Ernesto Ayala Heredia v. Commissioner of Social Security

Opinion

1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 FOR THE EASTERN DISTRICT OF CALIFORNIA 10 11 Ernesto Ayala Heredia, No. 1:25-cv-00514-GSA 12 Plaintiff, OPINION & ORDER DIRECTING ENTRY OF JUDGMENT IN FAVOR OF 13 v. DEFENDANT COMMISSIONER OF SOCIAL SECURITY AND AGAINST 14 Commissioner of Social Security, PLAINTIFF 15 Defendants. (ECF No. 16) 16 I. Introduction 17 Plaintiff Ernesto Ayala Heredia seeks judicial review of a final decision of the 18 Commissioner of Social Security denying his applications for social security disability insurance 19 benefits and supplemental security income under Titles II and XVI the Social Security Act.1 20 II. Factual and Procedural Background 21 On February 8, 2022, Plaintiff applied for social security disability insurance benefits and 22 supplemental security income alleging disability beginning on July 14, 2018. AR 242, 250. 23 Plaintiff’s claim was initially denied on March 25, 2022 (AR 89–90), and upon reconsideration 24 on July 27, 2022 (AR 123–24). A hearing before an ALJ was held on March 27, 2024. AR 37. 25 The ALJ issued an unfavorable decision on May 1, 2024. AR 16. 26 III. The Disability Standard 27

28 1 The parties consented to the jurisdiction of a United States Magistrate Judge. Docs. 7, 12. 1 Pursuant to 42 U.S.C. §405(g), this court has the authority to review a decision by the 2 Commissioner denying a claimant disability benefits. “This court may set aside the 3 Commissioner’s denial of disability insurance benefits when the ALJ’s findings are based on 4 legal error or are not supported by substantial evidence in the record as a whole.” Tackett v. 5 Apfel, 180 F.3d 1094, 1097 (9th Cir. 1999) (citations omitted). Substantial evidence is evidence 6 within the record that could lead a reasonable mind to accept a conclusion regarding disability 7 status. See Richardson v. Perales, 402 U.S. 389, 401 (1971). It is more than a scintilla, but less 8 than a preponderance. See Saelee v. Chater, 94 F.3d 520, 522 (9th Cir. 1996) (internal citation 9 omitted). 10 When performing this analysis, the court must “consider the entire record as a whole and 11 may not affirm simply by isolating a specific quantum of supporting evidence.” Robbins v. Social 12 Security Admin., 466 F.3d 880, 882 (9th Cir. 2006) (citations and quotations omitted). If the 13 evidence could reasonably support two conclusions, the court “may not substitute its judgment for 14 that of the Commissioner” and must affirm the decision. Jamerson v. Chater, 112 F.3d 1064, 15 1066 (9th Cir. 1997) (citation omitted). “[T]he court will not reverse an ALJ’s decision for 16 harmless error, which exists when it is clear from the record that the ALJ’s error was 17 inconsequential to the ultimate nondisability determination.” Tommasetti v. Astrue, 533 F.3d 18 1035, 1038 (9th Cir. 2008). 19 To qualify for benefits under the Social Security Act, a plaintiff must establish that he or 20 she is unable to engage in substantial gainful activity due to a medically determinable physical or 21 mental impairment that has lasted, or can be expected to last, for a continuous period of not less 22 than twelve months. 42 U.S.C. § 1382c(a)(3)(A). An individual shall be considered to have a 23 disability only if . . . his/her physical or mental impairment or impairments are of such severity 24 that he or she is not only unable to do his or her previous work, but cannot, considering his age, 25 education, and work experience, engage in any other kind of substantial gainful work which 26 exists in the national economy, regardless of whether such work exists in the immediate area in 27 which he lives, or whether a specific job vacancy exists for him, or whether he or she would be 28 hired if he or she applied for work. 42 U.S.C. §1382c(a)(3)(B). 1 To achieve uniformity in the decision-making process, the Commissioner has established 2 a sequential five-step process for evaluating a claimant’s alleged disability. 20 C.F.R. §§ 3 416.920(a)-(f). The ALJ proceeds through the steps and stops upon reaching a dispositive finding 4 that the claimant is or is not disabled. 20 C.F.R. §§ 416.927, 416.929. 5 Specifically, the ALJ is required to determine: 1- whether a claimant engaged in 6 substantial gainful activity during the period of alleged disability; 2- whether the claimant had 7 medically determinable “severe impairments”; 3- whether these impairments meet or are 8 medically equivalent to one of the listed impairments set forth in 20 C.F.R. § 404, Subpart P, 9 Appendix 1; 4- whether the claimant retained the residual functional capacity (“RFC”) to perform 10 past relevant work; and 5- whether the claimant had the ability to perform other jobs existing in 11 significant numbers at the national and regional level. 20 C.F.R. § 416.920(a)-(f). While the 12 Plaintiff bears the burden of proof at steps one through four, the burden shifts to the 13 commissioner at step five to prove that Plaintiff can perform other work in the national economy 14 given his/her RFC, age, education and work experience. Garrison v. Colvin, 759 F.3d 995, 1011 15 (9th Cir. 2014). 16 IV. The ALJ’s Decision 17 At step one, the ALJ found Plaintiff had not engaged in substantial gainful activity since 18 July 14, 2018, the alleged onset date. AR 24. At step two, the ALJ found that Plaintiff had 19 severe impairments of lumbar radiculopathy and herniated intervertebral disc of lumbar spine. AR 20 24. The ALJ found that Plaintiff did not have an impairment or combination of impairments that 21 met or medically equaled the severity of one of the listed impairments in 20 CFR Part 404, 22 Subpart P, Appendix 1. AR 25. The ALJ determined that Plaintiff had the RFC to perform a 23 range of light work as defined by the regulations, except:

24 can occasionally climb ramps and stairs, but no climbing of ladders, ropes, and 25 scaffolds; can occasionally stoop, kneel, crouch, or crawl; can no more than occasionally operate a motor vehicle, and have no more than occasional exposure to 26 vibration; and can understand, remember, and carry out simple, routine tasks. 27 AR 25–26. 28 Based on this residual functional capacity determination and the testimony of a vocational 1 expert, the ALJ found Plaintiff could not perform his past relevant work but could perform other 2 work in the national economy, namely: garment sorter, marking clerk, and assembler small 3 products. AR 29–30. Accordingly, the ALJ found Plaintiff was not disabled at any time since the 4 alleged onset date of July 14, 2018. AR 31. 5 V. Issues Presented 6 Plaintiff asserts two claims of error: 1- The ALJ failed to properly evaluate the medical 7 opinions, and 2- The ALJ failed to include work-related limitations in the RFC consistent with the 8 nature and intensity of Plaintiff’s limitations and failed to offer any reason for rejecting Plaintiff’s 9 subjective complaints. 10 A. Medical Opinions 11 1. Applicable Law 12 Before proceeding to steps four and five, the ALJ determines the claimant’s residual 13 functional capacity (RFC) which is “the most [one] can still do despite [his or her] limitations” 14 and represents an assessment “based on all the relevant evidence.” 20 C.F.R. § 416.945(a)(1). 15 The RFC must consider all of the claimant’s impairments, severe or not. 20 C.F.R. §§ 16 416.920(e), 416.945(a)(2). “The ALJ can meet this burden by setting out a detailed and thorough 17 summary of the facts and conflicting evidence, stating his interpretation thereof, and making 18 findings.” Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989). 19 For applications filed on or after March 27, 2017, new regulations eliminate the prior 20 hierarchy of medical opinions and provide that “[w]e will not defer or give any specific 21 evidentiary weight, including controlling weight, to any medical opinion(s) or prior 22 administrative medical finding(s), including those from your medical sources.” 20 C.F.R. § 23 404.1520c(a). Instead, when evaluating any medical opinion, the regulations provide that the 24 ALJ will consider the factors of supportability, consistency, treatment relationship, specialization 25 and other factors. 20 C.F.R. § 404.1520c(c). 26 Supportability and consistency are the two most important of these factors, and the agency 27 will articulate how the factors of supportability and consistency are considered. Id. “Even under 28 the new regulations, an ALJ cannot reject an examining or treating doctor's opinion as 1 unsupported or inconsistent without providing an explanation supported by substantial evidence.” 2 Woods v. Kijakazi, 2022 WL 1195334, (9th Cir. Apr. 22, 2022) at *6. 3 With respect to “supportability,” the new regulations provide that “[t]he more relevant the 4 objective medical evidence and supporting explanations presented by a medical source are to 5 support his or her medical opinion(s) or prior administrative medical finding(s), the more 6 persuasive the medical opinions or prior administrative medical finding(s) will be.” 20 C.F.R. § 7 416.920c(c)(1). Regarding “consistency,” the regulations provide that “[t]he more consistent a 8 medical opinion(s) or prior administrative medical finding(s) is with the evidence from other 9 medical sources and nonmedical sources in the claim, the more persuasive the medical opinion(s) 10 or prior administrative medical finding(s) will be.” 20 C.F.R. § 416.920c(c)(2). 11 2. Analysis2 12 a. Dr. Nadjmabadi 13 Plaintiff explains that Dr. Nadjmabadi opined both in June 2023 and again in January 14 2023 that Plaintiff was limited to a reduced range of sedentary work (AR 1946–49, 1954–57). 15 However, the ALJ was unpersuaded by Dr. Nadjmabadi’s opinion in part because the ALJ found 16 that the opinion was “offered on a check box form without explanation or supporting evidence. 17 The opinions are also inconsistent with [Plaintiff’s] treatment history, which has documented 18 some lower extremity weakness but generally indicated that he has intact physical functioning.” 19 AR 29 (emphasis added). Initially, as to this finding made by the ALJ, it is worth pausing for a 20 moment to recognize that use of check box forms is useful, and perhaps necessary to some extent, 21 in ascertaining a physician’s opinion on the regulations’ various exacting requirements. For 22 example, “Sedentary” work, “Light” work, and “Medium” work are all Social Security terms of 23 art. Importantly, the check-box form fleshes out the meaning behind those terms as it relates to 24 weightlifting limitations, frequency of weightlifting, duration of sitting/standing/walking both 25 consecutively and total in an 8-hour day. 26 2 It appears that Plaintiff inadvertently included an argument from another case concerning a Dr. 27 Bautisa along with the inclusion of a related remand order, neither of which is applicable here. Plaintiff did not address this issue when it was identified by Defendant, and a text search through 28 the OCR (text searchable) PDF reveals no hits for a Dr. Bautista. 1 The check box format also contains boxes and fill-in-the blanks which address a myriad of 2 other specific considerations, some with unique applicability in the social security disability 3 context including, but not limited to: 1-whether the impairments are expected to last 12 months or 4 more; 2-the percentage of off-task behavior expected and what that term means in this context; 3- 5 the ability to perform manipulative activities such as handling/fingering/feeling; 5-the need for 6 assistive devices; and 6- the ability to perform postural maneuvers such as bending and 7 crouching, and so on. To this end, the check-box format is arguably the most efficient, directed, 8 and time saving way to obtain a clinician’s opinion as it is a closed-ended format which limits the 9 range of the clinician’s potential responses to those that are relevant to the Commissioner’s 10 exertional thresholds. Finally, this allows the agency to neatly categorize the claimant. 11 It is also important to note that Dr. Nadjmabadi did not simply check boxes “without 12 explanation or supporting evidence”. To the contrary, Dr. Nadjmabadi provided a reasonable 13 and topical (albeit concise) justification in the spaces provided. Specifically, Dr. Nadjmabadi’s 14 responses, including short narratives when asked, explained that Plaintiff’s physical limitations 15 were due to radicular low back pain caused by a disc herniation, muscle spasms, sensory loss, 16 range of motion deficiency, and reduced strength of 4/5 in legs. AR 1946–49. Notwithstanding, 17 the ALJ nevertheless identified valid reasons in support of the RFC which diverged from Dr. 18 Nadjmabadi’s opinion. 19 Plaintiff additionally points to treatment notes submitted by Dr. Nadjmabadi which 20 Plaintiff contends fully support the opined limitations. See e.g. Ar. 958, 998, 1014, 1287, 1291, 21 1826-27, 1862, 1874, 1906, 1909- 10, 1964, 1968, 1972, 1976, 1979, 1984, 1988, 1993, 1998, 22 2002-03, 2018-19. Plaintiff explains that the objective findings regularly showed Plaintiff had 23 tenderness, decreased range of motion, decreased sensation, positive straight leg raise testing, 24 decreased strength, and an antalgic gait. To this the Defendant responds that although the ALJ 25 appropriately acknowledged that the record showed abnormal findings at times, it also showed 26 normal findings at other times, such as normal gait, no spine tenderness, full strength and intact 27 sensation. AR 27–28, citing AR 1044–45, 1218–19, 1227, 1252–53, 1921, 1963–64, 2018–19). 28 Defendant further explains that notwithstanding abnormal examination findings emphasized by 1 Plaintiff, Dr. Nadjmabadi cleared Plaintiff to “return to full work” in October 2022, which was 2 also noted by the ALJ (AR 28, citing AR 2026-27; see also AR 2023). 3 Here, both parties cite to records and offer explanations that are reasonably supported by 4 their respective citations to the record. For example, even though Dr. Nadjmabadi’s opinion was 5 reasonably well supported by explanation and supporting records showing various deficiencies in 6 strength and ROM, positive provocation signs (straight leg raise), all connected to abnormal 7 spinal pathology, namely disc herniation, the ALJ also cited countervailing findings on many of 8 the same. 9 In situations like this, when confronted with countervailing rational interpretations of the 10 evidence, the law is instructive. It states that where evidence is susceptible to more than one 11 rational interpretation, it is the ALJ’s conclusion that must be upheld, not the plaintiff’s 12 conclusion, even if the plaintiff’s conclusion is a rational one. Burch v. Barnhart, 400 F.3d 676, 13 679 (9th Cir. 2005). The primary question for the Court is not whether there is substantial 14 evidence that could support a finding of disability, but whether there is substantial evidence to 15 support the contrary conclusion: non-disability. See Jamerson v. Chater, 112 F.3d 1064, 1067 (9th 16 Cir. 1997). That is, the deferential “substantial evidence” standard applies to the ALJ’s 17 reasonably supported conclusion, not Plaintiff’s contrary (albeit reasonable) conclusion. 18 In addition however, it is questionable whether Dr. Nadjmabadi’s opinion is even 19 reasonable given that it limits Plaintiff to a reduced range of sedentary work (which includes 20 only occasionally lifting more than 10 pounds, rarely performing any postural maneuvers, and 21 walking and standing no more than 2 hours a day), when considering an individual with only 22 mild to moderate spinal abnormalities and no other severe impairments. Specifically, a May 4, 23 2020 MRI showed at L4 a 2.9mm “slightly left side disc protrusion and facet hypertrophy,” mild 24 to moderate canal stenosis, moderate right side foraminal stenosis, mild to moderate right sided 25 foraminal stenosis, at L5 a “possible spondylosis,” “slight irregularity” in the posterior elements 26 of the right side, 2mm bulging discs and facet hypertrophy, and a final note that “The 27 combination of these findings result in mild canal and moderate bilateral foraminal stenosis.” AR 28 1576 (emphasis added). The remaining findings, per the radiologist, were “otherwise negative of 1 the lumbar spine”. Id. 2 Thus, in light of the above discussion it cannot be said that the ALJ committed error when 3 evaluating the medical evidence.

4 B. Subjective Complaints 5 1. Applicable Law 6 An ALJ performs a two-step analysis to determine whether a Plaintifft’s testimony 7 regarding subjective pain or symptoms is credible. See Garrison v. Colvin, 759 F.3d 995, 1014 8 9 (9th Cir. 2014); Smolen, 80 F.3d at 1281; S.S.R 16-3p at 3. First, the Claimant must produce 10 objective medical evidence of an impairment that could reasonably be expected to produce some 11 degree of the symptom or pain alleged. Garrison, 759 F.3d at 1014; Smolen, 80 F.3d at 1281–82. 12 If the Claimant satisfies the first step and there is no evidence of malingering, the ALJ must 13 “evaluate the intensity and persistence of [the Claimant’s] symptoms to determine the extent to 14 which the symptoms limit an individual’s ability to perform work-related activities.” S.S.R. 16- 15 3p at 2. 16 17 An ALJ’s evaluation of a Claimant’s testimony must be supported by specific, clear and 18 convincing reasons. Burrell v. Colvin, 775 F.3d 1133, 1136 (9th Cir. 2014); see also S.S.R. 16- 19 3p at *10. Subjective testimony “cannot be rejected on the sole ground that it is not fully 20 corroborated by objective medical evidence,” but the medical evidence “is still a relevant factor in 21 determining the severity of Claimant’s pain and its disabling effects.” Rollins v. Massanari, 261 22 F.3d 853, 857 (9th Cir. 2001); S.S.R. 16-3p (citing 20 C.F.R. § 404.1529(c)(2)). 23 In addition to the objective evidence, other factors to be considered are: 1- daily activities; 24 25 2- the location, duration, frequency, and intensity of pain or other symptoms; 3- precipitating and 26 aggravating factors; 4- the type, dosage, effectiveness, and side effects of any medication; 5- 27 treatment other than medication; 6- other measures the Claimant uses to relieve pain or other 28 1 symptom; and 7- other factors concerning the Claimant’s functional limitations and restrictions 2 due to pain or other symptoms. See, 20 C.F.R. § 416.929(c)(3). 3 2. Analysis 4 To begin, Plaintiff’s 1.5 page discussion is simply an overview of the law applicable to 5 this issue but contains no distinct factual citations or discussion uniquely applicable to this case. 6 7 Plaintiff’s argument does not describe or cite to testimony or subjective complaints. There is also 8 no reference to Plaintiff’s subjective complaints in Plaintiff’s first argument section, which 9 addresses only the opinion of a Dr. Bautista which, as Defendant emphasizes, appears to be 10 related to a different case. As a result, with no subjective symptom testimony identified, the 11 issue is not preserved. See Carmickle v. Comm’r, Soc. Sec. Admin., 533 F.3d 1155, 1161 n.2 12 (9th Cir. 2008) (stating a reviewing court ordinarily will not consider an issue that a claimant fails 13 to argue with any specificity in the opening brief). 14 15 Notwithstanding, to the extent that Plaintiff’s Complaint implies that his subjective 16 symptoms cause him to be unable to meet the exertional requirements of the RFC (light work), 17 Plaintiff’s unadorned argument will nevertheless be considered. 18 In this regard, the ALJ noted as follows (truncated for brevity): 19 • On April 16, 2018, he had a work injury falling 2-3 feet, landing on his buttock. 20 • May 11, 2018 lumbar spine MRI noted disc extrusion at L4-5. • He continued light duty work until July 11, 2018. 21 • PT, acupuncture, injections, chiropractic, and pain meds provided some benefit. 22 • 2018 visit noted radicular back pain and weakness. • January 1, 2019 visit notes he “was returned to modified work,” with no pushing, 23 pulling, or lifting > 10 pounds, and no repetitive bending. • April 2019, PT notes improved overall functioning. 24 • October 2019 exam noted antalgic gait, tenderness, limited ROM, some weakness, 25 and he was returned to modified work, with lifting limitations increased to 20 pounds, but otherwise unmodified from the previous set of work limitations. 26 • May 4, 2020 MRI noted possible spondylosis, mild to moderate bilateral foraminal stenosis, DDD, and a slight SI joint irregularity bilaterally. 27 • Subsequent records note ongoing pain but with improved overall functioning. 28 • June 9, 2020 exam notes 7/10 radicular back pain. He denied neurological 1 symptoms, and had a normal gait, with no swelling or tenderness. • September 8, 2020 exam notes numbness, tingling, pain 6/10 on average, and 7- 2 8/10 with standing, prolonged sitting or walking. His gait, strength and sensation 3 were normal with no swelling or tenderness. Bilateral SLR was positive. • April 27, 2021 pain management visit noted normal gait, no swelling or 4 tenderness, intact strength, reduce ROM. • June 2, 2022 exam again noted positive SLR with decreased leg strength though 5 he could walk, motor exam was normal, and sensation and reflexes were intact. 6 • He was released to full work on October 6, 2022 after a physical exam. • November 17, 2022, exam noted pain, but no swelling or numbness. He had 7 tenderness, and 4/5 strength in both legs, antalgic gait favoring the right • December 7, 2023, exam noted pain, limited ROM, 4/5 strength in his legs, 8 antalgic gait, but was able to walk. He denied but denied numbness or weakness.

9 Here the ALJ, while acknowledging that the evidence documented lumbar dysfunction 10 limiting the claimant’s ability to perform some basic work-related physical activities, added that 11 “the claimant has substantially intact functional capabilities.” AR 27–28. On balance, the ALJ’s 12 discussion reflects evidence of functionality and the absence of extreme deficiencies upon 13 14 physical exam. 15 Objective medical evidence can undercut a claimant’s testimony if that evidence 16 contradicts the testimony or is inconsistent with it. See Smartt, 53 F.4tgh at 498 (collecting 17 authority). Granted, as Plaintiff emphasizes, if there is objective medical evidence of an 18 underlying impairment, as is the case here, the Commissioner may not discredit a claimant's 19 testimony as to the severity of symptoms merely because they are unsupported by objective 20 21 medical evidence. See Bunnell v. Sullivan, 947 F.2d 341, 347-48 (9th Cir. 1991) (emphasis 22 added). 23 As set forth fully above, and repeated here, relevant factors on this issue include: 1- 24 daily activities; 2- the location, duration, frequency, and intensity of pain or other symptoms; 3- 25 precipitating and aggravating factors; 4- the type, dosage, effectiveness, and side effects of any 26 medication; 5- treatment other than medication; 6- other measures the Claimant uses to relieve 27 pain or other symptom; and 7- other factors concerning the Claimant’s functional limitations and 28 1 restrictions due to pain or other symptoms. See, 20 C.F.R. § 416.929(c)(3). 2 As to these factors the ALJ noted: 1- Plaintiff’s reports of improved functioning (factor 1: 3 daily activities); 2-average pain level (factor 2: pain intensity); 3- aggravated by prolonged 4 standing/sitting/walking (factor 3: aggravating factors), which was improved with medication 5 (factor 4: medication efficacy), and, 4- improvement with PT, chiropractic, and acupuncture 6 7 (factor 5: alternative therapies besides medication). 8 Thus, it is clear that the ALJ did not “solely” rely on objective medical evidence but 9 appropriately considered several of the relevant factors enumerated in Bunnell based on 10 Plaintiff’s subjective reports to clinicians. Finally, Plaintiff’s subjective reports, often contained 11 in an HPI3, are not transformed into objective evidence simply because they appear in the medical 12 records. 13 VI. Conclusion 14 15 Substantial evidence and applicable law support the ALJ’s conclusion that Plaintiff 16 was not disabled. 17 VII. Order 18 Accordingly, it is ordered that: 19 1. Plaintiff’s motion for summary judgment (Doc. 16) is DENIED. 20 2. Defendant’s cross motion (Doc. 23) is GRANTED. 21 3. The decision of the Commissioner Social Security is AFFIRMED. 22 4. The Clerk of Court is directed to enter judgment in favor of Defendant 23 Commissioner of Social Security and against Plaintiff. 24 25 IT IS SO ORDERED. Dated : March 24, 2026 /s/ Gary S. Austin 26 UNITED STATES MAGISTRATE JUDGE 27 28