Sheila Jeanette Stephens v. Carolyn W. Colvin, 2:16-cv-02759

Background

Plaintiff Sheila Jeanette Stephens applied for Social Security disability insurance benefits on June 6, 2012; ALJ denied benefits in a decision dated January 9, 2015; Appeals Council denied review and plaintiff sued.
At step two the ALJ found severe impairments including obesity, bilateral knee degenerative joint disease, asthma, pansinusitis, affective disorder, and polyarthritis (lupus/fibromyalgia).
The ALJ assessed an RFC for light work with multiple limitations (sit/stand 6 of 8 hours, occasional posturals, frequent handling/fingering, no concentrated respiratory irritants, simple repetitive tasks, superficial public contact).
At step five the ALJ found jobs existed that plaintiff could perform and ruled not disabled.
Medical expert Dr. Harvey Alpern (telephonic) opined plaintiff more likely than not meets criteria for fibromyalgia; an examining rheumatologist (Dr. Ahmed) found diagnosis "most consistent with fibromyalgia" and documented multiple tender points and IBS.
The ALJ rejected Dr. Alpern’s opinion, reasoning the record lacked a solid diagnosis supported by tender-point discussion and associated problems; the district court found the ALJ’s reasons were not specific and legitimate and remanded for further proceedings.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether the ALJ properly rejected the non-examining medical expert’s fibromyalgia opinion	ALJ improperly rejected Dr. Alpern without specific and legitimate reasons; record contains rheumatologist findings (tender points, IBS) supporting fibromyalgia	ALJ permissibly discounted the opinion because the record allegedly lacked the detailed tender-point documentation required for fibromyalgia	Court held the ALJ failed to give specific and legitimate reasons; rejection not supported by substantial evidence and ALJ should have further developed record
Whether the ALJ fulfilled duty to develop the record concerning fibromyalgia diagnosis	Stephens: ALJ had duty to inquire further when record ambiguous about diagnostic basis	Commissioner: record did not show required diagnostic detail so ALJ permissibly relied on absence of documentation	Court held ALJ should have probed further; record ambiguous and further development is required
Whether error was harmless	Stephens: error affected dispositive medical opinion and prevented meaningful review	Commissioner: alleged defects were harmless because other evidence supported RFC	Court held error was not harmless and precluded meaningful review

Key Cases Cited

Treichler v. Comm’r of Soc. Sec. Admin., 775 F.3d 1090 (9th Cir. 2014) (standard for remand when record ambiguous and whether further proceedings would be useful)
Richardson v. Perales, 402 U.S. 389 (U.S. 1971) (definition of substantial evidence)
Lingenfelter v. Astrue, 504 F.3d 1028 (9th Cir. 2007) (review requires weighing whole record)
Orn v. Astrue, 495 F.3d 625 (9th Cir. 2007) (benefit of reasonable inferences to agency when record supports more than one interpretation)
Burrell v. Colvin, 775 F.3d 1133 (9th Cir. 2014) (ALJ may not rely on impermissible or unexplained inferences from claimant’s appearance/testimony)
Morgan v. Comm’r of Social Sec. Admin., 169 F.3d 595 (9th Cir. 1999) (nonexamining opinions can be substantial evidence if supported and consistent with record)
Holohan v. Massanari, 246 F.3d 1195 (9th Cir. 2001) (error to selectively rely on treatment notes to reject opinions)
Smolen v. Chater, 80 F.3d 1273 (9th Cir. 1996) (ALJ’s duty to fully and fairly develop the record)
Brown v. Heckler, 713 F.2d 441 (9th Cir. 1983) (ALJ's duty to develop record exists even with counsel)
Molina v. Astrue, 674 F.3d 1104 (9th Cir. 2012) (harmless error framework in Social Security cases)
Brown-Hunter v. Colvin, 806 F.3d 487 (9th Cir. 2015) (need for adequate reasons so reviewing court can follow ALJ’s reasoning)
Garrison v. Colvin, 759 F.3d 995 (9th Cir. 2014) (framework for credit-as-true doctrine and remand for benefits)
Andrews v. Shalala, 53 F.3d 1035 (9th Cir. 1995) (nonexamining medical advisor opinions may serve as substantial evidence when consistent with record)
Benecke v. Barnhart, 379 F.3d 587 (9th Cir. 2004) (rheumatologists may be particularly qualified to evaluate fibromyalgia)