial evidence did not support ALJ’s rejection of the
medical opinions of treating providers Dr. Ravi Bhalla and PA-C Paige Nelson because the
ALJ failed to discuss the supportability and consistency factors with citation to substantial
evidence. (Doc. 11 at 20). Plaintiff asserts that this was not harmless error because the
vocational expert testified that the limitations assessed by these providers would preclude
competitive employment. (Doc. 11 at 24–25). Conversely, Defendant argues that the ALJ’s
assessment of the medical opinions was reasonable and supported by substantial evidence.
(Doc. 12 at 8–9).
1. Legal Standard
In evaluating medical opinions, the Ninth Circuit previously employed the “treating
physician rule,” which distinguished between treating physicians, examining physicians,
and non-examining physicians, generally giving the greatest weight to the opinions of
treating physicians. See Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995). However, in
March 2017, the SSA amended their regulations to abrogate the treating physician rule,
among other changes, and all claims filed on or after March 27, 2017, must adhere to these
amended regulations. Alonzo v. Comm’r of Soc. Sec. Admin., No. CV-18-08317-PCT-JZB,
2020 WL 1000024, at *3 (D. Ariz. Mar. 2, 2020) (citing Revisions to Rules Regarding the
Evaluation of Medical Evidence, 82 Fed. Reg. 5844-01, 2017 WL 168819, at *5852–57
(Jan. 18, 2017)); see Woods v. Kijakazi, 32 F.4th 785, 791–92 (9th Cir. 2022). The amended
regulations state that an ALJ “will not defer or give any specific evidentiary weight,
including controlling weight, to any medical opinion(s) or prior administrative medical
finding(s), including those from [the claimant’s] medical sources.” 20 C.F.R.
§ 404.1520c(a).
Moreover, the Ninth Circuit has determined that in cases governed by the amended
regulations, the “specific and legitimate” standard is no longer applicable, meaning an ALJ
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is no longer required to articulate “specific and legitimate reasons” for rejecting a treating
physician’s opinion. Woods, 32 F.4th at 791–92. Instead, the amended regulations provide
that in considering all medical opinions, an ALJ should consider several enumerated
factors, including supportability, consistency, treatment relationship, specialization, and
other factors. 20 C.F.R. § 404.1520c(c); Alonzo, 2020 WL 1000024, at *3. Supportability
and consistency are the “most important factors,” and the ALJ must articulate how he
considered supportability and consistency in determining how persuasive a medical
opinion is. 20 C.F.R. § 404.1520c(b)(2). “Supportability means the extent to which a
medical source supports the medical opinion by explaining the ‘relevant . . . objective
medical evidence.’” Woods, 32 F.4th at 791–92 (quoting 20 C.F.R. § 404.1520c(c)(1)).
“Consistency means the extent to which a medical opinion is ‘consistent . . . with the
evidence from other medical sources and nonmedical sources in the claim.’” Id. (quoting
20 C.F.R. § 404.1520c(c)(2)). If the ALJ finds that two or more medical opinions differ
slightly but are equally well-supported and consistent with the record, then the ALJ must
also articulate how he considered the other enumerated factors. 20 C.F.R.
§ 404.1520c(b)(3).
2. Dr. Ravi Bhalla
Plaintiff argues that the ALJ erred in rejecting Dr. Bhalla’s medical opinion. (Doc.
11 at 21). The ALJ summarized Dr. Bhalla’s opinion as follows:
On August 10, 2023, Ravi Bhalla, M.D. completed a
Fibromyalgia form. He opined as follows, in part. She does not
have the stamina and endurance to work an easy job 8 hours
per day 5 days per week (with normal breaks every two hours).
She will require a job that permits shifting at will and would
need unscheduled breaks. The claimant would likely be absent
more than four days per month. (Exhibit 16F).
(Doc. 8-3 at 51). The ALJ found Dr. Bhalla’s opinion to be unpersuasive because his opined
limitations were vague, unsupported by the record, and inconsistent with the record. (Doc.
8-3 at 51).
Regarding supportability, the ALJ explained:
In terms of supportability, he completed a checkbox style form
with no accompanying narrative, and no significant
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explanation as to why the claimant was so limited. Further, Dr.
Bhalla provided no significant objective examinations or
diagnostic findings within the form to support the restrictions
given nor did he cite to any objective documentation or other
objective findings to support his opinions other than
identifying symptoms, sign, and associated conditions
provided within the checkbox form itself and notating 18
tender points.
(Doc. 8-3 at 51).
Plaintiff argues the ALJ should not have discounted Dr. Bhalla’s opinion based on
the “checkbox style form” because Dr. Bhalla’s underlying treatment notes support his
opinion. (Doc. 11 at 21). Specifically, Plaintiff argues that “Dr. Bhalla treated [Plaintiff]
since 2017 with numerous visits noting consistent symptoms, multiple tender points on
examination, and an ordered course of treatment that included medical trials and
adjustments for fibromyalgia and inflammation symptoms.” (Doc. 11 at 22). However,
Plaintiff did not point to anything in the treatment notes where Dr. Bhalla explained how
he concluded based on Plaintiff’s multiple tender points and course of treatment that
Plaintiff “does not have the stamina and endurance to work and easy job.” (Doc. 11 at 22;
Doc. 8-3 at 51).
Moreover, the ALJ determined that the vagueness of Dr. Bhalla’s opinion further
indicated that some of his opined limitations were unsupported. Regarding vagueness, the
ALJ explained:
[Dr. Bhalla] provided some vague opinions. For instance, he
indicated that the claimant would need to sit with legs elevated
with prolonged sitting but when asked to specify how high the
legs should be elevated and what percentage of time, he stated,
“no way to determine”. (Exhibit 16F/4) Further, he opined that
the claimant had restricted use of the hands, fingers, and arms
but again failed to specify to what degree or percentage of an
8-hour working day these would be restricted (Id.).
(Doc. 8-3 at 51).
Plaintiff argues that “Dr. Bhalla’s assessment was not vague as it related to
[Plaintiff’s] need for unscheduled breaks and absences, two limitations that the agency’s
vocational expert confirmed would preclude work.” (Doc. 11 at 22). However, as
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explained, the ALJ found that Dr. Bhalla’s opinion regarding Plaintiff’s need for
unscheduled breaks and absences was unsupported by and inconsistent with the record.
Regarding inconsistency, the ALJ explained:
Dr. Bhalla reports she has frequent and severe headaches, but
there is minimal evidence of treatment for headaches in the
record and minimal evidence of fatigue that he has reported.
The opinions of Dr. Bhalla are inconsistent with the balance of
treatment records that generally reveal that the medication
regimen does help keep the pain symptoms more tolerable and
aids in improving functional ability/capacity. (Exhibits 10F/12,
18, 24, 32, 38, 44, 50, 61; 13F/12, 19, 25, 31, 37; 15F/353, 368,
378, 388, 408, 418; 23F/23F/2, 11, 20, 29, 38, 47, 58, 67, 76,
85, 96, 105, 116). Dr. Bhalla’s opinions are not consistent with
the claimant’s activity including travels to Mexico, as
described herein.
(Doc. 8-3 at 51).
Plaintiff argues that Dr. Bhalla’s assessment of frequent and severe headaches and
fatigue is not inconsistent with the record because the record shows that Plaintiff reported
fatigue and headaches and was treated with medication trials for migraines. (Doc. 11 at
22). Plaintiff further argues that improvement in certain symptoms with medication and
travels to Mexico did not invalidate Dr. Bhalla’s opinion. (Doc. 11 at 22–23).
In determining Plaintiff’s severe impairments at Step Two, the ALJ found that
Plaintiff’s treatment history for migraines “tends to suggest her noted migraines were not
at the severity and frequency that she alleged.” (Doc. 8-3 at 43). The ALJ acknowledged
that even after achieving some improvement from treatment, Plaintiff still complained of
getting migraines after treatment. (Doc. 8-3 at 44). Contrary to Plaintiff’s assertion, the
ALJ considered Plaintiff’s treatment history for migraines and nonetheless concluded that
“[t]he record does not support a finding that she has experienced migraine headaches with
a frequency or severity to result in more than a minimal limitation in her ability to perform
work related activity.” (Doc. 8-3 at 44). Moreover, the ALJ reasonably concluded that
Plaintiff’s frequent travels to Mexico are inconsistent with the level of disabling fatigue
alleged by Dr. Bhalla. Accordingly, the ALJ did not err in rejecting Dr. Bhalla’s opined
limitations as inconsistent with the record.
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3. PA-C Paige Nelson
Plaintiff argues that the ALJ erred in rejecting PA-C Nelson’s opined limitations.
(Doc. 11 at 23). The ALJ summarized PA-C Nelson’s opinion as follows:
In a Medical Source Statement (Physical) dated February 8,
2022, Paige Nelson, PA-C, opined as follows, in part. She
would experience pain or other symptoms severe enough to
constantly interfere with attention and concentration to
perform simple tasks. She can sit less than 2 hours in an 8-hour
working day and stand/walk less than 2 hours in an 8-hour
working day. She must walk every 20 minutes for 5 minutes at
a time. She requires a job that permits shifting positions at will
and would require unscheduled breaks. She could rarely lift
less than 10 pounds, never look down, rarely turn head, and
occasionally hold head in static position. She should never
twist, stoop, crouch or climb ladders, occasionally climb stairs,
and would be able to use hands/fingers/arms 5% of an 8-hour
working day for handling, fine manipulations, and reaching.
She would likely be absent from work more than four days per
month. (Exhibits 4F; 5F).
(Doc. 8-3 at 50). The ALJ found PA-C Nelson’s opinion to be unpersuasive because her
opined limitations were unsupported by the record, inconsistent with other medical records,
and inconsistent with Plaintiff’s activities of daily living. (Doc. 8-3 at 50–51).
Regarding supportability, the ALJ explained:
The opinions of Ms. Nelson are not supported by the weight of
treatment records. As noted, the medical record supports that
the claimant generally obtained benefit from lumbar surgery.
On December 29, 2021, the claimant presented for 2-week post
operative appointment status post lumbar laminectomy and
fusion and “reports significant improvement in low back pain
and bilateral lower extremity pain”. (Exhibit 6F/3) On March
16, 2022, 3-months status post laminectomy and fusion from
L4-5, she reported continued soreness in her low back and
stretching sensation when she bends but “she has begun to
resume her regular activities”. (Exhibit 6F/5) On June 7, 2022,
approximately 6 months status post lumbar laminectomy and
fusion, the claimant reported intermittent stiffness but “overall
she is extremely pleased with the outcome of her surgery. She
denies bilateral lower extremity pain. She has completed
physical therapy as prescribed. She is beginning to resume her
regular activities without restrictions”. (Exhibit 7F/8) Further,
Ms. Nelson’s opinions are not supported by pain management
records that generally reveal that the medication regimen does
help keep the pain symptoms more tolerable and aids in
improving functional ability/capacity. (Exhibits 10F/12, 18,
24, 32, 38, 44, 50, 61; 13F/12, 19, 25, 31, 37; 15F/353, 368,
378, 388, 408, 418; 23F/23F/2, 11, 20, 29, 38, 47, 58, 67, 76,
85, 96, 105, 116).
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(Doc. 8-3 at 50).
Regarding inconsistency with other medical records, the ALJ explained:
Ms. Nelson’s opinions are out of proportion and inconsistent
with examinations from her own medical facility. For example,
examinations dated December 6, 2021, to February 28, 2022,
generally show she was alert, cooperative, and in no acute
distress and had intact strength and sensation symmetric
throughout, normal lower extremity findings, and normal gait.
(Exhibit 15F/114, 120, 126, 131) On exams dated June 23,
2022, to July 5, 2024, the claimant was generally in no acute
distress, was awake, alert, had normal motor function, normal
sensation, and normal gait. (Exhibit 15F/14, 24, 34, 44, 54, 64,
74, 83, 91, 100; 22F/9, 22, 33, 45, 56, 68; 24F/8, 18).
(Doc. 8-3 at 50–51).
Regarding inconsistency with Plaintiff’s activities of daily living, the ALJ
explained:
Ms. Nelson’s opinions are inconsistent with the claimant’s
testimony that suggests a greater degree of functioning than
proposed by Ms. Nelson. She testified traveling outside of
Maricopa County and affirmed going to Mexico not long ago.
The claimant testified traveling to Mexico three weeks ago and
was there for one week. She testified also going to Mexico in
February of this year. She reported flying when she travels to
Mexico. At the supplemental hearing, the claimant also
reported going to Mexico in May. The degree of limitations
proposed by Ms. Nelson is also not supported by the claimant’s
Function Report, which also suggests a greater degree of
functioning. In a Function Report, the claimant noted that she
tries to do household chores but has to sit down after 10
minutes. (Exhibit 3E/2) She indicated playing games on her
phone (Id.). The claimant indicated preparing her own meals.
(Exhibit 3E/3) She noted being able to clean or sweep/mop for
a little bit before she gets tired and has to sit down (Id.). She
indicated being able to go out alone and being able to drive.
(Exhibit 3E/4) The claimant indicated being able to shop in
stores, pay bills, count change, handle a savings account and
use a checkbook (Id.). The claimant indicated going to the mall
or out to eat with her daughters one time a week. (Exhibit 3E/5)
She reported being able to walk ½ mile before stopping to rest.
(Exhibit 3E/6) She indicated being able to pay attention for 2
hours and following written and spoken instructions “well”
(Id.).
(Doc. 8-3 at 51).
Plaintiff argues that PA-C Nelson’s opined limitations were supported by her
treatment notes, which indicated that Plaintiff’s pain symptoms persisted despite treatment.
(Doc. 11 at 23). Plaintiff further argues that PA-C Nelson’s opined limitations were not
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inconsistent with records of persistent pain. (Doc. 11 at 23). However, the ALJ did not
discount Plaintiff’s reports of pain; rather, the ALJ considered Plaintiff’s continued
symptoms of pain and determined that PA-C Nelson’s opined limitations were
disproportionate to Plaintiff’s pain symptoms. The ALJ did not err in finding that PA-C
Nelson’s opined limitations were unsupported by and disproportionate to Plaintiff’s
treatment records.
Plaintiff also argues that the ALJ did not explain how Plaintiff’s activities of daily
living, including travel to Mexico, were inconsistent with PA-C Nelson’s opined
limitations. (Doc. 11 at 24–25). The Ninth Circuit Court of Appeals has held that an ALJ
may validly reject a medical opinion if it is inconsistent with a claimant’s daily activities.
See, e.g., Ghanim, 763 F.3d at 1162; Carter v. Berryhill, 738 F. App’x 534, 535 (9th Cir.
2018); Burch v. Barnhart, 400 F.3d 676, 681 (9th Cir. 2005). The ALJ reasonably
concluded that Plaintiff’s daily activities, including frequent travels to Mexico, suggest a
greater degree of functioning than PA-C Nelson’s opined limitations. Therefore,
substantial evidence supports the ALJ’s conclusion that Plaintiff’s daily activities conflict
with a limitation to level one reasoning. See Burch, 400 F.3d at 680 (“Although the
evidence of [the claimant’s] daily activities may also admit of an interpretation more
favorable to [the claimant], the ALJ’s interpretations was rational, and we must uphold the
ALJ’s decision where the evidence is susceptible to more than one rational
interpretation.”).
Plaintiff additionally argues regarding both Dr. Bhalla and PA-C Nelson that the
ALJ erred in failing to explain how the record “better supported the agency opinions over
[Plaintiff’s] treating providers.” (Doc. 11 at 24; Doc. 8-3 at 52). However, as discussed
previously, the ALJ, not the reviewing court, is responsible for resolving any conflicts or
ambiguities within the medical testimony and medical record. See Andrews, 53 F.3d at
1039. Therefore, when the evidence of record could result in more than one rational
interpretation, “the ALJ’s decision should be upheld.” Orn, 495 F.3d at 630; see also
Matney ex rel. Matney v. Sullivan, 981 F.2d 1016, 1019 (9th Cir. 1992) (“[I]f the evidence
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can support either outcome, the court may not substitute its judgment for that of the ALJ.”).
Here, the ALJ determined that the opinion of a consulting examiner conflicted with the
opinion of Plaintiff’s treating providers. “When there is conflicting medical evidence, the
[ALJ] must determine credibility and resolve the conflict.” Thomas, 278 F.3d at 956–57
(quoting Matney v. Sullivan, 981 F.2d 1016, 1019 (9th Cir. 1989)). The Court must defer
to the ALJ’s weighing of conflicting medical opinions.
IV. CONCLUSION
For the foregoing reasons,
IT IS ORDERED that the ALJ’s decision is AFFIRMED.
IT IS FURTHER ORDERED that the Clerk of Court shall enter judgment
accordingly.
Dated this 14th day of April, 2026.
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