Arce v. Commissioner of Social Security Administration

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WO
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
Benny Arce,
Plaintiff,
v.
Commissioner of Social Security
Administration,
Defendant.
No. CV-25-02516-PHX-JAT
ORDER
Pending before the Court is Plaintiff Benny Arce’s (“Plaintiff”) appeal from the
Commissioner of the Social Security Administration’s (“Defendant”) denial of Social
Security benefits. (Doc. 14-3). The appeal is fully briefed, (Docs. 15, 17, 18), and the Court
now rules.
I. BACKGROUND
On appeal, this Court considers whether the ALJ erred by: (1) partially rejecting the
medical opinions of Plaintiff’s treating physician, and (2) rejecting Plaintiff’s subjective
symptom testimony.
A. Factual Overview
Plaintiff applied for a period of disability and disability insurance benefits on
November 17, 2021, alleging disability beginning May 14, 2021, including coronary artery
disease status post quadruple bypass surgery, hypertension, lumbar spine disorder, and
obesity. (Doc. 14-3 at 16; Doc. 14-4 at 3). Plaintiff alleged that his cardiac symptoms—
dizziness, fatigue, and shortness of breath—rendered him unable to work. (Doc. 14-3 at
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21–22). Plaintiff’s claim was initially denied on July 27, 2022, and upon reconsideration
on May 24, 2023. (Doc. 14-3 at 16). Plaintiff requested a hearing before an ALJ, which
was held on February 12, 2024. (Doc. 14-3 at 16). The ALJ issued his decision on June 21,
2024, finding that Plaintiff was not disabled under the Social Security Act from May 14,
2021, through the date of the decision. (Doc. 14-3 at 25). The SSA Appeals Council denied
Plaintiff’s request for review, and Plaintiff filed the present appeal. (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).
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At Step Three, the ALJ determines whether the claimant’s impairment(s) “meets or
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), (e). The claimant’s RFC refers to his ability to
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 a claimant’s 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), (e).
“Past relevant work” is work the claimant has “done within the past five years that was
substantial gainful activity.” 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.
Finally, at Step Five, 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)(4)(v). If so, the ALJ will find the claimant not disabled. Id. If the claimant
cannot make this adjustment, the ALJ will find the opposite. Id.
C. The ALJ’s Application of the Factors
Here, at Step One, the ALJ concluded that Plaintiff “has not engaged in substantial
gainful activity since May 14, 2021, the alleged onset date.” (Doc. 14-3 at 19–20). At Step
Two, the ALJ determined that Plaintiff had the following severe impairments: coronary
artery disease status post coronary artery bypass graft x4, hypertension, lumbar spine
disorder, and obesity. (Doc. 14-3 at 20).
At Step Three, the ALJ determined that Plaintiff did not have any impairment or
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combination of impairments that met or medically equaled a listed impairment in Appendix
1 to Subpart P of 20 C.F.R. Part 404. (Doc. 14-3 at 21). The ALJ then determined that
Plaintiff had the RFC
to perform light work as defined in 20 CFR 404.1567(b) except the claimant
can lift and carry 20 pounds occasionally, 10 pounds frequently, stand and
walk for 6 hours in an 8 hour day, and sit for 6 hours in an 8 hour day. The
claimant can occasionally climb ramps and stairs, but never climb ladders or
scaffolds. The claimant can frequently balance, and occasionally stoop,
kneel, crouch and crawl. The claimant must avoid concentrated exposure to
hazards.
(Doc. 14-3 at 21).
At Step Four, the ALJ found that Plaintiff was capable of performing his past
relevant work as a collections clerk, customer service representative, credit manager,
training manager, and credit clerk. (Doc. 14-3 at 25). The vocational expert testified that
given the RFC, Plaintiff could perform this past relevant work as actually and generally
performed. (Doc. 14-3 at 25). Accordingly, the ALJ concluded that Plaintiff was not
disabled under the Social Security Act from May 14, 2021, through the date of the decision.
(Doc. 14-3 at 25).
II. LEGAL 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 refers to “such
relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
Id. (quoting Desrosiers v. Sec’y of Health and Human Servs., 846 F.2d 573, 576 (9th Cir.
1988)). The Court, in its review, must consider the record in its entirety, “weighing both
the evidence 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
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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). Thus, 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, [the Court] must defer to the ALJ’s conclusion.”). Further, this Court may
only review the reasons the ALJ provides in the disability determination, and “may not
affirm the ALJ on a ground upon which he did not rely.” Garrison, 759 F.3d at 1010.
III. DISCUSSION
Plaintiff argues the ALJ committed materially harmful error by: (1) rejecting the
assessment from treating provider Joslynn Palomo, PA-C, without providing sufficient
explanation of the supportability and consistency factors as required under the regulations,
and (2) rejecting Plaintiff’s subjective symptom testimony without providing specific,
clear, and convincing reasons supported by substantial evidence. (Doc. 15 at 1–2). The
Court addresses each argument in turn.
A. PA Palomo’s Medical Opinion
Plaintiff’s first challenge concerns PA Palomo’s medical opinion. They assert the
ALJ erred by rejecting PA Palomo’s assessment without providing sufficient explanation
supported by substantial evidence, including “failing to explain the consideration of
supportability and consistency factors.” (Doc. 15 at 17). Defendant argues that the ALJ
reasonably considered PA Palomo’s opinion. (Doc. 17 at 8).
1. Legal Standard for Evaluation of Medical Opinions
Courts in the Ninth Circuit previously distinguished among 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). This distinction was referred to as the “treating physician rule.” See Regula v. Delta
Family-Care Survivorship Plan, 266 F.3d 1130, 1139 (9th Cir. 2001), cert. granted,
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vacated sub nom. Regula v. Delta Family-Care Disability & Survivorship Plan, 539 U.S.
901 (2003). However, “in March of 2017, the [SSA] amended their regulations to abrogate
the treating physician rule, among other changes.” Alonzo v. Comm’r of Soc. Sec. Admin.,
No. CV-18-08317-PCT-JZB, 2020 WL 1000024, *3 (D. Ariz. Mar. 2, 2020) (citing
Revisions to Rules Regarding the Evaluation of Medical Evidence, 82 Fed. Reg. 5844-01
2017 WL 168819, *5852–57 (Jan. 18, 2017)). Claims filed on or after March 27, 2017,
must adhere to the amended regulations. Id. These regulations state that the 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 . . .medical
sources.” 20 C.F.R. §§ 404.1520c, 416.920c.
In addition to the abrogation of the “treating physician rule,” as of March 20, 2017,
the amended SSA regulations specify that the ALJ must “consider all medical opinions
according to several enumerated factors, including, whether the opinion is supported by
objective medical evidence and whether the opinion is consistent with the evidence from
other sources.” Alonzo, 2020 WL 1000024, at *3. Supportability and consistency are the
“most important factors,” and the ALJ must explain how she considered the evidence in
light of these two factors for a medical source’s opinions. 20 C.F.R § 404.1520c(b)(3).
Moreover, the Ninth Circuit determined that in cases governed by the amended SSA
regulations above, the “specific and legitimate” standard is also no longer applicable. See
Woods v. Kijakazi, 32 F. 4th 785, 792 (9th Cir. 2022). In Woods, the Ninth Circuit
concluded the following:
Our requirement that ALJs provide “specific and legitimate reasons” for
rejecting a treating or examining doctor’s opinion, which stems from the
special weight given to such opinions, is likewise incompatible with the
revised regulations. Insisting that ALJs provide a more robust explanation
when discrediting evidence from certain sources necessarily favors the
evidence from those sources—contrary to the revised regulations.
Id. (quotations and internal citations omitted). Accordingly, it is not required that an ALJ
provide “specific and legitimate reasons” to reject a treating physician’s assessment. Id. at
791. Rather, an ALJ’s decision to discredit any medical opinion must simply be supported
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by substantial evidence. Id. at 787.
As discussed previously, the ALJ, not the reviewing Court, is responsible for
resolving ambiguities and conflicts in medical testimony and the medical record. See
Andrews, 53 F.3d at 1039. Thus, 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 can support either outcome, the [C]ourt may not substitute its judgment for that
of the ALJ.”).
2. The ALJ’s Evaluation of PA Palomo’s Opinion
PA Palomo completed a checkbox assessment form on July 3, 2023, opining that
Plaintiff could stand and walk for less than two hours in an eight-hour day, sit for less than
two hours, and lift and carry less than ten pounds. (Doc. 14-18 at 59). The form also
restricted Plaintiff’s ability to use his hands, bend, reach, and stoop, and indicated he would
miss work up to six days per month due to dizziness, fatigue, and the fact he was “easily
out of breath.” (Doc. 14-18 at 59–60).
Regarding PA Palomo’s assessment of Plaintiff, the ALJ found as follows:
Ms. Palomo’s opinion is not supported by her treatment records, or the
claimant’s other examinations, and thus is not persuasive. Ms. Palomo treats
the claimant at G&K Medical, but her exams show the claimant only with
tenderness to [his] back, but does not indicate any restrictions in standing,
sitting or lifting (Exhibit 12F). During some visits, there are no examinations
(Exhibit 18F/2); but other visits show normal findings. Ms. Palomo wrote the
opinion of the claimant’s limitations on July 3, 2023, after examining the
claimant during a visit on June 30, 2023. During that visit, the claimant was
noted as well developed and well nourished with no acute distress. The
claimant’s heart and lung function was normal. The claimant’s cranial nerves
were normal and his balance, gait and stance was normal. There was no
indication of difficulty walking, standing or sitting, or lifting and nothing to
indicate that he may miss work (Exhibit 18F/7). By contrast, [t]he claimant
was examined at the Core Institute on August 11, 2023 where he was found
to have full and active range of motion of his right shoulder, his strength was
full (5/5), and he had negative impingement tests (Exhibit 17F). Dr.
Cunningham’s exam the previous year in June 2022 showed the claimant to
have normal sitting, a slightly shuffling gait, but he was able to move and
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stand independently without an assistive device. The claimant showed a
normal range of motion of his shoulders and knees and his strength was full
(5/5) (Exhibit 7F). Thus, Ms. Palomo’s opinion is not supported by the
medical evidence and is not persuasive.
(Doc. 14-3 at 24–25).
Plaintiff’s challenge breaks down into three objections: (1) the ALJ erred by
focusing on musculoskeletal findings when PA Palomo based her opinion on cardiac
symptoms; (2) the ALJ improperly relied on ‘no acute distress’ notations; and (3) the ALJ’s
supportability analysis was inadequate. (Doc. 15 at 18–20). The Court addresses each of
these alleged errors in turn.
a. The Focus on Musculoskeletal Findings
PA Palomo completed a checkbox assessment form on July 3, 2023, opining that
Plaintiff was unable to sustain even sedentary work due to “dizziness, [being] easily out of
breath, [and] sudden fatigue.” (Doc. 14-18 at 59). The form indicated that Plaintiff’s
impairments would cause him to be off-task at a “moderately severe” level (16-20% of an
eight-hour workday) and that he would miss six or more days of work per month. (Doc.
14-18 at 60). The ALJ concluded that PA Palomo’s opinion was unsupported by her own
treatment records and other medical examinations in the record, which showed Plaintiff
had normal heart and lung function and normal “balance, gait, and stance.” (Doc. 14-3 at
24). Plaintiff argues the ALJ erred by citing unrelated musculoskeletal examination
findings to discredit PA Palomo’s opinion when her opinion was premised on Plaintiff’s
cardiac symptoms. (Doc. 15 at 18–19).
The Court acknowledges the ALJ’s discussion would be easier to follow if every
cited examination finding directly tracked the symptoms PA Palomo listed on the checkbox
assessment form. But the Court reads the decision as a whole, and the ALJ was not required
to discuss each piece of evidence in any particular location. See Kennedy v. Colvin, 738
F.3d 1172, 1178 (9th Cir. 2013). Even where the ALJ’s explanation is not perfectly
organized, the Court will uphold the decision if the ALJ’s path can reasonably be discerned
from the record and the decision as a whole. Alaska Dep’t of Env’t Conservation v. E.P.A.,
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540 U.S. 461, 497 (2004).
The ALJ identified several pieces of evidence that undermine PA Palomo’s extreme
assessment. First, citing PA Palomo’s own treatment note from June 30, 2023, the ALJ
noted that Plaintiff’s “heart and lung function was normal.” (Doc. 14-3 at 24; Doc. 14-19
at 8). This finding directly relates to PA Palomo’s stated basis for her opinion—that
Plaintiff was “easily out of breath.” The same treatment note also stated that Plaintiff
“passed the nuclear stress test” and that his “activities of daily living were normal.” (Doc.
14-19 at 6–7). Essentially, PA Palomo’s own treatment records showed normal cardiac
function, normal activities of daily living, and a passed stress test—yet three days later she
opined that Plaintiff could not sustain even sedentary work due to cardiac-related
symptoms. The mismatch between PA Palamo’s examination findings and her opinion
regarding Plaintiff’s extreme work restrictions constitutes substantial evidence supporting
the ALJ’s decision to discredit PA Palamo’s assessment. See Connett v. Barnhart, 340 F.3d
871, 874–75 (9th Cir. 2003) (opinion may be discounted when inconsistent with the
provider’s own notes).
Second, the assessment form itself reveals that PA Palomo did not review treatment
notes, records from other providers, radiographic reports, or laboratory reports before
rendering her opinion. Question 10 on the checkbox form asks: “Have you considered
and/or reviewed your treatment notes, records from other providers, radiographic reports,
laboratory reports, patient’s response to treatment, and/or other?” PA Palomo checked
“No” and explained: “Work up is still in progress: sleep study, holter monitor, etc.” (Doc.
14-18 at 60). PA Palomo’s admission that she based her opinion on incomplete
information—studies that had not yet been completed—undermines the supportability of
her assessment. See Thomas v. Barnhart, 278 F.3d 947, 957 (9th Cir. 2002) (ALJ may
discount medical opinion that is “brief, conclusory, and inadequately supported by clinical
findings”); see also Bray v. Comm’r of Soc. Sec. Admin., 554 F.3d 1219, 1228 (9th Cir.
2009).
Third, the ALJ cited other medical evidence that was inconsistent with PA Palomo’s
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extreme limitations. Dr. Robert Gordon, a consultative examiner, evaluated Plaintiff in
June 2022 and said he could perform light work, including standing and walking, for six
hours in an eight-hour day. (Doc. 14-12 at 34–35). Dr. Gordon noted that Plaintiff
“presented to the appointment with no assistive devices” and that he “no longer uses” the
walker he was given after surgery. (Doc. 14-12 at 30, 34). Dr. Keith Cunningham, another
consultative examiner, evaluated Plaintiff in April 2023 and similarly stated he could
perform light work. (Doc. 14-12 at 37–44). Dr. Cunningham noted that Plaintiff was
“independent with his ADLs and his personal needs,” “able to drive and drove to the office
today,” and “does not use any assistive or orthotic devices at this time.” (Doc. 14-12 at 37).
The state-agency medical consultants at both the initial and reconsideration levels also
opined that Plaintiff could perform light work. (Doc. 14-4 at 3–15, 18–25). Because this
evidence suggests Plaintiff can perform light work—contrary to PA Palomo’s opinion that
he cannot sustain even sedentary work—it is inconsistent with PA Palomo’s assessment.
Accordingly, substantial evidence supports the ALJ’s decision to find PA Palomo’s
opinion unpersuasive. Matney, 981 F.2d at 1019 (“The [ALJ] and not the reviewing court
must resolve conflicts in evidence, and if the evidence can support either outcome, the
court may not substitute its judgment for that of the ALJ.”).
b. The ALJ’s “No Acute Distress” Finding
In discrediting PA Palomo’s opinion, the ALJ referenced PA Palomo’s treatment
notes finding that Plaintiff “was in no acute distress.” (Doc. 14-3 at 24). Plaintiff argues
that the ALJ’s reliance on the “no acute distress” finding is insufficient because “acute”
refers to rapid onset conditions, not chronic impairments. (Doc. 15 at 19). However, the
ALJ did not rely solely on this finding. As discussed, the ALJ cited PA Palomo’s
documentation of normal cardiac function, normal activities of daily living, and Plaintiff’s
passed stress test—findings that directly relate to the cardiac symptoms PA Palomo cited
as the basis for her opinion. The ALJ also cited multiple other medical opinions finding
that Plaintiff was capable of performing light work. Even if the ALJ’s reliance on PA
Palomo’s “no acute distress” findings was an insufficient basis, standing alone, to discredit
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her, the ALJ provided other valid reasons supported by substantial evidence to discount
PA Palomo’s opinion. See Carmickle v. Comm’r, Soc. Sec. Admin., 533 F.3d 1155, 1162
(9th Cir. 2008).
c. The ALJ’s Supportability Analysis
Plaintiff also asserts that the ALJ failed to perform an adequate supportability
analysis. (Doc. 15 at 20). Ultimately, the Court need not address this argument at length
because the ALJ reasonably found the opinion unpersuasive based on inconsistencies
between PA Palomo’s assessed limitations and her own treatment findings, as well as other
medical evidence supporting light work. (Doc. 14-3 at 24–25). Because the ALJ’s
inconsistency analysis is supported by substantial evidence, any deficiency in the
supportability discussion does not warrant reversal. Archunde v. Comm’r of Soc. Sec.
Admin., No. CV-24-01993-PHX-JAT, 2025 WL 520534, at *6 (D. Ariz. Feb. 18, 2025)
(citing Woods, 32 F.4th at 793 n.4 (indicating that even where an ALJ provides no
supportability analysis for a medical opinion, the ALJ may properly find the opinion
unpersuasive if there is an inconsistency finding supported by substantial evidence)); see
also Collins v. Colvin, No. 23-35526, 2024 WL 5040992, at *2 (9th Cir. Dec. 9, 2024)
(because the inconsistency of the doctor’s opinion provided a sufficient basis to find it
unpersuasive, “any error related to the supportability analysis counts as harmless and does
not provide a basis for reversing”).
B. Plaintiff’s Subjective Symptom Testimony
Plaintiff argues the ALJ committed materially harmful error by rejecting Plaintiff’s
symptom testimony without providing specific, clear, and convincing reasons supported
by substantial evidence. (Doc. 15 at 12). Defendant asserts that the ALJ reasonably
considered Plaintiff’s subjective complaints. (Doc. 17 at 3). The Court considers the
argument below.
1. Legal Standard for Evaluation of Subjective Symptom Testimony
In assessing the credibility of a claimant’s subjective symptom testimony, an ALJ
must engage in a two-step analysis. Vasquez v. Astrue, 572 F.3d 586, 591 (9th Cir. 2009).
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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.
2007) (quoting Bunnell v. Sullivan, 947 F.2d 341, 344 (9th Cir.1991)). If there is such
objective evidence, and “no evidence of malingering,” “the ALJ can reject the claimant’s
testimony about the severity of [his] symptoms only by offering specific, clear and
convincing reasons for doing so.” Id. (quoting Smolen v. Chater, 80 F.3d 1273, 1282 (9th
Cir. 1996)). “The standard isn’t whether [the reviewing] court is convinced, but instead
whether 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) (emphasis added).
When assessing witness credibility, an ALJ may consider “(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.” Ghanim v.
Colvin, 763 F.3d 1154, 1163 (9th Cir. 2014) (quoting Smolen, 80 F.3d at 1282).
2. The ALJ’s Evaluation of Plaintiff’s Subjective Symptom Testimony
The ALJ found that Plaintiff’s “medically determinable impairments could
reasonably be expected to cause some of the alleged symptoms,” but that Plaintiff’s
statements about “the intensity, persistence and limiting effects of these symptoms [were]
not entirely consistent with the medical evidence and other evidence in the record.” (Doc.
14-3 at 22). The ALJ provided a summary of the medical evidence and found as follows:
The claimant mentioned that he had a heart attack, but a review of the record
does not reference a heart attack. The claimant was having a lot of chest pain
and it was decided to do a bypass graft for the arteries of his heart (Exhibit
3F). This went well and the claimant’s chest pain was resolved. The rest of
the records show maintenance of his heart condition, but his exams are
normal (Exhibits 4F, 9F). Overall, the record supports light work (Exhibits
12F, 17F).
(Doc. 14-3 at 23).
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Plaintiff argues that the ALJ failed to connect anything specific in the medical
record to a specific inconsistency with any particular portion of his work-preclusive
symptom testimony. (Doc. 15 at 15). Plaintiff testified that he stopped working in May
2021 due to cardiac issues and subsequent quadruple bypass surgery. (Doc. 14-3 at 40–42).
He testified that he experiences daily headaches, constant dizziness, and fatigue. (Doc. 14-
3 at 42–43). He stated that he naps four to six hours a day uncontrollably, falls asleep while
sitting, and cannot cook because he forgets the stove is on. (Doc. 14-3 at 43–44, 50). He
testified that he uses a walker and brought his cane to both consultative examinations. (Doc.
14-3 at 46). He also testified that the cardiac rehabilitation program stopped his
participation due to dizziness and fall risk. (Doc. 14-3 at 50–51).
Substantial evidence—such as Plaintiff’s inconsistent statements and medical
evidence in the record—supports the ALJ’s finding that Plaintiff’s allegations about the
degree of his limitations were not fully consistent with the record.
a. Inconsistent Statements Regarding Assistive Devices
Plaintiff testified that he started using a walker after his surgery in October 2021
and that he had his cane with him at both consultative examinations. (Doc. 14-3 at 46). As
discussed above, both consultative examiners documented that Plaintiff arrived without
assistive devices, and Dr. Gordon noted Plaintiff’s report that he “no longer uses” the
walker he was given after surgery. (Doc. 14-12 at 28, 30, 37). The state agency reviewer
similarly noted “No AD use has been documented at visits.” (Doc. 14-4 at 23). The ALJ
could reasonably consider this evidence inconsistent with Plaintiff’s description of ongoing
balance problems severe enough to require a walker.
b. Inconsistent Statements Regarding Activities of Daily Living
Plaintiff testified he cannot do chores or cook safely and needs significant help from
his son. (Doc. 14-3 at 44–45). However, as noted above, PA Palomo’s own treatment note
states Plaintiff’s “activities of daily living were normal,” and Dr. Cunningham found him
“independent with his ADLs.” (Doc. 14-19 at 7; Doc. 14-12 at 37). This evidence supports
the ALJ’s conclusion that Plaintiff’s self-reported limitations were overstated.
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c. Objective Medical Evidence
The ALJ also reasonably relied on objective evidence suggesting improvement after
bypass surgery and generally stable cardiac findings. (Doc. 14-3 at 22–23). Plaintiff
reported feeling well after surgery with resolved chest pain, denied exertional shortness of
breath at his January 2022 follow-up, and later records reflect that Plaintiff was “stable
with no anginal complaints.” (Doc. 14-3 at 22; Doc. 14-19 at 6). As discussed, multiple
medical sources stated Plaintiff could perform light work. (Doc. 14-4 at 3–15, 18–25; Doc.
14-12 at 28–44). The ALJ could reasonably view this evidence as inconsistent with
Plaintiff’s testimony that dizziness, fatigue, and shortness of breath preclude all work
activity.
Taken together, these inconsistencies and objective findings provide specific, clear,
and convincing reasons, supported by substantial evidence, for the ALJ’s evaluation of
Plaintiff’s subjective symptom allegations. Smartt, 53 F.4th at 499. Plaintiff’s argument
that the ALJ did not discuss every asserted symptom (including fatigue, napping, and
cardiac rehabilitation) does not establish reversible error where the ALJ gave legally
sufficient reasons that undermine the alleged degree of limitation and supported an RFC
for light work with restrictions. See Howard ex rel. Wolff v. Barnhart, 341 F.3d 1006, 1012
(9th Cir. 2003); Ghanim, 763 F.3d at 1163.
IV. ALTERNATIVE PROCEEDINGS
Finally, Plaintiff requests remand for a calculation of benefits pursuant to the credit-
as-true rule, or in the alternative, further administrative proceedings. (Doc. 15 at 21).
However, because the Court is upholding the ALJ’s decision, the Court denies Plaintiff’s
request for remand without considering the credit-as-true doctrine. See Leon v. Berryhill,
880 F.3d 1041, 1047 (9th Cir. 2017) (stating a direct award of benefits is only appropriate
“when the record clearly contradicted an ALJ’s conclusory findings and no substantial
evidence within the record supported the reasons provided by the ALJ for a denial of
benefits”).
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V. 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 23rd day of February, 2026.
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