Fonseca v. Commissioner of Social Security Administration

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WO
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
Laura Lynne Fonseca,
Plaintiff,
v.
Commissioner of Social Security
Administration,
Defendant.
No. CV-24-08245-PCT-KML
ORDER
Plaintiff Laura Lynne Fonseca seeks review of the Social Security Commissioner’s
final decision denying her disability insurance benefits. Because the Administrative Law
Judge’s (“ALJ’s”) decision is supported by substantial evidence and is not based on
harmful legal error, it is affirmed.
I. Background
Fonseca filed an application for disability insurance benefits on March 23, 2022,
alleging a disability beginning May 2, 2021. (Administrative Record (“AR”) 17.) The claim
was denied initially and upon reconsideration. (AR 17.) After a hearing, an ALJ denied her
claim on July 12, 2024. (AR 36.) The Appeals Council denied Fonseca’s request for review
(AR 2), and she then appealed to this court.
II. Legal Standard
The court may set aside the Commissioner’s disability determination only if it is not
supported by substantial evidence or is based on legal error. Orn v. Astrue, 495 F.3d 625,
630 (9th Cir. 2007). “Substantial evidence is more than a mere scintilla but less than a
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preponderance” and is such that “a reasonable mind might accept as adequate to support a
conclusion.” Id. (quoting Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005)). The court
reviews only those issues raised by the party challenging the decision. See Lewis v. Apfel,
236 F.3d 503, 517 n.13 (9th Cir. 2001).
III. Analysis
Fonseca argues only that the ALJ committed materially-harmful legal error by not
sufficiently accounting for the migraine symptoms she alleged in her testimony when
determining her RFC.1 (Doc. 12 at 7.) She seeks a remand for further administrative
proceedings. (Doc. 12 at 8.)
A. The ALJ’s Five-Step Disability Evaluation Process
Under the Social Security Act, a claimant for disability insurance benefits must
establish disability prior to the date last insured. 42 U.S.C. § 423(c); 20 C.F.R. § 404.131.
A claimant is disabled under the Act if she cannot engage in substantial gainful activity
because of a medically-determinable physical or mental impairment that has lasted, or can
be expected to last, for a continuous period of twelve months or more. 42 U.S.C.
§§ 423(d)(1)(A); 1382c(a)(3)(A).
Whether a claimant is disabled is determined by a five-step sequential process. See
Woods v. Kijakazi, 32 F.4th 785, 787 n.1 (9th Cir. 2022) (summarizing 20 C.F.R.
§ 404.1520(a)(4)). The claimant bears the burden of proof on the first four steps, but the
burden shifts to the Commissioner at step five. Tackett v. Apfel, 180 F.3d 1094, 1098 (9th
Cir. 1999). At step three, the claimant must show that her impairment or combination of
impairments meets or equals the severity of an impairment listed in Appendix 1 to Subpart
P of 20 C.F.R. Part 404. 20 C.F.R. § 404.1520(a)(4)(iii). If the claimant meets her burden
at step three, she is presumed disabled and the analysis ends. If not, at step four, the
claimant must show her residual functional capacity (“RFC”)—the most she can do with
her impairments—precludes her from performing her past work. Id. If the claimant meets
1 Fonseca claims “[t]he ALJ improperly rejected [her] testimony regarding her migraines.”
(Doc. 12 at 4, 8.) But she also says “at no point did the ALJ discount or suggest that [her]
testimony regarding her migraines was not credible.” (Doc. 12 at 7.)
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her burden at step four, then at step five the Commissioner must determine if the claimant
is able to perform other work that “exists in significant numbers in the national economy”
given the claimant’s RFC, age, education, and work experience. Id. § 404.1520(a)(4)(v). If
so, the claimant is not disabled. Id.
The ALJ found Fonseca had “not engaged in substantial gainful activity” since her
disability onset date and that she had multiple severe impairments (including migraines)
for a continuous period of twelve months, satisfying her burden at steps one and two (AR
20–21). Id. § 404.1520(a)(4)(i)–(ii). At step three, the ALJ determined Fonseca’s
impairments or combination of impairments did not meet or medically equal the severity
of a listed impairment (AR 22), and at step four that Fonseca had the RFC to perform light
work with some additional limitations (AR 25). In evaluating Fonseca’s RFC, the ALJ
partially discounted her symptom testimony. The ALJ found inconsistent Fonseca’s
“statements about the intensity, persistence, and limiting effects of . . . her
symptoms[ ] . . . because the evidence demonstrates a fairly conservative treatment history
and generally benign objective medical findings.” (AR 27; see also AR 27 (finding
Fonseca’s statements “not entirely consistent with the medical evidence and other evidence
in the record”).)
The ALJ used Fonseca’s RFC to conclude at step four that she was unable to
perform any of her past relevant work. (AR 33.) But the ALJ determined at step five that
“there were jobs that existed in significant numbers in the national economy that [Fonseca]
could have performed,” so she was not disabled. (AR 34.)
B. The ALJ’s Evaluation of Fonseca’s Symptom Testimony
Fonseca argues the ALJ erred by discounting her symptom testimony regarding her
migraines. (Doc. 12 at 6.) When a claimant has presented objective medical evidence of an
underlying impairment which could reasonably be expected to cause the severity of the
symptoms alleged and there is no evidence of malingering, an ALJ may only reject
subjective symptom-severity testimony by offering “specific, clear and convincing reasons
for doing so.” Revels v. Berryhill, 874 F.3d 648, 655 (9th Cir. 2017) (quoting Garrison v.
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Colvin, 759 F.3d 995, 1014–15 (9th Cir. 2014)). Such findings are sufficiently specific
when they permit a reviewing court to conclude the ALJ “did not arbitrarily discredit [a]
claimant’s testimony.” Tommasetti v. Astrue, 533 F.3d 1035, 1039 (9th Cir. 2008)
(simplified), superseded on other grounds by 20 C.F.R § 404.1502(a). Because the ALJ
did not find that Fonseca was malingering, she could only discredit the symptom testimony
by providing “specific, clear and convincing” reasons for doing so. Revels, 874 F.3d at 655.
One of the ALJ’s “specific, clear, and convincing” reasons for discounting
Fonseca’s symptom testimony was her response to treatment—specifically, her migraine
symptom improvement from Botox injections. The ALJ discussed Fonseca’s testimony
related to her migraines multiple times. (See AR 26 (Fonseca testified “that she ha[d] daily
headaches, and migraines once or twice per month”), 31 (at one point Fonseca “complained
of migraine headaches 30 days per month, lasting six hours” and described them as
“pulsating and throbbing”).) But after discussing how the objective medical evidence
showed Fonseca’s migraine symptoms improved after receiving Botox injections, the ALJ
concluded her migraines were only “likely to cause non-disabling limitations.” (AR 31.)
And the ALJ “accounted for [Fonseca’s] migraines” by limiting her to light exertional work
and in finding she must avoid concentrated exposure to “loud noise” (which Fonseca had
described as a trigger), “vibration, and chemicals, odors, dust, fumes, and gases.” (AR 31.)
This finding contradicts Fonseca’s argument that the ALJ “described her migraines as
doing better after Botox” but ignored limitations that stemmed from them. (Doc. 15 at 1.)
The ALJ found Fonseca’s migraines were not disabling because Fonseca reported
to medical providers multiple times throughout the relevant period that her migraine
symptoms significantly improved after receiving Botox injections. (See AR 31 (citing AR
1297 (in March 2022, Fonseca reported that she had “significant relief [from her migraines]
in the last four months with Botox [injections]”), 2693 (in April 2022, she reported that
Botox had improved her migraines by 50%), 2140 (in May 2022, she reported 50% relief
in intensity and reduction in the number of migraine episodes), 2155 (same in August
2022)).) The frequency of Fonseca’s migraines dropped from 30 days per month in March
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2022 (AR 31), as the ALJ noted, to one-to-two per month when she testified (AR 63). And
there were at least six other instances in the record in which Fonseca reported significant
migraine relief and symptom control via Botox injections. (See Doc. 14 at 6–7 (citing
records).)
Fonseca argues the improvement in her migraine symptoms must be taken in context
given that “she qualified for [Botox] treatment on multiple occasions [which] suggests that
even with a 50% improvement [in symptoms], [she] was still having migraines and
headaches at significant frequencies.” (Doc. 12 at 7.) But for an ALJ to use improvement
from treatment to discount symptom testimony, the ALJ need not find treatment cured the
claimant’s symptoms completely and instead “that the pain was ‘controlled,’ i.e., no longer
debilitating.” Lopez v. Colvin, 194 F. Supp. 3d 903, 911 (D. Ariz. 2016) (quoting Warre v.
Comm’r of Soc. Sec., 439 F.3d 1001, 1006) (9th Cir. 2016)). And as the Commissioner
argues, even if a claimant’s treatment “does not wholly resolve [their] headaches, an ALJ
can evaluate allegations of disabling headaches based on evidence of improvement.” (Doc.
14 at 6–7.)
In fact, migraine improvement from Botox injections has been found to be a
“specific, clear, and convincing” reason to discount a claimant’s testimony regarding
disabling migraine symptoms on many occasions. See Woods-White v. Comm’r of Soc. Sec.
Admin., No. CV-24-01405-PHX-JAT, 2025 WL 325527, at *11 (D. Ariz. Jan. 29, 2025)
(Botox reducing migraine headaches by at least 50-65% undermined the claimant’s
symptom testimony regarding the severity of her migraines even if they “did not fully
control her migraines or pain”); Sanchez v. Comm’r of Soc. Sec. Admin., No. CV-21-0155-
PHX-DLR (JFM), 2022 WL 4798452, at *7 (D. Ariz. Aug. 26, 2022) (a 50% reduction in
daily migraines showed migraine symptoms were “well controlled”), report and
recommendation adopted, 2022 WL 4783758 (D. Ariz. Sept. 30, 2022); Martinez v.
Comm’r of Soc. Sec. Admin., No. CV-21-00498-PHX-DLR, 2022 WL 4078219, at *3 (D.
Ariz. Sept. 6, 2022) (30-40% improvement in migraines after Botox injections was a “clear
and convincing” reason to discount the claimant’s symptom testimony regarding his
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migraines). For these reasons, the ALJ properly considered Fonseca’s improvement from
Botox injections as a reason for discounting her symptom testimony.
The ALJ also discounted Fonseca’s migraine symptom testimony because it was
“not entirely consistent with the medical evidence and other evidence in the record.” (AR
26–27.) Fonseca argues an “ALJ may use inconsistent objective medical evidence in the
record to discount subjective testimony, but ‘cannot effectively render a claimant’s
subjective symptom testimony superfluous by demanding positive objective medical
evidence fully corroborating every allegation within the subjective testimony.’” (Doc. 12
at 5 (quoting Smartt v. Kijakazi, 53 F.4th 489, 498 (9th Cir. 2022) (simplified)).) As in
Smartt, that is not what the ALJ did here. See Smartt, 53 F.4th at 498 (ALJ who noted
claimant’s symptoms were “not entirely consistent with the medical evidence” simply
meant the record contained conflicting evidence between claimant’s testimony and the
objective medical evidence). Indeed, two State agency medical consultants discounted the
severity of Fonseca’s migraines and assigned her similar exertional and environmental
limitations as the ALJ did to account for them. (See Doc. 14 at 5 (citing AR 33, 85–88, 88–
103).) The state agency consultants’ findings too were based on Fonseca’s “significant
relief” from Botox injections that generally rendered her migraine symptoms “well
controlled” and on other evidence in the record. (Doc. 14 at 5 (quoting AR 84, 102); see
also AR 85–88, 88–103.) And as the Commissioner points out, “[e]ven ‘[w]here evidence
is susceptible to more than one rational interpretation, it is the [ALJ’s] conclusion that must
be upheld.’” (Doc. 14 at 2 (quoting Burch, 400 F.3d at 679).)
Fonseca also argues the ALJ erred in considering her symptom testimony because
she did not account for her “need to enter a dark space in order to reduce migraine
symptoms” or present that limitation to the vocational expert. (Doc. 12 at 8.) But the ALJ
properly discounted Fonseca’s symptom testimony, so she was not required to assess all
the limitations on Fonseca’s work abilities that Fonseca claimed were necessary or to pose
those limitations to the vocational expert. See Shipman v. Comm’r of Soc. Sec., 271 F.
Supp. 3d 899, 909 (E.D. Mich. 2017) (rejecting claimant’s argument that the ALJ did “not
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account for his full degree of limitation” because the ALJ “adequately explained his
reasons for discounting [the claimant’s] more extreme but unsupported allegations of
limitation” and so “the ALJ was not required to include them in either the hypothetical
question [to the vocational expert] or [in the] ultimate RFC”). The ALJ’s purported failure
to account for Fonseca’s photophobia and need for a dark room is therefore not harmful
legal error.
The ALJ properly evaluated Fonseca’s migraine symptom testimony. She described
it at length, referred to it repeatedly in her decision, and used it as one of the bases for
finding Fonseca could only do work that required light exertion with some additional
limitations. The ALJ specifically referenced Fonseca’s improvement from Botox injections
and the medical opinions of two State agency consultants as reasons for not imposing
additional limitations. The ALJ thus provided “clear and convincing” reasons for
discounting Fonseca’s migraine symptom testimony that were sufficiently specific to
conclude the ALJ “did not arbitrarily discredit” her testimony. Revels, 874 F.3d at 655
(quoting Garrison, 759 F.3d at 1014–15); Tommasetti, 533 F.3d at 1039. Thus, the ALJ’s
decision to discredit Fonseca’s symptom testimony was supported by substantial evidence.
See Marsh, 792 F.3d at 1173.
IV. Conclusion
Fonseca’s contention that the ALJ erred in discounting her migraine symptom
testimony fails. She does not otherwise argue the ALJ’s non-disability finding was not
supported by substantial evidence or was otherwise based on harmful legal error, so the
ALJ’s decision is affirmed.
/
/
/
/
/
/
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Accordingly,
IT IS ORDERED affirming the July 12, 2024, decision of the ALJ.
IT IS FURTHER ORDERED directing the Clerk to enter final judgment
consistent with this Order and close this case.
Dated this 4th day of November, 2025.
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