1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 CENTRAL DISTRICT OF CALIFORNIA 10 11 CHRISTINE HELEN D.,1 Case No. 2:18-cv-08126-AFM 12 Plaintiff, MEMORANDUM OPINION AND 13 v. ORDER AFFIRMING DECISION 14 ANDREW M. SAUL, OF THE COMMISSIONER 15 Commissioner of Social Security,
16 Defendant. 17 Plaintiff filed this action seeking review of the Commissioner’s final decision 18 denying her applications for disability insurance benefits and supplemental security 19 income. In accordance with the Court’s case management order, the parties have filed 20 memorandum briefs addressing the merits of the disputed issues. The matter is now 21 ready for decision. 22 BACKGROUND 23 In July 2015, Plaintiff applied for disability insurance benefits and 24 supplemental security income, alleging disability since March 27, 2013. Plaintiff’s 25 applications were denied initially and upon reconsideration. (Administrative Record 26
27 1 Plaintiff’s name has been partially redacted in accordance with Federal Rule of Civil Procedure 5.2(c)(2)(B) and the recommendation of the Committee on Court Administration and Case 28 1 [“AR”] 112-121, 125-138.) A hearing took place on May 12, 2017 before an 2 Administrative Law Judge (“ALJ”). Plaintiff, who was represented by counsel, and 3 a vocational expert (“VE”) testified at the hearing. (AR 29-73.) 4 In a decision dated August 15, 2017, the ALJ found that Plaintiff suffered from 5 the severe impairment of interstitial cystitis. (AR 16.) After concluding that 6 Plaintiff’s impairment did not meet or equal a listed impairment, the ALJ assessed 7 Plaintiff’s residual functional capacity (“RFC”). (AR 17-18.) The ALJ determined 8 that Plaintiff retained the ability to perform light work with the exception that she 9 can only occasionally climb, balance, kneel, stoop, crouch or crawl; and requires “10 10 minutes of extra break time in the AM and 15 minutes of extra break time in the PM 11 of each workday, in addition to normal breaks.” (AR 17.) Relying on the testimony 12 of the VE, the ALJ concluded that Plaintiff could perform her past relevant work. 13 Accordingly, the ALJ concluded that Plaintiff was not disabled. (AR 22.) 14 The Appeals Council subsequently denied Plaintiff’s request for review (AR 15 1-6), rendering the ALJ’s decision the final decision of the Commissioner. 16 DISPUTED ISSUES 17 1. Whether the ALJ properly evaluated the medical opinions. 18 2. Whether the ALJ properly rejected Plaintiff’s subjective complaints. 19 3. Whether the ALJ properly determined that Plaintiff is able to perform 20 her past relevant work. 21 STANDARD OF REVIEW 22 Under 42 U.S.C. § 405(g), this Court reviews the Commissioner’s decision to 23 determine whether the Commissioner’s findings are supported by substantial 24 evidence and whether the proper legal standards were applied. See Treichler v. 25 Comm’r of Soc. Sec. Admin., 775 F.3d 1090, 1098 (9th Cir. 2014). Substantial 26 evidence means “more than a mere scintilla” but less than a preponderance. See 27 Richardson v. Perales, 402 U.S. 389, 401 (1971); Lingenfelter v. Astrue, 504 F.3d 28 1028, 1035 (9th Cir. 2007). Substantial evidence is “such relevant evidence as a 1 reasonable mind might accept as adequate to support a conclusion.” Richardson, 402 2 U.S. at 401. This Court must review the record as a whole, weighing both the 3 evidence that supports and the evidence that detracts from the Commissioner’s 4 conclusion. Lingenfelter, 504 F.3d at 1035. Where evidence is susceptible of more 5 than one rational interpretation, the Commissioner’s decision must be upheld. See 6 Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007). 7 DISCUSSION 8 I. Relevant Medical Evidence 9 In February 2013, Plaintiff was admitted to the emergency room of Charleston 10 Area Medical Center, complaining of urinary urgency and frequency, “severe at 11 times,” sometimes urinating every 10 minutes. She also complained of nocturia, 12 sleeping only 2-3 hours a night. (AR 334.) The following month, Plaintiff presented 13 to the Women’s Medicine Clinic for a follow-up. She reported vaginal bleeding and 14 dysuria (painful urination). (AR 329-330.) Later in March 2013, Plaintiff presented 15 herself at Harbor-UCLA Urgent Care Clinic complaining of continued frequent and 16 painful urination. She was treated for a urinary tract infection. (AR 350.) 17 On January 7, 2014, Plaintiff was treated at St. Joseph’s Hospital for 18 complaints of “extreme pelvic pain and overactive bladder.” Plaintiff stated that the 19 pain had been intermittent in the last six months, but was currently constant. She also 20 reported suffering a feeling of incontinence for over a year. She was referred to 21 Douglas McKinney, M.D. (AR 395, 492.) Plaintiff was seen by Dr. McKinney on 22 January 27, 2014. She reported urinary frequency of once every hour and sometimes 23 as often as every 20 minutes, though use of Oxytrol patches “may decrease her 24 frequency to every three hours.” (AR 492.) John M. Rollins, M.D., recommended 25 cystoscopy and instillation of potassium chloride to confirm a suspected diagnosis of 26 interstitial cystitis (“IC”). (AR 495.) On February 3, 2014, Plaintiff reported that she 27 felt “somewhat improved.” (AR 391.) 28 1 Plaintiff underwent a cystoscopy on February 4, 2014. The test confirmed 2 Dr. McKinney’s IC diagnosis. (AR 486-490.) Dr. McKinney recommended that 3 Plaintiff start Elmiron, amitriptyline, Prelief, and an IC diet. He noted that it could 4 take 3 to 6 months for Elmiron to take effect. (AR 488-489.) 5 On a March 4, 2014 follow up, Plaintiff reported that her pelvic pain was “now 6 much better.” (AR 387.) On May 7, 2014, Plaintiff was doing “a little better,” but 7 had not improved as much as she would have liked. (AR 475.) Per Dr. McKinney’s 8 recommendation, Plaintiff underwent intravesical instillation procedures on May 7 9 and May 14, 2014. (AR 471-473, 475-478.) 10 On May 15, 2014, Plaintiff complained of increased pelvic pain and bladder 11 problems. Dr. Rollins recommended a hysterectomy with BSO, and Plaintiff agreed. 12 (AR 383-386.) In June 2014, however, Plaintiff reported “fairly good relief of pain” 13 with two instillation procedures. She further reported that Oxybutynin helped her 14 frequency and urgency. She explained that she took the medication when she was 15 “going to be outside her home and may go up to five hours between urinations.” She 16 also said that Prelief helped her symptoms. (AR 467.) 17 On July 15, 2014, Plaintiff began treatment with Tawfik Zein, M.D., a 18 urologist at St. Joseph’s Hospital. At her initial appointment, Dr. Zein diagnosed 19 Plaintiff with chronic IC. He noted Plaintiff’s complaints of persistent symptoms of 20 pelvic pain, urinary frequency, urgency, and incontinence. He also noted that after 21 beginning Elmiron and Oxybutynin, Plaintiff’s symptoms improved to less frequency 22 “1-2 hours,” but she still had a feeling of urgency. (AR 463-466.) On July 29, 2014, 23 Plaintiff returned a “Urinary Diary.” According to Plaintiff’s diary, in spite of 24 medication, Plaintiff “is going around 10 x per day.” (AR 458.) 25 On July 30, 2014, Plaintiff underwent a hysterectomy.2 Her post-operative 26 diagnoses included chronic pelvic pain, uterine fibroids, urinary urgency, and 27 2 Although not entirely clear, the record suggests that the hysterectomy was performed, at least in 28 1 abdominopelvic adhesions. (AR 375-377.) During an August 22, 2014 follow up, 2 Dr. Zein noted that Plaintiff had recovered from her hysterectomy, but still suffered 3 from urinary frequency. (AR 454.) 4 At her September 10, 2014 follow up, Plaintiff had no complaints. Her bowel 5 and bladder functions were normal. (AR 368.) Treatment notes from November 2014 6 indicate that Plaintiff had no complaints of pain and no urinary complaints. 7 Dr. Rollins noted that Plaintiff was “much improved with Vagifem Rx.” (AR 365- 8 367.) Likewise, notes from December 4, 2014 indicate that Plaintiff “is better now.” 9 Specifically, Plaintiff had no more nocturia and no incontinence; “her only symptom 10 is urgency and is triggered by some words at work or by certain thoughts.” (AR 427.) 11 On December 17, 2014, however, Plaintiff again complained of pain and 12 underwent intravesical instillation. (AR 421-423.) On December 22, 2014, Plaintiff 13 reported that the last intravesical instillation did not have the effects that she was 14 expecting and she wanted to discuss the option of PTNS (transcutaneous electrical 15 nerve stimulation). (AR 417-420.) 16 On January 21, 2015, Plaintiff complained of worsening IC symptoms. (AR 17 415.) She reported that the Vagifem, which had initially helped her symptoms, now 18 made her symptoms worse. (AR 360.) Dr. Rollins opined that none of Plaintiff’s 19 symptoms was related to Vagifem. He noted that Plaintiff was “very anxious and 20 stressed.” Dr. Rollins’s diagnostic impression was that Plaintiff suffered from both 21 chronic IC and “mixed anxiety and depressive disorder.” He indicated that Plaintiff 22 appeared to be “trapped in a poor relationship with no way out” and recommended 23 that Plaintiff obtain services for women in crisis. (AR 363.) 24 On her March 9, 2015 follow up, Plaintiff stated that she was “doing well,” 25 with “no new problems or concerns.” (AR 411-412.) Treatment notes from May 2015 26 also state that Plaintiff “feels much better, no more as frequency and urgency as 27 before.” (AR 407.) 28 1 In July 2015, Dr. Zein noted that Plaintiff suffered from frequency and nocturia 2 2-3X. (AR 401.) 3 In August 2015, Plaintiff was seen by Susan Long, M.D., for evaluation of 4 pelvic pain. Plaintiff reported that her pain had “gotten worse over the past several 5 months.” (AR 511.) 6 On September 1, 2015, Plaintiff was seen by Peter Edgerton, M.D., for a 7 urological consultation. Plaintiff reported that she had obtained “no pain relief” (AR 8 527.) Dr. Edgerton assessed Plaintiff with IC. (AR 528.) He performed a cystoscopy 9 on September 15, 2015, which revealed “questionable endometriosis.” (AR 532.) In 10 a follow-up appointment later that month, Dr. Edgerton diagnosed Plaintiff with IC 11 and bladder endometriosis. (AR 539.) 12 Under the care of Dr. Zein, Plaintiff underwent a session of PTNS on 13 December 16, 2015. On that date, Plaintiff reported that she had “not had a good 14 week” and complained that she had suffered bladder pain for the last 48 hours. (AR 15 574.) On December 30, 2015, Plaintiff again reported worsening bladder pain and 16 urinary symptoms. She underwent another thirty-minute session of PTNS. (AR 571.) 17 Plaintiff moved to California in January 2016 and began treatment with 18 Athanasia Kakoyannis, D.O., at the Venice Family Clinic. (AR 611-678.) She was 19 subsequently referred to Thomas Johnson, M.D., a urologist. Dr. Johnson examined 20 Plaintiff in February 2016 and remarked that Plaintiff suffered from a “complex, 21 chronic bladder pathology,” and “would be better served by being treated by a 22 ‘Female Urology’ Specialist.” (AR 609-610.) Plaintiff saw Dr. Johnson again in June 23 2016. She complained of problems with urinary control or incontinence, and reported 24 urinating “more frequently now than usual.” (AR 606.) In treatment notes from 25 September 2016, Dr. Johnson indicated that Plaintiff had tried “multiple modalities 26 to combat OAB [overactive bladder] symptoms. Nothing has worked. She has seen 27 various doctors for her problem, but again has not received any satisfaction.” (AR 28 604.) 1 On March 17, 2017, Plaintiff underwent a complete internal medicine 2 evaluation by Steven B. Gerber, M.D. Dr. Gerber noted that Plaintiff reported that 3 she has “interstitial cystitis” and complained of frequent urination, which occurs as 4 frequently as every 20 minutes. (AR 556.) Dr. Gerber reviewed no medical records. 5 (AR 556.) Dr. Gerber rendered the following impression: 6 The claimant is a 56-year-old Caucasian female with a history of urinary 7 frequency and “Interstitial cystitis,” but no documentation has been 8 provided. Physical examination did not reveal any significant 9 abnormalities to account for the subjective complaint. 10 (AR 560.) 11 II. The ALJ’s Consideration of the Medical Opinions 12 Plaintiff contends that the ALJ failed to provide legally sufficient reasons for 13 rejecting the opinions of Drs. Zein, Kakoyannis, and Gerber. For the following 14 reasons, Plaintiff’s contention lacks merit. 15 A. Relevant Law 16 The medical opinion of a claimant’s treating physician is entitled to controlling 17 weight so long as it is supported by medically acceptable clinical and laboratory 18 diagnostic techniques and is not inconsistent with other substantial evidence in the 19 record. Trevizo v. Berryhill, 871 F.3d 664, 675 (9th Cir. 2017). If a treating or 20 examining physician’s medical opinion is uncontradicted, the ALJ may only reject it 21 based on clear and convincing reasons. Trevizo, 871 F.3d at 675; Ryan v. Comm’r of 22 Soc. Sec. Admin., 528 F.3d 1194, 1198 (9th Cir. 2008). If a treating or examining 23 physician’s opinion is contradicted, the ALJ must provide specific and legitimate 24 reasons supported by substantial evidence in the record before rejecting it. Trevizo, 25 871 F.3d at 675; Ghanim v. Colvin, 763 F.3d 1154, 1160-1061 (9th Cir. 2014); 26 Garrison v. Colvin, 759 F.3d 995, 1012 (9th Cir. 2014). The ALJ can meet the 27 requisite specific and legitimate standard “by setting out a detailed and thorough 28 summary of the facts and conflicting clinical evidence, stating his interpretation 1 thereof, and making findings.” Trevizo, 871 F.3d at 675 (citations and internal 2 quotation marks omitted). Because the opinions of Plaintiff’s treating physicians 3 were contradicted by the opinion of the examining physician (AR 560) and the State 4 agency physician (AR 97-100), the ALJ was required to provide specific and 5 legitimate reasons for rejecting them. 6 B. Dr. Zein 7 Dr. Zein provided three separate opinions: 8 A statement dated December 22, 2014, in which he wrote that 9 Plaintiff’s IC “forces her to use the bathroom frequently.” (AR 359.) 10 A Physical RFC Questionnaire completed on October 23, 2015 11 indicating that he treated Plaintiff on a weekly basis. Dr. Zein listed 12 Plaintiff’s IC symptoms as including pelvic pain, urinary frequency, 13 urinary urgency, incontinence, nocturia with disrupted sleep, 14 daytime drowsiness and lack of mental clarify, anxiety and 15 depression. (AR 547-551.) Dr. Zein indicated that Plaintiff must 16 urinate “frequently.” (AR 548.) More specifically, Dr. Zein opined 17 that Plaintiff required 8 unscheduled restroom breaks of 5-10 18 minutes each during an 8-hour workday, and must be permitted 19 “ready access to a restroom.” (AR 549.) According to Dr. Zein, 20 Plaintiff was able to stand and/or walk less than 2 hours in an 8-hour 21 day, could only stand for 20 minutes at a time, could rarely lift twenty 22 pounds or less, rarely twist, stoop or climb stairs, and never crouch 23 or climb ladders. (AR 549-550.) He further opined that Plaintiff’s 24 symptoms would constantly interfere with the attention and 25 concentration needed to perform even simple work tasks; that she is 26 incapable of even low stress jobs due to unabated pain and stress, and 27 that she would likely miss more than four work days per month. (AR 28 548-550.) 1 A statement dated December 8, 2015, in which he wrote that 2 Plaintiff’s IC causes her “abdominal and pelvic pain which prevents 3 her from being able to do routine daily activities.” (AR 552.) 4 The ALJ rejected Dr. Zein’s December 22, 2014 statement that Plaintiff’s IC 5 “forces her to use the bathroom frequently,” explaining that the opinion “was 6 unaccompanied by any clinical support” and “does not provide a functional 7 assessment or even an opinion as to how often the claimant would need to use the 8 restroom.” (AR 19, 359.) 9 An ALJ may properly reject a treating physician’s opinion that is conclusory 10 or unsupported by clinical findings. Chaudhry v. Astrue, 688 F.3d 661, 671 (9th Cir. 11 2012); Batson v. Comm’r of the Soc. Sec. Admin., 359 F.3d 1190, 1195 (9th Cir. 12 2004). The ALJ reasonably found that Dr. Zein’s one sentence letter was conclusory. 13 Not only does the letter fail to include reference to clinical support, but it lacks any 14 meaningful description of how Plaintiff’s IC caused functional limitations and fails 15 to indicate how frequently Plaintiff would need to use the restroom. Thus, the ALJ 16 provided legally sufficient reason for rejecting this opinion. See Rivera v. Berryhill, 17 2017 WL 2233619, at *7 (C.D. Cal. May 22, 2017) (ALJ properly rejected treating 18 physician’s opinion on ground that it was “not probative or significant because it was 19 not based on any apparent objective or clinical findings, it did not articulate with any 20 specificity what Plaintiff could still do, and it appeared to be limited to a brief 21 description of Plaintiff’s symptoms”). 22 Next, the ALJ also rejected Dr. Zein’s October 23, 2015 functional assessment, 23 providing several reasons for doing so. First, the ALJ explained that Dr. Zein’s 24 assessment “listed multiple subjective symptoms and extreme functional limitations, 25 yet the only objective support was suprapubic tenderness on physical examination.” 26 (AR 20.) As set forth above, not only did Dr. Zein opine that Plaintiff requires eight 27 unscheduled restroom breaks and that her symptoms are severe enough to interfere 28 constantly with her attention and concentration, but he opined that she is significantly 1 limited in numerous other functional activities – i.e., she is unable to stand and/or 2 walk for more than two hours in a day or more than twenty minutes at a time, and 3 rarely able to lift less than ten pounds, climb stairs, stoop, or twist. (AR 548-550.) In 4 support of this litany of limitations, Dr. Zein cited a single clinical finding – 5 suprapubic tenderness on physical examination. (AR 547.) In light of the foregoing, 6 the ALJ’s conclusion that Dr. Zein’s opinion lacked objective support is supported 7 by substantial evidence. Accordingly, this was a legitimate reason for rejecting it. See 8 Chaudhry, 688 F.3d at 671; Batson, 359 F.3d at 1195. 9 The Commissioner also contends that the ALJ properly relied upon the 10 inconsistency between Dr. Zein’s description of Plaintiff’s pain as “unabated” and 11 treatment notes reflecting numerous occasions on which Plaintiff’s pain and 12 symptoms had improved. (ECF No. 26 at 10-11, citing AR 19-20.) As the 13 Commissioner points out, the ALJ cited treatment records reflecting significant 14 periods during which Plaintiff reported suffering less pain or no pain. (See AR 19- 15 20, citing AR 387 (March 2014); AR 467 (June 2014); AR 372 (August 2014); AR 16 368 (September 2014); AR 365-367 (November 2014); AR 427 (December 2014); 17 AR 411 (March 2015), AR 407 (May 2015).) A contradiction between a treating 18 physician’s opinion and other substantial evidence in the record constitutes a specific 19 and legitimate reason for rejecting the treating physician’s opinion. See Tommasetti 20 v. Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008); Batson, 359 F.3d at 1195. 21 Plaintiff, on the other hand, argues that proper consideration of IC must take 22 into account that its symptoms may vary in incidence, duration, and severity. (ECF 23 No. 23 at 13, citing SSR 15-1p.) Plaintiff points to numerous treatment records 24 indicating that while her pain and symptoms periodically improved, they also 25 returned. While Plaintiff’s characterization of the record may be accurate, it does not 26 necessarily undermine the ALJ’s conclusion that Dr. Zein’s opinion that she suffered 27 from “unabated pain” was inconsistent with at least significant portions of the record 28 demonstrating her pain had, in fact, abated. 1 Moreover, even assuming the ALJ erred in relying on this inconsistency or in 2 any other reason provided for rejecting Dr. Zein’s opinion, the error is harmless 3 because the ALJ provided at least one specific and legitimate reason for rejecting 4 Dr. Zein’s opinion. See Green v. Berryhill, 731 F. App’x 596, 599 (9th Cir. 2018) 5 (where ALJ provided specific and legitimate reason to reject treating physician’s 6 opinion, any error in relying on additional reasons is harmless) (citing Molina v. 7 Astrue, 674 F.3d 1104, 1115 (9th Cir. 2012)). 8 Last, the ALJ rejected Dr. Zein’s December 8, 2015 letter which stated that 9 Plaintiff’s abdominal and pelvic pain “prevents her from performing routine daily 10 activities” because Dr. Zein did not provide any clinical or objective evidence to 11 support it. (AR 20-21, citing AR 552.) Dr. Zein’s two-sentence letter includes no 12 reference to any clinical or objective evidence. Thus, this was a valid reason for the 13 ALJ to reject it. See Bray v. Comm’r of Soc. Sec. Admin., 554 F.3d 1219, 1228 (9th 14 Cir. 2009) (“[T]he ALJ need not accept the opinion of any physician, including a 15 treating physician, if that opinion is brief, conclusory, and inadequately supported by 16 clinical findings.”). 17 As Plaintiff points out, the ALJ also stated that Dr. Zein’s opinion appeared to 18 be generated with the intent of supporting Plaintiff’s disability application. (ECF No. 19 23 at 15, citing AR 20.)3 The ALJ likely erred in attributing an improper motive to 20 Plaintiff’s treating physicians. See Reddick v. Chater, 157 F.3d 715, 725-726 (9th 21 Cir. 1998). Nevertheless, the error was harmless because the ALJ also provided 22 legally sufficient reasons for rejecting these opinions. 23 C. Dr. Kakoyannis 24 Dr. Kakoyannis provided a letter dated December 1, 2016, in which she stated 25 that Plaintiff suffers from chronic IC and gastric problems “which interfere with her 26 ability to work.” Dr. Kakoyannis opined that Plaintiff was unable to sustain full-time 27
28 1 employment “due to the pain and discomfort from these conditions which necessitate 2 frequent breaks and rest periods throughout the day and week.” (AR 611.) 3 The ALJ assigned little weight to Dr. Kakoyannis’s opinion, explaining that it 4 provided no clinical support other than the diagnoses themselves, did not specify the 5 number of breaks or their duration, and it conclusorily states the physician’s opinion 6 that Plaintiff is unable to sustain full-time employment. (AR 21.) 7 The ALJ properly rejected Dr. Kakoyannis’s opinion on the ground that it was 8 unsupported, vague, and offered an opinion on the ultimate conclusion that Plaintiff 9 is disabled. See, e.g., Thornsberry v. Colvin, 552 F. App’x 691, 692 (9th Cir. 2014) 10 (“[A] doctor’s opinion that a claimant is disabled is not itself a medical opinion but 11 an issue reserved exclusively for the Commissioner.”) (citation omitted); Durham v. 12 Colvin, 2015 WL 9305627, at *4 (C.D. Cal. Dec. 21, 2015) (ALJ provided specific 13 and legitimate reason to reject physician’s opinion where ALJ found opinion “vague 14 and conclusory, and does not provide specific work-related limitations for the 15 claimant, or objective findings upon which this opinion is based); Brown v. Colvin, 16 2015 WL 5601400, at *4 (E.D. Cal. Sept. 22, 2015) (letter from claimant’s therapist 17 “merely offered the conclusion of a disability, stating plaintiff was unable to work” 18 and such “disability determinations ... are reserved to the Commissioner”). 19 D. Dr. Gerber 20 Dr. Gerber opined that Plaintiff’s impairment resulted in no functional 21 limitations, but stated that she “should be afforded ready access to restroom 22 facilities.” (AR 560.) The ALJ assigned significant weight to Dr. Gerber’s opinion, 23 concluding it was supported by Dr. Gerber’s examination findings, medical records 24 showing improvement in Plaintiff’s condition, and Plaintiff’s reported daily 25 activities. (AR 21.) “Nonetheless,” the ALJ explained: 26 the undersigned has given the claimant’s subjective complaints of 27 urinary frequency the benefit of the doubt, such that the residual 28 functional capacity restricts the claimant to light exertion work and 1 includes additional protective limitations regarding restroom use and 2 breaks. 3 (AR 21.) 4 Plaintiff contends that the ALJ erred because he “implicitly rejected” 5 Dr. Gerber’s opinion that she be provided “ready access to the restroom” by failing 6 to specifically include it in his RFC. (ECF No. 23 at 16.) 7 The ALJ’s decision makes clear that the ALJ considered Dr. Gerber’s opinion 8 to be subsumed in the RFC he assessed, which provided Plaintiff with two additional 9 breaks to accommodate her need to use the bathroom. As the Commissioner points 10 out, Plaintiff’s past work as a sedentary professional already includes a morning 11 break, lunch break, and afternoon break. See SSR 96-9p (sedentary work includes 12 morning break, afternoon break, and lunch period); Learnaham v. Astrue, 2010 WL 13 3504936, at *5 (E.D. Cal. Sept. 3, 2010) (noting “normal morning break, lunch break, 14 and afternoon break to which workers performing sedentary work are entitled”). 15 Consequently, the ALJ’s inclusion of two additional break periods resulted in 16 Plaintiff having two 10-minute breaks in the morning, a lunch break, and two more 17 break periods in the afternoon, one 10-minutes and the other 15-minutes. 18 Furthermore, these breaks are unscheduled, meaning that they contemplate providing 19 Plaintiff access to the restroom five times throughout the day when needed to 20 accommodate her urinary frequency. 21 Plaintiff fails to provide a definition of “ready access to the restroom,” let alone 22 point to any regulation or statute defining that phrase. The Court is aware of no 23 authority defining “ready access to a restroom” as requiring something other than 24 what the ALJ’s RFC contemplates. In fact, the few cases this Court has found reveal 25 varying interpretations of the phrase. See, e.g., Elzig v. Berryhill, 2019 WL 2024953, 26 at *5 (E.D. Cal. May 8, 2019) (“ready access to a restroom” could be accommodated 27 by the normal morning, lunch, and afternoon breaks); McGee v. Berryhill, 2018 WL 28 1378750, at *16 (D. Mont. Mar. 19, 2018) (interpreting “ready access to a restroom” 1 “as immediate access without regard to any routine, scheduled breaks”); Strawn v. 2 Berryhill, 2017 WL 3393403, at *2 (D. Ariz. Aug. 8, 2017) (plaintiff required “ready 3 access to a restroom, which is defined as a workstation within a five-minute walk 4 from a restroom”). In the absence of a legally-binding definition, it was reasonable 5 for the ALJ to construe Dr. Gerber’s opinion such that it was satisfied by five breaks 6 during an eight-hour workday during which she could access the restroom. 7 III. The ALJ’s Credibility Determination 8 Plaintiff contends that the ALJ erred in rejecting her testimony regarding her 9 subjective symptoms and limitations. (ECF No. 23 at 17-23.) 10 A. Plaintiff’s Testimony 11 In her Function Report, Plaintiff stated that she was disabled by chronic, 12 debilitating pain and compromised bladder function, both of which impair her ability 13 to concentrate. (AR 276.) Her daily activities include a short meditation, feeding and 14 tending her cat, eating, checking e-mail, “lots of bathroom time,” reading and sleep. 15 She is able to perform her own personal care, prepare her own meals, make her bed 16 and do laundry. (AR 277-278.) She goes outside two times a week, is able to travel 17 alone and drive a car. She is able to shop for groceries or medicine. (AR 279.) Her 18 hobbies include reading, playing solitaire, and doing crossword puzzles. However, 19 Plaintiff stated that she tires easily and the length of time she can read is limited. (AR 20 280.) She found it difficult to focus beyond the pain caused by her impairment and 21 when asked how long she was able to pay attention, Plaintiff responded, “I don’t 22 know.” (AR 281.) Plaintiff indicated she had last worked in 2015, but stopped 23 because the job was temporary. (AR 255.)4 24 At the hearing, Plaintiff testified that she experienced chronic pain and urinary 25 frequency. She explained that she did experience some improvement in her 26 symptoms after beginning medication, but that those medications stopped working 27 in 2015. Even though the medications were no longer effective in relieving her
28 1 urinary symptoms, Plaintiff continued to take them because she feared that her 2 condition could regress and get worse. (AR 41-42.) Plaintiff further testified that she 3 had good and bad days. On a good day, she was able to go to the grocery store or the 4 pharmacy, but there were many days when she could not leave the house. On such 5 days, her symptoms are almost constant and she uses the restroom up to 17 times a 6 day. (AR 47, 60.) 7 When the ALJ noted that Plaintiff had worked from January through May of 8 2015, Plaintiff explained that she had experienced improvement in her urinary 9 symptoms and took a project job at a university in West Virginia doing chemical 10 inventory. While working, however, her urinary symptoms increased such that she 11 ended up missing work about once a week. (AR 44, 58-59.) Although other projects 12 may have been available through the university, Plaintiff did not apply for them 13 because she suffered urinary frequency (needing to use the restroom every 10 to 20 14 minutes), severe incontinence, and pain. (AR 59.) 15 Plaintiff had experienced significant weight loss – from approximately 110 16 pounds to 88 pounds as of the date of the hearing – which she attributed to IC, 17 although her doctors had not provided an official diagnosis for the weight loss. (AR 18 41-42, 61.) At the time of the hearing, Plaintiff had been referred to a female urology 19 specialist, but was awaiting approval from her insurance company. (AR 61-63.) 20 In order to be able to attend an appointment such as the hearing before the ALJ, 21 Plaintiff would “dehydrate” herself – that is, stop all liquids the night before the 22 appointment. (AR 59.) According to Plaintiff, her ability to work was due not only 23 to her urinary frequency and incontinence, but also to the fatigue and pain associated 24 with IC. The fatigue and pain caused difficulty concentrating for longer than about 25 10 minutes. (AR 67-68.) 26 After the ALJ inquired about her mental health, Plaintiff revealed that she had 27 been psychiatrically hospitalized in 2011 on a 72-hour psychiatric hold and again 28 overnight in 2013. (AR 54-56.) Plaintiff noted that she’d been in an abusive 1 relationship with a roommate and also with her mother. She was currently living with 2 her mother at her mother’s senior facility. (AR 43, 52.) Nevertheless, Plaintiff was 3 adamant that her inability to work was due solely to chronic IC and not mental illness. 4 (AR 40.) Thus, she declined the ALJ’s suggestion that she participate in a mental 5 health examination. (AR 56-57.) 6 B. Relevant Law 7 Where, as here, a claimant has presented objective medical evidence of an 8 underlying impairment that could reasonably be expected to produce pain or other 9 symptoms and the ALJ has not made an affirmative finding of malingering, an ALJ 10 must provide specific, clear and convincing reasons before rejecting a claimant’s 11 testimony about the severity of his symptoms. Trevizo, 871 F.3d at 678 (9th Cir. 12 2017) (citing Garrison, 759 F.3d at 1014-1015). “General findings [regarding a 13 claimant’s credibility] are insufficient; rather, the ALJ must identify what testimony 14 is not credible and what evidence undermines the claimant’s complaints.” Burrell v. 15 Colvin, 775 F.3d 1133, 1138 (9th Cir. 2014) (quoting Lester v. Chater, 81 F.3d 821, 16 834) (9th Cir. 1995)). The ALJ’s findings “must be sufficiently specific to allow a 17 reviewing court to conclude the adjudicator rejected the claimant’s testimony on 18 permissible grounds and did not arbitrarily discredit a claimant’s testimony regarding 19 pain.” Brown-Hunter v. Colvin, 806 F.3d 487, 493 (9th Cir. 2015) (quoting Bunnell 20 v. Sullivan, 947 F.2d 341, 345-346 (9th Cir. 1991) (en banc)). 21 Factors an ALJ may consider when making such a determination include the 22 objective medical evidence, the claimant’s treatment history, the claimant’s daily 23 activities, unexplained failure to pursue or follow treatment, and inconsistencies in 24 testimony. See Ghanim, 763 F.3d at 1163; Molina, 674 F.3d at 1112. 25 C. Analysis 26 The Commissioner argues that the ALJ’s credibility determination is 27 supported by the following legally sufficient grounds: Plaintiff’s subjective 28 complaints were (1) not supported by the objective medical record; (2) inconsistent 1 with the medical evidence showing that she experienced consistent improvement 2 with treatment; (3) inconsistent with her ability to work for about six months at 3 substantial gainful activity levels in 2015; and (4) inconsistent with her daily 4 activities. (ECF No. 26 at 13-16.) 5 1. Objective Evidence 6 “Although lack of medical evidence cannot form the sole basis for discounting 7 pain testimony, it is a factor that the ALJ can consider in his credibility analysis.” 8 Burch v. Barnhart, 400 F.3d 676, 681 (9th Cir. 2005); see Batson, 359 F.3d at 1197 9 (lack of objective medical evidence to support claimant’s subjective complaints 10 constitutes substantial evidence in support of an ALJ’s adverse credibility 11 determination). 12 Here, the ALJ summarized Plaintiff’s subjective complaints, including her 13 allegations of urinary frequency and pain, as well as her claim that pain and fatigue 14 made it difficult for her to concentrate. The ALJ also summarizing the medical record 15 before concluding that although Plaintiff’s IC resulted in some functional limitations, 16 the objective evidence did not support the severity of Plaintiff’s allegations. (AR 18- 17 20.) 18 As set forth in detail above, the objective medical evidence essentially reveals 19 a diagnosis of IC with a history of urinary frequency and bladder problems. In light 20 of the record, the ALJ properly relied upon the absence of objective medical support 21 as one factor in his decision to discount Plaintiff’s subjective complaints to the extent 22 they exceeded the limitations incorporated in the RFC. 23 2. Evidence showing “consistent improvement with treatment” 24 The Commissioner argues that the ALJ properly discounted Plaintiff’s 25 credibility based upon evidence showing that Plaintiff experienced “consistent 26 improvement with treatment.” (ECF No. 26 at 14-15, citing AR 18-19.) Generally, 27 the effectiveness of treatment is a relevant factor in determining the severity of a 28 claimant’s symptoms. 20 C.F.R. § 404.1529(c)(3); see also Tommasetti, 533 F.3d at 1 1039-1040; Warre v. Comm’r of Soc. Sec. Admin., 439 F.3d 1001, 1006 (9th Cir. 2 2006). Accordingly, substantial evidence of effective treatment may provide a 3 specific, clear, and convincing reason to discount a claimant’s subjective symptom 4 testimony. See Youngblood v. Berryhill, 734 F. App’x 496, 499 (9th Cir. 2018). 5 Contrary to the Commissioner’s argument, however, the ALJ’s decision does 6 not include a finding that Plaintiff experienced “consistent improvement with 7 treatment” nor does it include a clear indication that the ALJ relied upon such a 8 conclusion. Furthermore, to the extent the ALJ’s decision could be construed as 9 reaching such a conclusion, it is not clear that such a finding is supported by 10 substantial evidence. 11 The Commissioner points out that the ALJ identified numerous medical 12 records reflecting that Plaintiff experienced improvement in her symptoms. (ECF No. 13 26 at 14-15.) Specifically, the ALJ noted the following treatment notes in which 14 Plaintiff reported feeling either “much better,” “improved,” or which showed no 15 complaints: March 2014 (AR 387); June 2014 (AR 467); August 2014 (AR 372); 16 September 2014 (AR 368); November 2014 (AR 365-367); December 2014 (AR 17 427); March 2015 (AR 411) and May 2015 (AR 407). (See AR 19-20.) At the same 18 time, however, the record contains treatment notes reflecting that Plaintiff’s pain and 19 symptoms had returned and/or increased including the following: two dates in 20 December 2014 (AR 417-422); January 2015 (AR 415); August 2015 (AR 511); 21 September 2015 (AR 532); and December 2015 (AR 571.) 22 The Commissioner selectively discusses those records showing improvement 23 while ignoring records – sometimes from the very same month – indicating that 24 Plaintiff’s symptoms had returned or become worse. For example, the ALJ relied 25 upon a treatment note dated December 4, 2014 revealing that Plaintiff was “better” 26 due to intravesical treatment and medication, she denied nocturia and incontinence, 27 and her “only issue was urgency triggered by words at work or certain thoughts.” 28 (AR 19, citing AR 425-427.) Both the ALJ and the Commissioner fail to mention 1 treatment notes dated December 17 and December 22, 2014 which revealed that 2 Plaintiff returned with increased IC pain, underwent another intravesical instillation, 3 and after the procedure did not relieve her pain, discussed the option of a different 4 treatment (PTNS). (AR 417-422.) 5 Thus, any conclusion that Plaintiff’s pain and symptoms had been effectively 6 treated is based upon a selective and incomplete consideration of the medical record 7 as a whole, and would not be supported by substantial evidence. See Ghanim, 763 8 F.3d at 1164 (rejecting ALJ’s adverse credibility determination because ALJ did not 9 account for record “as a whole,” but rather relied on “cherry-picked” evidence); 10 Oestman v. Colvin, 2017 WL 10719697, at *2 (C.D. Cal. Mar. 15, 2017) (reversing 11 credibility determination where ALJ “cited to isolated pieces of evidence as support 12 for his conclusions, without giving any indication that he had considered the medical 13 record as a whole”); Vega v. Colvin, 2015 WL 2166596, at *4 (C.D. Cal. May 8, 14 2015) (reversing credibility determination where ALJ selectively cited records 15 undermining claimant’s allegations of persistent diarrhea and frequent bathroom use 16 but ignored records consistent with claimant’s allegations, stating that an “ALJ may 17 not make an adverse credibility determination by cherry-picking from the record”). 18 3. Ability to perform work in 2015 19 The ALJ found it significant that Plaintiff was able to work for approximately 20 six months at substantial gainful activity levels. (AR 20.) As set forth above, Plaintiff 21 was employed performing a temporary chemical inventory project for a university. 22 She performed full-time work from January through May 2015, when the job ended. 23 An ALJ may properly discount a claimant’s credibility based upon his or her work 24 record. See 20 C.F.R. § 404.1529(c)(3); Bray, 554 F.3d at 1227 (affirming ALJ’s 25 credibility determination which was based in part on fact that claimant had recently 26 worked as a caregiver and also sought other work). 27 Plaintiff points to her testimony that her condition deteriorated while she was 28 working, that she had to miss work at least twice a month and as much as once a 1 week, and that she did not apply for another project once the first one ended because 2 of her IC symptoms. (ECF No. 23 at 22-23, citing AR 58-59.) Based upon this 3 testimony, Plaintiff argues that the ALJ’s conclusion was “not justified.” Plaintiff’s 4 argument is unpersuasive. Notwithstanding Plaintiff’s assertion, the ALJ’s 5 interpretation of the record was both reasonable and supported by substantial 6 evidence. Although the ALJ may have drawn other inferences based upon the 7 evidence, it was not improper for the ALJ to discount Plaintiff’s credibility in light 8 of the evidence that she was able to complete the terms of her employment during a 9 time when she was allegedly disabled. See Orn, 495 F.3d at 630 (where evidence is 10 susceptible of more than one rational interpretation, the Commissioner’s decision 11 must be upheld). 12 4. Daily activities 13 Last, the Commissioner points out that the ALJ’s credibility determination was 14 based, in part, upon Plaintiff’s daily activities. 15 An ALJ may discredit testimony when a claimant reports participation in 16 everyday activities indicating capacities that are transferable to a work setting. 17 Molina, 674 F.3d at 1113. In addition, “[e]ngaging in daily activities that are 18 incompatible with the severity of symptoms alleged can support an adverse 19 credibility determination.” Ghanim, 763 F.3d at 1165. Nevertheless, the Ninth Circuit 20 has made clear that “ALJs must be especially cautious in concluding that daily 21 activities are inconsistent with testimony about pain, because impairments that would 22 unquestionably preclude work and all the pressures of a workplace environment will 23 often be consistent with doing more than merely resting in bed all day.” Garrison, 24 759 F.3d at 995. “[T]he mere fact that a plaintiff has carried on certain daily activities, 25 such as grocery shopping, driving a car, or limited walking for exercise, does not in 26 any way detract from her credibility as to overall disability.” Vertigan v. Halter, 260 27 F.3d 1044, 1050 (9th Cir. 2001). Furthermore, an ALJ should explain “which daily 28 1 activities conflicted with which part of [a] Claimant’s testimony.” See Burrell, 775 2 F.3d at 1138. 3 Here, the ALJ observed that Plaintiff was able to cook, “perform chores,” 4 walk, shop, perform self-care, and go out alone. He noted that Plaintiff’s day consists 5 of meditating, checking emails, reading, and caring for a cat, and that she was able 6 to watch movies, play solitaire, and do crossword puzzles. (AR 22.) Neither the ALJ 7 nor the Commissioner suggest that these activities involve skills that would translate 8 to the workplace or indicate an ability to perform sustained activity in a work setting 9 for eight hours a day, five days a week. See Benjamin v. Colvin, 2014 WL 4437288, 10 at *4 (C.D. Cal. Sept. 9, 2014). Furthermore, in relying on these daily activities to 11 discount Plaintiff’s credibility, the ALJ did not explain how any specific activity was 12 inconsistent with Plaintiff’s allegations that on most days, she needs to use the 13 bathroom every 20 minutes or that she has difficulty concentrating due to pain, 14 urinary urgency and/or fatigue. The ALJ’s mere recitation of Plaintiff’s daily 15 activities in their entirety, without any explanation of which activity he considered to 16 be inconsistent with which of Plaintiff’s alleged symptom or limitation is insufficient 17 to meet the Ninth Circuit’s “requirements of specificity.” See Burrell, 775 F.3d at 18 1138 (quoting Connett v. Barnhart, 340 F.3d 871, 873 (9th Cir. 2003); see also 19 Smolen v. Chater, 80 F.3d 1273, 1287 n. 7 (9th Cir. 1996) (“The Social Security Act 20 does not require that claimants be utterly incapacitated to be eligible for benefits, and 21 many home activities may not be easily transferable to a work environment where it 22 might be impossible to rest periodically or take medication.”) (citation omitted); 23 Christine G. v. Andrew M. Saul, 2019 WL 4038217, at *10-11 (C.D. Cal. Aug. 27, 24 2019) (ALJ improperly relied upon daily activities to discredit claimant’s testimony 25 where record showed claimant’s participation in those activities was limited – i.e., 26 claimant “shops, but only goes twice a month for an hour; she reads, but not for too 27 long…she spends time with her grandson, but that consists of reading and watching 28 cartoons”). 1 Although the ALJ’s lack of specificity renders reliance upon Plaintiffs daily 2 || activities improper, the error is harmless in light of the other sufficiently clear and 3 || convincing reasons supporting the ALJ’s credibility determination. See Bray, 554 4 || F.3d at 1227 (where the ALJ presented four other independent proper bases for 5 || discounting the plaintiffs testimony, reliance on claimant’s continued smoking to 6 || discredit her, even if erroneous, amounted to harmless error); Carmickle v. □□□□□□ 7 || Soc. Sec. Admin., 533 F.3d 1155, 1163 (9th Cir. 2008) (ALJ’s error in relying on 8 || claimant’s receipt of unemployment benefits and on relatively conservative pain 9 || treatment regime was harmless where ALJ provided other specific and legitimate 10 || reasons for finding claimant’s testimony incredible). 11 |} IV. The ALJ’s Determination That Plaintiff Could Perform Her Past 12 Relevant Work 13 Plaintiff contends that the ALJ erred by concluding that she could perform her 14 || past relevant work. According to Plaintiff, the ALJ’s hypothetical was flawed 15 || because it did not incorporate all of the limitations testified to by Plaintiff and 16 || assessed by treating and examining physicians. (ECF No. 23 at 23-24.) This claim is 17 || premised upon Plaintiffs underlying contentions challenging the ALJ’s RFC on the 18 || ground he improperly rejected medical opinions and discounted Plaintiffs subjective 19 || complaints. Because the Court already has rejected these contentions, this separate 20 || claim presents nothing further to discuss. 21 ORDER 22 IT IS THEREFORE ORDERED that Judgment be entered affirming the 23 || decision of the Commissioner of Social Security and dismissing this action with 24 || prejudice. 25 || DATED: 10/3/2019 (Wy Moe f<——~ ALEXANDER F. MacKINNON 28 UNITED STATES MAGISTRATE JUDGE 22