1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 CENTRAL DISTRICT OF CALIFORNIA 10 KAREN TREJO H.,1 ) Case No. CV 19-7378-JPR 11 ) Plaintiff, ) 12 ) MEMORANDUM DECISION AND ORDER v. ) AFFIRMING COMMISSIONER 13 )

ANDREW M. SAUL, )

14 Commissioner of Social ) Security, ) 15 ) Defendant. ) 16 17

I. PROCEEDINGS

18 Plaintiff seeks review of the Commissioner’s final decision 19 denying her application for Social Security supplemental security 20 income benefits (“SSI”). The parties consented to the 21 jurisdiction of the undersigned U.S. Magistrate Judge under 28 22 U.S.C. § 636(c). The matter is before the Court on the parties’ 23 Joint Stipulation, filed July 20, 2020, which the Court has taken 24 under submission without oral argument. For the reasons stated 25 26 1 Plaintiff’s name is partially redacted in line with 27 Federal Rule of Civil Procedure 5.2(c)(2)(B) and the recommendation of the Committee on Court Administration and Case 28 Management of the Judicial Conference of the United States. 1 1 below, the Commissioner’s decision is affirmed. 2 II. BACKGROUND 3 Plaintiff was born in 1981 and moved to the United States 4 from Honduras around 1990. (See Administrative Record (“AR”) 5 118, 251.) She graduated high school in 2000 and worked part 6 time as a nurse’s assistant or caregiver from March 2009 until 7 September 2011. (AR 135-36.) 8 On November 18, 2011, Plaintiff applied for SSI, alleging 9 that she had been unable to work full time since July 1, 2004, 10 because of chronic cocci meningitis.2 (AR 118, 135; see AR 29.) 11 After her applications were denied initially and on 12 reconsideration (AR 75, 80; see also AR 54, 65), she requested a 13 hearing before an Administrative Law Judge (AR 85). One was held 14 on August 29, 2013, at which Plaintiff appeared without 15 representation and testified through a Spanish-language 16 interpreter. (AR 38-40, 42-43, 115-17.) The ALJ issued an 17 unfavorable decision on November 5, 2013, finding that she was 18 not disabled as of her filing date, November 18, 2011.3 (AR 20, 19 27.) After retaining counsel, Plaintiff requested review from 20 the Appeals Council (AR 15-16), which denied it on April 23, 2015 21 (AR 1). 22 Plaintiff appealed (AR 576-78, 596-600), and on September 23 24 2 Cocci meningitis is a form of “disseminated” coccidioidomycosis, colloquially referred to as “Valley Fever,” 25 in which a fungal infection spreads throughout the body. See 26 Edison v. United States, 822 F.3d 510, 513-14 (9th Cir. 2016). 27 3 Because SSI payments may not be awarded retroactively, Plaintiff’s effective onset date is her filing date. See SSR 83- 28 20, 1983 WL 31249, at *1 (1983). 2 1 27, 2016, this Court reversed and remanded for further 2 administrative proceedings (AR 579-95). On June 28 and September 3 20, 2018, and January 23 and May 22, 2019, the ALJ conducted 4 additional hearings, at which Plaintiff, who was represented by 5 counsel, her mother, her aunt, and a VE testified. (See AR 457- 6 550.) In a written decision dated June 13, 2019, the ALJ again 7 found Plaintiff not disabled. (AR 429-49.) This action 8 followed. 9 III. STANDARD OF REVIEW 10 Under 42 U.S.C. § 405(g), a district court may review the 11 Commissioner’s decision to deny benefits. The ALJ’s findings and 12 decision should be upheld if they are free of legal error and 13 supported by substantial evidence based on the record as a whole. 14 See Richardson v. Perales, 402 U.S. 389, 401 (1971); Parra v. 15 Astrue, 481 F.3d 742, 746 (9th Cir. 2007). Substantial evidence 16 means such evidence as a reasonable person might accept as 17 adequate to support a conclusion. Richardson, 402 U.S. at 401; 18 Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007). It 19 is “more than a mere scintilla, but less than a preponderance.” 20 Lingenfelter, 504 F.3d at 1035 (citing Robbins v. Soc. Sec. 21 Admin., 466 F.3d 880, 882 (9th Cir. 2006)). “[W]hatever the 22 meaning of ‘substantial’ in other contexts, the threshold for 23 such evidentiary sufficiency is not high.” Biestek v. Berryhill, 24 139 S. Ct. 1148, 1154 (2019). To determine whether substantial 25 evidence supports a finding, the court “must review the 26 administrative record as a whole, weighing both the evidence that 27 supports and the evidence that detracts from the Commissioner’s 28 conclusion.” Reddick v. Chater, 157 F.3d 715, 720 (9th Cir. 3 1 1998). “If the evidence can reasonably support either affirming 2 or reversing,” the reviewing court “may not substitute its 3 judgment” for the Commissioner’s. Id. at 720-21. 4 IV. THE EVALUATION OF DISABILITY 5 People are “disabled” for Social Security purposes if they 6 can’t engage in any substantial gainful activity owing to a 7 physical or mental impairment that is expected to result in death 8 or has lasted, or is expected to last, for a continuous period of 9 at least 12 months. 42 U.S.C. § 423(d)(1)(A); Drouin v. 10 Sullivan, 966 F.2d 1255, 1257 (9th Cir. 1992). 11 A. The Five-Step Evaluation Process 12 An ALJ follows a five-step sequential evaluation process to 13 assess whether someone is disabled. 20 C.F.R. § 416.920(a)(4); 14 Lester v. Chater, 81 F.3d 821, 828 n.5 (9th Cir. 1995) (as 15 amended Apr. 9, 1996). In the first step, the Commissioner must 16 determine whether the claimant is currently engaged in 17 substantial gainful activity; if so, the claimant is not disabled 18 and the claim must be denied. § 416.920(a)(4)(i). If not, the 19 second step requires the Commissioner to determine whether the 20 claimant has a “severe” impairment or combination of impairments 21 significantly limiting her ability to do basic work activities; 22 if not, a finding of not disabled is made and the claim must be 23 denied. § 416.920(a)(4)(ii). 24 If the claimant has a “severe” impairment or combination of 25 impairments, the third step requires the Commissioner to 26 determine whether the impairment or combination of impairments 27 meets or equals an impairment in the Listing of Impairments 28 (“Listing”) set forth at 20 C.F.R., part 404, subpart P, appendix 4 1 1; if so, disability is conclusively presumed and benefits are 2 awarded. § 416.920(a)(4)(iii). If not, the fourth step requires 3 the Commissioner to determine whether the claimant has sufficient 4 residual functional capacity (“RFC”)4 to perform her past work; 5 if so, she is not disabled and the claim must be denied. 6 § 416.920(a)(4)(iv). The claimant has the burden of proving she 7 is unable to perform past relevant work. Drouin, 966 F.2d at 8 1257. If the claimant meets that burden, a prima facie case of 9 disability is established. Id. 10 If that happens or if the claimant has no past relevant 11 work, the Commissioner bears the burden of establishing that the 12 claimant is not disabled because she can perform other 13 substantial gainful work available in the national economy, the 14 fifth and final step of the sequential analysis. 15 § 416.920(a)(4)(v). 16 B. The ALJ’s Application of the Five-Step Process 17 At step one, the ALJ found that Plaintiff had not engaged in 18 substantial gainful activity since November 18, 2011, the 19 application date. (AR 438.) At step two, he determined that she 20 had severe impairments of “chronic cocci meningitis, status post 21 ventricular peritoneal shunt,” and hydrocephalus.5 (Id.) He 22 23 4 RFC is what a claimant can do despite existing exertional and nonexertional limitations. § 416.945; see Cooper v. 24 Sullivan, 880 F.2d 1152, 1155 n.5 (9th Cir. 1989). The Commissioner assesses the claimant’s RFC between steps three and 25 four. Laborin v. Berryhill, 867 F.3d 1151, 1153 (9th Cir. 2017) 26 (citing § 416.920(a)(4)). 27 5 Hydrocephalus results from an excessive accumulation of cerebrospinal fluid in the brain, causing abnormal widening of 28 (continued...) 5 1 concluded that her low-back condition and left-leg pain were not 2 severe because there was “little objective medical evidence for 3 these conditions, and the record show[ed] that the pain she 4 reported was intermittent, addressed primarily with over-the- 5 counter medication, and did not continue in any significant way 6 after November 2015.” (AR 441.) At step three, he found that 7 her impairments did not meet or equal a Listing. (Id.) At step 8 four, he determined that she had the RFC to perform light work 9 with some limitations: she was “able to lift or carry up to 20 10 pounds occasionally [and] 10 pounds frequently”; could “stand or 11 walk for up to 6 hours of an 8-hour workday”; could “sit for up 12 to 8 hours cumulatively in an 8-hour workday”; could 13 “occasionally climb, bend, kneel, and stoop”; “must avoid 14 crawling”; could “less than occasionally push or pull and reach 15 above shoulder level on the bilateral upper extremities”; “should 16 not work at dangerous heights, climb ladders, or operate 17 dangerous, moving machinery”; and “must avoid driving a motor 18 vehicle or ambulating over uneven terrain.” (AR 441-42.) The 19 ALJ found her unable to perform any past relevant work (AR 447), 20 but she could work in other positions existing in significant 21 numbers in the national economy (AR 447-48). Accordingly, he 22 found her not disabled. (AR 448-49.) 23 24 25 5 (...continued) 26 spaces in brain ventricles and potentially harmful pressure on brain tissues. Hydrocephalus Fact Sheet, Nat’l Inst. Neuro. 27 Disorders & Stroke, http://www.ninds.nih.gov/disorders/ hydrocephalus/detail_hydrocephalus.htm (last visited June 22, 28 2021). 6 1 V. DISCUSSION 2 Plaintiff alleges that the ALJ erred in assessing her 3 symptom testimony and the statements and testimony of her aunt 4 and mother and therefore erroneously concluded that she was not 5 disabled. (See J. Stip. at 4-7, 9-12, 17-18.) For the reasons 6 discussed below, the ALJ properly discounted her symptom 7 statements, and any error in assessing the lay-witness testimony 8 was harmless. 9 A. The ALJ Properly Discounted Plaintiff’s Symptom 10 Statements 11 Plaintiff asserts that the ALJ failed to properly evaluate 12 her subjective symptom statements. (J. Stip. at 9-12.) For the 13 reasons discussed below, the ALJ did not err. 14 1. Applicable law 15 An ALJ’s assessment of a claimant’s allegations concerning 16 the severity of her symptoms is entitled to “great weight.” 17 Weetman v. Sullivan, 877 F.2d 20, 22 (9th Cir. 1989) (as 18 amended); Nyman v. Heckler, 779 F.2d 528, 531 (9th Cir. 1985) (as 19 amended Feb. 24, 1986). “[T]he ALJ is not ‘required to believe 20 every allegation of disabling pain, or else disability benefits 21 would be available for the asking, a result plainly contrary to 22 42 U.S.C. § 423(d)(5)(A).’” Molina v. Astrue, 674 F.3d 1104, 23 1112 (9th Cir. 2012) (quoting Fair v. Bowen, 885 F.2d 597, 603 24 (9th Cir. 1989)). 25 In evaluating a claimant’s subjective symptom testimony, the 26 ALJ engages in a two-step analysis. See Lingenfelter, 504 F.3d 27 at 1035-36; see also SSR 16-3p, 2016 WL 1119029, at *3 (Mar. 16, 28 2016). “First, the ALJ must determine whether the claimant has 7 1 presented objective medical evidence of an underlying impairment 2 ‘[that] could reasonably be expected to produce the pain or other 3 symptoms alleged.’” Lingenfelter, 504 F.3d at 1036 (quoting 4 Bunnell v. Sullivan, 947 F.2d 341, 344 (9th Cir. 1991)). If such 5 objective medical evidence exists, the ALJ may not reject a 6 claimant’s testimony about the severity of her symptoms merely 7 because it lacks evidential support. See id. 8 If the claimant meets the first test, the ALJ may discount 9 her subjective symptom testimony only if he makes specific 10 findings that support the conclusion. See Berry v. Astrue, 622 11 F.3d 1228, 1234 (9th Cir. 2010). Absent a finding or affirmative 12 evidence of malingering, the ALJ must provide a “clear and 13 convincing” reason for rejecting the claimant’s testimony. 14 Brown-Hunter v. Colvin, 806 F.3d 487, 493 (9th Cir. 2015) (as 15 amended) (citing Lingenfelter, 504 F.3d at 1036); Treichler v. 16 Comm’r of Soc. Sec. Admin., 775 F.3d 1090, 1102 (9th Cir. 2014). 17 The ALJ may consider, among other factors, the claimant’s (1) 18 reputation for truthfulness, prior inconsistent statements, and 19 other testimony that appears less than candid; (2) unexplained or 20 inadequately explained failure to seek treatment or to follow a 21 prescribed course of treatment; (3) daily activities; (4) work 22 record; and (5) physicians’ and third parties’ statements. See 23 Rounds v. Comm’r Soc. Sec. Admin., 807 F.3d 996, 1006 (9th Cir. 24 2015) (as amended); Thomas v. Barnhart, 278 F.3d 947, 958-59 (9th 25 Cir. 2002). If the ALJ’s evaluation of a plaintiff’s alleged 26 symptoms is supported by substantial evidence in the record, the 27 reviewing court “may not engage in second-guessing.” Thomas, 278 28 F.3d at 959. 8 1 2. Relevant background 2 a. Plaintiff’s Medical History 3 In 2004, Plaintiff was diagnosed with recurrent cocci 4 meningitis and “communicating” hydrocephalus.6 (AR 237, 400-02.) 5 She was prescribed voriconazole7 on a long-term basis. (AR 237.) 6 She was hospitalized overnight in 2009 with a flare-up. (AR 391- 7 93.) An October 2011 brain scan showed “hydrocephalus with 8 enlarged lateral and third ventricles,” with “hypodensity 9 surrounding the frontal horns of the lateral ventricles, 10 suggestive of transependymal fluid flow.”8 (AR 237-38.) In 11 October 2011, she stopped taking her medication because she 12 wanted to become pregnant, but she soon required hospitalization 13 after developing worsening headaches, nausea, and vomiting. (AR 14 237, 242.) A shunt was placed in her brain. (AR 237.) 15 Following this surgery, she reported that she was “doing well,” 16 with some dizziness but none of the headaches, nausea, or blurred 17 18 6 “Communicating” means that cerebrospinal fluid can still 19 flow between the ventricles, which remain open. See Hydrocephalus, Health, https://www.hopkinsmedicine.org/health/ 20 conditions-and-diseases/hydrocephalus (last visited June 22, 2021). 21 22 7 Voriconazole is used to treat a variety of fungal infections. See Voriconazole, WebMD, https://www.webmd.com/ 23 drugs/2/drug-63366-5326/voriconazole-oral/voriconazole-oral/ details (last visited June 22, 2021). 24 8 Transependymal fluid flow occurs when increased pressure 25 within the cerebral ventricles causes the ependymal lining to be 26 disrupted and allows the migration of cerebrospinal fluid into the brain parenchyma around the cerebral ventricles. 27 Transependymal Edema, Radiopaedia, https://radiopaedia.org/ articles/transependymal-oedema (last visited June 29, 2021). It 28 usually occurs during acute obstructive hydrocephalus. Id. 9 1 vision she had experienced before the surgery. (AR 2364.) 2 In March and April 2013, she was “stable,” and in August 3 2013, her condition was “well controlled on voriconazole without 4 symptoms.” (Suppl. AR 1225-26, 1229, 1231.)9 In August 2014, 5 she reported having headaches three or four times a month but 6 said that had “improved from before” the shunt was placed. 7 (Suppl. AR 1218.) 8 In August 2014, she became pregnant against medical advice. 9 (Suppl. AR 1214, 1285.) She had a catheter placed in September 10 and began taking a different, intravenous medication. (Suppl. AR 11 1209-13, 1283.) Her pregnancy was ectopic and was discontinued 12 (Suppl. AR 1274-75, 1278), and she resumed taking voriconazole 13 (Suppl. AR 1144). 14 In August 2015, she had a headache, which she treated with 15 ibuprofen with “good relief.” (Suppl. AR 1090.) She refused her 16 doctor’s recommendation to go to the emergency department for 17 further evaluation. (Suppl. AR 1091.) 18 A September 2015 CT scan of her brain showed “slit-like” 19 lateral and third ventricles, but the fourth ventricle appeared 20 “slightly larger” than in the previous CT scan, which “rais[ed a] 21 suspicion for focal entrapment.”10 (Suppl. AR 1257.) But there 22 23 9 Exhibit 9F was not included in the Certified Administrative Record filed with the Court on February 26, 2020. 24 On January 14, 2021, prompted by the Court, Defendant filed Exhibit 9F and paginated it 1086 through 1291. Because the 25 original AR includes different documents with those page numbers 26 (see AR 1086-291), the Court uses “Suppl. AR” in referring to the pages of Exhibit 9F. 27 10 Focal entrapment of a ventricle is an obstruction to the 28 (continued...) 10 1 was no hydrocephalus, “extra-axial fluid collections,” or edema 2 along the shunt catheter. (Id.) That same month, she complained 3 of right-sided “intermittent, throbbing . . . headache[s]” and 4 reported having “some dizziness.” (Suppl. AR 1086.) On November 5 6, she reported having a headache that had started the previous 6 week, but ibuprofen provided “good relief.” (AR 1251.) Kernig11 7 and Brudzinski12 tests were negative, and she deferred going to 8 the emergency department because the headache was not severe and 9 she was otherwise asymptomatic. (Id.) 10 In January 2016, she reported that her headaches had 11 returned. (AR 1465.) But they were “much less severe” than when 12 she had meningitis, and she had no dizziness, nausea, or 13 phonophobia.13 (Id.) Ibuprofen provided relief. (Id.) A 14 15 10 (...continued) entry and exit path of cerebrospinal fluid through the ventricle. 16 Trapped Ventricle, Radiopaedia, https://radiopaedia.org/articles/ 17 trapped-ventricle (last visited June 29, 2021). 18 11 A Kernig sign indicates the presence of meningitis. Medical Definition of Kernig Sign, MedicineNet, https:// 19 www.medicinenet.com/kernig_sign/definition.htm (last visited June 22, 2021). The test is done by having the person lie flat 20 on the back, flex the thigh so that it is at a right angle to the trunk, and completely extend the leg at the knee joint. Id. If 21 the leg cannot be completely extended because of pain, that may 22 indicate meningitis. Id. 23 12 A Brudzinski test is used to diagnose meningitis. Brudzinski’s Sign, Physiopedia, https://www.physio-pedia.com/ 24 Brudzinski%E2%80%99s_Sign (last visited June 22, 2021). Severe neck stiffness causes a patient’s hips and knees to flex when the 25 neck is flexed, which is a symptom of meningitis. Id. 26 13 Phonophobia is an intolerance of or hypersensitivity to 27 sound. Phonophobia, Merriam-Webster, https:// www.merriam-webster.com/dictionary/phonophobia (last visited June 28 30, 2021). 11 1 February 2016 brain scan revealed that her “shunt catheter tip 2 placement” was “stable.” (AR 1362.) Her lateral and third 3 ventricles were “slightly enlarged when compared to” a September 4 2015 scan “but remain[ed] small to normal in size.” (Id.) The 5 fourth ventricle was “enlarged and slightly larger when compared 6 to [the] prior CT” scan. (Id.) In August 2016, she reported 7 that she had headaches two or three times a week, but they 8 “completely improve[d] with ibuprofen.” (AR 1190.) She stated 9 that she was under a lot of stress because of a “recent divorsc 10 [sic] and living with parents, trying to find a job.” (Id.) On 11 December 5, 2016, she reported that her headaches were 12 “improved,” and she was taking ibuprofen as needed up to three 13 times a week. (AR 1069.) On December 8, she discontinued 14 voriconazole because of a skin reaction and began taking 15 posaconazole.14 (AR 1026.) 16 On January 9, 2017, Plaintiff had a head CT scan, which 17 showed “[n]o significant change from the prior examination,” with 18 the “shunt . . . in stable position with unchanged size of the 19 ventricular system.” (AR 1991.) She reported “intermittent 20 headaches” on January 17, 2017, but said they were relieved by 21 over-the-counter medication; she denied any other complaints. 22 (AR 2068.) During an examination, she could “[m]ove all 23 extremities without difficulty” and had “5/5 strength 24 25 14 Posaconazole is an antifungal used to prevent fungal 26 infections in patients who have weakened immune systems. See Posaconazole 100 Mg Tablet, Delayed Release Azole Antifungals- 27 Systemic, WebMD, https://www.webmd.com/drugs/2/drug-145142-1598/ posaconazole-oral/posaconazole-delayed-release-oral/details (last 28 visited June 22, 2021). 12 1 throughout,” a “[s]teady gait upon ambulation,” and no pain. 2 (Id.) In March 2017, she reported that she was taking 3 posaconazole without any issues and denied having any headaches, 4 nausea, or vomiting. (AR 1990.) In September 2017, she again 5 reported that she was “doing well,” with “no issues,” and denied 6 having headaches, nausea, or vomiting. (AR 1942.) 7 In November 2017, she complained of a “few episodes of 8 confusion” within the previous two weeks, “including not knowing 9 where she was” and being “slower in answers.” (AR 1858.) She 10 denied having any headaches, fever, chills, neck pain, or 11 stiffness. (Id.) She was referred to a neurologist. (AR 1859.) 12 On November 30, 2017, she reported that her “episodes of 13 confusion ha[d] completely resolved.” (AR 1775.) On that date, 14 “[s]he was fully oriented to person, place, and time, and knew 15 who the president was.” (Id.) “Her conversation was fluid,” 16 “without hesitation or delay,” and she “denie[d] any headaches, 17 fever/chills/sweats.” (Id.) During a neurological examination 18 on December 7, 2017, she presented with “no complaints” and 19 “continue[d] to have resolution of her confusion issues.” (AR 20 1693.) Her examination was “unremarkable,” and the neurologist 21 noted that the “most likely causes” of the confusion episodes 22 were “sleep deprivation and/or stress in her life.” (AR 1694.) 23 Plaintiff had a head CT scan on December 12, 2017, in which 24 “[t]he lateral and 3rd ventricles appear[ed] well-decompressed, 25 without significant interval change in size, although minimally 26 larger than the prior examination.” (AR 1652.) “The 4th 27 ventricle [was] enlarged, but grossly unchanged from the prior 28 examination.” (Id.) There was “no gross acute infarct, mass, 13 1 bleed, midline shift, or abnormal extra-axial fluid collections.” 2 (Id.) 3 On February 1, 2018, she reported that she had been 4 “persistently without symptoms since November” and denied any 5 dizziness, confusion, difficulty walking, or headache. (AR 6 1565.) She again denied any symptoms on February 13, 2018, and 7 was “neuro[logically] intact.” (AR 2066.) 8 On March 2, 2018, she went to an emergency department with 9 confusion and headache. (AR 2251.) She refused a head scan 10 because she was pregnant and underwent an MRI, which revealed no 11 issues with her shunt. (Id.) A March 5, 2018 head scan showed 12 that her “ventricular shunt [was] in place,” with “mild to 13 moderate hydrocephalus, unchanged in degree from [the] prior 14 MRI.” (AR 2082.) There was no hemorrhage, extra-axial fluid 15 collections, or masses. (Id.) Despite the lack of changes, 16 Plaintiff underwent a right frontal shunt revision that day. 17 (AR 2265.) The next day she complained of dizziness and 18 “difficulty fixating” (AR 2270), demonstrated a “slow, cautious 19 gait,” “required occasional assistance to manage [a] front 20 wheeled walker,” and her walking “[d]istance [was] limited by 21 fatigue” (AR 2274). While she was in the hospital it was 22 discovered that her pregnancy had ended as a result of a 23 spontaneous abortion. (AR 2278.) A March 8 head CT scan 24 confirmed that the ventricular shunt had been revised and showed 25 that the lateral ventricles and the third ventricle were 26 “significantly decreased in size,” but the fourth ventricle 27 “remain[ed] unchanged in size.” (AR 2076.) On March 20, 2018, 28 Plaintiff reported that she was “doing well,” with “no headaches, 14 1 nausea, vomiting, dizziness or confusion.” (AR 2297.) 2 In October 2018, Plaintiff again became pregnant. (AR 3 4243.) She stopped taking posaconazole (AR 4044) and started 4 undergoing intravenous infusion of Ambisome15 through her first 5 trimester of pregnancy. (AR 4636.) In January 2019, she was 6 “doing well,” had “occasional nausea,” which she thought was “due 7 to pregnancy,” and had “[n]o other neuro[logical symptoms].” 8 (AR 7119.) 9 b. The ALJ’s Decision 10 The ALJ noted that Plaintiff 11 testified she has many headaches, dizziness, loss of 12 balance, and back pain. She testified she becomes dizzy 13 when she bends over, and she moves around slowly. She 14 testified she does not take public transportation alone, 15 and her aunt goes with her when she goes out to walk. 16 She testified her aunt helps her with bathing, caring for 17 her hair, and cooking. She testified she must rest 18 during the day because she feels weak and fatigued. She 19 testified she has headaches every day, for which she 20 takes Tylenol. She testified . . . she was forgetting 21 things prior to her surgery in March 2018, and her memory 22 has not improved since then. 23 (AR 442.) The ALJ reviewed these claimed limitations and found 24 that her “medically determinable impairment[s] could reasonably 25 26 15 Ambisome is used to treat a variety of serious fungal infections in patients who cannot tolerate other treatments and 27 is usually given by injection. Ambisome Vial, WebMD, https:// www.webmd.com/drugs/2/drug-6421/ambisome-intravenous/details 28 (last visited June 22, 2021). 15 1 be expected to cause the alleged symptoms; however, [her] 2 statements concerning the intensity, persistence and limiting 3 effects of these symptoms [were] not entirely consistent with the 4 medical evidence and other evidence in the record.” (AR 443.) 5 He discounted her subjective symptom statements because they were 6 inconsistent with the medical record. The medical record 7 shows relatively few complaints of headaches, dizziness, 8 or other symptomology. 9 (Id.) 10 He also noted that her symptom statements were inconsistent 11 with her conservative treatment, stating that 12 except for when she stopped taking her medication in 13 October 2011, she uniformly reported that ibuprofen 14 resolved the headaches, and the record contain[ed] little 15 or no evidence of [her] requiring stronger medication for 16 her headaches. 17 (Id.) 18 Next, he found her symptom statements inconsistent with her 19 admitted daily activities, noting that 20 [i]n August 2014, she reported she had gone to Guatemala 21 a couple of months before. In September 2015, she was 22 planning to travel to Brazil . . . . 23 At her first occupational therapy visit after the 24 March 2018 revision of her shunt [she] indicated she 25 previously had no limitation, was driving, and enjoyed 26 dancing . . . . 27 At the consultative psychological evaluation, 28 [Plaintiff] reported watching television, listening to 16 1 music, caring for pets, exercising, . . . performing 2 household chores[,] . . . socializing with friends on 3 weekends[, and] . . . work[ing] as a babysitter from 4 approximately 2005 to 2006 until 2012. 5 (AR 444-45 (some citations omitted).) 6 Finally, he noted that despite her alleged debilitating 7 symptoms, “in much of the medical record,” her “primary concern 8 appear[ed] to be with contraception or conceiving a child.” 9 (AR 445.) 10 3. Analysis 11 Plaintiff challenges the ALJ’s discounting of her subjective 12 symptom statements. (See J. Stip. at 9-12.) For the reasons 13 discussed below, the ALJ did not err. 14 a. Plaintiff’s Symptom Statements and Testimony 15 i. Medical and other evidence 16 The ALJ properly concluded that Plaintiff’s subjective 17 symptom statements were inconsistent with the medical record’s 18 “relatively few complaints of headaches, dizziness, or other 19 symptomology.” (AR 443); Morgan v. Comm’r of Soc. Sec. Admin., 20 169 F.3d 595, 600 (9th Cir. 1999) (finding “conflict” with 21 “objective medical evidence in the record” to be “specific and 22 substantial reason[]” undermining plaintiff’s allegations); 23 § 416.929(c)(2). Among other things, the ALJ noted that neither 24 of two consultative internal-medicine evaluations supported the 25 “low level of functionality” Plaintiff claimed. (AR 443.) A 26 February 2012 evaluation noted that she reported having 27 “occasional headaches” and “sometimes get[ting] dizzy.” (AR 28 289.) She denied any fatigue, seizures, or other medical 17 1 problems. (Id.) Her memory “appeared to be average,” and she 2 “appeared to be in no acute distress.” (AR 290.) She 3 “ambulate[d] with a normal gait,” exhibited “no evidence of 4 incoordination,” and was able to perform a tandem walk. (AR 291- 5 92.) Her cerebellar testing was “intact without dysmetria16 on 6 finger-to-nose,” and heel-to-shin testing was intact. (AR 292.) 7 At an April 2018 consultative evaluation, she walked with a 8 normal gait and balance, exhibited normal muscle bulk and tone 9 without atrophy, and had 5/5 strength throughout without focal 10 motor deficits except for some weakness in her grip. (AR 443; 11 see AR 2427-29.) She reported having chronic daily headaches (AR 12 2426), but three weeks later she denied any headaches to her own 13 medical provider and reported “feeling well with no specific 14 concerns or questions.” (AR 2519.) 15 And as the ALJ noted, treatment records indicate that her 16 symptoms were not as severe or frequent as she described. For 17 instance, her reported dizziness and confusion reported in mid- 18 November 2017 had completely resolved on its own by November 30. 19 (AR 1775.) During a December neurological examination she 20 reported that the confusion had not returned. (AR 1693.) The 21 medical records showed that her headaches, too, were less 22 frequent and debilitating than she described. She reported on 23 numerous dates that she had no headaches or other symptoms, that 24 any headaches were only occasional, and that they were well 25 26 16 Dysmetria is the inability to control the distance, speed, and range of motion necessary to perform smoothly 27 coordinated movements. Dysmetria: What Is It, Causes, Diagnosis, Treatment, and More, Osmosis, https://www.osmosis.org/answers/ 28 dysmetria (last visited June 29, 2021). 18 1 controlled with ibuprofen. (See AR 1251 (Nov. 2015), 1465 (Jan. 2 2016), 1190 (Aug. 2016), 1069 (Dec. 2016), 2068 (Jan. 2017), 1942 3 (Sept. 2017), 1775 (Nov. 2017), 1858 (Nov. 2017), 1693-94 (Dec. 4 2017), 1565 (Feb. 2018), 2066 (Feb. 2018), 2297 (Mar. 2018).) 5 At most, the few records cited by Plaintiff establish that 6 the medical evidence was susceptible of more than one rational 7 interpretation, which is insufficient to warrant reversal. See 8 Molina, 674 F.3d at 1111 (holding that in such circumstances “we 9 must uphold the ALJ’s findings if they are supported by 10 inferences reasonably drawn from the record”); Tommasetti v. 11 Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008) (ALJ is “final 12 arbiter with respect to resolving ambiguities in the medical 13 evidence”). The ALJ properly considered the objective record in 14 discounting Plaintiff’s symptom statements. 15 ii. Conservative treatment 16 The ALJ properly discounted Plaintiff’s allegations because 17 the record showed that her symptoms were generally controlled 18 with conservative treatment. As an initial matter, Plaintiff has 19 not discussed or contested the ALJ’s reliance on this reason to 20 discount her symptom statements. By failing to do so, she 21 implicitly concedes its legitimacy. See Arlene R.M. v. Comm’r of 22 Soc. Sec., No. 17-CV-370-FVS, 2019 WL 267912, at *5 (E.D. Wash. 23 Jan. 18, 2019) (rejecting plaintiff’s argument that her 24 “credibility” was “bolstered” by certain evidence when she 25 “fail[ed] to address the reasons cited by the ALJ or demonstrate 26 any error”). For that reason alone, remand is not warranted on 27 this claim. In any event, this reason and the others the ALJ 28 gave were clear and convincing and fully supported by the record. 19 1 Parra, 481 F.3d at 750-51 (finding “conservative treatment,” such 2 as “treat[ment] with an over-the-counter pain medication,” 3 sufficient to discount claimant’s testimony as to severity of 4 impairment). Although Plaintiff took various medications for her 5 chronic cocci meningitis and periodically underwent scans to 6 evaluate her headaches, she repeatedly reported that the latter 7 resolved with ibuprofen, and she did not need stronger 8 medication, as the ALJ noted (AR 443), or more aggressive 9 treatment. 10 For instance, on November 6, 2015, she reported that she had 11 had a headache the prior week one day when waking up and that she 12 “[t]ried ibuprofen with good relief.” (AR 1251.) Although the 13 attending physician recommended that she go to the emergency room 14 “for further evaluation,” she refused, stating that she “would 15 like to defer ER admission since she [was] otherwise 16 asymptomatic.” (Id.) A January 27, 2016 neurosurgery- 17 consultation note indicates that she believed her headaches were 18 related to stress caused by her separation from her husband and 19 that when she “[took] ibuprofen 600 mg . . . [they went] away.” 20 (AR 1465.) And on August 22, 2016, she reported that her 21 headaches still occurred “2-3x/week [but were] completely 22 improve[d] with ibuprofen.” (AR 1190.) She reiterated the 23 effectiveness of her ibuprofen treatment and that she had no 24 symptoms on numerous other dates. (See AR 2068 (Jan. 2017), 1942 25 (Sept. 2017), 1775 (Nov. 2017), 1858 (Nov. 2017), 1693 (Dec. 26 2017), 1565 (Feb. 2018), 2066 (Feb. 2018), 2297 (Mar. 2018).) 27 True, she underwent surgeries in October 2011 (AR 237), 28 before her effective onset/application date, and March 2018 (AR 20 1 2265), even though her head scan was unchanged (AR 2082), to 2 place a shunt in her brain and to revise it, respectively. But 3 her conservative medication treatment consistently provided 4 effective symptom relief between those surgeries and afterward. 5 See Patricia W. v. Saul, No. SA CV 19-1537-PLA, 2020 WL 2523242, 6 at *12 (C.D. Cal. May 18, 2020) (holding that ALJ properly 7 discounted plaintiff’s testimony based on her generally 8 conservative treatment even though she underwent hip surgery, 9 given that she was able to work until four months before surgery 10 and walked with normal gait and had less hip pain after it). 11 Therefore, the ALJ properly discounted Plaintiff’s symptom 12 statements and testimony as inconsistent with her conservative 13 treatment. 14 iii. Daily activities 15 The ALJ properly discounted Plaintiff’s allegations as 16 inconsistent with her daily activities. (AR 444.) An ALJ may 17 discredit a claimant’s subjective symptom testimony “when [she] 18 reports participation in everyday activities indicating 19 capacities that are transferable to a work setting.” Molina, 674 20 F.3d at 1113. “Even where those activities suggest some 21 difficulty functioning, they may be grounds for discrediting the 22 claimant’s testimony to the extent that they contradict claims of 23 a totally debilitating impairment,” id., or “suggest” that her 24 “claims about the severity of [her] limitations were 25 exaggerated,” Valentine v. Comm’r Soc. Sec. Admin., 574 F.3d 685, 26 693 (9th Cir. 2009). 27 The ALJ noted that Plaintiff reported at various times that 28 she had traveled out of the country, was driving, enjoyed 21 1 dancing, cared for pets, exercised, performed household chores, 2 socialized with friends on the weekends, and worked as a 3 babysitter. (AR 444-45.) The ALJ properly concluded that these 4 activities suggested some ability to work and were inconsistent 5 with her claims of complete disability. See Burch v. Barnhart, 6 400 F.3d 676, 680 (9th Cir. 2005) (ALJ properly discounted 7 plaintiff’s statements when her activities “suggest[ed] that she 8 is quite functional” because she was “able to care for her own 9 personal needs, cook, clean and shop,” “interact[] with her 10 nephew and her boyfriend,” and “manage her own finances”); 11 Fleming v. Astrue, 274 F. App’x 571, 572 (9th Cir. 2008) (ALJ 12 properly discounted plaintiff’s claims concerning effects of her 13 chronic fatigue syndrome given her daily activities, which 14 included gardening and bicycling). 15 iv. Planned pregnancy 16 Finally, the ALJ discounted Plaintiff’s symptom statements 17 as inconsistent with her plans and attempts to conceive a child. 18 As the ALJ noted, despite her alleged debilitating symptoms, “in 19 much of the medical record,” her “primary concern appear[ed] to 20 be with contraception or conceiving a child.” (AR 445.) She 21 attempted to get pregnant despite the risks a pregnancy posed for 22 someone with her condition. In fact, she discontinued the 23 medication that controlled her cocci meningitis in order to 24 accommodate a pregnancy. (AR 4636.) 25 Even assuming the ALJ erred, however, any error was harmless 26 because as discussed he provided three clear and convincing 27 reasons for partially discounting Plaintiff’s testimony — 28 inconsistency with the medical record, conservative treatment, 22 1 and daily activities. See Larkins v. Colvin, 674 F. App’x 632, 2 633 (9th Cir. 2017) (“[B]ecause the ALJ gave specific, clear and 3 convincing reasons for finding [plaintiff] not fully credible, 4 any error in the additional reasons the ALJ provided . . . was 5 harmless.”). 6 b. RFC and VE Hypotheticals 7 The ALJ properly discounted Plaintiff’s testimony, so he was 8 not required to posit hypotheticals to the VE based on her 9 subjective symptoms or include them in the RFC. (See J. Stip. at 10 5-7 (claiming that ALJ erroneously discounted her subjective 11 symptoms and therefore erred in hypotheticals he presented to 12 VE)); Bayliss v. Barnhart, 427 F.3d 1211, 1217 (9th Cir. 2005) 13 (failure to include limitations in RFC was not erroneous when ALJ 14 properly discounted plaintiff’s testimony regarding severity of 15 her symptoms related to them); Batson v. Comm’r of Soc. Sec. 16 Admin., 359 F.3d 1190, 1197 (9th Cir. 2004) (RFC assessment that 17 was contrary to VE’s opinion was not erroneous when ALJ properly 18 discounted testimony on which VE opinion was based). As 19 discussed, substantial evidence supported the ALJ’s discounting 20 of Plaintiff’s subjective symptom statements. 21 B. Any Error In Discounting the Lay-Witness Testimony of 22 Plaintiff’s Relatives Was Harmless 23 Plaintiff asserts that the ALJ failed to properly evaluate 24 the lay-witness testimony of her mother and aunt. (J. Stip. at 25 17-18.) For the reasons discussed below, any error was harmless. 26 1. Applicable law 27 “In determining whether a claimant is disabled, an ALJ must 28 consider lay witness testimony concerning a claimant’s ability to 23 1 work.” Bruce v. Astrue, 557 F.3d 1113, 1115 (9th Cir. 2009) 2 (citing Stout v. Comm’r, Soc. Sec. Admin., 454 F.3d 1050, 1053 3 (9th Cir. 2006)). “Such testimony is competent evidence and 4 ‘cannot be disregarded without comment.’” Bruce, 557 F.3d at 5 1115 (emphasis in original) (quoting Nguyen v. Chater, 100 F.3d 6 1462, 1467 (9th Cir. 1996)); Robbins, 466 F.3d at 885 (“[T]he ALJ 7 is required to account for all lay witness testimony in the 8 discussion of his or her findings.”). When rejecting the 9 statements of a lay witness, an ALJ must give specific reasons 10 germane to that witness. Diedrich v. Berryhill, 874 F.3d 634, 11 640 (9th Cir. 2017); Bruce, 557 F.3d at 1115. 12 If an ALJ errs by providing reasons that are not germane, 13 the error may be harmless. See Valentine, 574 F.3d at 694. Such 14 an error is harmless if it is “‘inconsequential to the ultimate 15 nondisability determination’ in the context of the record as a 16 whole,” Molina, 674 F.3d at 1122; see also Tommasetti, 533 F.3d 17 at 1038, as when “the same evidence that the ALJ referred to in 18 discrediting [the claimant’s] claims also discredits [the lay 19 witness’s] claims,” Molina, 674 F.3d at 1122 (alterations in 20 original) (citing Buckner v. Astrue, 646 F.3d 549, 560 (8th Cir. 21 2011)). 22 2. The ALJ’s decision 23 The ALJ noted that Plaintiff’s aunt 24 testified that when she talks to [Plaintiff], she seems 25 lost, very quiet, and forgetful [and] reports having 26 frequent headaches and reports dizziness. She testified 27 that she and [Plaintiff] go on walks together, and 28 [Plaintiff] walks very slowly. [Plaintiff’s aunt] . . . 24 1 is afraid to leave [Plaintiff] alone and takes her along 2 when [she] leaves the house. The witness stated that 3 during the day, [Plaintiff] is sad, depressed, and does 4 not want to do very much. 5 [Plaintiff’s] mother . . . testified she is with her 6 daughter every day [and] helps her daughter to wash her 7 clothes and cook. She testified that [Plaintiff] 8 “always” has headaches[,] sometimes gets dizzy, and . . 9 . sometimes forgets things or does not understand and 10 repeats herself. She testified that sometimes a friend 11 comes to take [Plaintiff] out for a walk or to go to the 12 movies. She testified that [Plaintiff] sometimes cannot 13 lift her left leg and holds her left hand in a clenched 14 fist position. She testified that [Plaintiff] and family 15 members go to church together every Sunday, and they read 16 the Bible and books together. 17 (AR 442-43.) The ALJ reviewed this testimony and discounted it 18 for the same reasons he discounted Plaintiff’s testimony: it was 19 “inconsistent with the medical record” (AR 443), her conservative 20 treatment (id.), and her daily activities (AR 444-45). 21 3. Analysis 22 The lay-witness testimony was largely consistent with 23 Plaintiff’s, and the ALJ discounted it for the same reasons. 24 Plaintiff’s aunt testified that Plaintiff “forg[ot] things,” got 25 “[l]ots of headaches,” walked slowly, got dizzy, had loss of 26 appetite, lay down “most of the time,” had leg and hand pain, was 27 depressed, and had trouble using her left arm. (AR 502-04, 540- 28 46.) She testified that she helped Plaintiff with bathing and 25 1 making meals and went to the hospital with her. (AR 541-42.) 2 Plaintiff’s mother testified that she sometimes drove Plaintiff 3 to the hospital and doctor’s appointments, washed her clothes, 4 and cooked for her. (AR 513-14.) She added that Plaintiff had 5 dizziness, headaches, and trouble lifting her left leg and hand; 6 forgot things; and sometimes repeated questions. (AR 515, 517- 7 18.) 8 The Ninth Circuit has held that lack of support from medical 9 evidence is not a germane reason for discounting lay 10 observations, at least in some cases. See Diedrich, 874 F.3d at 11 640 (noting that lay observations “may offer a different 12 perspective than medical records alone,” which “is precisely why 13 such evidence is valuable at a hearing”). But see Bayliss, 427 14 F.3d at 1218 (inconsistency with medical evidence can be germane 15 reason for rejecting testimony of “friends and family”). Thus, 16 as a matter of law, the ALJ may have erred by discounting the 17 lay-witness observations on this ground. Any error was harmless, 18 however. 19 As discussed, the ALJ provided clear and convincing reasons 20 for discounting Plaintiff’s own testimony, thereby establishing a 21 sufficient basis for rejecting the similar statements of her 22 mother and aunt. See Valentine, 574 F.3d at 694 (finding that 23 although ALJ improperly discounted claimant’s wife’s testimony in 24 part because she was “an interested party,” any error was 25 harmless because ALJ gave clear and convincing reasons for 26 rejecting claimant’s “similar” subjective complaints); Molina, 27 674 F.3d at 1122 (holding that ALJ’s error in rejecting lay 28 witnesses’ testimony was “harmless” because “ALJ had validly 26 1} rejected all the limitations described by the lay witnesses in discussing [claimant’s] testimony”). 3 Thus, because the ALJ provided sufficient reasons to 4} discount Plaintiff’s similar testimony, any error in discounting 5 || the lay-witness testimony was harmless and remand is not 6} warranted on this ground.

CONCLUSION

8 Consistent with the foregoing and under sentence four of 42 9WU.S.C. § 405(g), IT IS ORDERED that judgment be entered 10 |] AFFIRMING the Commissioner’s decision, DENYING Plaintiff’s 11 | request for remand, and DISMISSING this action with prejudice. 12 13oarep: July 6, 2021 [te Freeda

JEAN ROSENBLUTH

14 U.S. Magistrate Judge 15 16 17 18 19 20 21 22 23 24 25 26 27 28 27