Shirley June Trepanier v. Carolyn W. Colvin, No. 2:2013cv09027 - Document 20 (C.D. Cal. 2014)
Court Description: MEMORANDUM OPINION AND ORDER by Magistrate Judge Douglas F. McCormick. For the reasons stated above, the decision of the Social Security Commissioner is AFFIRMED and the action is DISMISSED with prejudice. (twdb)
Download PDF
<![CDATA[
1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 CENTRAL DISTRICT OF CALIFORNIA 10 WESTERN DIVISION 11 SHIRLEY JUNE TREPANIER, Plaintiff, 12 v. 13 14 15 CAROLYN W. COLVIN, Acting Commissioner of Social Security, 16 Defendant. ) Case No. CV 13-9027-DFM ) ) ) MEMORANDUM OPINION AND ) ) ORDER ) ) ) ) ) ) 17 18 Plaintiff Shirley June Trepanier ( Plaintiff ) appeals the decision of the 19 Administrative Law Judge ( ALJ ) denying her application for Supplemental 20 Security Income ( SSI ) benefits. The Court concludes that the ALJ offered 21 specific and legitimate reasons for rejecting the opinion of her treating 22 physician and that any error was harmless. Therefore, the ALJ s decision is 23 affirmed. 24 I. 25 FACTUAL AND PROCEDURAL BACKGROUND 26 Plaintiff filed an application for SSI on August 22, 2006, alleging 27 disability beginning July 1, 2004. Administrative Record ( AR ) 9. Her 28 1 application was denied by an ALJ in a decision dated March 28, 2008, but was 2 remanded by the Appeals Council on grounds unrelated to this appeal. AR 61- 3 71, 73-75. Following the receipt of additional evidence, including testimony 4 from Plaintiff, a medical expert, and a vocational expert, an ALJ found that 5 Plaintiff had the following medically determinable impairments: atypical 6 headaches, migrainous in nature; mild myofascial pain disorder; mild 7 degenerative disc disease of the cervical spine; chronic iron deficiency anemia; 8 history of vertigo; and history of gastritis. AR 11. The ALJ found that these 9 impairments in combination were severe. AR 12. The ALJ concluded, 10 however, that Plaintiff was not disabled because there was work available in 11 significant numbers in the national and regional economies that she could 12 perform. AR 17-18. 13 II. 14 ISSUE PRESENTED The parties dispute whether the ALJ erred in assessing the opinion of 15 16 Plaintiff s treating neurologist, Dr. Faisal Qazi. See Joint Stipulation ( JS ) at 17 3, 12. 18 III. 19 STANDARD OF REVIEW 20 Under 42 U.S.C. § 405(g), a district court may review the 21 Commissioner s decision to deny benefits. The ALJ s findings and decision 22 should be upheld if they are free from legal error and are supported by 23 substantial evidence based on the record as a whole. 42 U.S.C. § 405(g); 24 Richardson v. Perales, 402 U.S. 389, 401 (1971); Parra v. Astrue, 481 F.3d 25 742, 746 (9th Cir. 2007). Substantial evidence means such relevant evidence as 26 a reasonable person might accept as adequate to support a conclusion. 27 Richardson, 402 U.S. at 401; Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th 28 Cir. 2007). It is more than a scintilla, but less than a preponderance. 2 1 Lingenfelter, 504 F.3d at 1035 (citing Robbins v. Soc. Sec. Admin., 466 F.3d 2 880, 882 (9th Cir. 2006)). To determine whether substantial evidence supports 3 a finding, the reviewing court must review the administrative record as a 4 whole, weighing both the evidence that supports and the evidence that detracts 5 from the Commissioner s conclusion. Reddick v. Chater, 157 F.3d 715, 720 6 (9th Cir. 1996). If the evidence can reasonably support either affirming or 7 reversing, the reviewing court may not substitute its judgment for that of 8 the Commissioner. Id. at 720-21. 9 IV. 10 DISCUSSION Plaintiff contends that the ALJ failed to provide specific and legitimate 11 12 reasons supported by substantial evidence for giving little weight to Dr. 13 Qazi s opinion as expressed in a November 11, 2011 medical source statement. 14 JS at 4; see AR 17. 15 A. Background Plaintiff first began suffering chronic headaches in July 2004, at which 16 17 time Dr. K. Greg Tomassian appears to have been her primary-care physician. 18 See AR 320-22, 330, 355-56. She visited a number of specialists about her 19 headaches and related physical complaints, both through referrals from 20 Dr. Tomassian s clinic and in connection with her application for benefits. 21 Plaintiff also underwent repeated head and neck imaging and cerebrospinal- 22 fluid testing from 2004 to 2011, all of which were normal. See AR 653-56 23 (hearing testimony of medical expert discussing testing); see, e.g., AR 281, 24 283, 288; 357-60; 621-22; 623-24; 631-32. On September 10, 2004, Dr. Sergio Fuenzalida, a neurologist, reported a 25 26 normal neurological exam and that the reason for Plaintiff s continued issues 27 was unclear. AR 356. 28 /// 3 1 On November 30, 2004, Plaintiff was first seen by Dr. Richard Hollcraft, 2 a rheumatologist. See AR 335-38. Upon initial examination, Dr. Hollcraft 3 detected trapezius spasm and resultant limitation in Plaintiff s cervical range of 4 motion, but found that she was otherwise normal. AR 336-37. On November 5 16, 2005, Dr. Hollcraft reported that, although Plaintiff s rheumatological 6 workup was negative, he suspected that she might be suffering from chronic 7 trapezius myofascitis with tension muscle headaches. AR 548. Dr. Hollcraft 8 noted that Plaintiff refused to take any of the medication he prescribed, instead 9 relying only on Tylenol, and that therefore there is little I can offer. Id. 10 On April 28, 2005, Dr. Chan Kim, another neurologist, examined 11 Plaintiff after a referral from Dr. Tomassian and found Plaintiff to be 12 mentally clear and oriented without any deficit. AR 550. Dr. Kim also noted 13 normal test results, including a brain MRI, and opined that Plaintiff s 14 complaints were psychosomatic. Id. 15 On May 10, 2007, a state-agency consultant, Dr. John Sedgh, examined 16 Plaintiff. AR 382-86. He found that Plaintiff had reduced range of motion in 17 her cervical spine but was otherwise normal. Id. He noted x-ray evidence of 18 early degenerative disc disease. AR 386. He opined that Plaintiff was capable 19 of medium work and had no postural or manipulative limitations. Id. 20 On July 12, 2007, another neurologist, Dr. Christine Wong, examined 21 Plaintiff after a referral by Dr. Tomassian. AR 488-90. Upon examination, Dr. 22 Wong found Plaintiff to be neurologically intact but noted psychomotor 23 retardation. AR 489. Dr. Wong suspected a possible diagnosis of decreased 24 intracranial pressure, possibly secondary to a cerebrospinal leak. Id. Dr. Wong 25 noted pseudotumor cerebri as a possible differential diagnosis but found that 26 inconsistent with imaging and other evidence. Id. She recommended an MRI 27 and vision testing. AR 490. The record does not indicate whether Plaintiff 28 followed up with Dr. Wong. 4 On September 20, 2008, another neurologist, Dr. James Lin, examined 1 2 Plaintiff after a referral by Dr. Tomassian. AR 539. The record does not reflect 3 his findings or recommendation. 4 On February 11, 2011, a state-agency consultant, Dr. Sarah Maze, 5 performed a neurological examination of Plaintiff. AR 429-32. Dr. Maze noted 6 that Plaintiff took Tylenol for her frequent head pain, which she described as 7 being a 6 or 7 on a scale of 10. AR 429. Plaintiff reported that a prior 8 doctor s concern that she had pseudotumor cerebri was never confirmed. Id. 9 She had seen an orthopedic surgeon regarding her neck pain. Id. Dr. Maze s 10 findings on examination were normal, with good motor strength and 11 coordination, except for slight blurring of optic disc margins. AR 430, 431. Dr. 12 Maze suspected possible pseudotumor cerebri and noted that Plaintiff had not 13 sought consistent medical attention despite being insured. AR 431. Dr. Maze 14 opined that Plaintiff was capable of medium work with no other restrictions. 15 AR 432; see also AR 433-38. Dr. Maze noted that Plaintiff s subjective 16 complaints cannot be explained by objective findings on exam. AR 438. On February 18, and April 1, and September 23, 2011, Plaintiff saw Dr. 17 18 Faisal Qazi of Inland Neurological Consultants. He found Plaintiff on each 19 visit to be grossly neurologically intact. See AR 446, 448, 451. He assessed 20 neck pain, right greater-occipital-nerve tenderness, chronic migraine without 21 aura, dizziness, and tinnitus. See AR 446, 448, 451-52. Although Dr. Qazi 22 ordered diagnostic testing and requested Plaintiff s prior records, it is unclear 23 whether he received either. See AR 447, 449, 451. He prescribed a migraine 24 preventive (Topamax) and neuropathic pain reliever (gabapentin), but Plaintiff 25 reported no relief from either and side effects from both. See AR 447, 448-49, 26 450. 27 In March 2012, Plaintiff provided both a typed summary of her 28 symptoms and medical history and a form completed by or on behalf of Dr. 5 1 Qazi on November 11, 2011. AR 636-40. The form noted that Dr. Qazi had 2 treated Plaintiff since February 2011 and had diagnosed chronic migraine 3 without aura and neck pain. AR 638. The form noted symptoms of right 4 greater-occipital-nerve tenderness, headache, migraines, fatigue, and epigastric 5 distress syndrome and deemed Plaintiff s prognosis guarded. Id. The form 6 reported that Plaintiff could sit, stand, or walk for zero hours and never lift 7 anything over 10 pounds in an eight-hour day. AR 638-39. The form indicated 8 that Plaintiff required an assistive walking device and was incapable of 9 stooping, pushing, kneeling, prolonged standing or walking, work requiring 10 detailed tasks, repetitive fingering or handling, repetitive reaching, bending, 11 prolonged fixed positioning of the neck, and work requiring hypervigilance. 12 AR 639. Plaintiff was expected to be absent from work more than three times a 13 month because of her impairments. Id. 14 At the March 27, 2012 hearing, medical expert Dr. David Brown 15 testified that the evidence established impairments of myofascial pain disorder, 16 atypical migrainous headaches, mild degenerative disc disease, anemia, history 17 of gastritis, and history of vertigo. See AR 651-53. He opined that there was no 18 evidence of any neuropathology that would cause Plaintiff s headaches and 19 cranial pressure. AR 656. Dr. Brown opined that Plaintiff should be limited to 20 light work with some additional environmental limitations. AR 657-58. 21 B. 22 Applicable Law Three types of physicians may offer opinions in Social Security cases: 23 those who directly treated the plaintiff, those who examined but did not treat 24 the plaintiff, and those who did not treat or examine the plaintiff. See 20 25 C.F.R. § 416.927(c)(2); Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1996). A 26 treating physician s opinion is generally entitled to more weight than that of an 27 examining physician, which is generally entitled to more weight than that of a 28 non-examining physician. Lester, 81 F.3d at 830. Thus, when a treating 6 1 doctor s opinion is not contradicted by another doctor, it may be rejected only 2 for clear and convincing reasons. Id. When a treating doctor s opinion is 3 contradicted by another doctor, the ALJ must provide specific, legitimate 4 reasons based on substantial evidence in the record for rejecting the treating 5 doctor s opinion. Orn v. Astrue, 495 F.3d 625, 632 (9th Cir. 2007); Lester, 81 6 F.3d at 830-31. However, [t]he ALJ need not accept the opinion of any 7 physician, including a treating physician, if that opinion is brief, conclusory, 8 and inadequately supported by clinical findings. Thomas v. Barnhart, 278 9 F.3d 947, 957 (9th Cir. 2002); accord Tonapetyan v. Halter, 242 F.3d 1144, 10 1149 (9th Cir. 2001). 11 C. Analysis 12 The ALJ offered the following reasons for discounting Dr. Qazi s 13 opinion: his limited treatment of Plaintiff; the inconsistency between his 14 opinion and the findings and opinions of her other doctors; that Dr. Qazi dated 15 Plaintiff s symptoms to July 2004 but did not evince knowledge of her medical 16 history predating February 2011; his inclusion of history of meningitis among 17 Plaintiff s diagnoses; and concerns regarding the credibility of the November 18 2011 form. See AR 16-17. Some of these arguably were not legitimate bases for 19 discounting Dr. Qazi s opinion. Because, however, the ALJ s analysis did 20 include other specific, legitimate bases for according Dr. Qazi s opinion little 21 weight, and because the weight of evidence contrary to the statements in the 22 November 2011 form was so great, any error did not alter the ultimate 23 credibility determination, and was therefore harmless. See Carmickle v. 24 Comm r, Soc. Sec. Admin., 533 F.3d 1155, 1162-63 (9th Cir. 2008) (holding 25 that harmless error is error that does not negate validity of ALJ s ultimate 26 credibility determination); Stout v. Comm r, 454 F.3d 1050, 1055 (9th Cir. 27 2006) (nonprejudicial mistakes harmless). 28 The ALJ noted that the record shows that Dr. Qazi saw Plaintiff only 7 1 three times and thus had a limited treatment history with Plaintiff. AR 17. 2 Although the fact that Dr. Qazi saw Plaintiff only three times is not alone a 3 sufficient basis to reject his opinion outright, the ALJ validly considered the 4 length and nature of Dr. Qazi s treatment relationship with the Plaintiff in 5 weighing his opinion. See Orn, 495 F.3d at 631 (noting that factors in assessing 6 treating physician s opinion include length of treatment relationship, frequency 7 of examination, and nature and extent of treatment relationship). 8 9 Dr. Qazi s limited treatment of Plaintiff is particularly noteworthy given that, as the ALJ noted, the findings in the November 2011 form find no 10 support in and frequently contradict the findings of the other doctors who 11 treated or examined plaintiff, including other neurologists. AR 16 ( Other than 12 Dr. Q[a]zi, no other treating physician supports the claimant s allegation of 13 disability and [Dr. Vee, another treating physician,] stated that there was 14 insufficient evidence to even formulate a diagnosis. ); see, e.g., AR 356 (Dr. 15 Fuenzalida), 606 (Dr. Vee); 548 (Dr. Hollcraft); 550 (Dr. Chan); 431 (Dr. 16 Maze). That the statements in the November 2011 form are inconsistent with 17 the findings and opinions of several other doctors was a specific and legitimate 18 reason to accord Dr. Qazi s opinion little weight. See 20 C.F.R. § 19 416.927(c)(4) ( Generally, the more consistent an opinion is with the record as 20 a whole, the more weight we will give to that opinion. ); Tonapetyan, 242 21 F.3d at 1149 (holding that contrary medical opinions based on doctors own 22 findings served as specific and legitimate reasons for rejecting medical opinion 23 unsupported by objective evidence); Houghton v. Comm r Soc. Sec. Admin., 24 493 F. App x 843, 845 (9th Cir. 2012) (holding that ALJ properly discounted 25 treating doctor s opinion in favor of other doctors opinions that were better 26 supported by the evidence and more consistent with the record as a whole ); 27 Buckner-Larkin v. Astrue, 450 F. App x 626, 628 (9th Cir. 2011) (holding that 28 ALJ properly discounted treating physician s opinion that was inconsistent 8 1 with other medical evidence and opinions, including the opinions of other 2 treating and examining physicians ). 3 The ALJ also noted that Dr. Qazi did not indicate in the November 2011 4 form that he had reviewed any of Plaintiff s prior treatment records. AR 17. 5 Although Dr. Qazi appears to have sought Plaintiff s prior records, AR 449, 6 and possibly received some of them, see AR 448 (noting 2004 testing), it is 7 unclear from his treatment notes or the November 2011 form whether and to 8 what extent Dr. Qazi actually reviewed Plaintiff s prior medical history. 9 Because it is unclear how familiar Dr. Qazi was with Plaintiff s prior treatment 10 records, the ALJ legitimately found that Dr. Qazi s opinion could not establish 11 limitations predating his initial visit with Plaintiff in February 2011. See 12 Thomas, 278 F.3d at 957 (ALJ need not accept opinion inadequately 13 supported by clinical findings). 14 To the extent, however, that the ALJ discounted the credibility of 15 Dr. Qazi s assessment of Plaintiff because Dr. Qazi indicated that her 16 limitations first began in July 2004, the ALJ likely erred. See AR 17. Even if 17 Dr. Qazi did not review all of Plaintiff s pre-2011 medical records, he likely 18 knew the date upon which her symptoms began because she was referred to 19 Dr. Qazi by clinicians who had been managing her care since at least 2003. See 20 AR 320-22, 615. The record confirms that Plaintiff first began suffering 21 headaches in July 2004. See, e.g., AR 319, 330, 655. That Dr. Qazi did not 22 begin treating her until 2011 does not alter the date upon which her issues 23 began, even if it limits the period about which he can reasonably opine. 24 The ALJ also likely erred in discounting Dr. Qazi s opinion because his 25 report gives a history of viral meningitis, whereas the record does not 26 establish a meningitis diagnosis. AR 17. Although the ALJ refers to the 27 document noting Plaintiff s history of viral meningitis as Dr. Qazi s report, he 28 appears to reference a treatment record reflecting a follow-up visit with Dr. Vee 9 1 and receipt of medical report from Dr. Qazi. AR 12; see AR 610-11. Indeed, 2 Dr. Qazi s treatment notes do not reflect a history of meningitis but rather 3 prior significant abnormalities on MRI (diffuse meningeal enhancement), 4 meriting additional imaging. AR 447; see also AR 446, 448 (noting only 5 gastritis in section for past medical history). It thus appears that this was not a 6 well-taken basis for discounting Dr. Qazi s opinion. 7 The ALJ also noted some credibility concerns with respect to the 8 November 2011 document. AR 17. Specifically, the November 2011 form was 9 submitted by Plaintiff, rather than Dr. Qazi s office, and appears to contain the 10 handwriting of at least two people. Id. Moreover, as the Commissioner notes 11 (JS at 12), Dr. Qazi s name is misspelled on the form, an error unlikely to be 12 made by him or his staff. AR 639. Although these are reasonable grounds to 13 suspect that the document did not reflect Dr. Qazi s medical opinion, it is a 14 close call whether the ALJ identified sufficient indicia of unreliability to 15 dismiss the document as not credible. 16 The record contains other grounds to reject the opinions contained in the 17 November 2011 form. The form is largely a check-off form, provides only 18 brief, conclusory statements about Plaintiff s symptoms and limitations, and 19 contains no support for the significant limitations indicated therein. See Crane 20 v. Shalala, 76 F.3d 251, 253 (9th Cir. 1996) (holding that ALJ permissibly 21 rejected check-off reports that did not contain any explanation of the bases of 22 their conclusions ); Batson v. Comm r of Soc. Sec. Admin., 359 F.3d 1190, 23 1195 (9th Cir. 2004) (treating physicians opinions properly rejected when 24 conclusory, brief, and inconsistent with the record). 25 Moreover, nothing in the rather extensive treatment notes from 26 Plaintiff s three appointments with Dr. Qazi suggests a finding of limitations as 27 significant as those indicated on the form. Rather, Dr. Qazi found upon 28 examination that Plaintiff was neurologically intact, sought prior records and 10 1 further testing, and attempted to treat her pain with medication. See AR 446- 2 51. See Connett v. Barnhart, 340 F.3d 871, 875 (9th Cir. 2003) (holding that 3 doctor s opinion was properly rejected when treatment notes provide no basis 4 for the functional restrictions he opined should be imposed on [claimant] ); 5 Rollins v. Massanari, 261 F.3d 853, 856 (9th Cir. 2001) (holding that ALJ 6 permissibly rejected treating physician s opinion when opinion was 7 inconsistent with treatment reports). Nor are such limitations consistent with 8 Plaintiff s reliance on Tylenol alone for pain management and her reported 9 activities. See AR 237-38 (Plaintiff stating that she is able to prepare meals, 10 help her children, do chores, bathe, walk short distances, carry light items, and 11 occasionally shop but does so slowly to accommodate fatigue and cranial 12 pressure). 13 It is the ALJ s job to weigh opinion evidence. Lingenfelter, 504 F.3d at 14 1042 ( When evaluating the medical opinions of treating and examining 15 physicians, the ALJ has discretion to weigh the value of each of the various 16 reports, to resolve conflicts in the reports, and to determine which reports to 17 credit and which to reject. ); Morgan v. Comm r of Soc. Sec. Admin., 169 18 F.3d 595, 601 (9th Cir. 1999) (noting that questions of credibility and 19 resolution of conflicts in the testimony are functions solely of the 20 [Commissioner] (internal quotation marks omitted)). To the extent that the 21 ALJ erred in assessing Dr. Qazi s opinion, because the ALJ cited other 22 specific, legitimate reasons to discount Dr. Qazi s opinion, any error was 23 harmless because the ALJ s ultimate credibility determination was unaffected. 24 As is evident from the ALJ s recitation of the medical evidence, the weight of 25 evidence from other doctors, including other neurology specialists and 26 physicians who had treated Plaintiff for years, counseled against accepting the 27 28 11 1 outlier opinion expressed in the November 2011 form.1 See Hamilton v. 2 Comm r Soc. Sec. Admin., 368 F. App x 724, 726 (9th Cir. 2010) (holding that 3 ALJ s failure to explicitly reject treating doctor s assertion of disability was 4 harmless when ALJ s findings contain[ed] numerous specific and legitimate 5 reasons for rejecting a conclusion that [claimant] was disabled and could not 6 work ); Morales v. Colvin, 534 F. App x 589, 591 (9th Cir. 2013) (holding 7 ALJ s error in rejecting opinion of treating medical source harmless where 8 there existed other reasons to reject opinion). 9 10 Plaintiff s claim that the ALJ committed reversible error is accordingly rejected. 11 V. 12 CONCLUSION 13 For the reasons stated above, the decision of the Social Security 14 Commissioner is AFFIRMED and the action is DISMISSED with prejudice. 15 16 Dated: August 26, 2014 ______________________________ DOUGLAS F. McCORMICK United States Magistrate Judge 17 18 19 20 21 22 23 24 25 26 27 1 For the same reason, the ALJ had no duty to further develop the record by contacting Dr. Qazi. See Mayes v. Massanari, 276 F.3d 453, 459-60 (9th Cir. 2001) (ALJ s duty to further develop record triggered only when record contains ambiguous evidence or is inadequate to allow for proper evaluation of evidence); cf. Brinegar v. Astrue, 337 F. App x 711, 712 (9th Cir. 2009). 28 12
]]>
Some case metadata and case summaries were written with the help of AI, which can produce inaccuracies. You
should read the full case before relying on it for legal research purposes.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
