Robinson v. Commissioner of Social Security Administration

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WO
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
Nikki Robinson,
Plaintiff,
v.
Commissioner of Social Security
Administration,
Defendant.
No. CV-25-00048-PHX-SPL
ORDER
Plaintiff Nikki Robinson seeks judicial review of the denial of her application for
disability insurance benefits under the Social Security Act, 42 U.S.C. § 405(g). Before the
Court are Plaintiff’s Opening Brief (Doc. 12), Defendant Commissioner of Social Security
Administration’s Answering Brief (Doc. 16), Plaintiff’s Reply Brief (Doc. 17), and the
Administrative Record (“AR”) (Docs. 8–11). Upon review, the Court reverses the
Administrative Law Judge’s decision (AR at 12–40) and remands for further proceedings.
I. BACKGROUND
Plaintiff filed a Title XVI application for supplemental security income on May 19,
2021, for a period of disability beginning April 7, 2017. (AR at 15). Her claims were
initially denied on June 9, 2022, and again upon reconsideration on January 26, 2023. (AR
at 15). Plaintiff testified at an administrative hearing on November 15, 2023 (AR at 15, 41–
58), after which the Administrative Law Judge (“ALJ”) found Plaintiff was not disabled.
(AR at 12–40). On December 3, 2024, the Appeals Council denied Plaintiff’s request for
review and adopted the ALJ’s decision as the agency’s final decision. (AR at 1–6).
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The Court has reviewed the medical evidence in its entirety and will discuss the
pertinent medical evidence in addressing the issues raised by the parties. Upon considering
the medical records and opinions, the ALJ evaluated Plaintiff’s disability based on the
following medically determinable impairments: fibromyalgia, mixed connective tissue
disease, Raynaud’s syndrome, peripheral neuropathy, tachycardia, migraine headaches,
lupus, and pulmonary embolism. (AR at 18). Ultimately, the ALJ concluded that Plaintiff
“has not been under a disability, as defined in the Social Security Act, since May 19, 2021,
the date the application was filed.” (AR at 33).
II. LEGAL STANDARD
A person is considered “disabled” for the purpose of receiving social security
benefits if she is unable to “engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be expected to result in
death or which has lasted or can be expected to last for a continuous period of not less than
12 months.” 42 U.S.C. § 423(d)(1)(A). In determining whether to reverse an ALJ’s
decision, the district court reviews only those issues raised by the party challenging the
decision. See Lewis v. Apfel, 236 F.3d 503, 517 n.13 (9th Cir. 2001). The Court may set
aside the Commissioner’s disability determination only if it is not supported by substantial
evidence or is based on legal error. Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007).
Substantial evidence is relevant evidence that a reasonable person might accept as adequate
to support a conclusion. Id. To determine whether substantial evidence supports a decision,
the Court “must consider the entire record as a whole and may not affirm simply by
isolating a ‘specific quantum of supporting evidence.’” Id. (citation omitted). Generally,
“[w]here the evidence is susceptible to more than one rational interpretation, one of which
supports the ALJ’s decision, the ALJ’s conclusion must be upheld.” Thomas v. Barnhart,
278 F.3d 947, 954 (9th Cir. 2002).
To determine whether a claimant is disabled for purposes of the Act, the ALJ
follows a five-step process. Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999) (citing
20 C.F.R. § 404.1520(a)). The claimant bears the burden of proof on the first four steps,
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and the burden shifts to the Commissioner at step five. Id. At the first step, the ALJ
determines whether the claimant is presently engaging in substantial gainful activity. 20
C.F.R. § 404.1520(a)(4)(i). At step two, the ALJ determines whether the claimant has a
“severe” medically determinable physical or mental impairment. 20 C.F.R. §
404.1520(a)(4)(ii). At step three, the ALJ considers whether the claimant’s impairment or
combination of impairments meets or medically equals an impairment listed in Appendix
1 to Subpart P of 20 C.F.R. Part 404. 20 C.F.R. § 404.1520(a)(4)(iii). If so, the claimant is
automatically found to be disabled. Id. At step four, the ALJ assesses the claimant’s
residual functional capacity (“RFC”) and determines whether the claimant is still capable
of performing past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). If not, the ALJ proceeds
to the fifth and final step, where she determines whether the claimant can perform any other
work in the national economy based on the claimant’s RFC, age, education, and work
experience. 20 C.F.R. § 404.1520(a)(4)(v). If not, the claimant is disabled. Id.
III. ANALYSIS
Plaintiff argues the ALJ erred for two reasons: (1) the ALJ failed to articulate clear
and convincing reasons to discount Plaintiff’s symptom testimony, and (2) the ALJ failed
to adequately articulate the supportability and consistency of opinion evidence. (Doc. 12
at 2). The Court will consider each argument in turn.
A. Plaintiff’s Symptom Testimony
Plaintiff argues that the ALJ erred by rejecting her symptom testimony. (Doc. 12 at
10–16). An ALJ performs a two-step analysis to evaluate the credibility of a claimant’s
testimony regarding subjective pain and symptoms. Garrison v. Colvin, 759 F.3d 995, 1014
(9th Cir. 2014). First, the ALJ evaluates whether the claimant has presented objective
medical evidence of an 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) (citation omitted). If the claimant presents such evidence then “the ALJ can reject
the claimant’s testimony about the severity of [their] symptoms only by offering specific,
clear and convincing reasons for doing so.” Garrison, 759 F.3d at 1014–15 (citation
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omitted).
A finding that a claimant’s testimony is not credible “must be sufficiently specific
to allow a reviewing court to conclude the adjudicator rejected the claimant’s testimony on
permissible grounds and did not arbitrarily discredit a claimant’s testimony regarding
pain.” Bunnell v. Sullivan, 947 F.2d 341, 345–46 (9th Cir. 1991) (quotation marks omitted).
“General findings are insufficient; rather, the ALJ must identify what testimony is not
credible and what evidence undermines the claimant’s complaints.” Reddick v. Chater, 157
F.3d 715, 722 (9th Cir. 1998) (citation omitted); see also Holohan v. Massanari, 246 F.3d
1195, 1208 (9th Cir. 2001) (“[T]he ALJ must specifically identify the testimony she or he
finds not to be credible and must explain what evidence undermines the testimony.”);
Smolen v. Chater, 80 F.3d 1273, 1284 (9th Cir. 1996) (“To determine whether the
claimant’s testimony regarding the severity of her symptoms is credible, the ALJ may
consider, for example: (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.”).
Although the ALJ must specify what testimony he finds not credible, Burch v.
Barnhart, 400 F.3d 676, 680 (9th Cir. 2005), he is not required to perform a “line-by-line
exegesis of the claimant’s testimony” to meet the clear and convincing standard, Lambert
v. Saul, 980 F.3d 1266, 1277 (9th Cir. 2020). Additionally, if the ALJ’s decision is made
“with ‘less than ideal clarity,’ a reviewing court will not upset the decision on that account
‘if the agency’s path may reasonably be discerned.’” Alaska Dep’t. of Envtl. Conservation
v. E.P.A., 540 U.S. 461, 497 (2004); see Brown-Hunter v. Colvin, 806 F.3d 487, 492 (9th
Cir. 2015) (applying this standard to social security); Moreno v. Comm’r of Soc. Sec.
Admin., No. CV19-5792 PHX DGC, 2020 WL 6610990, at *8 (D. Ariz. Nov. 12,
2020)(“While the ALJ’s reasons for discounting [an] opinion may have been scattered
across [the] report, ‘all of the puzzle pieces were present, even if not neatly assembled
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before the Court.’” (citation omitted)).
After considering the evidence, the ALJ found that although Plaintiff’s “medically
determinable impairments could reasonably be expected to cause the alleged symptoms,”
Plaintiff’s “statements concerning the intensity, persistence and limiting effects of these
symptoms are not entirely consistent with the medical evidence and other evidence in the
record.” (AR at 28). Plaintiff asserts that the ALJ failed to provide clear and convincing
reasons for rejecting Plaintiff’s symptom testimony for several reasons. (See Doc. 12).
First, Plaintiff argues that the ALJ erred by failing to consider the combined effect
of all the impairments compared to the symptom testimony. (Id. at 12). Plaintiff cites to 20
C.F.R. § 416.923(c), which states that to determine “whether your physical or mental
impairment or impairments are of a sufficient medical severity that such impairment or
impairments could be the basis of eligibility under the law,” the ALJ must consider the
“combined effect” of the impairments. (Id.).1 It appears the ALJ did consider the combined
effect of the impairments. The ALJ stated that in determining the RFC, the ALJ
“considered all symptoms and the extent to which these symptoms can reasonably be
accepted as consistent with the objective medical evidence and other evidence.” (AR at
25). Regarding the symptom testimony, the ALJ concluded that Plaintiff’s “medically
determinable impairments” could not be expected to cause the symptoms. (AR at 28).
Though the ALJ addressed each of the medical conditions, it does not appear that the ALJ
compared Plaintiff’s symptoms to each of the conditions on their own. Rather, the ALJ
considered all of the medical evidence in comparison with all of Plaintiff’s symptoms. The
Court does not find error in how the ALJ assessed the medical evidence with respect to
Plaintiff’s symptom testimony.
1 To the extent Plaintiff is alleging error at Step Two, the Court does not find that the
ALJ erred at Step Two. Plaintiff argues that the ALJ “found that connective tissue disease
was nonsevere because it was not accurately diagnosed as systemic lupus erythematosus
and there were no objective signs of SLE.” (Doc. 12 at 11). Further, Plaintiff argues that
even if there were not signs of SLE, there are many kinds of connective tissue disorders.
(Id.). As Defendant points out, the ALJ found that mixed connective tissues disease was a
severe impairment. (Doc. 16 at 5 (citing AR at 18)). Therefore, Plaintiff has not shown that
the ALJ erred at Step Two.
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Next, Plaintiff argues that the ALJ mischaracterized her treatment for degenerative
disc disease as conservative, and therefore erred in rejecting her symptom testimony on
that basis. (Doc. 12 at 12–13). The ALJ stated that Plaintiff’s treatment with medication
and injections was “conservative.” (AR at 28). However, Plaintiff points out that she was
being treated with “Botox injections, increasingly high doses of opioids, and sacroiliac
injections.” (Doc. 12 at 12). The ALJ also wrote that in April 2022, a surgeon determined
that Plaintiff did not require surgical intervention. (AR at 28 (citing AR at 1893)).
However, Plaintiff points out that she was not a surgical candidate “largely because she
would need to stop using blood thinners to have surgery or to undergo epidural steroid
injections.” (Doc. 12 at 13). Indeed, the provider noted in April 2022 that Plaintiff “had
DVTs and pulmonary emboli due to her lupus condition resulting in hypercoagulability.
She is on blood thinners.” (AR at 1893). Further, the provider reported that he did not see
anything requiring “any type of surgical intervention” and continued to discuss treatment
options that would allow Plaintiff to stay on her anticoagulation medication. (Id.). The ALJ
cited another physician’s treatment notes from August 20232 which stated that surgery was
unnecessary. (AR 28 (citing AR 2908)). Plaintiff argues that the statement does not bear
on the severity of the degenerative disc disease because Plaintiff was consulting with the
neurosurgeon about hip pain. (Doc. 12 at 13). Plaintiff emphasizes that the fact that her
“spinal disease did not cause her hip pain does not mean the hip pain did not exist” and
therefore, the opinion that surgery is unnecessary is not a clear and convincing reason to
discount Plaintiff’s symptom testimony. (Id.).
The Court agrees that the ALJ failed to explain how the nature of the treatment
contradicts Plaintiff’s symptom testimony. The fact that the providers did not recommend
surgery, in this case, does not constitute a clear and convincing reason to reject Plaintiff’s
symptom testimony. See Garrison v. Colvin, 759 F.3d 995, 1015 (9th Cir. 2014) (finding
error when the ALJ discredited symptom testimony, in part, based on improvement from
2 The ALJ writes that that the physician’s opinion was from June 2023. (AR at 28).
The treatment notes are dated August 21, 2023. (AR at 2908).
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conservative treatment when the symptoms did not improve); Loniza v. King, No. 23-00352
MWJS-RT, 2025 WL 435943, at *6 (D. Haw. Feb. 7, 2025) (“[W]hen an ALJ rejects [a
claimant’s] severity testimony on the ground that the claimant received conservative
treatment, the Court may affirm that reasoning only if the administrative record contains
substantial evidence that the treatment was in fact conservative––that is, that at least one
more aggressive treatment option was available.”).
Finally, Plaintiff argues that the ALJ’s findings that Plaintiff’s “pain and fatigue
from a systematic connective tissue disorder were not readily apparent on gross physical
examination” is not a clear and convincing reason to discount Plaintiff’s symptom
testimony. (Id. at 14). Plaintiff testified that she experienced physical pain in her head,
neck, shoulders, back, pelvis, hip joints, legs, and thighs, on average, at a level eight out of
ten. (AR at 51). She testified that she can walk or stand for about ten minutes (AR at 50),
and can go grocery shopping for twenty or thirty minutes, but has to lean on the cart or use
a motorized scooter. (AR at 53).
In rejecting Plaintiff’s symptom testimony, the ALJ highlighted that although there
were clinical findings in the medical evidence related to pain, there is also evidence
showing good function on examination. (AR at 28). The ALJ continued to cite treatment
records where Plaintiff was reported to have normal strength, normal gait, and normal
range of motion. (AR at 28–29). But as Plaintiff points out, “[p]ain that is aggravated by
performing an activity over a time span of multiple minutes is not necessarily visible on
gross examination of a person sitting relatively still in a physician’s office.” (Doc. 12 at
15). Moreover, the ALJ cited many examples of clinical findings showing, tenderness,
pain, discomfort, and antalgic gait. (AR at 27). The ALJ does not explain how the normal
function examinations contract the evidence of clinical findings or Plaintiff’s symptom
testimony. See Smartt v. Kijakazi, 53 F.4th 489, 495 (9th Cir. 2022) (“[A]n ALJ cannot
effectively render a claimant’s subjective symptom testimony superfluous by demanding
positive objective medical evidence ‘fully corroborating’ every allegation within the
subjective testimony.”) (alteration omitted).
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The Court finds that the ALJ erred in rejecting Plaintiff’s symptom testimony
relating to her pain. The ALJ’s characterization of Plaintiff’s treatment for degenerative
disc disease as conservative is not supported by substantial evidence in the record. In
addition, the ALJ highlighted findings of good function on examination, but again, did not
explain how these findings contradicted Plaintiff’s testimony. Therefore, the Court finds
error.
B. Medical Opinion Evidence
In January 2017, the SSA amended the regulations concerning the evaluation of
medical opinion evidence. See Revisions to Rules Regarding Evaluation of Medical
Evidence, 82 Fed. Reg. 5844, 5844 (Jan. 18, 2017). Because the new regulations apply to
applications filed on or after March 27, 2017, they are applicable here. The new regulations,
which eliminate the previous hierarchy of medical opinions, provide in relevant part as
follows:
We 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 your
medical sources. . . . The most important factors we consider when
we evaluate the persuasiveness of medical opinions and prior
administrative medical findings are supportability . . . and
consistency . . . .
20 C.F.R. § 404.1520c(a).
Regarding the “supportability” factor, the new regulations explain that the “more
relevant the objective medical evidence and supporting explanations presented by a
medical source are to support his or her medical opinion(s) . . . the more persuasive the
medical opinions . . . will be.” Id. § 404.1520c(c)(1). Regarding the “consistency” factor,
the “more consistent a medical opinion(s) . . . is with the evidence from other medical
sources and nonmedical sources in the claim, the more persuasive the medical opinion(s) .
. . will be.” Id. § 404.1520c(c)(2).
The Ninth Circuit confirmed that the “changes to the Social Security
Administration’s regulations displace our longstanding case law requiring an ALJ to
provide ‘specific and legitimate’ reasons for rejecting an examining doctor’s opinion.”
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Woods v. Kijakazi, 32 F.4th 785, 787 (9th Cir. 2022). Thus, “the former hierarchy of
medical opinions—in which we assign presumptive weight based on the extent of the
doctor’s relationship with the claimant—no longer applies. Now, an ALJ’s decision,
including the decision to discredit any medical opinion, must simply be supported by
substantial evidence.” Id. With that said, “[e]ven under the new regulations, an ALJ cannot
reject an examining or treating doctor’s opinion as unsupported or inconsistent without
providing an explanation supported by substantial evidence. The agency must articulate
how persuasive it finds all of the medical opinions from each doctor or other source and
explain how it considered the supportability and consistency factors in reaching these
findings.” Id. at 792 (internal quotation marks, alterations, and citations omitted).
Here, Plaintiff argues that the ALJ erred by finding that Plaintiff’s primary care
physician, Christaine Sanburn, M.D.’s opinion was not supported by the medical evidence.
(Doc. 12 at 17). In a questionnaire dated August 16, 2021, Dr. Sanburn opined that Plaintiff
could sit for 2–3 hours in a workday, stand or walk for one hour in a workday, and should
be permitted to shift positions every forty minutes. (AR at 1573). Dr. Sanburn also
estimated that Plaintiff would likely be absent from work 3–4 days per month and specified
that Plaintiff would require “significant constant change in positioning.” (AR at 1574).
Upon review, the ALJ found that Dr. Sanburn’s opinion was “not persuasive as she
provided no support for it, only noting the diagnoses and the claimant’s symptoms.” (AR
at 31). Further the ALJ explained that the “medical evidence does not support limitation to
the sedentary exertion level, a sit/stand option, or work absences as it shows conservative
treatment and good function on examination, including normal strength and gait.” (AR at
31). The ALJ also states that the medical evidence does not support “time off task as it does
not show objective findings of fatigue.” (AR 32).
As to supportability, Defendant argues that the evidence in the questionnaire does
not support Dr. Sanburn’s opinion and Dr. Sanburn did not provide an explanation for her
opinion. (Doc. 16 at 10–11). Dr. Sanburn’s opinion takes the form of a two-page
questionnaire. (AR at 1573–74). However, “there is no authority that a ‘check-the-box’
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form is any less reliable than any other type of form; indeed, agency physicians routinely
use these types of forms to assess the intensity, persistence, or limiting effects of
impairments.” Trevizo v. Berryhill, 871 F.3d 664, 677 n.4 (9th Cir. 2017). In addition, “the
supportability of a physician’s opinion necessarily still includes a review of that doctor’s
treatment notes, not just the narrative explanation on the form.” Curtin v. Comm’r of Soc.
Sec. Admin., No. CV-21-00790-PHX-GMS, 2023 WL 387202, at *6 (D. Ariz. Jan. 25,
2023). The ALJ did not assess supportability by reviewing the treatment notes, and instead,
simply stated that Dr. Sanburn “provided no support for [her opinion], only noting the
diagnoses and the claimant’s symptoms.” (AR at 31). Therefore, the ALJ’s supportability
analysis was not supported by substantial evidence.
As to consistency, Defendant argues that the ALJ provided substantial evidence
showing that Plaintiff had good function on examination.3 (Doc. 16 at 11). As is explained
above, the examinations showing normal gait and strength do not contradict the limitations
that Dr. Sanburn provided. Dr. Sanburn’s opinions were focused largely on Plaintiff’s
“headache,” “neck pain,” “lumbar pain,” and “shortness of breath” and the fact that
Plaintiff could not stay in one position for more than forty minutes at a time. (AR at 1573–
74). The ALJ did not explain why these examinations were inconsistent with Dr. Sanburn’s
opinions. In addition, there is evidence in the record that is consistent with Dr. Sanburn’s
opinion. The ALJ discussed the diagnostic findings of degenerative disc disease of the
cervical and lumbar spine as well as clinical findings showing pain and tenderness. (AR at
26–27). Although it is up to the ALJ to resolve conflicting evidence in the record, it is not
clear how the evidence provided is inconsistent with Dr. Sanburn’s medical opinion. See
Thomas v. Barnhart, 278 F.3d 947, 956–57 (9th Cir. 2002) (“When there is conflicting
medical evidence, the Secretary must determine credibility and resolve the conflict.”)
(citation omitted). The ALJ’s rejection of Dr. Sanburn’s opinion is not supported by
substantial evidence in the record. Therefore, the Court finds error.
3 Defendant also argues that the ALJ’s determination that the record did not “show
objective findings of fatigue” is an accurate recitation of the evidence. (Doc. 16 at 11 (citing
AR at 32)). Even so, the Court still finds error.
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IV. CONCLUSION
Finding error in the ALJ’s evaluation of Plaintiff’s symptom testimony as well as
the opinion from Plaintiff’s physician, this case will be remanded. “[T]he proper course,
except in rare circumstances, is to remand to the agency for additional investigation or
explanation.” Treichler v. Comm’r of Soc. Sec., 775 F.3d 1090, 1099 (9th Cir. 2014)
(citation omitted). Indeed, Plaintiff requests “remand for reconsideration of the evidence.”
(Doc. 12 at 2, 18). In considering “whether the record as a whole is free from conflicts,
ambiguities, or gaps, whether all factual issues have been resolved, and whether the
claimant’s entitlement to benefits is clear under the applicable legal rules,” the Court agrees
that further administrative proceedings would be useful. Id. at 1103–04.
Accordingly,
IT IS ORDERED that the final decision of the Commissioner of the Social Security
Administration is vacated and remanded for further proceedings consistent with this
order.
IT IS FURTHER ORDERED directing the Clerk of Court to enter judgment
accordingly and terminate this case.
Dated this 27th day of February, 2026.
Honorable Steven P. Logan
United States District Judge
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