Johnsamson v. Saul

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ALASKA
STEPHEN MATAKATLA JOHNSAMSON,
Plaintiff,
vs.
ANDREW SAUL,1
Commissioner of Social Security,
Defendant. 	Case No. 3:18-cv-00198-SLG
DECISION AND ORDER
On or about May 31, 2016, Stephen Matakatla Johnsamson filed an application for
Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (“the Act”),2
alleging disability beginning September 1, 2015.3 	Mr. Johnsamson has exhausted his
administrative remedies and filed a Complaint seeking relief from this Court.4
Mr. Johnsamson’s opening brief asks the Court to reverse and remand the agency
decision.5 	The 	Commissioner 	filed 	an Answer 	and 	a 	brief 	in 	opposition 	to 	Mr.
1 Andrew Saul is now the Commissioner of Social Security and is automatically substituted as a
party pursuant to Fed. R. Civ. P. 25(d). See also section 205(g) of the Social Security Act, 42
U.S.C. 405(g) (action survives regardless of any change in the person occupying the office of
Commissioner of Social Security).
2 The Court uses the terms “disability benefits” and “DIB” throughout the Decision and Order.
3 Administrative Record (“A.R.”) 262–63. The ALJ decision cites April 28, 2016 as the
application date for Mr. Johnsamson’s DIB claim. A.R. 38.
4 Docket 1 (Johnsamson’s Compl.).
5 Docket 14 (Johnsamson’s Br.).
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 1 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 2 of 44
Johnsamson’s opening brief.6 	Mr. Johnsamson filed a reply brief on March 24, 2019.7
Oral argument was not requested and was not necessary to the Court’s decision. 	This
Court has jurisdiction to hear an appeal from a final decision of the Commissioner of
Social Security.8 For the reasons set forth below, Mr. Johnsamson’s request for relief will
be granted.
I. 	STANDARD OF REVIEW
A decision by the Commissioner to deny disability benefits will not be overturned
unless it is either not supported by substantial evidence or is based upon legal error.9
“Substantial evidence” has been defined by the United States Supreme Court as “such
relevant evidence as a reasonable mind might accept as adequate to support a
conclusion.”10 Such evidence must be “more than a mere scintilla,” but may be “less than
a preponderance.”11 	In reviewing the agency’s determination, the Court considers the
evidence in its entirety, weighing both the evidence that supports and that detracts from
6 Docket 12 (Answer); Docket 15 (Defendant’s Br.).
7 Docket 16 (Reply).
8 42 U.S.C. § 405(g).
9 Matney ex rel. Matney v. Sullivan, 981 F.2d 1016, 1019 (9th Cir. 1992) (citing Gonzalez v.
Sullivan, 914 F.2d 1197, 1200 (9th Cir. 1990)).
10 Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consol. Edison Co. v. NLRB, 305
U.S. 197, 229 (1938)).
11 Perales, 402 U.S. at 401; Sorenson v. Weinberger, 514 F.2d 1112, 1119 n.10 (9th Cir. 1975)
(per curiam).
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 2 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 3 of 44
the administrative law judge (“ALJ”)’s conclusion.12 If the evidence is susceptible to more
than one rational interpretation, the ALJ’s conclusion must be upheld.13 A reviewing court
may only consider the reasons provided by the ALJ in the disability determination and
“may not affirm the ALJ on a ground upon which [he] did not rely.”14 An ALJ’s decision
will not be reversed if it is based on “harmless error,” meaning that the error “is
inconsequential to the ultimate nondisability determination . . . or that, despite the legal
error, the agency’s path may reasonably be discerned, even if the agency explains its
decision with less than ideal clarity.”15 	Finally, the ALJ has a “special duty to fully and
fairly develop the record and to assure that the claimant’s interests are considered.”16 In
particular, the Ninth Circuit has found that the ALJ’s duty to develop the record increases
when the claimant is unrepresented or is mentally ill and thus unable to protect his own
interests.17
//
//
12 Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985).
13 Gallant v. Heckler, 753 F.2d 1450, 1453 (9th Cir. 1984) (citing Rhinehart v. Finch, 438 F.2d
920, 921 (9th Cir. 1971)).
14 Garrison v. Colvin, 759 F.3d 995, 1010 (9th Cir. 2014).
15 Brown-Hunter v. Colvin, 806 F.3d 487, 492 (9th Cir. 2015) (internal quotation marks and
citations omitted).
16 Smolen v. Chater, 80 F.3d 1273,1288 (9th Cir. 1996) (quoting Brown v. Heckler, 713 F.2d 441,
443 (9th Cir. 1983)); see also Garcia v. Comm’r of Soc. Sec., 768 F.3d 925, 930 (9th Cir. 2014).
17 Tonapetyan v. Halter, 242 F.3d 1144, 1150 (9th Cir. 2001).
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 3 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 4 of 44
II. 	DETERMINING DISABILITY
The Act provides for the payment of disability insurance to individuals who have
contributed to the Social Security program and who suffer from a physical or mental
disability.18 In addition, SSI may be available to individuals who are age 65 or older, blind,
or disabled, but who do not have insured status under the Act.19 Disability is defined in
the Act as follows:
[I]nability to engage in any substantial gainful activity by reason of any
medically 	determinable 	physical 	or 	mental 	impairment 	which 	can 	be
expected to result in death or which has lasted or can be expected to last
for a continuous period of not less than 12 months.20
The Act further provides:
An individual shall be determined to be under a disability only if his physical
or mental impairment or impairments are of such severity that he is not only
unable to do his previous work but cannot, considering his age, education,
and work experience, engage in any other kind of substantial gainful work
which exists in the national economy, regardless of whether such work
exists in the immediate area in which he lives, or whether a specific job
vacancy exists for him, or whether he would be hired if he applied for work.
For purposes of the preceding sentence (with respect to any individual),
“work which exists in the national economy” means work which exists in
significant numbers either in the region where such individual lives or in
several regions of the country.21
18 42 U.S.C. § 423(a).
19 42 U.S.C. § 1381a.
20 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A).
21 42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B).
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 4 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 5 of 44
The Commissioner has established a five-step process for determining disability
within the meaning of the Act.22 A claimant bears the burden of proof at steps one through
four in order to make a prima facie showing of disability.23 	If a claimant establishes a
prima facie case, the burden of proof then shifts to the agency at step five.24 	The
Commissioner can meet this burden in two ways: “(a) by the testimony of a vocational
expert, or (b) by reference to the Medical-Vocational Guidelines at 20 C.F.R. pt. 404,
subpt. P, app. 2.”25 The steps, and the ALJ’s findings in this case, are as follows:
Step 1. Determine whether the claimant is involved in “substantial gainful activity.”
The ALJ concluded that Mr. Johnsamson engaged in substantial gainful activity after the
alleged onset date of September 1, 2015 through November 2015. The ALJ noted that
the remaining findings in the decision addressed the period during which Mr. Johnsamson
did not engage in substantial activity.26
Step 2. 	Determine whether the claimant has a medically severe impairment or
combination of impairments. A severe impairment significantly limits a claimant’s physical
or mental ability to do basic work activities and does not consider age, education, or work
experience. 	The severe impairment or combination of impairments must satisfy the
22 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4).
23 Treichler v. Comm’r Soc. Sec. Admin., 775 F.3d 1090, 1096 n.1 (9th Cir. 2014) (quoting
Hoopai v. Astrue, 499 F.3d 1071, 1074–75 (9th Cir. 2007)); see also Tackett v. Apfel, 180 F.3d
1094, 1098 (9th Cir. 1999).
24 Treichler, 775 F.3d at 1096 n.1; Tackett, 180 F.3d at 1098 (emphasis in original).
25 Tackett, 180 F.3d at 1101.
26 A.R. 40.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 5 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 6 of 44
twelve-month duration requirement. The ALJ determined that Mr. Johnsamson had the
following severe impairments: 	diabetes mellitus; hypertension; hyperlipidemia; sleep
apnea; degenerative disc disease and degenerative joint disease of the cervical and
lumbar spine; osteoarthritis of the bilateral shoulders; and plantar fasciitis.27
Step 3. Determine whether the impairment or combination of impairments meets
or equals the severity of any of the listed impairments found in 20 C.F.R. pt. 404, subpt.
P, app.1 so as to preclude substantial gainful activity. 	If the impairment(s) is(are) the
equivalent of any of the listed impairments, and meet(s) the duration requirement, the
claimant is conclusively presumed to be disabled. If not, the evaluation goes on to the
fourth step. 	The ALJ determined that Mr. Johnsamson did not have an impairment or
combination of impairments that met or medically equaled the severity of a listed
impairment.28
Before proceeding to step four, a claimant’s residual functional capacity (“RFC”) is
assessed. 	Once determined, the RFC is used at both step four and step five. An RFC
assessment is a determination of what a claimant is able to do on a sustained basis
despite the limitations from his impairments, including impairments that are not severe.29
The ALJ concluded that Mr. Johnsamson had the RFC to perform medium work except
27 A.R. 40.
28 A.R. 41.
29 20 C.F.R. § 404.1520(a)(4).
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 6 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 7 of 44
that he was additionally limited to “only frequent kneeling and climbing [of] ladders, ropes
or scaffolds.”30
Step 4. 	Determine whether the claimant is capable of performing past relevant
work. 	At this point, the analysis considers whether past relevant work requires the
performance of work-related activities that are precluded by the claimant’s RFC. 	If the
claimant can still do his past relevant work, the claimant is deemed not to be disabled.
Otherwise, the evaluation process moves to the fifth and final step. The ALJ found that
Mr. Johnsamson was capable of performing past relevant work as a schedule clerk,
porter, and medical records clerk.31
Step 5. 	Determine whether the claimant is able to perform other work in the
national economy in view of his age, education, and work experience, and in light of his
RFC. If so, the claimant is not disabled. If not, the claimant is considered disabled. The
ALJ determined that Mr. Johnsamson was capable of past relevant work and did not reach
step five in his analysis.32
The ALJ concluded that Mr. Johnsamson was not disabled at any time from
September 1, 2015 through August 21, 2017, the date of the decision.33
30 A.R. 42.
31 A.R. 45.
32 A.R. 45.
33 A.R. 45–46.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 7 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 8 of 44
III. 	PROCEDURAL AND FACTUAL BACKGROUND
Mr. Johnsamson was born in 1963; he is 56 years old.34 He reported last working
as a traffic management specialist for the Department of Defense from June 2014 to
October 2015. 	Mr. Johnsamson also reported working in the past as a transportation
assistant for the Department of Defense, as a patient services assistant for the Alaska VA
Healthcare System, as a passenger and baggage processor for the U.S. Air Force, and
as an active duty service member of the U.S. Air Force.35
On January 30, 2017, the Social Security Administration (“SSA”) determined that
Mr. Johnsamson was not disabled under the applicable rules.36 On March 30, 2017, Mr.
Johnsamson requested a hearing before an ALJ.37 On August 1, 2017, Mr. Johnsamson
appeared and testified without a representative at a hearing held before ALJ Paul
Hebda.38 On August 21, 2017, the ALJ issued an unfavorable ruling from September 1,
2015 through the date of his decision.39 	On December 7, 2017, the Appeals Council
denied Mr. Johnsamson’s request for review.40 On October 24, 2018, the Appeals Council
34 A.R. 262.
35 A.R. 342–56. At the August 1, 2017 hearing, Mr. Johnsamson testified that he stopped
working on November 4, 2015. A.R. 59–60.
36 A.R. 38, 119.
37 A.R. 38, 126.
38 A.R. 59–62, 83–96.
39 A.R. 35–46.
40 A.R. 4–9.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 8 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 9 of 44
granted Mr. Johnsamson’s request for an extension of time to commence a civil action.41
Mr. Johnsamson appealed to this Court on September 5, 2018.42
Medical Records
Although Mr. Johnsamson’s medical records date back to 1992, the Court focuses
on the relevant medical records after the alleged onset date of September 1, 2015.43
However, the following are the most relevant records before September 1, 2015:
On June 7, 2007, Mr. Johnsamson visited Lori Kelsey, M.D., for a compensation
and pension examination. Dr. Kelsey assessed Mr. Johnsamson with the following: (1)
right elbow calcific tendonitis distal triceps tendon; (2) right shoulder rotator cuff tendonitis
with prior cuff tear; (3) middle back degenerative disease; (4) hypertension with trace
proteinuria; (5) bilateral carpal tunnel syndrome; (6) bilateral plantar fasciitis and achilles
tendonitis; 	(7) 	insomnia; 	(8) 	allergic 	rhinitis 	and 	deviated 	septum 	status 	post
septorhinoplasty; (9) vitiligo affecting 3% of the total body and exposed surface area; (10)
gastroesophageal reflux disease; (11) bilateral knee strain; (12) anal fissures; (13)
enthesopathy tendonitis; and (14) hyperlipidemia.44
On September 24, 2007, the Department of Veterans Affairs issued a disability
rating decision. It determined that Mr. Johnsamson had a service connection for insomnia
41 A.R. 1.
42 Docket 1.
43 There are multiple duplicate treatment notes in the Court’s record. To the extent possible, the
Court cites the first treatment note to appear in the medical record.
44 A.R. 582–88.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 9 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 10 of 44
with an evaluation of 30 percent; for anal fissure with 20 percent; bilateral plantar fasciitis
with 10 percent; bilateral knee strain with 10 percent; hypertension with 10 percent;
gastroesophageal reflux disease with 10 percent; and facial and extremity vitiligo with 10
percent. His entitlement to individual unemployability was deferred pending receipt of Mr.
Johnsamson’s application, but the rating decision noted that Mr. Johnsamson met the
criteria for individual unemployability.45
On January 23, 2008, the Department of Veterans Affairs granted a service
connection for tinnitus with an evaluation of 10 percent.46
On March 13, 2009, Mr. Johnsamson went to the emergency department at Alaska
Regional Hospital. 	He reported lower back pain after a motor vehicle accident. 	X-rays
showed no acute injury to the cervical, thoracic, or lumbar spine. He was assessed with
cervical lumbar strain.47
On May 6, 2009, Mr. Johnsamson had an MRI of the lumbar spine. 	The MRI
showed “[s]ignificant L5-S1 paracentral/left foraminal disc bulge, which results in left
lateral recess stenosis and moderate to severe left neural foraminal narrowing”; a “[s]mall
L4-5 right far lateral and right foraminal disc bulge, which results in mild right neural
foraminal narrowing”; and an anterior annular tear at L3-4. Additionally, Mr. Johnsamson
had an MRI of the thoracic spine and cervical spine. 	The MRI of the thoracic spine
45 A.R. 194–209.
46 A.R. 213–17.
47 A.R. 400–01, 653–55.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 10 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 11 of 44
showed “[d]egenerative spondylosis of the thoracic spine without posterior disc bulges,
central canal stenosis, nor neural foraminal narrowing.” 	The MRI of the cervical spine
showed 	“[m]ultilevel 	spondylosis, 	worst 	at 	the 	C6-7 	level”; 	“C6-7 	significant 	right
paracentral and right foraminal disc bulge is noted, which offaces the right side of the
anterior thecal sac and impresses on the cord, and results in severe right neural foraminal
narrowing”’ and “C5-6 central disc bulge with annular tear which, in combination with
bilateral uncovertebral facet arthropathy, results in mild to moderate right neural foraminal
narrowing.”48
On June 30, 2010, Mr. Johnsamson visited Larry Kropp, M.D., an interventional
anesthesiologist in Anchorage, Alaska. He reported a 10-year history of lower back pain
that had recently worsened. Dr. Kropp noted the recent MRI showed “a large protrusion
at 	L5/S1 	with 	foraminal 	stenosis 	mainly 	on 	the 	left” 	with 	minor 	protrusions 	and
degenerative changes at other levels. On physical examination, Mr. Johnsamson had a
positive straight leg raise test on the left with 5/5 strength in all extremities and no obvious
deficits in sensation. 	He was assessed with lumbar displaced disc. 	Dr. Kropp
recommended a steroid injection at L5 on the left and added that “if that fails he may need
surgery.”49
On July 16, 2010, Mr. Johnsamson had a steroid injection at L5 on the left.50
48 A.R. 645–49.
49 A.R. 405.
50 A.R. 407.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 11 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 12 of 44
On May 10, 2012, Mr. Johnsamson had x-rays taken of both knees and his lumbar
spine. 	The x-ray of his left knee was normal. 	The x-ray of his right knee was also
unremarkable. 	The x-ray of his lumbar spine showed “osteophytic changes,” but
“relatively good preservation of the intervertebral disc spaces.”51
On August 27, 2012, the Department of Veterans Affairs rated Mr. Johnsamson’s
combined disability rating as 90%.52
On May 8, 2013, Mr. Johnsamson had x-rays taken of his left and right knees.
Both x-rays showed “[n]o acute osseous abnormality or osteoarthritis.”53
On October 3, 2013, Mr. Johnsamson had a steroid injection in his left knee.54
On October 11, 2013, Mr. Johnsamson had bilateral feet and knee x-rays taken.
The x-rays of the feet showed bilateral calcifications, achilles enthesophytes, and minimal
degenerative changes. The x-rays of the knees showed “[m]inimal degenerative changes
to 	the 	tibiofemoral 	joints” 	and 	“[m]inimal 	to 	mild 	degenerative 	changes 	to 	the
patellofemoral joints.”55
51 A.R. 656–57.
52 A.R. 227–31.
53 A.R. 631–32.
54 A.R. 756.
55 A.R. 760–62.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 12 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 13 of 44
On December 9, 2013, Mr. Johnsamson had an MRI of the left knee. 	The MRI
showed a small effusion with no fracture and a “[h]eterogeneously increased signal
consistent with tear at the medial meniscal root.”56
On December 20, 2014, Mr. Johnsamson had an MRI of the lumbar spine. 	The
MRI showed:
“[m]ild congenital central spinal stenosis. 	Multilevel degenerative disc
disease with a small disc herniation at L2-L3, a right posterior lateral disc
herniation at L3-L4 resulting in mild right neural foraminal narrowing. A right
posterior lateral disc herniation at L4-L5 causing mild right neural foraminal
with borderline impingement upon the exiting right L4 nerve root, and a
broad-based 	left 	paracentral/posterior 	lateral 	disc 	herniation 	at L5-S1
resulting in compression of the low left S1 nerve root causes severe left and
moderate 	central 	spinal 	stenosis. 	No 	evidence 	of 	cauda 	equina
compression.”57
On February 20, 2015, Mr. Johnsamson had an x-ray of his lumbosacral spine.
The x-ray showed “[m]ild straightening of the normal lumbar lordosis” and “[m]ild
multilevel degenerative disc disease with vertebral body spurring.”58 On the same date,
Mr. Johnsamson had an MRI of the lumbar spine. 	The MRI showed right sided disc
herniation at L4-L5 impinging on the right L4 nerve root and left sided disc herniation at
L5-S1 compressing the S1 nerve root.59
56 A.R. 764.
57 A.R. 957.
58 A.R. 640–41.
59 A.R. 544–45.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 13 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 14 of 44
On May 20, 2015, Mr. Johnsamson had a CT scan of his head. The CT showed
no acute intracranial findings. 	On the same date, Mr. Johnsamson had an x-ray of his
cervical spine. The x-ray showed “[d]egenerative cervical spondylosis.”60
On May 28, 2015, Mr. Johnsamson visited Regina Krel, M.D., at the VA neurology
outpatient clinic in Northport, New York. 	He reported headaches and neck pain. 	Mr.
Johnsamson also reported that his neck pain and headaches interfered with his daily
activities and that he had “taken multiple sick days due to his pain.” 	He was assessed
with cervicogenic headaches; hypertension, acceptably controlled; dyslipidemia; diabetes
mellitus; GERD; obstructive sleep apnea; insomnia; and chronic back pain/neck pain.61
On June 15, 2015, Mr. Johnsamson had a CT scan of his cervical spine. The CT
scan showed “[p]rominent anterior bulky osteophytes” from C4-7,” but “[n]o other
significant abnormalities” were seen.62
On June 25, 2015, Mr. Johnsamson had an CT scan of the lumbar spine. The CT
scan showed multilevel degenerative changes “superimposed on congenitally narrowed
central canal, worse at L2-3 and L5-S1”; atherosclerotic disease; and “[m]ultiple scattered
shotty retroperitoneal lymph nodes.” 	The radiologist noted that the findings of the MRI
were not significantly changed since the December 20, 2014 evaluation, although the
imaging techniques differed.63
60 A.R. 638–39.
61 A.R. 547–53, 569–72.
62 A.R. 637–38.
63 A.R. 618–19, 635–36.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 14 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 15 of 44
On July 15, 2015, Mr. Johnsamson visited Marilyn Otero, P.A., at the Brooklyn HHS
Veteran’s Hospital. He reported chronic lower back pain “since the year 2000, worsening
in recent years, with left lower extremity pain since 2008.” He reported that his lower back
pain was both left and right-sided with left mid-lateral thigh numbness and left lower
extremity paresthesia. Mr. Johnsamson also reported that his mid-lower back pain was
“worse on prolonged sitting or ambulation.” On physical examination, Mr. Johnsamson’s
motor strength was 5/5 throughout, but with lower back pain on left lower extremity
resistance. 	PA 	Otero 	observed 	negative 	Hoffman’s 	and 	Clonus 	tests 	and 	Mr.
Johnsamson’s sensation to light touch was intact distally. 	PA Otero opined that
decompression surgery “would most likely address his left lower extremity radicular
symptoms; but not address his chronic complaints of back pain.” 	She also opined that
Mr. Johnsamson was “neurologically stable except for his subjective complaints of left
lower 	extremity 	numbness.” 	She 	recommended 	conservative 	therapies, 	including
physical therapy; pool therapy; back school; HEP; acupuncture; and an interventional
pain management consultation for an epidural steroid injection evaluation.64
On August 1, 2015, Mr. Johnsamson had bilateral x-rays taken of his knees. The
x-rays showed “[b]ilateral patella alta and lateral patellar tilt” with “[m]arginal spurring at
the lower pole of the patella on the right” with “[t]ibiofemoral joints appearing intact.”65 He
64 A.R. 13–16, 554–55. On August 24, 2015, PA Otero added an addendum to her treatment
notes of July 15, 2015, noting that Mr. Johnsamson had telephoned the clinic and she had had
“a conversation regarding disability papers.” A.R. 666. On September 2, 2015, a second
addendum noted that Mr. Johnsamson’s disability papers had been filled out. A.R. 667–70.
65 A.R. 643–44.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 15 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 16 of 44
also had bilateral x-rays taken of his wrists. The x-rays showed “[b]orderline widening of
the scapholunate joint bilaterally” and “[m]ild spurring at the scapholunate joint on the
right” with “[m]ild to moderate arthrosis at the basal joint bilaterally.”66 On the same date,
Mr. Johnsamson saw Steven Olster, RPA-C, for an examination and consultation
regarding his ankle, knee, lower leg, and wrist conditions. He reported that he was unable
to tolerate stairs, walk more than five blocks, or drive without pain. 	Mr. Johnsamson
reported that his knee condition limited his “standing, sitting at work.” 	He also reported
that his knee condition caused him to miss days at work, leave work early due to pain,
and “stand up and move around after being seated too long.” 	He also reported that he
had to go home at least once per week and on occasion had to leave early or come in
late due to his wrist condition. 	On physical examination, PA Olster noted that Mr.
Johnsamson’s right and left ankles and right and left wrists were outside the normal range
of motion due to pain on examination, but the pain did not result in or cause functional
loss. His range of motion of the knees bilaterally was also limited due to stated pain. Mr.
Johnsamson had no knee joint instability on either side. His strength testing was normal
at 5/5 bilaterally in his lower and upper extremities and he had no muscle atrophy or
ankylosis. There were no signs or symptoms of carpal tunnel syndrome on examination
of his wrists.67
66 A.R. 542–43.
67 A.R. 513–43.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 16 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 17 of 44
On August 10, 	2015, the 	Department 	of Veterans Affairs 	decided 	that 	Mr.
Johnsamson had a service connection for chronic right and left wrist sprain and right and
left knee patellofemoral pain syndrome at 10 percent disabling.68
On August 31, 2015, Mr. Johnsamson visited Heather Jones, M.D., at Capstone
Family Medicine in Eagle River, Alaska. He reported neck pain and low back pain caused
by 	standing 	or 	sitting 	for 	prolonged 	periods. 	Dr. 	Jones 	recommended 	that 	Mr.
Johnsamson “pursue pain management for his neck as he is very young and should still
be able to pursue a meanin[g]ful career and should be able to get his neck and back pain
under control” and that he “may have to adjust [his] work station, get lumbar support or
have pain management [prescription] medications for pain.” 	Dr. Jones opined that Mr.
Johnsamson’s limitations on sitting and standing “should not preclude him from working.”
She also opined that he “is able to work but may need to pursue a different type job.”69
The following are the more relevant records after the September 1, 2015 alleged
onset date:
On September 2, 2015, Donato Pacione, M.D., a neurosurgeon at NYHH VAMC,
completed a health provider form on Mr. Johnsamson’s behalf. Dr. Pacione assessed Mr.
Johnsamson with chronic disc herniation as of 2011, pursuant to Mr. Johnsamson’s
report. 	He recommended interventional pain management and physical therapy with
operative intervention at a future date if conservative measures failed. 	Dr. Pacione
68 A.R. 192–93, 221–26.
69 A.R. 671–72.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 17 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 18 of 44
opined that Mr. Johnsamson was unable to tolerate prolonged sitting or standing. 	On
physical 	examination, 	Dr. 	Pacione 	observed 	that 	Mr. 	Johnsamson 	was 	“intact”
neurologically.70
On September 12, 2015, Mr. Johnsamson had an MRI of his thoracic spine. The
MRI showed “[m]ild degenerative changes in the thoracic spine” with “no significant disc
herniation” and “[n]o canal or foraminal stenosis in the thoracic spine, with no cord
compression.”71
On November 5, 2015, Mr. Johnsamson initiated care with Myron Schweigert,
D.C., at Chugach Chiropractic Clinic in Eagle River, Alaska. DC Schweigert observed no
abnormal changes in Mr. Johnsamson’s deep tendon reflexes in the upper extremities
and “low normal” deep tendon reflexes in the patellar and achilles. DC Schweigert also
observed a positive Kemp’s Test and Bragard’s sign bilaterally. 	He observed that Mr.
Johnsamson’s movement was painful.72
On December 15, 2015, Mr. Johnsamson initiated care with Diana Hess, N.P., at
Cornerstone Medical Clinic in Anchorage, Alaska. He reported back pain, neck pain, knee
pain, migraines, dry eyes, and skin tags on his inner thighs. He reported that chiropractic
70 A.R. 291–95.
71 A.R. 959.
72 A.R. 808–12. Mr. Johnsamson attended chiropractic sessions on November 6, 2015,
November 13, 2015, November 17, 2015, November 23, 2015, December 3, 2015, and
December 10, 2015. A.R. 813–28.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 18 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 19 of 44
treatments helped “a little,” but he wanted to pursue other options. 	NP Hess assessed
Mr. Johnsamson with HTN, GERD, DMII, hyperlipidemia, and migraines.73
On December 21, 2015, Mr. Johnsamson saw DC Schweigert for chiropractic
treatment.74
On March 15, 2016, Mr. Johnsamson initiated care with James Glenn, PA-C, at the
Veterans Hospital in Anchorage, Alaska. He reported cervical spine pain and lower back
pain with numbness and “tingling down the ‘whole’ left leg.” On physical examination PA
Glenn observed no swallowing difficulty, no breathing difficulty, heel to toe walking without
difficulty; weakness in muscle strength in the bilateral grip, hand intrinsics, and slightly
with wrist extension, but 5/5 strength in the remaining upper extremities; and limited
cervical spine range of motion due to pain. 	PA Glenn noted that Mr. Johnsamson
experienced the same amount of pain with and without downward pressure on his neck.
X-rays of the cervical spine taken at the visit showed “seven well-formed cervical
vertebrae 	without 	profound 	significant 	disc 	degeneration,” 	but 	“significant 	anterior
osteophytes anterior to C4-C5, C6-C7.” PA Glenn noted that the largest osteophyte was
over C4-C5 with a “bone which does protrude about 8 to 9 mm anteriorly,” but “[n]o
instability on flexion and extension views and no acute osseous abnormalities.” PA Glenn
diagnosed Mr. Johnsamson with “[c]hronic cervical spine pain with referral symptoms into
73 A.R. 780–82.
74 A.R. 829. Mr. Johnsamson attended additional chiropractic sessions on December 23, 2015,
December 28, 2015, and December 30, 2015, February 26, 2016, March 4, 2016, March 8,
2016, March 11, 2016, March 15, 2016, March 17, 2016, and March 21, 2016. A.R. 830–68.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 19 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 20 of 44
the paraspinal musculature over occipital lob down into bilateral trapezius without frank
radiculopathy”; “[w]eakness in bilateral uppers with hand intrinsics”; “[s]ignificant anterior
osteophytes from C4-C7”; and lower back pain, “not fully evaluated today.”75
On March 21, 2016, David Prentice, D.C., at Chugach Chiropractic Clinic,
completed a health provider certification form for the U.S. Department of Labor. 	He
opined that Mr. Johnsamson was unable to perform prolonged sitting or standing. 	DC
Prentice recommended rehabilitation and chiropractic care.76
On March 24, 2016, Mr. Johnsamson saw Byron Perkins, D.O., at Cornerstone
Medical Clinic. 	He reported lower back, neck, and bilateral knee pain. 	On physical
examination, Dr. Perkins observed intact cranial nerves, a neurosensory exam within
normal limits, good hip flexion and knee extension against resistance, preserved balance,
equal and symmetric motor strength, full squat and return to standing without difficulty,
and a normal straight leg test. Dr. Perkins performed osteopathic manipulation at the visit
and noted that Mr. Johnsamson demonstrated improved range of motion and reported
less pain following treatment.77 On the same date, Mr. Johnsamson visited DC Prentice
for chiropractic treatment.78
On March 25, 2016, Mr. Johnsamson had an MRI of the cervical spine. The MRI
showed “[m]ild multilevel cervical spondylosis” and “[a] large right posterior paracentral
75 A.R. 22–24, 677–79.
76 A.R. 287–90.
77 A.R. 785–88.
78 A.R. 869–73.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 20 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 21 of 44
disc osteophyte complex and uncovertebral osteophytes at C6-7” causing “severe right
neural foraminal origin stenosis and mild central spinal canal stenosis.”79
On 	March 	30, 	2016, 	Mr. 	Johnsamson 	visited 	DC 	Prentice 	for 	chiropractic
treatment.80
On March 31, 2016, Mr. Johnsamson saw PA Glenn. He reported “ongoing cervical
spine pain mainly on the left with feelings of continued weakness into his hands.” 	PA
Glenn diagnosed Mr. Johnsamson with ongoing chronic cervical spine pain with right C6-
C7 disc protrusion; weakness in bilateral upper hands and hand intrinsics; significant
anterior osteophytes C4-C7; and lower back pain, not fully evaluated. PA Glenn reviewed
the MRI and noted that Mr. Johnsamson had “degenerative changes with degenerative
spondylosis throughout his cervical spine with a larger disc protrusion at the right at C6-
C7” and that the protrusion did “impress upon what appears to be the exiting C7 nerve
root,” but that Mr. Johnsamson had “[n]o other significant abnormalities” and the “cord
diameter [was] maintained at about 10 mm.” 	PA Glenn noted that he did “not think [Mr.
Johnsamson was] fully disabled” and that Mr. Johnsamson was “able to perform some
type of employment.” He noted that Mr. Johnsamson indicated he did “not want to do an
epidural” and did not “seem like he [wanted] to get much better with treatments that I
offered.”81 PA Glenn also completed a health care provider form for FMLA. 	He opined
79 A.R. 20–21, 682–83.
80 A.R. 874–77.
81 A.R. 25–26, 680–81. On the same date, Mr. Johnsamson visited Shelly Waltrip, LMT, at
Chugach Chiropractic for manual muscle therapy. A.R. 878–79.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 21 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 22 of 44
that Mr. Johnsamson was unable to work at the time, but if his symptoms improved he
“may be able to return to work in the future.” PA Glenn recommended an epidural steroid
injection.82
On April 8, 2016, Mr. Johnsamson visited DC Prentice for chiropractic care.83
On July 6, 2016, Mr. Johnsamson saw Cynthia Davis, RN, at the Elmendorf
Disease 	Management 	clinic, 	for 	follow 	up 	on 	diabetes 	mellitus, 	type 	2, 	without
complications.84
On August 16, 2016, Mr. Johnsamson followed up with NP Hess. He reported that
he continued to have back and neck pain and he needed a referral for more chiropractor
visits.85
On September 12, 2016, Mr. Johnsamson followed up at Chugach Chiropractic
Clinic for chiropractic treatment.86
On December 21, 2016, Mr. Johnsamson initiated care with Zachary Johnson, PA-
C, at Anchorage Fracture and Orthopedic Clinic. 	He reported right shoulder pain and
bilateral knee pain. 	On physical examination of the shoulder, PA Johnson observed no
ecchymosis and no edema, “good strength with resisted abduction and an external
82 A.R. 283–86.
83 A.R. 880–84. Mr. Johnsamson also attended chiropractic treatment sessions on April 14,
2016, May 17, 2016, May 24, 2016, May 31, 2016, June 7, 2016, June 16, 2016, June 21, 2016,
June 28, 2016, July 12, 2016, July 22, 2016, and August 3, 2016. A.R. 885–941.
84 A.R. 776.
85 A.R. 789–91.
86 A.R. 942–50.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 22 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 23 of 44
rotation,” but “slight weakness with internal rotation”; and a positive Neer and Hawkins
impingement sign. 	On physical examination of the knees, PA Johnson observed no
ecchymosis; no edema; tenderness at the medial and lateral joint line and medial and
lateral aspects of the patella; a stable varus and valgus stress test, and a negative
Lachman’s and anterior and posterior drawer. 	PA Johnson assessed Mr. Johnsamson
with 	“[c]hronic 	right 	shoulder 	pain 	concerning 	for 	rotator 	cuff 	tendinopathy”;
“[o]steoarthritis of the knees bilaterally”; and “[c]hronic bilateral knee pain with concerns
for possible meniscus injury of the left knee.” X-rays of the right shoulder showed “[m]ild
osteoarthritis of the right acromioclavicular joint and possible injury to the rotator cuff.” X-
rays of the knees showed “[o]steoarthritis of the knees bilaterally.”87
On December 27, 2016, Mr. Johnsamson had an MRI of his right shoulder. 	The
MRI showed moderate acromioclavicular osteoarthritis and mild subacromial subdeltoid
bursitis; “[s]evere anterior infraspinatus tendinopathy and partial-thickness intrasubstance
degenerative tear of the anterior infraspinatus tendon insertion”; and “[m]ild partial-
thickness glenohumeral chondrosis.” Mr. Johnsamson also had an MRI of his left knee.
The left knee MRI showed mild lateral patellofemoral chondrosis.88
On December 29, 2016, Mr. Johnsamson had an MRI of the lumbar spine. 	The
MRI showed “[d]iffuse congenital narrowing of the lumbar spinal canal along with
prominent intraspinal fat that causes diffuse mild stenosis of the subarachnoid space”;
87 A.R. 965–67.
88 A.R. 17–18, 977–78.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 23 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 24 of 44
“L2-L3 disc protrusion that combined with above causes moderate to severe stenosis of
the subarachnoid space”; L3-L4 and L4-L5 degenerative joint disease with mild left L3-L4
and bilateral L4-L5 mild neural foramen stenoses; and L5-S1 disc extrusion with severe
left lateral recess and neural foramen stenoses.89
On January 3, 2017, Mr. Johnsamson saw Ernest Meinhardt, M.D., for an
evaluation of his right shoulder and bilateral knee pain. 	On physical examination, Dr.
Meinhardt observed decreased range of motion of the shoulder and pain with abduction
and rotation; bilateral knee pain to palpation; and a slow, shuffling gait with a limp favoring
his left leg.90
On January 12, 2017, Shirley Fraser, M.D., a state agency reviewing physician,
opined that Mr. Johnsamson could perform his past relevant work as a transportation
assistant. She opined that Mr. Johnsamson was limited to lifting and carrying 25 pounds
occasionally and 20 pounds frequently; standing a total of four hours and sitting a total of
six hours 	in 	an 	eight-hour 	workday; 	and pushing and 	pulling with 	the 	right 	arm
occasionally. Dr. Fraser also opined that Mr. Johnsamson was limited to climbing ramps
and stairs occasionally; climbing ladders, ropes, and scaffolds occasionally; and stooping,
89 A.R. 19, 975–76. On December 30, 2016, PA Johnson recommended a cortisone injection for
“mild lateral patellofemoral chondrosis” of the left knee and a cortisone injection for his right
shoulder. A.R. 979.
90 A.R. 983–86.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 24 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 25 of 44
kneeling, crouching, and crawling occasionally. 	Dr. Fraser opined that Mr. Johnsamson
should avoid excess cold and heat and avoid hazards.91
On January 26, 2017, the Office of Personnel Management wrote a letter notifying
Mr. Johnsamson that he was found to be disabled “for your position as [a] Traffic
Management Specialist for Intervertebral Disc Disorder-Lumbar, Chronic Neck Pain only.”
His application for disability retirement under the Federal Employees Retirement System
(“FERS”) was approved.92
On March 25, 2017, Mr. Johnsamson followed up at Chugach Chiropractic Clinic.93
On April 19, 2017, Mr. Johnsamson saw PA Johnson at Anchorage Fracture and
Orthopedic Clinic for a cortisone injection in the right shoulder and the left knee.94
On May 2, 2017, Mr. Johnsamson initiated care with Jaclyn Levesque, PT, DPT, at
Healthwise Physical Therapy in Eagle River, Alaska for physical therapy to relieve low
back pain. 	He reported difficulty sleeping, that he was unable to work, and was unable
to sit, stand, or walk more than 20 minutes.95
91 A.R. 113–15.
92 A.R. 31. As discussed infra, this document was not in the record before the ALJ, but was later
submitted to the Appeals Council.
93 A.R. 1015–16. Mr. Johnsamson also followed up at Chugach Chiropractic Clinic on March 31,
2017, April 6, 2017, April 11, 2017, April 19, 2017, April 27, 2017, May 5, 2017, May 10, 2017,
May 15, 2017, May 20, 2017, May 26, 2017, June 2, 2017, and June 9, 2017. A.R. 1017–72,
1087–88.
94 A.R. 1194–97.
95 A.R. 987–92. Mr. Johnsamson also attended physical therapy sessions at Healthwise
Physical Therapy on May 4, 2017, May 8, 2017, May 17, 2017, May 19, 2017, May 26, 2017,
May 30, 2017, June 1, 2017, June 8, 2017, June 20, 2017, June 27, 2017, and July 11, 2017.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 25 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 26 of 44
In an undated letter, DC Prentice opined that “based on objective medical findings
and in my professional opinion,” Mr. Johnsamson was “functionally limited and impaired
from work-related physical activities such as prolonged sitting or standing, lifting or
carrying of other [sic] than light objects placed conveniently for him to pick up without
bending or twisting, sustained walking, or travel of long distances without the flexibility to
take frequent breaks or change position.”96
Hearing Testimony on August 1, 2017
Mr. Johnsamson attended a hearing before ALJ Hebda on August 1, 2017 without
an attorney or other representative. 	He testified that he last worked in November 2015
as a traffic management specialist and that it was an office job, but it involved lifting boxes
and computers. He testified that in the past he also worked in patient services assistance,
as a passenger baggage processor, and air transportation specialist. At the hearing, Mr.
Johnsamson testified that, “my neck and my back are the two main problems, that’s the
reason I can’t work.” 	He also indicated that he had problems with his knees, right
shoulder, and back. 	Mr. Johnsamson reported that he had headaches, plantar fasciitis,
insomnia, carpal tunnel, hearing loss, dry eyes, and sleep apnea. 	He indicated that his
back pain was in his lower back, mid-back, and neck and averaged a seven or eight on a
scale of one to ten. 	He testified that his neck pain was the worst pain and that it was
sharp and shot up his right side. 	Mr. Johnsamson testified that Motrin worked “up to a
A.R. 993–1013, 1145–56, 1192–93.
96 A.R. 30.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 26 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 27 of 44
point” and that he also took Flexeril for his pain. He testified that he could not bend down
and lift up with his legs, go up and down stairs, or walk more than 40 minutes. 	Mr.
Johnsamson testified that he had difficulty dressing himself, but he could shower and
bathe on his own. 	He indicated that he did not perform any household chores and did
not do yard work. He testified that he spent his day reading the news, sitting or lying on
the couch, working on the computer, and going to doctor’s appointments. 	He reported
that he would occasionally go for a walk with his family for 20-30 minutes and see his
grandbaby “once in a while.” He also testified that he lived in a three-story house and he
could drive.97
Robert Sklaroff, M.D., testified as the medical expert. Based on his review of the
record, Dr. Sklaroff indicated that Mr. Johnsamson’s primary physical problems were
related 	to 	his 	neck, 	degenerative 	joint 	disease, 	degenerative 	disc 	disease, 	and
headaches. Dr. Sklaroff noted that there was “no evidence of radiculopathy.” Dr. Sklaroff
opined that Mr. Johnsamson had “a metabolic syndrome associated with exogenous
obesity, and that is associated with the diabetes, the hypertension and the sleep apnea.”
He also noted, “all of those other metabolic problems as you confirmed are really not
major issues in terms of what would be an impairment that would cause an inability to
work.” 	Dr. Sklaroff indicated that Mr. Johnsamson’s pain was managed by pain
medications. Specifically, he testified, “there is no mention also of the Gabpentin, nor is
there any mention of the failure to use any narcotic medication to alleviate the pain
97 A.R. 59–62, 65–69, 83–96.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 27 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 28 of 44
because of the problems regarding dizziness.” 	He opined that although there was a
diagnosis 	of 	weakness 	in 	the 	bilateral 	upper 	hands 	and 	hand 	intrinsics 	in 	Mr.
Johnsamson’s medical record, “whatever problem the person would have in terms of
lifting, there can be compensation for the left arm even if the right arm can’t lift as much.”
He testified that Mr. Johnsamson was not “at maximum medical improvement” and
“potentially would benefit from a bariatric consultation.” 	Dr. Sklaroff opined that Mr.
Johnsamson could stand, sit, or walk up to six hours each in an eight-hour workday. He
also opined that Mr. Johnsamson could lift 50 pounds occasionally, 25 pounds frequently
with no limitations pushing, pulling, squatting, bending, or reaching.98 	Although Mr.
Johnsamson reported having a VA disability rating, Dr. Sklaroff testified that he did “not
depend upon the VA disability evaluations, but [he] didn’t see one.”99 Also at the hearing,
Mr. Johnsamson testified that he provided neurology records from Manhattan, New York,
but the ALJ asked Dr. Sklaroff “to just proceed based on what we have in the file.”100
98 A.R. 62–83.
99 At the August 1, 2015 hearing:
Mr. Johnsamson stated, “Sir, were you able to look at the VA disability rating
when they examined me?”
Dr. Sklaroff replied, “I do not depend upon the VA disability evaluations, but I
didn’t see one.
Mr. Johnsamson then stated, “It’s on 1-D, and it shows all my back problems.”
Dr. Sklaroff stated, “1-D I do not have. I only have 1-F.” A.R. 79–80.
100 A.R. 67–69. After Mr. Johnsamson testified that he provided documentation from a
neurologist in Manhattan, the ALJ stated:
We have very strict rules and regulations regarding the submission of medical
evidence . . . [n]ow you’re talking about something that we don’t have in the
record, and we’re sitting here in the hearing right now . . . and you’re talking
about something that is a number of years before the period of time that we’re
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 28 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 29 of 44
John Head testified as the vocational expert (“VE”). 	Based on the ALJ’s first
hypothetical, he opined that Mr. Johnsamson could perform all of his past work “with the
exception of the baggage handler.”101 	Based on the ALJ’s further limitation of frequent
kneeling, VE Head opined that the positions of schedule clerk and medical record clerk
“would be satisfactory.” 	Based on the ALJ’s limitation of light work instead of medium
work, VE Head opined that the individual could still work as a scheduling clerk and
medical records clerk.102
Mr. Johnsamson’s Function Report
Mr. Johnsamson completed a function report on September 8, 2016. He reported
that he could not stand or sit due to chronic back, neck, and knee pain. 	He also noted
that he had “frequent migraines that start from my neck and go to my head” and that they
“are continually getting worse and more frequent which prevents me from concentrating
on my work” and “led to routine mistakes at work.” Mr. Johnsamson reported that he had
pain and insomnia and his sleep medications made him “groggy” and unable to
“concentrate the next morning.” 	He reported that his back pain “also cause[d] anal
leakage that must be managed throughout the day with frequent bathroom visits.” 	He
dealing with . . . [a]nd I’m going to ask the doctor to just proceed based on what
we have in the file. A.R. 68–69.
101 The ALJ’s first hypothetical was as follows:
I have an individual with the claimant’s age, education, past work experience,
who would be able to perform medium level work as defined by the Social
Security Administration, with the following limitations. We would have frequent
climbing of ladders, ropes and scaffolding. A.R. 98.
102 A.R. 96–100.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 29 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 30 of 44
reported that he did not prepare his own meals because he was “unable to stand or bend”
and experienced a “loss of sensation in [his] hands to heat and cold.” He noted that he
could do light chores that did not involve standing or bending, but did not do yard work.
Mr. Johnsamson indicated that he went outside 3-4 times a week; could drive and ride in
a car; shop in stores, by mail, and by computer; and pay bills and count change. 	He
indicated that he watched television and videos; read; and went to doctor’s appointments.
He also indicated that he attended church services but his attendance was “very limited.”
Mr. Johnsamson reported that his chronic pain and medication side-effects, including
mood changes, affected lifting, squatting, bending, standing, reaching, walking, sitting,
kneeling, hearing, 	stair-climbing, 	seeing, memory, 	completing tasks, 	concentration,
understanding, following instructions, using his hands, and getting along with others. He
also noted that medication side effects and hearing difficulties affected his comprehension
of written and spoken instructions.103
IV. 	DISCUSSION
Mr. Johnsamson is now represented by counsel. 	In his opening brief, Mr.
Johnsamson asserts that the “agency decision failed to take account of the additional
evidence that Mr. Johnsamson submitted to the Appeals Council.” 	He also alleges that
the ALJ: (1) failed to fully and fairly develop the record “by carrying out the specific
recommendation for further diagnostic testing that was made at [the] hearing by medical
expert Dr. Sklaroff” and (2) failed to “account for and to weigh the functional medical
103 A.R. 357–65.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 30 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 31 of 44
evaluation and medical source statement of treating physician Heather Jones, M.D..”104
The Commissioner disputes Mr. Johnsamson’s assertions.105 The Court addresses each
of Mr. Johnsamson’s assertions in turn:
A. Additional Evidence
In its decision, the Appeals Council stated that Mr. Johnsamson had submitted
additional documents to the Council from: (1) James Glenn, PA-C, dated March 15, 2016
to March 31, 2016; (2) medical records from Imaging Associates dated March 25, 2016
to December 29, 2016; (3) Brooklyn HSS Veterans Hospital dated August 24, 2015 to
September 2, 2015; and (4) Office of Personnel Management statement dated January
26, 2017. The Appeals Council determined that this evidence did not “show a reasonable
probability that they would change the outcome of the decision” and it did not “consider
and exhibit this evidence.”106
Mr. Johnsamson asks the Court “to fulfill its role by reversing the final agency
decision and remanding the claim to the agency for fact finding in the first instance to take
account of the entire record, including additional evidence.” Specifically, he asserts that
the Brooklyn HSS Veterans Hospital records “corroborate Mr. Johnsamson’s hearing
testimony” and update an earlier medical record regarding “substantial lower back pain
that impacted his ability to sit and to stand.” 	Mr. Johnsamson also argues that the
104 Docket 14 at 3.
105 Docket 15 at 6–14.
106 A.R. 5.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 31 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 32 of 44
additional VA records from James Glenn, PA-C, show that Mr. Johnsamson “may not be
able to perform his work, and that opinion was rendered in the context of a decision that
found Mr. Johnsamson not disabled based on [his] purported ability to return to past
relevant work.” 	He also asserts that the medical records from Imaging Associates
“continue[d] 	the 	examination 	of 	and 	medical 	planning 	of 	spinal 	difficulties, 	the
degenerative joint disease and degenerative disc disease.”107
1. 	Legal Standard
When the Appeals Council declines review, its decision is not subject to judicial
review and “the ALJ’s decision becomes the final decision of the Commissioner.”108
However, the district court considers the additional evidence, “which was rejected by the
Appeals Council, to determine whether, in light of the record as a whole, the ALJ’s
decision was supported by substantial evidence and was free of legal error.”109 The SSA
permits a claimant to provide evidence from non-physician sources as to the severity of
an impairment and how it affects a claimant’s ability to work, including 	evidence from a
nurse 	practitioner, 	physician 	assistant 	(PA), 	chiropractor, 	or 	therapist, 	including a
107 Docket 14 at 13–14.
108 Taylor v. Comm’r of Soc. Sec. Admin., 659 F.3d 1228, 1231 (9th Cir. 2011); see Klemm v.
Astrue, 543 F.3d 1139, 1144 (9th Cir. 2008) (“The Social Security Act grants to district courts
jurisdiction to review only ‘final decisions’ of the Commissioner”) (citing 42 U.S.C. § 405(g)).
109 Id. at 1232. See also Brewes v. Comm’r of Soc. Sec. Admin., 682 F.3d 1157, 1163 (9th Cir.
2012) (“[W]e hold that when the Appeals Council considers new evidence in deciding whether to
review a decision of the ALJ, that evidence becomes part of the administrative record, which the
district court must consider when reviewing the Commissioner’s final decision for substantial
evidence.”).
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 32 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 33 of 44
physical therapist.110 	The ALJ may discount opinions from these “other sources” if the
ALJ “gives reasons germane to each witness for doing so.”111
2. 	PA Glenn’s Records dated March 15, 2016 through March 31, 2016
Mr. Johnsamson initiated care with PA Glenn on March 15, 2016. 	The medical
records submitted to the Appeals Council from PA Glenn included treatment notes from
March 15, 2016 through March 31, 2016.112 These same treatment notes were in the
record before the ALJ.113 	However, the ALJ’s decision does not reference or discuss
these records.
On March 31, 2016, PA Glenn opined that Mr. Johnsamson was not disabled at
that time and that “he [was] able to perform some type of employment.” PA Glenn also
noted that Mr. Johnsamson “may not be able to go back to what he was doing before
and he states that he cannot concentrate due to the pain, but I did advise him that the
whole purpose of us seeing him is to treat his pain, get it under better control so that he
can go back to work and do his normal job or at least be employed in some type of
capacity.”114 	PA Glenn completed a health care provider form on the same date and
opined that Mr. Johnsamson was unable to work at the time, but if his symptoms
110 20 C.F.R. §§ 404.1513(d), 416.913(d). These sections apply to claims filed before March 27,
2017.
111 Turner v. Comm’r of Soc. Sec., 613 F.3d 1217, 1224 (9th Cir. 2010) (quoting Lewis v. Apfel,
236 F.3d 503, 511 (9th Cir. 2001)).
112 A.R. 22–26.
113 A.R. 677–81.
114 A.R. 25–26, 680–81.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 33 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 34 of 44
improved he “may be able to return to work in the future.”115 Based on his diagnoses at
the March 2016 visits, PA Glenn recommended an epidural steroid injection.116 	PA
Glenn’s work opinion was based on treatment records from a limited time period of
approximately one month, but it was supported by the work opinion of Dr. Jones and the
VA rating of 100% disability.117 	Therefore, the ALJ was required to provide germane
reasons for discounting PA Glenn’s opinion.118 But in this case, the ALJ did not address
PA Glenn’s opinions in his decision.119 	In light of the record as a whole, the ALJ’s
decision not to address PA Glenn’s work opinion at all was legal error.
3. 	Imaging Associates’ Records dated March 25, 2016 to December 29, 2016
Imaging Associates’ MRI records were submitted to the Appeals Council and were
also part of the record before the ALJ.120 	Further, the ALJ briefly discussed this MRI
115 A.R. 283–86.
116 A.R. 25, 680. An epidural injection may be considered more than conservative treatment.
“Conservative treatment” has been characterized by the Ninth Circuit as, for example,
“treat[ment] with an over-the-counter pain medication” (see, e.g., Parra v. Astrue, 481 F.3d 742,
751 (9th Cir. 2007); Tommasetti v. Astrue, 533 F.3d 1035, 1040 (9th Cir. 2008) (holding that ALJ
properly considered the plaintiff’s use of “conservative treatment including physical therapy and
the use of anti-inflammatory medication, a transcutaneous electrical nerve stimulation unit, and
a lumbosacral corset”)), or a physician’s failure “to prescribe . . . any serious medical treatment
for [a claimant’s] supposedly excruciating pain,” Meanel v. Apfel, 172 F.3d 1111, 1114 (9th
Cir.1999).
117 A.R. 22–26, 44, 677–81, 671–72.
118 Turner, 613 F.3d at 1224. See also infra notes 135, 140.
119 The ALJ’s discussion of the opinion evidence involved discounting non-examining medical
expert Shirley Fraser’s opinions and providing great weight to non-examining medical expert Dr.
Sklaroff’s testimony and opinions. A.R. 45.
120 A.R. 17–21, 682–83, 951–54, 975–76, 1157–60.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 34 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 35 of 44
evidence in his opinion.121 	Therefore, in light of the record as a whole, the ALJ’s
discussion of the MRI evidence from Imaging Associates from March 25, 2016 to
December 29, 2016 was supported by substantial evidence and free from legal error.
4. 	Brooklyn 	HHS 	Veterans 	Hospital 	Records 	dated 	August 	24, 	2015 	to
September 2, 2015
The medical records from Brooklyn HHS Veterans Hospital from August 24 to
September 2, 2015 were submitted to the Appeals Council. 	However, it appears they
were also in the record before the ALJ at the time of his decision.122 As of July 15, 2015,
PA Otero opined that a “decompression would most likely address [Mr. Johnsamson’s]
left lower extremity radicular symptoms; but not address his chronic complaints of back
pain.” 	PA Otero also opined that Mr. Johnsamson was “neurologically stable except for
his subjective complaints of left lower extremity numbness” and she recommended a trial
of conservative therapy including physical therapy, back school, HEP, acupuncture, and
other modalities as needed; an interventional pain management consultation for ESI
evaluation; and pool therapy. 	PA Otero’s update on August 24, 2015 noted that Mr.
Johnsamson had called to request paperwork and the addendum on September 2, 2015
noted that PA Otero had filled out FERS disability forms pursuant to Mr. Johnsamson’s
request.123
121 The ALJ noted that in December 2016, “while MRI images showed osteoarthritic and
degenerative changes, the course of recommended treatment was simply steroid injections.”
A.R. 44.
122 A.R. 5, 12–16, 666–70; but see Docket 16 at 2-4.
123 A.R. 12–16, 666–70.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 35 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 36 of 44
At the hearing, it appeared that neither the ALJ nor Dr. Sklaroff had reviewed the
VA records from the Brooklyn HHS Veterans Hospital. Yet the ALJ “ask[ed] the doctor to
just proceed based on what we have in the file.”124 The ALJ then gave “great weight” to
Dr. Sklaroff’s testimony and opinions.125 	Although the records from Brooklyn HHS
Veterans Hospital were evidently part of the record before the ALJ, the testifying medical
expert indicated he had not reviewed them. Hence it is unknown whether the opinions of
PA Otero would have had any impact on Dr. Sklaroff’s testimony. 	Likewise, the ALJ’s
decision does not reference the VA records from Brooklyn and PA Otero’s assessment.
The failure to address these records constituted legal error.
5. 	The FERS Disability Determination
On 	January 	26, 	2017, 	the 	Office 	of 	Personnel 	Management 	wrote 	to 	Mr.
Johnsamson to inform him that he had been found “disabled for your position as an Traffic
Management Specialist,” and his application for FERS disability retirement had been
approved.126 This document was not before the ALJ; the Appeals Council received but
did not consider this document, as it concluded it “does not show a reasonable probability
that [it] would change the outcome of the decision.”127
Mr. Johnsamson’s opening brief failed to explain how the OPM letter was likely to
124 A.R. 67–69. See supra note 99, 100.
125 A.R. 45.
126 A.R. 31–32.
127 A.R. 5.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 36 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 37 of 44
change the outcome of the agency’s decision.128 As this matter is being remanded on
other bases, on remand the ALJ must consider the FERS disability rating.129 In particular,
based on this Court’s review of the testimony at the administrative hearing, it appears that
one of the jobs that the vocational examiner testified could still be performed by Mr.
Johnsamson, the schedule clerk, is the same job that FERS determined in January 2017
that Mr. Johnsamson could no longer perform, the traffic management specialist position
he had held.130
Thus, considering the record as a whole, including the records from the Brooklyn
HHS Veterans Hospital, PA Glenn’s undiscussed work opinion, and the FERS disability
determination, the ALJ’s decision was not supported by substantial evidence and not free
from legal error.
B. Development of the Record
Mr. Johnsamson asserts that the ALJ failed to fully and fairly develop the record by
failing to “follow through on Dr. Sklaroff’s recommendation” that Mr. Johnsamson
“potentially would benefit from a bariatric consultation.”131 The ALJ has an “independent
duty to fully and fairly develop the record and to assure that the claimant’s interests are
128 See Smith v. Univ. of Wash., 194 F.3d 1045, 1052 (9th Cir. 1999) (holding arguments
not properly raised in opening brief deemed waived).
129 Cf. McLeod v. Astrue, 640 F.3d 881, 885 (9th Cir. 2011) (holding that VA disability
rating “must be considered and ordinarily must be given great weight”).
130 See A.R. 83, 86 (“Traffic management specialist. That was a desk job mainly billing
and scheduling and stuff.”).
131 Docket 14 at 3, 16; A.R. 78.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 37 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 38 of 44
considered.”132 An “ALJ’s duty to develop the record farther is triggered only when there
is ambiguous evidence or when the record is inadequate to allow for proper evaluation of
the evidence.” 	Additionally, the “ALJ must be especially diligent when the claimant is
unrepresented or has only a lay representative.”133 If the evidence is insufficient to make
a decision regarding disability or the ALJ cannot reach a conclusion based on the
evidence it has before him, he may recontact a treating physician, psychologist, or other
medical source; request additional existing records; or ask for more information from the
claimant or others.134 	An ALJ has broad discretion in determining whether to order a
consultative examination and may do so when “ambiguity or insufficiency in the evidence
. . . must be resolved.”135
Here, Mr. Johnsamson testified that his inability to work was due to functional
limitations caused by pain in his neck, back, shoulder, and knee, as well as related
headaches and insomnia.136 	In his function reported, Mr. Johnsamson stated that he
132 Tonapetyan v. Halter, 242 F.3d 1144, 1150 (9th Cir. 2001) (internal citations and quotations
omitted).
133 McLeod v. Astrue, 640 F.3d 881, 885 (9th Cir. 2011) (internal citations omitted).
134 Smolen v. Chater, 80 F.3d 1273, 1288 (9th Cir. 1996) (“If the ALJ thought he needed to know
the basis of [a doctor’s] opinions in order to evaluate them, he had a duty to conduct an
appropriate inquiry, for example, by subpoenaing the physicians or submitting further questions
to them.”); see also 20 C.F.R. §§ 404.1520b, 416.920b (effective until March 27, 2017).
135 Reed v. Massanari, 270 F.3d 838, 842 (9th Cir. 2001) (citation omitted). See also 20 C.F.R. §
404.1519a(b) (A consultative examination may be purchased “to try to resolve an inconsistency
in the evidence, or when the evidence as a whole is insufficient to allow us to make a
determination or decision on your claim.”).
136 A.R. 43, 63, 65–66, 90–96.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 38 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 39 of 44
was “unable to sit or stand due to chronic back, neck, and knee pain.” He also noted he
had “frequent migraines that start from my neck” and was “unable to sleep at night.”137
The medical record does not show uncontrolled hypertension, hyperlipidemia, diabetes
mellitus or problems with medications for those conditions.138
For the foregoing reasons, the ALJ was not required to order a bariatric
consultation examination in this case and no legal error occurred in this regard.
C. 	Medical Opinion
Mr. Johnsamson asserts that the ALJ “failed to account for and to weigh the
functional medical evaluation and medical source statement of treating physician Heather
Jones, M.D., which is inconsistent with the residual functional capacity that led to Step
Four denial of this claim.” 	Specifically, he alleged that the ALJ “vaguely acknowledged
Heather Jones, M.D., but did not weigh her medical source statement and functional
medical evaluation.”139
1. 	Legal Standard
“Regardless of its source, [the SSA] will evaluate every medical opinion [it]
receive[s].”140 	Medical opinions come from three types of sources: those who treat the
137 A.R. 43, 357
138 e.g., A.R. 227–31, 547–53, 569–72, 776.
139 Docket 14 at 3, 19; see A.R. at 44 (stating in ALJ decision, “other examining physicians
aware of the claimant’s 100% VA disabled status have noted that the claimant should still be
able to pursue a meaningful career and not be precluded from working due to his neck and back
pain.”).
140 20 C.F.R. § 404.1527(c). This section applies to claims filed before March 27, 2017.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 39 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 40 of 44
claimant; those who examine but do not treat the claimant; and those who neither
examine nor treat the claimant. 	“As a general rule, more weight should be given to the
opinion of a treating source than to the opinion of doctors who do not treat the
claimant.”141 In the Ninth Circuit, “[t]o reject [the] uncontradicted opinion of a treating or
examining doctor, an ALJ must state clear and convincing reasons that are supported by
substantial evidence.”142 When “a treating or examining doctor’s opinion is contradicted
by another doctor’s opinion, an ALJ may only reject it by providing specific and legitimate
reasons supported by substantial evidence.”143 	This can be done by “setting out a
detailed and thorough summary of the facts and conflicting clinical evidence, stating his
interpretation thereof, and making findings.” In disability benefits cases, physicians “may
render medical, clinical opinions, or they may render opinions on the ultimate issue of
disability –– the claimant’s ability to perform work.”144 “Where an ALJ does not explicitly
reject a medical opinion or set forth specific, legitimate reasons for crediting one medical
opinion over another, he errs.”145 Further, a VA disability rating “must be considered and
ordinarily must be given great weight.”146
141 Garrison v. Colvin, 759 F.3d 995, 1012 (9th Cir. 2014) (quoting Lester v. Chater, 81 F.3d 821,
830 (9th Cir. 1995)).
142 Trevizo v. Berryhill, 871 F.3d 664, 675 (9th Cir. 2017) (alternations in original) (quoting
Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th Cir. 2005)).
143 Revels v. Berryhill, 874 F.3d 648, 654 (9th Cir. 2017) (quoting Bayliss, 42 F.3d at 1216).
144 Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998) (internal citations omitted).
145 Garrison v. Colvin, 759 F.3d at 1012.
146 McLeod v. Astrue, 640 F.3d at 886.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 40 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 41 of 44
2. 	Analysis
Dr. Jones, a family practitioner, examined Mr. Johnsamson and opined that she
“believe[d] [Mr. Johnsamson was] able to work but may need to pursue a different type
job.” Additionally, she recommended he “pursue pain management for his neck as he [is]
very young and should still be able to pursue a meanin[g]ful career and should be able to
get his neck and back pain under control.” She added that Mr. Johnsamson may “have
to adjust [his] workstation, get lumbar support or have pain management [prescription]
medications for pain.”147
Dr. Jones’s opinion that Mr. Johnsamson was capable of working at a different job
and her opinion that Mr. Johnsamson could work with adjustments to his workstation,
lumbar support, and pain management through medications were contradicted by the
VA’s 100% disabled rating.148 It was also at odds with the testimony of Dr. Sklaroff, who
identified only minimal limitations in Mr. Johnsamson’s functionality.149 Therefore, the ALJ
was required to provide specific and legitimate reasons for discounting Dr. Jones’s work
opinion, including her opinion that although she believed Mr. Johnsamson could work, he
may have to work at another job.150
147 A.R. 671–72.
148 The VA’s most recent update to its 2012 rating decision was issued on August 10, 2015.
A.R. 192–93, 227–31. See also Hiler v. Astrue, 687 F.3d 1208, 1212 (9th Cir. 2012) (holding
ALJ must “ordinarily give great weight to a VA determination of disability.”).
149 A.R. 62-83.
150 See Hill v. Astrue, 688 F.3d 1144, 1151 (9th Cir. 2012) (holding that ALJ erred in disregarding
examining psychologist’s assessment that claimant was unlikely to be able to sustain full time
employment), superseded by Hill v. Astrue, 698 F.3d 1153, 1160 (9th Cir. 2012) (holding same).
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 41 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 42 of 44
Although the ALJ did not name Dr. Jones specifically in his decision nor assign her
work opinion a specific weight, the ALJ used the portion of her opinion that Mr.
Johnsamson “should still be able to pursue a meaningful career and not be precluded
from working due to his neck and back pain” to discount the 100% disabled VA rating.151
But the ALJ cannot simply choose to include the part of Dr. Jones’s opinion that supports
his decision and ignore the entirety of the opinion, even on the ultimate issue of
disability.152
For the foregoing reasons, the Court finds that the ALJ did not provide specific or
legitimate reasons for discounting Dr. Jones’s work opinion. As a result, and considering
the record as a whole, the ALJ’s step four decision that Mr. Johnsamson could return to
his previous work was not supported by substantial evidence.
D. 	Scope of Remand
The “ordinary remand rule” applies to disability cases. 	Under this rule, if “the
reviewing court simply cannot evaluate the challenged agency action on the basis of the
record before it, the proper course, except in rare circumstances, is to remand to the
151 A.R. 44, 671–72.
152 Ghanim v. Colvin, 763 F.3d 1154, 1164 (9th Cir. 2014) (“[T]he ALJ improperly cherry-picked
some of Dr. Dees’s characterizations of Ghanim’s rapport and demeanor instead of considering
these factors in the context of Dr. Dees’s diagnoses and observations of impairment.”). See
also Holohan v. Massanari, 246 F.3d 1195, 1202 (9th Cir. 2001) (“In disability benefits cases,
physicians typically provide two types of opinions: medical opinions that speak to the nature and
extent of a claimant’s limitations, and opinions concerning the ultimate issue of disability.”);
Garrison v. Colvin, 759 F.3d at 1012–13 (“[A]n ALJ errs when he rejects a medical opinion or
assigns it little weight while doing nothing more than ignoring it, asserting without explanation
that another medical opinion is more persuasive, or criticizing it with boilerplate language that
fails to offer a substantive basis for his conclusion.”).
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 42 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 43 of 44
agency for additional investigation or explanation.”153 Here, the Court has found that, in
light of the record as a whole, the ALJ’s decision was not supported by substantial
evidence or free of legal error regarding the evidence submitted to the Appeals Council,
most of which was already in the administrative record. 	Specifically, the ALJ did not
provide germane reasons for ignoring PA Glenn’s work opinions. Additionally, it is unclear
if the testifying medical expert reviewed the Brooklyn HHS Veterans Hospital records, yet
the ALJ afforded the expert’s opinions great weight. 	The Court has also found that the
ALJ failed to provide specific or legitimate reasons for discounting Dr. Jones’s work
opinion and the ALJ’s step four decision that Mr. Johnsamson could return to previous
work was not supported by substantial evidence.
Mr. Johnsamson asks the Court to “reverse the final agency decision and remand
the claim to the agency for de novo hearing and a new decision.”154 Therefore, the case
will be remanded for the ALJ to adequately analyze the opinions of PA Glenn and Dr.
Jones, as well as other medical providers’ functional and work opinions, in light of the
record as a whole and the VA and FERS 100% disability ratings. 	Additionally, the ALJ
should take new testimony from a medical expert regarding the Brooklyn HHS Veterans
Hospital records and other neurology reports in the record as necessary, adjust the RFC
as warranted, and proceed to steps four or five as appropriate.
153 Treichler, 775 F.3d at 1099 (quoting Fla. Power & Light Co. v. Lorion, 470 U.S. 729, 744
(1985)).
154 Docket 14 at 22.
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 43 of 44

Case No. 3:18-cv-00198-SLG, Johnsamson v. Saul
Decision and Order
Page 44 of 44
V. 	ORDER
The Court, having carefully reviewed the administrative record, finds that the ALJ’s
determinations are not free from legal error. 	Accordingly, IT IS ORDERED that Mr.
Johnsamson’s request for relief at Docket 14 is GRANTED, the Commissioner’s final
decision is VACATED, and the case is REMANDED to the SSA for further proceedings
consistent with this decision.
The Clerk of Court is directed to enter a final judgment accordingly.
DATED this 16th day of October 2019 at Anchorage, Alaska.
/s/ Sharon L. Gleason____________
UNITED STATES DISTRICT JUDGE
Case 3:18-cv-00198-SLG Document 18 Filed 10/16/19 Page 44 of 44