0:25-cv-00847•Case Name in Social Security Case - Unavailable
Gesamter Gesetzestext
UNITED STATES DISTRICT COURT DISTRICT OF MINNESOTA Victoria H., Plaintiff, v. Frank Bisignano,1 Commissioner of Social Security, Defendant. Case No. 25-cv-00847 (JMB/ECW) REPORT AND RECOMMENDATION This matter is before the Court on Plaintiff Victoria H.’s (“Plaintiff”) brief seeking remand or reversal of the Commissioner’s decision to deny her claim for Supplemental Security Income (“SSI”) under Title XVI of the Social Security Act (Dkt. 9); and Defendant Commissioner of Social Security Administration Frank Bisignano’s (“the Commissioner”) brief in opposition (Dkt. 14).2 For the reasons stated below, the Court recommends granting Plaintiff’s request insofar as Plaintiff seeks reversal of the Commissioner’s decision and an award of benefits and denying the Commissioner’s 1 The Complaint named Leland Dudek, who was the Acting Commissioner of the Social Security Administration when Plaintiff filed his Complaint. (See Dkt. 1.) Frank Bisignano became the Commissioner of Social Security on May 7, 2025. Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure, Frank Bisignano should be substituted as the Defendant in this suit. No further action need be taken to continue this suit by reason of the last sentence of section 205(g) of the Social Security Act, 42 U.S.C. § 405(g). 2 As of December 1, 2022, Social Security Actions under 42 U.S.C. § 405(g) are “presented for decision on the parties’ briefs,” rather than summary judgment motions. Supplemental Rules for Social Security Actions under 42 U.S.C. § 405(g), Rule 5. CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 1 of 83
2 request that the Court affirm the denial of benefits. In the alternative, the Court recommends reversing the denial of benefits and remanding for further proceedings. I. PROCEDURAL BACKGROUND On January 13, 2022, Plaintiff filed an application for supplemental security income (“SSI”) alleging disability beginning April 2, 2018. (R. 249.)3 Plaintiff listed her medical conditions as major depressive disorder, persistent depression disorder, dysthymia, generalized anxiety disorder, social anxiety with agoraphobia, attention deficit hyperactivity disorder (“ADHD”), gastroesophageal reflux disease (“GERD”), polycystic ovary syndrome (“PCOS”), chronic fatigue, hypersomnia, and circadian rhythm sleep disorder. (R. 71.) Plaintiff’s application was denied initially and on reconsideration. (R. 80, 92.) Plaintiff requested a hearing before an administrative law judge, which took place via video conference before Administrative Law Judge Roy LaRoche (“the ALJ”) on December 11, 2023. (R. 31.) In a decision dated February 6, 2024, the ALJ concluded that Plaintiff was not disabled. (R. 24.) Following the five-step sequential evaluation process under 20 C.F.R. § 404.416.920(a)(4),4 the ALJ first determined at Step 1 that Plaintiff had not engaged in 3 The Social Security Administrative Record (“R.”) is available at Docket 7. 4 The five steps are as follows: (i) At the first step, we consider your work activity, if any. If you are doing substantial gainful activity, we will find that you are not disabled. . . . (ii) At the second step, we consider the medical severity of your impairment(s). If you do not have a severe medically determinable physical CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 2 of 83
3 substantial gainful activity since the date of her application. (R. 16.) At Step 2, the ALJ determined that Plaintiff had the following severe impairments: major depressive disorder; generalized anxiety disorder; attention-deficit hyperactivity disorder; and autism spectrum disorder. (R. 16.) At the third step, the ALJ determined that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, subpart P, Appendix 1. (R. 18.) At Step 4, after reviewing the entire record, the ALJ concluded that Plaintiff had the residual functional capacity (“RFC”) to perform “light work as defined in 20 CFR 416.967(b)” with the following limitations: • work limited to simple, routine, and repetitive tasks; or mental impairment that meets the duration requirement in § 416.909, or a combination of impairments that is severe and meets the duration requirement, we will find that you are not disabled. . . . (iii) At the third step, we also consider the medical severity of your impairment(s). If you have an impairment(s) that meets or equals one of our listings in appendix 1 to subpart P of part 404 of this chapter and meets the duration requirement, we will find that you are disabled. . . . (iv) At the fourth step, we consider our assessment of your residual functional capacity and your past relevant work. If you can still do your past relevant work, we will find that you are not disabled. . . . (v) At the fifth and last step, we consider our assessment of your residual functional capacity and your age, education, and work experience to see if you can make an adjustment to other work. If you can make an adjustment to other work, we will find that you are not disabled. If you cannot make an adjustment to other work, we will find that you are disabled. 20 C.F.R. § 416.920(a)(4). CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 3 of 83
4 • involving only simple, work-related decisions with few, if any, workplace changes; • the work should require quota-based tasks as opposed to production requirements; and • no more than incidental contact with coworkers (i.e., no tandem tasks) and no contact with the public. (R. 18.) At Step 5, the ALJ found that Plaintiff had no past relevant work. (R. 22.) The ALJ considered Plaintiff’s age, education, work experience, and RFC, and concluded that there were jobs that existed in significant numbers in the national economy that the Plaintiff could have performed. (R. 23.) These jobs included Garment Sorter (DOT 222.687-014) (light and SVP 2) (55,000 jobs nationally), Folder (DOT 369.687-018) (light and SVP 2) (53,000 jobs nationally), and Checker I, clerical (DOT 222.687-010) (light and SVP 2) (52,000 jobs nationally).” (R. 23.) Accordingly, the ALJ concluded that Plaintiff was not disabled. (R. 24.) Plaintiff filed a request for review of this decision, and the Appeals Council denied further review on January 8, 2025. (R. 1.) Because the Appeals Council did not assume jurisdiction, the ALJ’s February 6, 2024 decision is the final decision of the Commissioner subject to judicial review. Plaintiff now seeks judicial review pursuant to 42 U.S.C. § 405(g). (Dkt. 1.) II. FACTUAL BACKGROUND The Court has reviewed the entire administrative record, giving particular attention to the facts and records cited by the parties. The Court will recount the facts of record only to the extent they are helpful for context or necessary for resolution of the CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 4 of 83
5 specific issues presented by the parties. At issue in this case are the social limitations that the ALJ found as part of Plaintiff’s RFC. Plaintiff was 21 years old at the time her application was filed. (R. 23.) She lives with her mother and sister and receives food stamps. (R. 40.) Plaintiff completed high school in 2019. (R. 341.) She took an extra year to graduate due to attendance issues. (R. 45.) Plaintiff testified that her physical and mental health symptoms caused her to miss school approximately one third of the time. (R. 46, see also R. 355-56.) School records show that Plaintiff had “trouble concentrating; remembering to do assignments and to turn them in” and “[d]oesn’t approach adults for assistance” and that Plaintiff’s “mental health challenges make motivation and maintaining teacher contact very difficult.” (R. 338, 344.) While in school, Plaintiff received accommodations for her ADHD, depression, and anxiety diagnoses, as well as her sleep issues, including extended time on assignments and accommodations related to communication between Plaintiff, her teachers, and her mother. (R. 338, 344.) Plaintiff eventually transferred to an online high school but continued to miss classes and struggled to focus. (R. 46-47, 347-48.) Plaintiff has no friends and no significant other. (R. 55.) Plaintiff has never worked and has never attempted to get a job. (R. 42.) She does not have a driver’s license and never attempted to get one. (R. 40.) Plaintiff testified that she did not remember the last time she left her home without her mother. (R. 57.) On March 16, 2017, Plaintiff was seen by Elaine Marie Hoffman Holstine, MD, for fatigue. (R. 1257.) Plaintiff’s mother attended the appointment with her, and reported that Plaintiff had been missing a lot of school. (R. 1257.) Dr. Hoffman Holstine CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 5 of 83
6 noted that Plaintiff was not making eye contact and was looking around at walls. (R. 1257.) Plaintiff’s appearance was noted as normal but very tired. (R. 1260.) On July 19, 2017, Plaintiff was seen by Aimee M. Maxwell, LICSW, for a mental health intake appointment. (R. 622.) Plaintiff’s mother was present for the appointment. (R. 623.) Plaintiff had been referred by her pediatrician, Dr. Hoffman Holstine, for fatigue, hypersomnia, and anxiety. (R. 622.) Plaintiff reported difficulty talking to people, such as cashiers, and explained that if she has to talk to someone to get something, she will go without it. (R. 623.) Plaintiff also reported trouble with sleep, stomach pain, and headaches. (R. 623.) Plaintiff’s mother reported that Plaintiff’s symptoms caused her to miss so much school that she did not complete her 11th grade year. (R. 623.) Plaintiff had a history of ADHD and had been prescribed Adderall. (R. 623.) Maxwell noted Plaintiff’s appearance was disheveled with poor hygiene, her behavior was cooperative, her eye contact was avoidant, and her affect was depressed and anxious. (R. 626.) Maxwell also recorded that Plaintiff appeared distracted and had to have questions asked to her several times as she seemed to get lost in her own thoughts and got easily distracted. (R. 628.) On July 31, 2017, Plaintiff was seen by Dr. Hoffman Holstine. (R. 616.) Plaintiff’s mother attended the appointment with her. (R. 616.) Plaintiff presented with fatigue that had been ongoing for the past six months. (R. 616.) Plaintiff reported sleeping approximately 12 hours a day. (R. 616.) Dr. Hoffman Holstine noted Plaintiff’s appearance as normal, pleasant, alert and appropriate for her age, but noted that she did look very tired. (R. 619.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 6 of 83
7 On September 7, 2017, Plaintiff was seen by Aditi Garg, MBBS, for a psychiatry intake appointment. (R. 609, 1224.) Plaintiff’s mother was present for this appointment. (R. 610, 1225.) Plaintiff endorsed symptoms of depression anxiety, and ADHD. (R. 610, 1225.) Plaintiff’s PHQ-95 score was 14 and her GAD-76 score was 10. (R. 1228.) Dr. Garg recorded Plaintiff’s general appearance as well-appearing with appropriate grooming. (R. 1229.) Plaintiff’s mental status exam indicated that her behavior was calm, cooperative, and easily engaged during the interview. (R. 1229.) Dr. Garg noted that Plaintiff’s social anxiety had stopped her from attending school, making friends, and going out to restaurants, and had led to isolation. (R. 1230.) Dr. Garg diagnosed Plaintiff with social anxiety disorder, dysthymia, and ADHD. (R. 1231.) On September 28, 2017, Plaintiff had a psychiatry appointment with Dr. Garg. (R. 604, 1220.) Plaintiff’s mother attended the appointment with her. (R. 604, 1220.) Plaintiff reported trouble with sleep, and discussed her online school. (R. 605, 1220.) Plaintiff reported that the hardest part of school was talking to teachers and writing 5 The Patient Health Questionnaire (“PHQ-9”) is a tool used to screen for depression. Kurt Kroenke, Robert L Spitzer and Janet B W Williams, The PHQ-9, Nat’l Lib. of Med. https://pmc.ncbi.nlm.nih.gov/articles/PMC1495268/ [https://perma.cc/GWE7-APUT] (last visited Jan. 28, 2026). A score of 5-9 on the PHQ- 9 indicates mild depression, 10-14 indicates moderate depression, 15-19 indicates moderately severe depression, and 20-27 indicates severe depression. Id. 6 The Generalized Anxiety Disorder (“GAD-7”) is a tool used to screen for anxiety. Amit Sapra et al., Using Generalized Anxiety Disorder-2 (GAD-2) and GAD-7 in a Primary Care Setting, Nat’l Lib. of Med. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7306644/ [https://perma.cc/GQP9- 9NED] (last visited Jan. 28, 2026). A score of 5-9 on the GAD-7 indicates mild anxiety, 10-14 indicates moderate anxiety, 15 or higher indicates severe anxiety. Id. CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 7 of 83
8 essays, and that she had to touch base with teachers once a month. (R. 605, 1220.) Plaintiff’s affect was blunted, her attitude was cooperative, engaged, and calm with good eye contact. (R. 1223.) On October 26, 2017, Plaintiff had another psychiatry appointment with Dr. Garg. (R. 1216.) Plaintiff’s mother attended this appointment with her. (R. 1217.) Plaintiff reported feeling less anxious and sleeping better. (R. 1217.) Her PHQ-9 score was 14 and her GAD-7 score was 10. (R. 1217.) Plaintiff’s affect was more reactive, and her attitude was cooperative, engaged, and calm with good eye contact. (R. 1218.) Plaintiff had another psychiatry appointment with Dr. Garg on November 29, 2017. (R. 598, 1213.) Plaintiff’s mother participated in the appointment. (R. 1214.) Plaintiff’s PHQ-9 score was 18 and her GAD-7 score was 11. (R. 1214.) Plaintiff appeared exhausted, her affect was more reactive, and her attitude was cooperative, engaged, and calm with good eye contact. (R. 599-600.) Plaintiff reported that her anxiety was improved but she continued to struggle with low energy, lack of motivation and poor concentration. (R. 600, 1215.) Plaintiff had another psychiatry appointment scheduled with Dr. Garg on January 3, 2018. (R. 1211.) However, Plaintiff “wasn’t feeling physically and emotionally well enough to come in.” (R. 1211.) Plaintiff’s mother attended the appointment alone and reported that Plaintiff still refused to go out or do her homework. (R. 1211.) Plaintiff attended her next psychiatry appointment with Dr. Garg on January 25, 2018. (R. 594, 1209.) Plaintiff’s mother attended the appointment with her. (R. 594, 1209.) Plaintiff reported struggling with school, which she attended online. (R. 1209.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 8 of 83
9 Plaintiff reported that some lessons require her to talk to teachers, and “due to fear,” she did not ask them questions and did not understand the material. (R. 1209.) Plaintiff’s mother reported that Plaintiff had not been willing to get out of the house. (R. 1209.) On May 10, 2018, Plaintiff had a psychiatry appointment with Dr. Garg. (R. 591, 1206.) Plaintiff’s mother was present for the appointment. (R. 592, 1207.) Dr. Garg noted that Plaintiff reported an improved mood and anxiety but showed an ongoing lack of motivation and energy. (R. 593.) Dr. Garg prescribed Wellbutrin7 in addition to the Sertraline8 and Adderall9 that Plaintiff was already taking and recommended having a skills worker go to Plaintiff’s home. (R. 593, 1208.) Plaintiff had a psychiatry appointment with Dr. Garg on June 14, 2018. (R. 588.) Plaintiff’s mother was present for this appointment. (R. 588.) Dr. Garg noted that Plaintiff reported improved mood and anxiety, but objectively, she continued to have a low functioning level and struggled to do instrumental activities of daily life. (R. 590.) 7 Wellbutrin is a brand name for the medication bupropion, which is used to treat depression. Bupropion, Nat’l Lib, of Med. https://medlineplus.gov/druginfo/meds/a695033.html [https://perma.cc/53AV-66VL] (last visited Jan. 28, 2026). 8 Sertraline is a medication used to treat depression, obsessive-compulsive disorder, panic attacks, posttraumatic stress disorder, and social anxiety disorder. Sertraline, Nat’l Lib, of Med. https://medlineplus.gov/druginfo/meds/a697048.html [https://perma.cc/8HSF-LSEG] (last visited Jan. 28, 2026). 9 Adderall is the brand same for a medication that is a combination of dextroamphetamine and amphetamine, and is used to treat ADHD. Dextroamphetamine and Amphetamine, Nat’l Lib, of Med. https://medlineplus.gov/druginfo/meds/a601234.html [https://perma.cc/SN9D-S9EX] (last visited Jan. 28, 2026). CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 9 of 83
10 On July 26, 2018, Plaintiff had a psychiatry appointment with Dr. Garg. (R. 584.) Plaintiff’s mother attended the appointment with her. (R. 585.) Plaintiff reported that she was meeting with a life coach once a week, and that she had a goal to text friends to hang out together. (R. 585.) On September 6, 2018, Plaintiff had a psychiatry appointment with Dr. Garg. (R. 578.) Plaintiff’s mother was present for the appointment and reported that it was an ongoing struggle for Plaintiff to take care of herself. (R. 582.) On November 8, 2018, Plaintiff had a psychiatry appointment with Dr. Garg. (R. 578.) Plaintiff’s mother attended the appointment with her. (R. 579.) Plaintiff’s mother reported that Plaintiff was showering without prompting once in a week and a half, which used to be worse. (R. 579.) On January 8, 2019, Plaintiff was seen by Dr. Hoffman Holstine for tremors in her hands. (R. 1184.) Plaintiff’s mother attended the appointment. (R. 1185.) Dr. Hoffman Holstine noted that Plaintiff’s general appearance was normal, pleasant, alert, and appropriate for her age, and that Plaintiff was alert and oriented with an appropriate affect. (R. 1186-87.) Plaintiff’s PHQ-9 score was 15 and her GAD-7 score was 14. (R. 1187-88.) Dr. Hoffman Holstine advised that the tremors were likely a side effect of Wellbutrin. (R. 1189.) On January 10, 2019, Dr. Hoffman Holstine consulted with Mirza Baig, MD, regarding Plaintiff. (R. 1180-81.) Dr. Hoffman Holstine explained that Plaintiff had “such severe anxiety and depression that she hardly left the house for a year.” (R. 1180.) Plaintiff and her mother had reported that Plaintiff’s progress on her current medications CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 10 of 83
11 had plateaued, and that while Plaintiff could now go out “for a little bit in certain situations,” she still spent most of her time in the house. (R. 567.) Dr. Baig suggested medication changes and therapy. (R. 1181.) On January 28, 2019, Dr. Hoffman Holstine spoke to Plaintiff’s mother on the phone. (R. 569-70.) Plaintiff’s mother was concerned about Plaintiff’s energy levels and reported that when Plaintiff goes to see her psychiatrist, “that will be it for the day” and then she will go back to sleep. (R. 570.) Plaintiff’s mother reported that Plaintiff slept more than she was awake. (R. 570.) Plaintiff’s mother explained that Plaintiff stopped going to therapy because she missed so many appointments, and that when Plaintiff had appointments often, she would feel like she simply could not get out of bed and she just would not go. (R. 570.) Dr. Hoffman Holstine discussed options, including intensive outpatient therapy and neuropsych testing, and encouraged Plaintiff’s mother to discuss her concerns with Dr. Garg. (R. 570.) On January 29, 2019, Plaintiff saw Dr. Garg for a psychiatry appointment. (R. 564, 1176.) Plaintiff’s mother attended the appointment with her. (R. 1177.) Plaintiff reported that she had been talking to more people and had initiated conversations, but that she had not been going in for therapy. (R. 564.) Dr. Garg prescribed Lexapro10 and adjusted the doses of Plaintiff’s other medications. (R. 1179.) 10 Lexapro is the brand name for Escitalopram, which is used to treat depression and generalized anxiety disorder. Escitalopram, Nat’l Lib. Of Med. https://medlineplus.gov/druginfo/meds/a603005.html [https://perma.cc/C6SP-JKZJ] (last visited Jan. 28, 2026). CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 11 of 83
12 On March 27, 2019, Plaintiff had another psychiatry appointment with Dr. Garg. (R. 560, 1172.) Plaintiff’s mother attended this appointment with her. (R. 1173.) Plaintiff reported that since her medication change, her anxiety felt a bit better and it was easier for her to go in for the appointment. (R. 561.) On April 23, 2019, Plaintiff had a checkup with Jessica Stewart, NP. (R. 552, 1163.) Plaintiff’s mother attended the appointment with her. (R. 1165.) Stewart noted that Plaintiff had tried therapy in the past, but it was difficult to get her there due to how she was feeling. (R. 1165.) On May 2, 2019, Plaintiff saw Dr. Garg for a psychiatry appointment. (R. 549, 1161.) Plaintiff’s mother attended the appointment with her. (R. 549, 1161.) Plaintiff reported that she had been able to talk on the phone more with her sister and to text her teachers more. (R. 549, 1161.) Plaintiff’s mother reported that Plaintiff had tried to make pasta for the first time in years. (R. 549, 1161.) Plaintiff reported sleeping 9.5 to 15 hours a day. (R. 549, 1161.) On July 18, 2019, Plaintiff had a psychiatry appointment with Dr. Garg. (R. 530, 1150.) Plaintiff reported that her sleep was chaotic and that she had been sleeping 12-14 hours a day. (R. 530, 1150.) On August 22, 2019, Plaintiff saw Dr. Garg for a psychiatry appointment. (R. 1147.) Plaintiff’s mother attended the appointment with her. (R. 1147.) Plaintiff reported that she had been doing better than usual and that she had gone to the Renaissance Festival a few days prior. (R. 1147.) Dr. Garg recorded that Plaintiff was poorly groomed with disheveled hair. (R. 1148.) Plaintiff’s mother indicated that she CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 12 of 83
13 wanted Plaintiff to work on hygiene and take showers at least weekly. (R. 1147.) Dr. Garg also recorded that Plaintiff’s attitude was calm, cooperative, and engaged with good eye contact; her speech showed increased latency and was soft and monotonous; and her affect was depressed. (R. 1148.) On September 25, 2019, Plaintiff had a psychiatry appointment with Dr. Garg. (R. 1143.) Plaintiff’s mother attended this appointment with her. (R. 1143.) Plaintiff reported that she had been changing her clothes once every other day, which was “a lot more often,” and that she had been willing to use the toaster, which was progress for her. (R. 1143.) Dr. Garg recorded that Plaintiff was poorly groomed with disheveled hair. (R. 1144.) Plaintiff’s attitude was calm, cooperative and engaged with good eye contact; her speech showed increased latency and was soft and monotonous; and her affect was depressed. (R. 1144.) On October 24, 2019, Plaintiff had a psychiatry appointment with Dr. Garg. (R. 529, 1139-40.) Plaintiff’s mother attended the appointment with her. (R. 1140.) Dr. Garg recorded that Plaintiff was poorly groomed with disheveled hair. (R. 1141.) Plaintiff’s attitude was calm, cooperative and engaged with good eye contact; her speech showed increased latency and was soft and monotonous; and her affect was depressed. (R. 1141.) On November 11, 2019, Plaintiff was seen by Dr. Dan Barron, a clinical psychologist, for a diagnostic interview. (R. 361.) Plaintiff’s mother attended the appointment with her. (R. 361.) Plaintiff “presented in a casually dressed and groomed manner.” (R. 361.) Dr. Barron noted that Plaintiff was “pleasant but very reserved,” her CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 13 of 83
14 eye contact was good, and she responded to questions adequately. (R. 361.) When asked about social relationships, Plaintiff responded that “I don’t have any friends that are super close.” (R. 362.) Plaintiff reported that she had had suicidal thoughts in the past but “not really anymore.” (R. 362.) Dr. Barron noted that Plaintiff presented with diagnoses of ADHD and depression, noted to rule out “Social Anxiety Disorder,” “Other Anxiety and Mood Disorders,” and possible Polycystic Ovary Syndrome (“PCOS”). (R. 362.) Plaintiff’s diagnostic interview with Dr. Barron continued in a second appointment on November 13, 2019. (R. 371.) Plaintiff’s mother was present at this appointment as well. (R. 371.) During this appointment, Dr. Barron reviewed the results of Plaintiff’s Personality Assessment Inventory (“PAI”).11 Dr. Barron described Plaintiff’s PAI profile as: [M]arked by high degrees of depression and unhappiness. She has an uncomfortable level of anxiety and she is plagued by worry to the degree that her ability to concentrate and attend are compromised. She has difficulty relaxing, and experiences fatigue-perhaps as a result of high perceived stress. Physical manifestations of anxiety, such as sweaty palms, shakiness, irregular heartbeats, and shortness of breath are also acknowledged by [Plaintiff]. (R. 371.) Diagnostic considerations suggested by Plaintiff’s PAI included Generalized Anxiety Disorder and Dysthymic Disorder. (R. 371.) In an appointment with Dr. Barron on December 5, 2019, it was noted that that Plaintiff had been diagnosed with PCOS. (R. 370.) In an appointment on December 17, 11 Dr. Barron describes the PAI as “a nationally standardized psychological test that explores aspects of an adult’s personality, such as their emotional functioning, thought processes, self-concept, interpersonal relationships, and interest in and motivation for change.” (R. 371.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 14 of 83
15 2019, Plaintiff “endorsed some of the symptoms consistent with Generalized Anxiety, social anxiety, panic disorder, agoraphobia, and perhaps somatic symptom disorder.” (R. 369.) Plaintiff’s mother attended these appointments with her. (R. 369-70.) On December 17, 2019, Plaintiff and her mother attended a therapy appointment with Dr. Barron. (R. 369.) Dr. Barron began by meeting with Plaintiff alone before her mother joined. (R. 369.) Plaintiff reported that she felt anxiety about coming to the therapy appointment. (R. 369.) In an appointment on January 8, 2020, Plaintiff discussed with Dr. Barron her efforts to do things that were challenging for her. (R. 367.) Plaintiff reported that she had been to a mall with her sister, which made her “quite nervous.” (R. 367.) She discussed the anticipatory anxiety she felt before offering a compliment to a salesperson. (R. 367.) In another appointment on January 16, 2020, Dr. Barron discussed the rationale behind exposure therapy and asked Plaintiff to begin keeping an exposure log. (R. 366.) Plaintiff’s mother was present for this appointment. (R. 366-67.) On January 23, 2020, Plaintiff had a psychiatry appointment with Dr. Garg. (R. 522, 1132.) Plaintiff’s mother attended this appointment with her. (R. 1133.) Dr. Garg recorded that Plaintiff was poorly groomed and had disheveled hair. (R. 1134.) Plaintiff’s attitude was calm, cooperative and engaged with good eye contact, her speech showed increased latency and was soft and monotonous, and her affect was depressed. (R. 1134.) Plaintiff reported that she had been pushing herself more and doing more, including going out to lunch with a friend and talking more to family members. (R. 1133.) Plaintiff’s mother reported that going to therapy appointments was very CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 15 of 83
16 demanding for Plaintiff, and expressed concern that Plaintiff was being pushed too much in therapy. (R. 1133.) Dr. Garg prescribed Buspar in order to manage anxiety without making her more tired. (R. 1136.) Plaintiff had another therapy appointment with Dr. Barron on January 30, 2020. (R. 365.) Plaintiff had begun keeping an exposure log as Dr. Barron had suggested and discussed the log with Dr. Barron at this appointment. (R. 365.) Plaintiff reported engaging in activities that were anxiety provoking, including texting her sister, her grandmother, and her friends, “arranging to go out to lunch and dinner with friends,” and going to the grocery store with her mother.” (R. 365.) In another appointment with Dr. Barron on February 4, 2020, Plaintiff reported that she had been “challenging herself to do some things that make her nervous-such as calling her sister, and texting family members.” (R. 364-65). Plaintiff’s mother attended this appointment with her. (R. 364.) Plaintiff and her mother had another appointment with Dr. Barron on February 20, 2020. (R. 364.) Plaintiff reported that she had been keeping a list of activities to challenge her anxiety, and reported that she had visited her sister who was in college in Bemidji. (R. 364.) On February 25, 2020, Plaintiff had a psychiatry appointment with Dr. Garg. (R. 518, 1128.) Plaintiff’s mother participated in the appointment. (R. 1128.) Dr. Garg reported that Plaintiff was poorly groomed with disheveled hair. (R. 1130.) Plaintiff’s attitude was calm, cooperative and engaged with good eye contact; her speech showed increased latency and was soft and monotonous; and her affect was depressed. (R. 1130.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 16 of 83
17 Plaintiff reported that she had been feeling better since her last visit. (R. 1128.) She had made plans to go out with people more often, brushed her hair every day, and showered more than once per week. (R. 1128.) Plaintiff was seen by Dr. Barron again on February 27, 2020. (R. 363.) Plaintiff’s mother attended this appointment with her. (R. 363.) They discussed Plaintiff’s anxiety regarding making and checking in to appointments herself rather than having her mother do it for her. (R. 363.) At the end of the appointment, Plaintiff used her mother’s telephone to make an appointment at her primary care clinic. (R. 363.) On March 13, 2020, Plaintiff had another appointment with Dr. Garg. (R. 507, 1116.) Plaintiff’s mother attended the appointment with her. (R. 1117.) Plaintiff reported that she had started going out more. (R. 1117.) Plaintiff’s family was fostering a dog, and she went out with the dog every day. (R. 1117.) Plaintiff had attended adult education once that month and had been able to answer the phone and talk to someone. (R. 1118.) In a review of Plaintiff’s social history, Dr. Garg noted that once in a while Plaintiff will go out with her mother, another friend, and the friend’s mother. (R. 1119.) Plaintiff went to church once. (R. 1119.) Dr. Garg noted that Plaintiff’s grooming was appropriate; her behavior was calm, cooperative, and easily engaged; her speech was spontaneous, soft, and monotonous; and her affect was blunted. (R. 1120.) Dr. Garg diagnosed Plaintiff with agoraphobia. (R. 513, 1122.) On April 21, 2020, Plaintiff had a telehealth appointment with Dr. Garg. (R. 503, 1111.) Plaintiff’s mother participated in this appointment. (R. 1112.) Plaintiff reported spending time with family and attending a support group. (R. 1112.) Dr. Garg noted that CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 17 of 83
18 Plaintiff appeared disheveled. (R. 1113.) Plaintiff reported that she had not been seeing her therapist because she did not have a rapport with him, and wanted to see a different therapist. (R. 1112). On May 5, 2020, Plaintiff had a telehealth appointment with a new therapist, Michael Hoiland, PHD, LP. (R. 498, 1106.) Dr. Hoiland noted that Plaintiff had good hygiene, her behavior was cooperative and sullen, her eye contact was appropriate and avoidant, and her mood was depressed and anxious. (R. 1107.) Dr. Hoiland noted that Plaintiff presented with exacerbation of anxiety, low self worth, worry, and avoidance of others. (R. 1111.) Plaintiff had another telehealth appointment with Dr. Hoiland on May 12, 2020. (R. 497, 1106.) Plaintiff reported sleeping for 16 hours and expressed concerns that her depression and related “vegetative symptoms” would interfere with her life. (R. 497.) Dr. Hoiland listed Plaintiff’s assessment/diagnosis as social anxiety disorder. (R. 1106.) On May 18, 2020, Plaintiff had a telehealth therapy appointment with Dr. Hoiland. (R. 496, 1104.) Plaintiff reported that her mood had been down, and she had less energy to do the things she enjoyed such as taking care of plants, spending time with her family, reading and playing games. (R. 496.) On June 2, 2020, Plaintiff had a telehealth therapy appointment with Dr. Hoiland. (R. 495, 1103.) Plaintiff reported excessive sleep. (R. 495.) Dr. Hoiland observed Plaintiff to have a flat affect and a depressed mood, and to be lethargic and tired. (R. 495.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 18 of 83
19 On June 9, 2020, Plaintiff had a telehealth appointment with Dr. Garg. (R. 491, 1099.) Plaintiff’s mother participated in this appointment. (R. 1100.) Dr. Garg noted that Plaintiff appeared disheveled, but her behavior was cooperative and easily engaged. (R. 1100.) Plaintiff reported that sleep was better for a while but got worse again. (R. 492.) Plaintiff’s mother participated in the appointment and commented that it was hard to gauge Plaintiff’s social anxiety because the pandemic prevented her from going out. (R. 492.) On June 25, 2020, Plaintiff had a telehealth therapy appointment with Dr. Hoiland. (R. 1098.) Plaintiff reported more self-initiated thinking, planning, and follow-through in day-to-day self-care activities. (R. 1098.) On July 7, 2020, Plaintiff had a telehealth therapy appointment with Dr. Hoiland. (R. 488.) Plaintiff reported working on budgeting and a daily list of chores with the goal of being more independent. (R. 488.) On August 6, 2020, Plaintiff had a telehealth therapy appointment with Dr. Hoiland. (R. 484, 1090.) Dr. Hoiland observed Plaintiff in her bed for the session and appearing lethargic. (R. 484.) On August 31, 2020, Plaintiff had a telehealth therapy appointment with Dr. Hoiland. (R. 483, 1089.) Plaintiff reported that her sleep had improved and noted that she had been able to see a hummingbird as a result of being up and alert during the daytime. (R. 483.) On September 9, 2020, Plaintiff met had an intake appointment for targeted case management services. (R. 1705.) This appointment took place via telephone with Bria CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 19 of 83
20 Grudzielanek, MSW, LICSW. (R. 1705.) Plaintiff’s mother participated in the appointment. (R. 1711.) Grudzielanek noted that after speaking with Plaintiff and her mother and reviewing records, there was no reason to challenge her psychiatrist’s diagnosis of MDD, severe persistent depressive disorder, social anxiety disorder, generalized anxiety disorder, agoraphobia, and ADHD. (R. 1711.) In particular, Grudzielanek noted that Plaintiff met the criteria for generalized anxiety disorder and social anxiety disorder (phobia) “due to ongoing symptoms of worry, fears of being negatively evaluated by others, and isolation at home due to worry and fears of how she will be perceived by others,” also noting “[t]hese symptoms have persisted for several years and grossly impacted her ability to perform in school and work.” (R. 1711.) Jesse Louviere was assigned as Plaintiff’s case manager. (R. 1705.) Plaintiff met with Louviere via telephone on September 11, 2020. (R. 1712.) Plaintiff’s mother was also on the call. (R. 1712.) Plaintiff reported that her main problem was feeling mentally and physically fatigued. (R. 1712.) She reported feeling anxiety at an 8 out of 10 most days and noted that she had trouble with motivation. (R. 1712.) On September 14, 2020, Plaintiff had a telehealth therapy appointment with Dr. Hoiland. (R. 482, 1088). Plaintiff reported that she had been assigned a county caseworker, and had met him virtually. (R. 482.) Plaintiff acknowledged anxiety regarding the related paperwork. (R. 482.) On September 24, 2020, Plaintiff’s case manager Louviere completed a functional assessment of Plaintiff. (R. 1715.) Louviere reported Plaintiff’s diagnoses as “major CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 20 of 83
21 depressive disorder (severe), persistent depressive disorder, social anxiety disorder, generalized anxiety disorder, agoraphobia, and attention deficit hyperactivity disorder.” (R. 1715.) Louviere noted that Plaintiff’s symptoms impaired her ability to trust and build rapport with providers; independently schedule and attend appointments with providers; identify employment options, apply, arrive for work consistently, and manage work demands; initiate and maintain relationships with friends; initiate activities or tasks, complete them, and maintain her self-care consistently; and that Plaintiff’s “symptoms of excessive worry, isolation, fatigue, and depressed mood impair her ability to drive independently or navigate public transportation.” (R. 1715-17.) On October 13, 2020, Plaintiff had a telehealth appointment with Dr. Hoiland. (R. 1086.) Plaintiff’s mother participated in this appointment. (R. 1087.) Plaintiff showed up to this appointment very late as she was sleeping. (R. 1087.) Dr. Hoiland administered the MMPI and BSI tests.12 (R. 1087.) On October 21, 2020, Plaintiff saw Courtney Lynn Messerly, MD, for a physical. (R. 1078.) Plaintiff’s mother attended this appointment with her. (R. 1079.) Plaintiff reported that she typically slept 12 hours per day. (R. 1079.) 12 The Minnesota Multiphasic Personality Inventory (“MMPI”) is a “psychometric test devised to assess personality traits and psychopathology.” National Institute of Health, Minnesota Multiphasic Personality Inventory, Nat’l Libr. of Med. (April 24, 2023) https://www.ncbi.nlm.nih.gov/books/NBK557525/ [https://perma.cc/42RG-9BA4]. The Brief Symptom Inventory (BSI) is a multidimensional symptom inventory designed to reflect psychological symptom patterns of psychiatric and medical patients. National Institute of Health, Brief Symptom Inventory, Nat’l Inst. on Drug Abuse (Feb. 25, 2016) https://datashare.nida.nih.gov/instrument/brief-symptom-inventory [https://perma.cc/52YU- SYQX]. CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 21 of 83
22 On October 22, 2020, Plaintiff had a telehealth therapy appointment with Dr. Hoiland to review the results from Plaintiff’s MMPI and BSI tests. (R. 472, 1071-72.) A review of the results suggested an underlying major depressive disorder and confirmed social phobia. (R. 1078.) Dr. Hoiland noted that Plaintiff had good hygiene and her eye contact was appropriate and avoidant. (R. 1077.) On October 29, 2020, Plaintiff had a telephone meeting with her case manager, Jesse Louviere. (R. 1722.) Plaintiff endorsed increased anxiety, depression, and difficulty coping. (R. 1722.) Plaintiff reported that she got overwhelmed with activities of daily living like showering and housework. (R. 1722.) Louviere provided Plaintiff with information about Adult Rehabilitative Mental Health Services (“ARMHS”).13 (R. 1722.) On November 10, 2020, Plaintiff had a telehealth therapy appointment with Dr. Hoiland. (R. 1071.) Plaintiff reported that she had recently talked to a social worker. (R. 1070-71.) Dr. Hoiland noted that Plaintiff was “more kempt looking.” (R. 1071.) On November 20, 2020, Plaintiff had a telephone meeting with her case manager, Jesse Louviere. (R. 1722.) Plaintiff reported feeling stress and depression, and feeling very tired physically and emotionally. (R. 1727.) 13 ARHMS is a state program that helps individuals with mental illness “build skills in areas of life essential for every day, independent living, when symptoms of their mental health have decreased functioning abilities.” Adult Rehabilitative Mental Health Services, Minn. Dep’t of Human Servs. (last visited Jan. 23, 2026) https://mn.gov/dhs/people-we- serve/people-with-disabilities/health-care/adult-mental-health/programs-services/armhs.jsp [https://perma.cc/2BTT-SKRV]. CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 22 of 83
23 On November 18, 2020, Plaintiff had a telehealth visit with Dr. Garg. (R. 1066.) Plaintiff reported that she had been spending more time with her family but was still struggling with self-care and was showering twice a week. (R. 1067.) Dr. Garg noted that Plaintiff’s appearance was more kempt than in the past and her behavior was cooperative and easily engaged. (R. 1067.) On December 15, 2020, Plaintiff attended a mental health outpatient program at Mercy Hospital. (R. 1055.) Plaintiff was seen by Jody M. Mork, LMFT. (R. 1054.) Plaintiff reported that she wanted to figure out ways to cope with anxiety so that she could do more things, and that she wanted to be more confident in interacting with people. (R. 1056.) Mork noted that Plaintiff struggled to be in social situations for long periods of time and struggled with talking to others, such as communicating with cashiers. (R. 1059.) On December 17, 2020, Plaintiff had a telehealth therapy appointment with Dr. Hoiland. (R. 1053.) Dr. Hoiland observed Plaintiff lying in bed and appearing lethargic with a constricted affect. (R. 1053.) Plaintiff reported that she planned to call or text her biological father who lived in Kentucky. (R. 1053.) On December 18, 2020, Plaintiff had a telephone meeting with her case manager, Jesse Louviere. (R. 1737.) Plaintiff reported that she had rescheduled a sleep appointment because she was overwhelmed with appointments. (R. 1737.) Plaintiff endorsed stress, feeling overwhelmed, and having social anxiety that impaired her ability to manage appointments and interact with people. (R. 1737.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 23 of 83
24 On December 31, 2020, Plaintiff participated in a telehealth group therapy session facilitated by Mork. (R. 1052.) Five patients attended the session. (R. 1052.) Plaintiff discussed anxiety and difficulty talking to others such as cashiers. (R. 1052.) Plaintiff also attended a virtual group psycho-education session later that day. (R. 1053.) Four patients attended that session. (R. 1053.) The facilitator, Victoria Hass, CTRS, noted that Plaintiff actively participated in the group by listening, commenting, and following along. (R. 1053.) On January 7, 2021, Plaintiff attended another telehealth group therapy session facilitated by Mork. (R. 1050.) Four patients attended the session. (R. 1050.) Plaintiff also participated in a virtual group psychoeducation session that day, in which four patients participated. (R. 1051.) On January 8, 2021, Plaintiff attended another a telehealth group therapy session facilitated by Mork and another virtual group psycho-education session. (R. 1048-49.) Plaintiff was engaged and participated in both sessions. (R. 1048-49.) On January 14, 2021, Plaintiff attended another a telehealth group therapy session facilitated by Mork and another virtual group psycho-education session. (R. 1048-49.) Plaintiff was engaged and participated in both sessions. (R. 1047-48.) On January 15, 2021, Plaintiff attended another a telehealth group therapy session, this time facilitated by Angela McCollow, LGSW, and another virtual group psycho- education session. (R. 1045-46.) Plaintiff was engaged and participated in both sessions. (R. 1045-46.) On January 21, 2021, Plaintiff emailed Mercy Hospital that she would no longer be attending the group sessions. (R. 440, 1044.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 24 of 83
25 On January 28, 2021, Plaintiff had an appointment with her case manager, Jesse Louviere, via telephone. (R. 1744.) Plaintiff reported that she discontinued her biweekly group therapy because it was demanding and they made her talk for four hours. (R. 1744.) She was open to resuming therapy but wanted a different therapist with a different approach. (R. 1744.) On February 11, 2021, Plaintiff had an appointment with her case manager, Jesse Louviere, via telephone. (R. 1747.) Plaintiff reported that her sleep had been poor and that she might need to cancel an upcoming 8:00 am appointment. (R. 1747.) Plaintiff reported stress and anxiety as 6 out of 10. (R. 1747.) On February 17, 2021, Plaintiff completed an initial assessment for services with the Associated Clinic of Psychology. (R. 399.) The assessment took place by telephone with Mike Driscoll, MA, LP. (R. 399.) Plaintiff completed the PHQ-9 and GAD-7 assessments and scored 20 and 12 respectively. (R. 399.) Plaintiff reported a long history of mental health issues, including ADHD, depression and anxiety. (R. 400.) Plaintiff reported being socially isolated and totally dependent on her mother, who was on the call with her. (R. 400.) Plaintiff’s attitude was friendly, and her mood was anxious. (R. 403.) On February 25, 2021, Plaintiff had an appointment with her case manager, Jesse Louviere, via telephone. (R. 1751.) Plaintiff reported that she had completed the ARMHS intake session. (R. 1751.) Plaintiff endorsed occasional passive suicidal ideation. (R. 1751.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 25 of 83
26 On March 11, 2021, Plaintiff had her first telephone therapy appointment with MariaLuisa Ramirez, PHD, LP of the Associated Clinic of Psychology. (R. 396.) Dr. Ramirez recorded Plaintiff’s symptoms as sad/depressed, sleep disturbance, and concentration. (R. 394.) Plaintiff’s affect was appropriate and her attitude was cooperative. (R. 396.) Plaintiff’s PHQ-9 score was an 18 and her GAD-7 score was a 15. (R. 396.) Plaintiff reported that she was not active socially. (R. 397.) She used to have lunch with a friend every two weeks or so. (R. 397.) She was not close to other kids in school and had been fairly isolated. (R. 397.) Plaintiff reported that she sent her grandmother text messages and that she had been talking with a cousin. (R. 397.) Plaintiff explained that this problem started in middle school. (R. 397.) She would not ride the bus and her mother had to convince her to go inside. (R. 397.) On March 34, 2021, Plaintiff’s case manager Jesse Louviere completed another functional assessment of Plaintiff. (R. 1758.) Louviere listed Plaintiff’s diagnoses as “major depressive disorder (severe), persistent depressive disorder, social anxiety disorder, generalized anxiety disorder, agoraphobia, and attention deficit hyperactivity disorder.” (R. 1758.) Louviere noted that Plaintiff’s mental health symptoms made it difficult for her to establish a regular sleep pattern and daily routine, and that these symptoms impacted her ability to make progress on her long-term goals, which included pursuing college education, establishing work history, socializing, and managing activities of daily living. (R. 1758.) Louviere reported that Plaintiff was impaired in her ability to independently schedule and attend appointments with providers; her ability to engage and participate in mental health services for extended periods of time; her ability CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 26 of 83
27 to identify employment options, apply, arrive for work consistently, and manage work demands; her ability to initiate and maintain relationships with friends; to initiate activities or tasks, complete them, and maintain her self-care consistently; to take medication consistently; and her ability to drive independently or navigate public transportation. (R. 1759-61.) On March 26, 2021, Plaintiff had another telephone therapy appointment with Dr. Ramirez. (R. 394.) Dr. Ramirez noted Plaintiff’s diagnoses as ADHD, major depressive disorder, and generalized anxiety disorder. (R. 396.) Dr. Ramirez recorded Plaintiff’s symptoms as sleep disturbance. (R. 394.) Plaintiff reported taking Prozac and Adderall. (R. 396.) Plaintiff’s affect was appropriate and her attitude was cooperative. (R. 394.) Her PHQ-9 score was 17 and her GAD-7 score was 10. (R. 394.) Plaintiff reported not wanting to die but not always wanting to live either. (R. 395.) She reported that the day- to-day tasks of being alive are bothersome to her. (R. 395.) On April 1, 2021, Plaintiff had a telephone therapy appointment with Dr. Ramirez. (R. 392.) Dr. Ramirez recorded Plaintiff’s symptoms as sad/depressed, and anxiety. (R. 392.) Plaintiff’s affect was appropriate and her attitude was cooperative. (R. 392.) Plaintiff’s PHQ-9 score was 14 and her GAD-7 score was 8. (R. 392.) Plaintiff described feeling overwhelmed and reported that she did not have a lot of contact with friends. (R. 393.) She used to meet a friend every one or two weeks. (R. 393.) This friend had bad social anxiety, but Plaintiff reported attempting to keep in contact through text messages. (R. 393.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 27 of 83
28 On April 13, 2021, Plaintiff had a telephone therapy appointment with Dr. Ramirez. (R. 387.) Dr. Ramirez recorded Plaintiff’s symptoms as sad/depressed, sleep disturbance, change in energy, anxiety, ruminations/worry, and restless. (R. 387.) Plaintiff’s affect was appropriate and her attitude was cooperative. (R. 382.) Plaintiff’s PHQ-9 score was 17 and her GAD-7 score was 10. (R. 387.) Plaintiff reported feeling tired and discussed issues with her sleep schedule. (R. 387.) She reported that she slept more than 12 hours a day. (R. 388.) On May 5, 2021, Plaintiff had a telephone therapy appointment with Dr. Ramirez. (R. 384.) Dr. Ramirez recorded Plaintiff’s symptoms as sleep disturbance and anxiety. (R. 384.) Plaintiff’s PHQ-9 score was 17 and her GAD-7 score was 9. (R. 384.) Plaintiff’s affect was appropriate and her attitude was cooperative. (R. 384.) Plaintiff discussed her issues with social anxiety, depression, and energy. (R. 385.) She reported that she left her home for the first time since her birthday, which was over a month before. (R. 385.) On June 4, 2021, Plaintiff had a telephone appointment with her case manager, Jesse Louviere. (R. 1770.) Plaintiff stated she needed to reschedule her therapy appointment but was too tired to do it. (R. 1771.) Louviere assessed Plaintiff’s medication adherence, and Plaintiff reported that she was “doing a terrible job” at taking her medication due to forgetting. (R. 1771.) Plaintiff reported that she had been feeling tired, overwhelmed, and stressed. (R. 1771.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 28 of 83
29 On July 6, 2021, Plaintiff had an appointment with her case manager, Jesse Louviere, in Plaintiff’s home. (R. 1773.) Plaintiff reported meeting with her ARMHS worker. (R. 1773.) On July 7, 2021, Plaintiff had a telephone therapy appointment with Dr. Ramirez. (R. 382.) Dr. Ramirez recorded Plaintiff’s symptoms as sad/depressed and change in energy. (R. 382.) Plaintiff’s affect was appropriate and her attitude was cooperative. (R. 382.) Plaintiff’s PHQ-9 score was 16 and her GAD-7 score was 11. (R. 382.) Plaintiff reported that she lacked motivation and energy, and that she left her home once a week. (R. 383.) On July 14, 2021, Plaintiff had a telephone therapy appointment with Dr. Ramirez. (R. 380.) Dr. Ramirez recorded Plaintiff’s symptoms as sad/depressed, hopeless/helpless, and sleep disturbance. (R. 380.) Plaintiff’s affect was blunt and her attitude was cooperative. (R. 380.) At this visit, Plaintiff discussed her issues with sleep and reported that she felt that she needed 12 hours of sleep a day. (R. 381.) On August 12, 2021, Plaintiff had an appointment with her case manager, Jesse Louviere, in Plaintiff’s home. (R. 1775.) Plaintiff reported switching therapists from Dr. Dr. Ramirez to Ellie Family Services and working with her ARMHS worker. (R. 1775.) Plaintiff stated she felt drained by interacting with others because of social anxiety, but was motivated by the possibility of getting a job, going back to school, and going to the Renaissance Fair. (R. 1775.) On September 10, 2021, Plaintiff had an appointment with her case manager, Jesse Louviere, in Plaintiff’s home. (R. 1777.) Plaintiff reported that her sleep had gotten CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 29 of 83
30 worse and that she was experiencing increased depression and anxiety. (R. 1777.) Plaintiff continued working with her ARMHS worker. (R. 1777.) On September 13, 2021, Louviere conducted another functional assessment of Plaintiff. (R. 1782.) Louviere listed Plaintiff’s diagnoses as “major depressive disorder (severe), persistent depressive disorder, social anxiety disorder, generalized anxiety disorder, agoraphobia, and attention deficit hyperactivity disorder. (R. 1782.) Louviere reported that Plaintiff’s symptoms impaired in her ability to independently schedule and attend appointments with providers; to identify employment options, apply, arrive for work consistently, and manage work demands; to initiate and maintain relationships with friends; to initiate activities or tasks, complete them, and maintain her self-care consistently; to take medication consistently; and to drive independently or navigate public transportation. (R. 1782-85.) Louviere noted that Plaintiff’s ARMHS worker provided Plaintiff with mental health support and assisted her with independent living skills such as building sleep habits and a daily routine. (R. 1782.) On September 15, 2021, Plaintiff’s mother contacted Dr. Garg to request a letter to provide her employer so that she could work from home in order to support Plaintiff. (R. 1032.) The letter was provided to Plaintiff’s mother in October 2021. (R. 1027-28.) On October 7, 2021, Plaintiff had a telehealth appointment with Dr. Garg. (R. 425, 1028.) Plaintiff’s mother was present during the visit. (R. 1029.) Plaintiff reported that she had been doing better. (R. 1029.) She had been meeting with an ARMHS worker recently and had been able to brush her teeth seven days a week, brush her hair every other day, and shower twice a week. (R. 1029.) Dr. Garg noted that Plaintiff’s CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 30 of 83
31 appearance was more kempt than in the past, and that she was cooperative and easily engaged. (R. 1029.) On October 27, 2021, Plaintiff met with a new case manager, Eric Stone, in her home. (R. 1787.) Stone reported that Plaintiff was just waking up at the time of the appointment, which was 3:30 PM. (R. 1787.) Plaintiff’s mother participated in the meeting. (R. 1787.) Plaintiff had been meeting with her ARMHS worker weekly. (R. 1787.) Plaintiff reported that she needed to transition to a new psychiatrist because Dr. Garg was focused on juvenile patients. (R. 1787.) Stone observed that Plaintiff was quiet, friendly, and open. (R. 1787.) On November 17, 2021, Plaintiff and her mother had another appointment with case manager Eric Stone in their home. (R. 1787.) Plaintiff had continued meeting with her ARMHS worker. (R. 1788.) Plaintiff reported that she had gotten to know some people through a church group and reported that she had a good friend. (R. 1788.) On November 30, 2021, Plaintiff completed a diagnostic assessment with Ellie Family Services. (R. 750.) Plaintiff’s mother was present for the session, which took place via video chat. (R. 757.) Plaintiff had been referred for therapy by her ARMHS worker to get support for worsening mental health symptoms that were impacting her functioning. (R. 756.) Plaintiff’s presenting issues included fears, phobias and worries, family concerns, sleeping concerns, depressed mood, financial concerns, and concerns about childhood. (R. 752-53.) Plaintiff appeared well groomed and her attitude was friendly. (R. 755.) Plaintiff was diagnosed with Dysthymic disorder. (R. 757.) Plaintiff CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 31 of 83
32 reported severe difficulty maintaining friendships, dealing with people she did not know, and joining community activities. (R. 757.) On December 2, 2021, Plaintiff saw Jason Byers, MD, for a physical. (R. 420, 1022.) Dr. Byers noted that Plaintiff had a long history of anxiety, depression, and chronic fatigue concerns, and that his major concern was Plaintiff’s ongoing fatigue. (R. 420.) Plaintiff’s PHQ-9 score was 16. (R. 422.) Dr. Byers reported Plaintiff’s general appearance as pleasant, alert, and appropriate appearance for her age. (R. 423.) Plaintiff was alert and oriented and had an appropriate affect. (R. 423.) On December 15, 2021, Plaintiff met with case manager Eric Stone at her home. (R. 1789.) Plaintiff reported that she was waiting to be assigned a permanent ARMHS worker in January. (R. 1789.) On January 21, 2022, Plaintiff had a consultation with Angela Smaciarz, CNP, APRN, at North Star Sleep Center. (R. 408, 1653.) Plaintiff’s mother attended the appointment with her. (R. 408.) Plaintiff was assessed with hypersomnia, depression, and circadian rhythm sleep disorder. (R. 409.) It was noted that Plaintiff had had a sleep study in 2017 and would benefit from another sleep study, but the staff needed to perform that study were not available at the time due to the COVID-19 pandemic. (R. 409.) Plaintiff was prescribed modafinil to regulate her sleep cycle. (R. 409). On January 18, 2022, Plaintiff conducted a functional assessment with Alyssa Stone of Ellie Family Services. (R. 776-80.) Plaintiff reported feeling anxious in social settings, struggling to make close friends, and feeling anxious out in public. (R. 776.) Plaintiff reported that she had experienced panic attacks when she had to go to school or CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 32 of 83
33 be around many people. (R. 777.) Plaintiff reported having casual acquaintances but not close friends and often feeling lonely at school. (R. 777-78.) Plaintiff reported that she spoke to some people online and that she used to have a friend that she would see before Covid. (R. 778.) Plaintiff also reported depressive symptoms and sleeping for twelve hours a day. (R. 776.) Plaintiff reported difficulty with daily self-care and hygiene. (R. 778.) On February 11, 2022, Plaintiff’s case manager called Dr. Garg because Plaintiff was having a hard time remembering to take her medications. (R. 1037.) The case manager asked if Dr. Garg could send the prescriptions to a pharmacy that fills prescriptions in bubble packs. (R. 1037.) On February 17, 2022, Plaintiff had a phone call with case manager Eric Stone. (R. 1792.) Plaintiff continued working with her ARMHS worker to find a new psychiatrist and establish a routine. (R. 1792.) On March 6, 2022, Plaintiff met with Megan Muraca of Ellie Family Services to create a treatment plain. (R. 770.) The treatment plan included that Plaintiff would “create a self-care routine to improve general hygiene such as showering and brushing teeth,” and that she would “review struggles and success on personal hygiene and self- care each week with clinician.” (R. 770.) It was also part of Plaintiff’s treatment plan to spend time outside and go for walks “to increase her comfortability level outside.” (R. 770.) On March 9, 2022, Plaintiff had a therapy appointment with Royce Vang of Ellie Mental Health. (R. 797.) Plaintiff discussed her relationship with her sister. (R. 797.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 33 of 83
34 On March 23, 2022, case manager Eric Stone spoke with Plaintiff’s mother. (R. 1793.) Stone had been urging Plaintiff’s mother to have Plaintiff call him to set up meeting times. (R. 1793.) Plaintiff’s mother reported that she handles scheduling and talking with providers for Plaintiff. (R. 1793.) Plaintiff’s mother explained that if Plaintiff met with her case manager without her mother present, she would be “wiped out for a few days.” (R. 1793.) On March 28, 2022, Plaintiff had a meeting at her home with case manager Eric Stone. (R. 1803.) Stone observed that Plaintiff was visibly uncomfortable meeting with him alone while her mother was in another room. (R. 1803.) Stone reported that Plaintiff was struggling with anxiety and agoraphobia that made it difficult for her to get out and meet with others that she did not know. (R. 1803.) Also on March 28, 2022, Stone conducted a functional assessment of Plaintiff. (R. 1800.) Stone listed Plaintiff’s diagnoses as “major depressive disorder (severe), persistent depressive disorder, social anxiety disorder, generalized anxiety disorder, agoraphobia, and attention deficit hyperactivity disorder.” (R. 1800.) Stone wrote that Plaintiff: continues to experience severe depression and anxiety / phobia symptoms that cause her to isolate at home, sleep most of the day and drain her energy and drive to get out and work on goals. . . Plaintiff struggles to get out and make some appts due to her depression and anxiety even when her Mother is there to bring her and manage coordinating directly with the doctor or provider. . . [Plaintiff’s] Mother manages her schedule, provider contacts, mail and paperwork and transportation needs. . . [Plaintiff’s] Mother has been present at all [case management] meetings. CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 34 of 83
35 (R. 1800.) Stone reported that Plaintiff’s symptoms impaired her ability to trust and build rapport with providers; independently schedule and attend appointments with providers; engage and participate in mental health services for extended periods of time; initiate activities or tasks, complete them, and maintain her self-care consistently. (R. 1800-02.) Stone noted that: [Plaintiff’s] depression and anxiety/phobia are significant barriers to making progress on long term vocational goals. Her anxiety/phobia is extremely triggered around any type of transportation apart from her Mother driving her places. Her social anxiety is very intense and she has a difficult time trusting others and being around others she does not know. Her depression leads her to sleep most of the day and maintaining a consistent schedule is very difficult for her. (R. 1801.) Stone recorded that Plaintiff did not have close friends that she engaged with regularly, and that her symptoms impaired her ability to initiate and maintain friendships. (R. 1801.) Stone noted that Plaintiff needed support with understanding and responding to important paperwork, and that she relied on her mother for transportation. (R. 1802.) On March 29, 2022, Plaintiff completed an updated diagnostic assessment with Amy Kalbrener, MA, of Ellie Family Services. (R. 760.) Plaintiff reported symptoms of Major Depressive Disorder, and noted that she lacked motivation with self-care needs. (R. 760.) Plaintiff also reported symptoms of Generalized Anxiety, including intense anxiety with meeting and talking to people, being in public places, not being able to drive, and not being able to attend college. (R. 760.) Kalbrener recorded that Plaintiff was well groomed and had an appropriate affect. (R. 763.) Kalbrener recommended autism screening. (R. 760.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 35 of 83
36 On April 4, 2022, Plaintiff completed a Function Report – Adult. (R. 281-90.) Plaintiff reported that she often needed reminders to take care of personal needs and grooming; she lacked motivation to dress, bathe and shave; and she had not gotten a haircut in years. (R. 282-83.) Plaintiff reported that she could do light cleaning, empty the dishwasher, or take out the trash, but only did these things a few times a month. (R. 283.) Plaintiff reported that she went outside once or twice a week at most. (R. 284.) Plaintiff reported that she was not able to pay bills or use a checkbook. (R. 284.) Plaintiff reported her hobbies and interests as reading and listening to music. (R. 285.) Plaintiff reported that she spent time with others in person and on the phone but noted that she did not do this very often, “pretty much just [with her] family.” (R. 285.) Plaintiff reported that there was nowhere she went on a regular basis, and that when she went places, she needed someone to accompany her. (R. 285.) Plaintiff reported that she had difficulty with talking, memory, completing tasks, concentration, and following instructions. (R. 286.) She reported that sometimes she could not pay attention for long, but sometimes she was hyperfocused. (R. 286.) Plaintiff reported that she got along with authority figures “well” but that it was “tough” for her to follow spoken instructions. (R. 286.) Plaintiff reported that she got “stressed all the time” and had trouble remembering things. (R. 287.) On April 28, 2022, Plaintiff had a meeting with case manager Eric Stone at her home. (R. 1804.) Plaintiff reported that she rarely left the house unless it was with her mother. (R. 1804.) Plaintiff and Stone discussed screening for autism. (R. 1804.) Plaintiff continued to work with her ARMHS worker. (R. 1804.) Stone observed that CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 36 of 83
37 Plaintiff was more open and engaging but still exhibited social anxiety symptoms including lack of eye contact, poor posture, and facing away from him. (R. 1804.) On May 25, 2022, Plaintiff had a therapy appointment with Royce Vang. (R. 795.) Plaintiff discussed her relationship with her sister. (R. 796.) On May 31, 2022, Plaintiff had a telephone meeting with case manager Eric Stone, during which they discussed Plaintiff’s engagement with therapy and medication. (R. 1805.) Plaintiff was motivated to engage in therapy but reported that she felt that medications had not helped in the past. (R. 1805.) On June 7, 2022, Plaintiff had a therapy appointment with Royce Vang. (R. 793.) Plaintiff appeared somewhat distressed and reported that her mood was depressed. (R. 793.) On June 14, 2022, Plaintiff had a telephone therapy session with Royce Vang. (R. 791.) Vang indicated that Plaintiff’s progress had deteriorated. (R. 791.) Plaintiff reported that she was really tired and did not have the energy to complete a full session. (R. 792.) On June 20, 2022, state agency psychological consultant Michael DeSanctis, PHD, LP, provided an opinion regarding Plaintiff’s SSI application. (R. 77.) Dr. DeSanctis opined that Plaintiff had severe impairments including Anxiety and Obsessive- Compulsive Disorders; Bipolar and Related Disorders; and Attention Deficit/ Hyperactivity Disorder. (R. 76.) However, Dr. DeSanctis opined that Plaintiff had only a mild limitation with respect to understanding, remembering, or applying information; a moderate limitation with respect to interacting with others; a moderate limitation with CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 37 of 83
38 respect to concentrating, persisting, or maintaining pace; and a moderate limitation with respect to adapting or managing oneself. (R. 76.) Dr. DeSanctis further opined that the evidence did not establish the presence of paragraph C criteria, and concluded that Plaintiff therefore did not meet a listing at Step 3 of the disability determination. (R. 76.) Dr. DeSanctis also opined regarding Plaintiff’s RFC at Step 4, and concluded that Plaintiff was moderately limited in: the ability to carry out detailed instructions, the ability to maintain attention and concentration for extended periods; the ability to work in coordination with or in proximity to others without being distracted by them; the ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods; and the ability to interact appropriately with the general public. (R. 78-79.) Dr. Desantis opined that Plaintiff was able to tolerate “brief, superficial, infrequent interactions with co-workers and the general public in entry-level work settings and accept ordinary levels of supportive supervision customary in entry-level work venues,” and that Plaintiff was “able to manage simple, daily production demands of a FT, 40-hour per week, RR, entry-level competitive work environment with low levels of interpersonal contact/pressure and low levels of ambient simulation/external distraction involving structured, predictable work flows and relaxed time constraints.” (R. 79.) Plaintiff was determined not disabled. (R. 80.) On June 21, 2022, Plaintiff had a telephone therapy appointment with Royce Vang. (R. 789-90.) Plaintiff reported that she had passed out in the shower and that she CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 38 of 83
39 might have had a mild concussion. (R. 790.) Plaintiff appeared to be somewhat distressed and her mood was depressed. (R. 789.) On June 23, 2022, Plaintiff had an appointment with Alyssa Stone of Ellie Family Servies in Plaintiff’s home. (R. 788.) Plaintiff and Stone discussed the barriers to Plaintiff’s self-care routine. (R. 788.) Plaintiff reported feeling better now that she had a reduction in appointments each week. (R. 788.) On June 29, 2022, Plaintiff met with case manager Eric Stone in her home. (R. 1806.) Plaintiff reported working with her therapist and her ARMHS worker, and showering “once every five days or so.” (R. 1806.) Stone reported that Plaintiff was talkative and open, but still struggled with anxiety, low motivation, and difficulties getting out of the house. (R. 1806.) On July 5, 2022, Plaintiff had a therapy appointment with Royce Vang. (R. 839.) On July 12, 2022, Plaintiff an appointment with Barb Stanton, PHD, LPCC, to assess for Autism Spectrum Disorder. (R. 837.) Plaintiff’s mother was present for the session, which took place via Microsoft Teams. (R. 837.) Dr. Stanton noted that Plaintiff’s grooming was appropriate. (R. 837.) Dr. Stanton observed enough characters of autism to warrant further assessment, and scheduled a follow up appointment. (R. 838.) On July 14, 2022, Plaintiff had a therapy appointment with Royce Vang. (R. 835.) Plaintiff stated that she was willing to take a shower but was just so exhausted. (R. 835.) On July 25, 2022, Plaintiff had a follow-up appointment with Dr. Stanton to continue assessing for autism. (R. 825.) Plaintiff’s mother was present for the CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 39 of 83
40 appointment. (R. 825.) Dr. Stanton conducted the Autism Diagnostic Observation Schedule 2 (“ADOS”), which is a semi-structured assessment of communication, social interaction, and play (or imaginative use of materials) for individuals suspected of having autism or other pervasive developmental disorders. (R. 825.) Dr. Stanton noted that Plaintiff’s eye contact was limited and did not appear to be socially motivated, and that Plaintiff stated that she did not like making eye contact. (R. 826.) Plaintiff showed limited direct facial expressions. (R. 826.) Plaintiff identified some sensory issues including sensitivity to smell, taste, texture, sounds, and being in crowds. (R. 826.) Dr. Stanton concluded that based on the ADOS, Plaintiff exceeded the threshold for a diagnosis of Autism Spectrum Disorder. (R. 825.) On July 27, 2022, Plaintiff had a telephone meeting with case manager Eric Stone. (R. 1807.) Plaintiff’s mother had called Stone to request a telephone meeting due to COVID concerns, and explained that it was too much for Plaintiff to call and manage her schedule on her own at that time. (R. 1807.) Stone met with Plaintiff and her mother via telephone, and Plaintiff reported feeling tired and wanting to get off the phone. (R. 1807.) On August 2, 2022, Plaintiff met with Dr. Stanton via Microsoft Teams to review the results of her assessment. (R. 830.) Dr. Stanton noted that Plaintiff’s grooming was appropriate. (R. 830.) On August 23, 2022, Plaintiff met with case manager Eric Stone in her home. (R. 1808.) Plaintiff discussed how she could only handle so much stimulation in the form of meetings, responsibilities, and contact with other people and explained that when she hit CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 40 of 83
41 her limit, she “just can’t function anymore.” (R. 1808.) Plaintiff reported continuing to work with her ARMHS worker and her therapist. (R. 1808.) On September 12, 2022, Plaintiff completed another Function Report – Adult. (R. 301-08.) This report noted Plaintiff’s autism diagnosis. (R. 301.) Plaintiff again reported that she often needed reminders to take care of personal needs and grooming. (R. 302-03.) Regarding housework, Plaintiff reported that she tried to keep her room clean, but that she no longer had the energy or motivation to help out around the house. (R. 303.) She also reported that she could not handle the sound of the vacuum or the bugs around the garbage. (R. 303.) Plaintiff again reported that she could not pay bills or use a checkbook and that while she spent time with others in person and on the phone, she did so mostly with her family, “not often at all” with others, as it “drain[ed]” her. (R. 304-05.) Plaintiff again reported that she needed someone to accompany her when she went places. (R. 305.) Plaintiff reported that she has difficulty with bending, standing, sitting, talking, memory, completing tasks, concentration, and following instructions. (R. 306.) She stated that she can only pay attention to “[s]omething like paperwork” for 30 seconds, but sometimes if she has a “burst of energy” she can get a lot done. (R. 306.) Plaintiff reported that she had “no issues” with authority figures, but it was “tough” for her to follow written instructions. (R. 306.) Plaintiff stated that she was stressed often, and that she handled stress by crying and isolating. (R. 307.) On September 19, 2022, Plaintiff met with case manager Eric Stone in her home. (R. 1810.) Plaintiff reported that she had been trying to cut back on some appointments because she had been overwhelmed with seeing specialists lately. (R. 1810.) Stone CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 41 of 83
42 observed that Plaintiff was tired and somewhat irritated. (R. 1810.) Plaintiff continued to isolate and did not leave her home without her mother. (R. 1810.) Also on September 19, 2022, Stone completed another functional assessment of Plaintiff. (R. 1811.) Stone noted Plaintiff’s diagnoses as major depressive disorder (severe), persistent depressive disorder, social anxiety disorder, generalized anxiety disorder, agoraphobia, and attention deficit hyperactivity disorder. (R. 1811.) Stone reported that Plaintiff continued to isolate and spend almost all of her time at home, and that the only time she left home was with her mother for medical appointments. (R. 1811.) Stone noted that Plaintiff’s symptoms impaired her ability to trust and build rapport with providers; independently schedule and attend appointments with providers; engage and participate in mental health services for extended periods of time; initiate activities or tasks, complete them; and maintain her self-care consistently. (R. 1811-13.) Stone noted that: [Plaintiff’s] depression and anxiety/phobia are significant barriers to making progress on long term vocational goals. Her anxiety/phobia is extremely triggered around any type of transportation apart from her Mother driving her places. Her social anxiety is very intense and she has a difficult time trusting others and being around others she does not know. Her depression leads her to sleep most of the day and maintaining a consistent schedule is very difficult for her. (R. 1812.) Stone recorded that Plaintiff did not have close friends that she engaged with regularly, and that her symptoms impaired her ability to initiate and maintain friendships. (R. 1812.) Stone also noted that Plaintiff’s “anxiety and phobia gets very severe around public transportation, such as buses, trains, Ubers, etc.” and that Plaintiff has been CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 42 of 83
43 “unable to utilize these methods due to how overwhelming her anxiety and phobia gets.” (R. 1814.) On October 17, 2022, Plaintiff met with case manager Eric Stone. (R. 1821.) Plaintiff reported feeling exhausted when she had appointments or meetings and that she still only leaves the home with her mother. (R. 1821.) Plaintiff stated that she wanted to have a normal life with friends but felt stuck. (R. 1821.) On November 3, 2022, Plaintiff’s mother submitted a third-party Function Report on her behalf. (R. 313-20.) Plaintiff’s mother reported that Plaintiff began showing symptoms in middle school when she “could not get to school every day.” (R. 314.) She reported that it got worse in high school, so Plaintiff switched to online school. (R. 314.) Plaintiff’s mother reported that Plaintiff slept up to 14 hours a day, and that she was “easily tired out by any strong emotion, stimulation, and talking to people, and will sleep a longer time after any of these.” (R. 314.) Plaintiff’s mother reported that Plaintiff only had the energy to bathe once a week, did not brush her hair often, and forgot to take her medicine. (R. 314.) Plaintiff’s mother reported that Plaintiff could heat food in the microwave, but that “following a recipe is too stressful, as is using the stove or oven.” (R. 315.) Plaintiff’s mother reported that Plaintiff went outside “an hour or two a month in non-bug months” but only “a few minutes a month in summer” because she was afraid of bugs and did not feel good in the heat. (R. 316.) Plaintiff’s mother reported that Plaintiff could not go out alone, and the last time she tried leaving Plaintiff alone for less than an hour, Plaintiff had a panic attack and then went to bed the rest of the day. (R. 316.) Plaintiff’s mother testified that Plaintiff went with her to the grocery store once CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 43 of 83
44 every two or three months. (R. 316.) Plaintiff’s mother reported that the two of them went out to eat every couple months, and that Plaintiff texted her grandmother and a cousin a couple times a year. (R. 317.) Plaintiff’s mother reported that they go to the Renaissance Festival once a year. (R. 317.) Plaintiff’s mother reported that Plaintiff went to doctors’ appointments, but could not go to more than one or two appointments in a week without becoming overwhelmed. (R. 317.) Plaintiff’s mother reported that Plaintiff could pay attention for 20 seconds to 15 minutes, depending on the subject and the day. (R. 318.) She reported that Plaintiff got along with authority figures “[v]ery well,” noting that she “likes to be kind and considerate.” (R. 319.) However, Plaintiff’s mother reported that Plaintiff did not follow written or spoken instructions well. (R. 318.) Plaintiff’s mother reported that Plaintiff handled stress very poorly, noting that Plaintiff will “shut down emotionally and sleep a lot more. She will also get depressed and stop doing things to take care of herself.” (R. 319.) On November 15, 2022, Plaintiff had a telehealth mental health appointment with Jennifer Gay, MSN, PMHNP. (R. 941.) Plaintiff’s mother was present. (R. 941.) Plaintiff reported that she didn’t really have any friends and that she slept 12 hours a day. (R. 942.) Plaintiff reported that she had been trying to spend more time with her family but spends a lot of time isolated. (R. 942.) Plaintiff reported that she experiences a lot of anxiety and that interacting with others is difficult. (R. 943.) Plaintiff reported that attention and concentration were difficult for her and worsened with anxiety. (R. 943.) Gay noted that Plaintiff’s grooming and hygiene was adequate, and her behavior was cooperative with good eye contact. (R. 944.) Gay reported that Plaintiff’s presentation CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 44 of 83
45 was most consistent with generalized anxiety disorder, major depressive disorder, inattentive ADHD and autism spectrum disorder. (R. 945.) On November 28, 2022, Plaintiff met with case manager Eric Stone and discussed that she would be transferring to a new case manager. (R. 1823.) On December 14, 2022, Plaintiff had a follow up telehealth appointment with psychiatric nurse practitioner Jennifer Gay. (R. 1990.) Gay noted that Plaintiff’s grooming and hygiene was adequate, her behavior was cooperative with good eye contact, and her mood was euthymic. (R. 1993.) Gay reported that Plaintiff’s current stressors included fatigue, and her current psychosocial functioning was poor. (R. 1993.) On December 20, 2022, Plaintiff met with her new case manager, Brianna Perry, MS. (R. 1825.) Plaintiff discussed wanting to cut back on the amount of appointments she had because it burns her out and she gets exhausted and sleeps all day. (R. 1826.) On January 6, 2023, Plaintiff had a telehealth appointment with psychiatric nurse practitioner Jennifer Gay. (R. 1984.) Gay noted that Plaintiff’s grooming and hygiene was adequate, her behavior was cooperative with good eye contact, and her mood was euthymic. (R. 1987.) Gay reported that Plaintiff’s current stressors included fatigue, and her current psychosocial functioning was poor. (R. 1988.) On January 18, 2023, Plaintiff had a meeting with case manager Brianna Perry. (R. 1829.) Plaintiff reported that she was having a hard time managing her stress level. (R. 1829.) On January 18, 2023, state agency psychological consultant Marci Mylan, PHD, LP, provided an opinion regarding Plaintiff’s SSI application at the reconsideration level. CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 45 of 83
46 (R. 89.) Dr. Mylan noted that Plaintiff had a new diagnosis of autism spectrum disorder and alleged worsening mental health symptoms. (R. 88.) However, Dr. Mylan observed that the updated functional assessments completed by Plaintiff and her mother in the fall of 2022 did not report a significant change in functioning. (R. 89.) Dr. Mylan concluded that the prior administrative finding “appeared to be consistent with and supported by the medical evidence.” (R. 89.) Plaintiff was again determined not disabled. (R. 92.) On February 28, 2023, Plaintiff had a telehealth appointment with clinical trainee Zarlasht Shinwari, BA. (R. 1982.) Plaintiff’s mother was present for the appointment. (R. 1983.) Shinwari planned to meet with the Plaintiff weekly to support Plaintiff in building coping skills for autism and ADHD, unless Plaintiff was overwhelmed and canceled the appointment. (R. 1983.) On March 1, 2023, case manager Brianna Perry completed a functional assessment of Plaintiff. (R. 1842.) Perry noted Plaintiff’s diagnoses as major depressive disorder (severe), persistent depressive disorder, social anxiety disorder, generalized anxiety disorder, agoraphobia, attention deficit hyperactivity disorder and autism. (R. 1842.) Perry reported that Plaintiff continued to isolate and spent almost all her time at home. (R. 1842.) The only time Plaintiff left her home was with her mother for medical appointments. (R. 1842.) Perry noted that Plaintiff’s symptoms impaired her ability to trust and build rapport with providers; independently schedule and attend appointments with providers; engage and participate in mental health services for extended periods of time; initiate activities or tasks and complete them; and maintain her self-care consistently. (R. 1842-44.) Perry reported that: CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 46 of 83
47 [Plaintiff’s] depression and anxiety/phobia are significant barriers to [Plaintiff] making progress on long term vocational goals. Her anxiety/phobia is extremely triggered around any type of transportation apart from her Mother driving her places. Her social anxiety is very intense and she has a difficult time trusting others and being around others she does not know. Her depression leads her to sleep most of the day and maintaining a consistent schedule is very difficult for her. (R. 1843.) Stone recorded that Plaintiff did not have close friends that she engaged with regularly, and that her symptoms impaired her ability to initiate and maintain friendships. (R. 1843.) Stone also noted that Plaintiff’s “anxiety and phobia gets very severe around public transportation, such as buses, trains, Ubers, etc.” and that Plaintiff has been “unable to utilize these methods due to how overwhelming her anxiety and phobia gets.” (R. 1844.) On March 7, 2023, Plaintiff had a telehealth appointment with psychiatric nurse practitioner Jennifer Gay, MSN, PMHNP. (R. 1976.) Plaintiff reported that “everything feels weird and bad.” (R. 1976.) Plaintiff reported overstimulation and noted that her sleep had worsened. (R. 1977.) Plaintiff described fluctuating between not sleeping enough and sleeping for 14 hours. (R. 1977.) Plaintiff described her mood by stating that “50% of the time it’s fine.” (R. 1977.) Gay noted that Plaintiff’s grooming and hygiene was adequate, her behavior was cooperative with good eye contact, and her mood was euthymic. (R. 1979.) Gay reported that Plaintiff’s current stressors included fatigue, and her current psychosocial functioning was poor. (R. 1979.) On March 14, March 28, and April 26, 2023, Plaintiff had telehealth appointments with Zarlasht Shinwari for support reducing symptoms of anxiety and depression and CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 47 of 83
48 building coping skills for autism and ADHD. (R. 1970-75.) Plaintiff’s mother was present for the appointments. (R. 1970-75.) On April 28, 2023, Plaintiff had a telehealth appointment with Gay. (R. 1901.) Plaintiff could not remember if she had taken her medication. (R. 1902.) Gay noted that Plaintiff had adequate grooming and hygiene, she was cooperative and exhibited good eye contact, and her mood was euthymic, but noted that her current psychosocial functioning was poor. (R. 1904-05.) On March 15, 2023, Plaintiff met with case manager Brianna Perry. (R. 1847.) They discussed Plaintiff’s progress towards engaging in self-care activities for her mental health. (R. 1848.) Plaintiff reported that she had been working with a new ARMHS worker. (R. 1848.) On April 28, 2023, Plaintiff met with a different case manager, Aryn Bissener. (R. 1854.) Plaintiff reported that she had officially been diagnosed with chronic fatigue disorder. (R. 1854.) Plaintiff reported that she had been meeting with her ARMHS worker, and also that her self-care had been minimum lately. (R. 1854.) On May 9 and May 23, 2023, Plaintiff had telehealth appointments with Zarlasht Shinwari for support reducing symptoms of anxiety and depression and building coping skills for autism and ADHD. (R. 1959-63.) Plaintiff’s mother was present for the appointments. (R. 1959-63.) During the May 23, 2023 appointment, Shinwari noted that the current presenting symptoms related to Plaintiff’s diagnosis were feelings of being overwhelmed, the inability to complete tasks, and shortened attention span. (R. 1959.) Shinwari reported that Plaintiff had begun waking up on time for sessions and was CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 48 of 83
49 staying engaged, but she still needed to learn skills to cope with her mental health conditions. (R. 1959.) Plaintiff continued meeting with Shinwari weekly between May and August 2023. (R. 1943-56.) Plaintiff’s mother was present for all of these sessions. (R. 1943-56.) Plaintiff continued meeting with case manager Brianna Perry monthly from May through August of 2023. (R. 1858-68.) In the summer of 2023, Plaintiff began seeing an occupational therapist with the goal of learning skills for stress management, energy conservation, and overstimulation management in order to participate in activities of daily living at home. (R. 2046, 2053.) On August 23, 2023, case manager Brianna Perry completed another functional assessment of Plaintiff. (R. 1874.) Perry listed Plaintiff’s diagnoses as major depressive disorder (severe), persistent depressive disorder, social anxiety disorder, generalized anxiety disorder, agoraphobia, attention deficit hyperactivity disorder and autism. (R. 1874.) Perry noted that Plaintiff continued to isolate and that the only time she left home was with her mother for medical appointments. (R. 1874.) Perry reported that Plaintiff’s symptoms impaired her ability to trust and build rapport with providers, independently schedule and attend appointments with providers, and engage and participate in mental health services for extended periods of time. (R. 1874.) Perry wrote that: Depression and anxiety/phobia are significant barriers to [Plaintiff] making progress on long term vocational goals. Her anxiety/phobia is extremely triggered around any type of transportation apart from her Mother driving her places. Her social anxiety is very intense and she has a difficult time trusting others and being around others she does not know. Her depression leads her to sleep most of the day and maintaining a consistent schedule is very difficult for her. CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 49 of 83
50 (R. 1875.) Perry noted that Plaintiff’s symptoms had impacted her social functioning “so severely that she has been unable to develop close friends that she engages with on a regular basis.” (R. 1875.) Perry noted that Plaintiff was impaired in her ability to initiate activities or tasks, complete them, and maintain her self-care consistently; manage healthcare appointments; and understand and follow treatment recommendations. (R. 1875-76.) Perry recorded that Plaintiff’s “[a]nxiety and phobia symptoms increase in severity around conversations about, as well as the thought of, taking public transportation, such as buses, trains, Ubers, etc. [Plaintiff] has been unable to utilize these methods due to how overwhelming her anxiety and phobia gets.” (R. 1876.) On August 24, 2023, Plaintiff had an occupational therapy appointment with Brittany Blomquist, OT. (R. 2037.) Plaintiff reported that she tried to brush her hair and bathe once a week, and that she wished she washed her face and moisturized more. (R. 2038.) Blomquist provided tips for energy conservation in activities of daily living and provided plaintiff with a journal to track her fatigue. (R. 2038.) On September 7, 2023, Plaintiff had an occupational therapy appointment with Blomquist. (R. 2032.) Plaintiff reported that she was very tired because she had attended the Renaissance Festival recently. (R. 2033.) Plaintiff reported that she used appliances so infrequently that she forgot how to use them, and Blomquist worked with Plaintiff’s mother to create memory aids to help Plaintiff use the dishwasher, washer, and dryer. (R. 2033.) On September 15, 2023, psychiatric nurse practitioner Gay completed a diagnostic assessment of Plaintiff. (R. 1898.) Gay listed the symptoms that impacted Plaintiff’s CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 50 of 83
51 functioning as depressed mood, decreased energy, sleep disturbances, hopelessness, distractibility, and anxiety. (R. 1898.) Gay noted that Plaintiff had functional impairments in interpersonal functioning, social functioning, mental health symptoms, and mental health service needs. (R. 1899.) Gay listed Plaintiff’s diagnoses as “Generalized Anxiety Disorder,” “Major Depressive Disorder-Single Episode-Moderate,” “ADHD- Predominantly Inattentive Presentation,” and “Autism Spectrum Disorder.” (R. 1899.) On September 19, 2023, Plaintiff had a telehealth appointment with clinical trainee Zarlasht Shinwari, BA, of Ellie Mental Health. (R. 1940.) Plaintiff’s mother was present for this appointment. (R. 1941.) Plaintiff and Shinwari discussed Plaintiff’s suicidal ideation and the call that Plaintiff had made to the hotline. (R. 1942.) On October 3, 2023, Plaintiff was seen by Zarlasht Shinwari for a renewal of diagnostic assessment. (R. 1928.) Plaintiff reported that she had major lapses in energy, and that she experienced anxiety on a daily basis. (R. 1928.) Plaintiff reported that she did not have any friends. (R. 1928.) Plaintiff reported that her weekly appointments were exhausting and that she had a hard time having the energy or concentration for them. (R. 1929.) Shinwari noted Plaintiff’s diagnoses as “Generalized anxiety disorder, Major depressive disorder, Single Episode, Moderate, Attention-deficit/hyperactivity disorder. Predominantly inattentive presentation, and Autism spectrum disorder.” (R. 1929.) Plaintiff endorsed symptoms including anxiety, depression, panic attacks, social isolation, sleep disturbance and suicidal ideation. (R. 1929.) Shinwari observed that Plaintiff’s appearance was disheveled, that her affect was appropriate and flat, and that CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 51 of 83
52 her mood was neutral, depressed, anxious and irritable. (R. 1933.) Shinwari observed that Plaintiff was responsive and engaged in the session, but would disengage “evidenced by long periods of silence and asking the clinician to repeat what they had said.” (R. 1935.) Shinwari noted that Plaintiff’s symptoms had caused her function to decline in the following areas: mental health symptoms, mental health service needs, interpersonal, self-care and independent living, medical health, and dental health. (R. 1934.) On October 5, 2023, Plaintiff had a telehealth appointment with psychiatric nurse practitioner Jennifer Gay. (R. 1921.) Plaintiff had recently started on a new medication, and noted that she had had enough energy to take her garbage out and spend more time visiting with her family, but that her anxiety had been worse than normal. (R. 1922.) Plaintiff’s mother reported that the medication had “mucked up her sleep schedule.” (R. 1922.) Gay observed that Plaintiff’s grooming and hygiene were adequate, Plaintiff was cooperative and demonstrated good eye contact, and her mood was euthymic. (R. 1924.) Gay reported that Plaintiff’s psychosocial functioning was poor. (R. 1925.) On October 10, 2023, Plaintiff had a telehealth appointment with Zarlasht Shinwari. (R. 1919.) Plaintiff’s mother was present for the appointment. (R. 1920.) Shinwari discussed with Plaintiff and her mother whether ARMHS had been effective. (R. 1920.) Plaintiff reported that “it’s been as good as it can be with [her] energy levels.” (R. 1920.) Plaintiff and her mother had another telehealth appointment with Shinwari on October 24, 2023. (R. 1917-18.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 52 of 83
53 On October 25, 2023, Plaintiff met with case manager Brianna Perry in her home. (R. 1888.) Plaintiff’s plan was to attend as many of her appointments as she was able to. (R. 1888.) On October 31 and November 7 2023, Plaintiff and her mother had telehealth appointments with Zarlasht Shinwari. (R. 1913-16.) On November 9, 2023, Plaintiff had a telehealth appointment with psychiatric nurse practitioner Jennifer Gay. (R. 1906.) Gay observed that Plaintiff’s grooming and hygiene were adequate, that Plaintiff was cooperative and demonstrated good eye contact, and that her mood was euthymic. (R. 1906.) Gay reported that Plaintiff’s psychosocial functioning was poor. (R. 1907.) On December 11, 2023, Plaintiff testified at the hearing before the ALJ. (R. 31.) Plaintiff’s mother was present but did not testify. (R. 33.) Plaintiff testified that she slept 11 to 12 hours a day. (R. 43.) Plaintiff testified that she spent approximately 15 minutes of social time with her family a day. (R. 43.) Plaintiff testified that on a good day she could get the mail herself, but otherwise she did not leave the house by herself. (R. 43- 44.) Plaintiff testified that she had gone up to a month without leaving the house. (R. 55.) Plaintiff also testified about the support she received through the ARMHS program. (R. 40, 53-54.) Specifically, ARMHS workers come to Plaintiff’s home and help her manage self-care tasks, like showering, brushing her teeth, and brushing her hair. (R. 54.) Plaintiff testified that in the past, she had gone weeks without bathing, changing her clothes, or brushing her teeth. (R. 54-55). CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 53 of 83
54 Vocational Expert Jessica Coles (“the VE”) also testified at the hearing. (R. 60.) The ALJ presented the VE with the following hypothetical: Assume a hypothetical individual of the claimant’s age, education and with no past vocational history. Further assume the individual can perform light work as defined in the regulations. However, the work would need to be limited to simple routine and repetitive tasks . . . involving only simple work- related decisions with fewer of any workplace changes. And the work should require quarter-based tasks as opposed to any type of production requirements. Further, no more than incidental contact with co-workers. And by that, I mean no kind of tasks and no contact with the public. (R. 60-61.) The VE responded that such an individual could perform the following jobs: garment sorter, DOT 222.687-014, with 55,000 jobs in the national economy; folder, DOT 369.687-018, with 53,000 jobs in the national economy; and checker I clerical, DOT 222.687-010, with 52,000 jobs in the national economy. (R. 61.) The VE testified that these positions could take up to and including 30 days to learn, and that period would include things like being oriented or trained by another employee or supervisor. (R. 65.) The VE further testified that for these jobs, it would be work preclusive if the individual needed to be reminded what they are supposed to do more than once per day, and that the maximum amount of time an individual could be off task was 10% of the time, spread evenly throughout the workday. (R. 61-62.) The VE also testified that it would preclude all work for an individual to be absent two days or more per month for more than six months. (R. 62.) This included arriving late to a work shift or leaving a work shift early. (R. 62-63.) The VE clarified that missing an entire work shift and part of a second shift in the same month would be work preclusive, and a person could miss only twelve days a year and still be considered employable. (R. 63-64.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 54 of 83
55 III. LEGAL STANDARD Judicial review of an ALJ’s denial of benefits is limited to determining whether substantial evidence on the record as a whole supports the decision, 42 U.S.C. § 405(g); Chismarich v. Berryhill, 888 F.3d 978, 979 (8th Cir. 2018), or whether the ALJ’s decision results from an error in law, Nash v. Comm’r, Soc. Sec. Admin. 907 F.3d 1086, 1089 (8th Cir. 2018). “Substantial evidence is less than a preponderance, but enough that a reasonable mind would find it adequate to support the Commissioner’s conclusions.” Id. (quoting Travis v. Astrue, 477 F.3d 1037, 1040 (8th Cir. 2007)). The Court “considers evidence that detracts from the Commissioner’s decision as well as evidence that supports it.” Id. “If substantial evidence supports the Commissioner’s conclusions, this court does not reverse even if it would reach a different conclusion, or merely because substantial evidence also supports the contrary outcome.” Id. In reviewing the record for substantial evidence, the Court may not substitute its own judgment or findings of fact for that of the ALJ. Hilkemeyer v. Barnhart, 380 F.3d 441, 445 (8th Cir. 2004). “Assessing and resolving credibility is a matter properly within the purview of the ALJ.” Chaney v. Colvin, 812 F.3d 672, 676 (8th Cir. 2016) (citing Edwards v. Barnhart, 314 F.3d 964, 966 (8th Cir. 2003) (“Our touchstone is that [a claimant’s] credibility is primarily a matter for the ALJ to decide.”)). IV. DISCUSSION Plaintiff makes three arguments for remand: the ALJ failed to identify agoraphobia as a severe impairment at Step 2, the ALJ’s Step 3 determination was not supported by substantial evidence, and the ALJ’s RFC assessment at Step 4 was not CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 55 of 83
56 supported by substantial evidence. (Dkt. 9 at 17, 20, 27.) For the reasons discussed below, the Court concludes that the Step 3 analysis requires reversal and an award of benefits.14 However, even if the Court did not reach that conclusion as to Step 3, it would recommend remand for further proceedings based on the analysis at Steps 2 and 4. The Court considers each of those steps below. A. Whether Agoraphobia Should Have Been Identified as a Severe Impairment at Step 2 Plaintiff argues that the ALJ erred by not identifying agoraphobia as a severe impairment at Step 2. (Dkt. 9 at 17-20.) At Step 2, an impairment is not severe if “it amounts only to a slight abnormality that would not significantly limit the claimant’s physical or mental ability to do basic work activities.” Kirby v. Astrue, 500 F.3d 705, 707 (8th Cir. 2007). It is the claimant’s burden to establish that his impairment or combination of impairments are severe. Kirby v. Astrue, 500 F.3d 705, 707 (8th Cir. 2007). Severity is neither an onerous standard nor a toothless standard. Id. The ALJ did not mention an agoraphobia diagnosis in his Step 2 analysis. (R. 16- 17.) Plaintiff cites to the fact that both Dr. Barron and Dr. Garg confirmed Plaintiff’s diagnosis of agoraphobia,15 as well as numerous medical records showing Plaintiff’s 14 As an alternative to an award of benefits at Step 3, the Court would recommend remand as to Step 3 for further proceedings as to paragraphs B and C. 15 Plaintiff overstates Dr. Barron’s conclusion, as he only noted that Plaintiff “had endorsed some of the symptoms consistent with . . . agoraphobia.” (R. 363-69.) Dr. Garg, however, did formally diagnose Plaintiff with agoraphobia. (R. 513.) The Court also notes that Bria Grudzielanek, MSW, LICSW, concluded that there was no reason to challenge Dr. Garg’s diagnosis of agoraphobia. (R. 1711.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 56 of 83
57 fears related to interacting with others and leaving the house without her mother. (Dkt. 9 at 18.) The Commissioner does not argue that Plaintiff has not met her burden to establish that her agoraphobia is a severe impairment. Rather, the Commissioner argues that, even assuming that the ALJ should have included agoraphobia as a severe impairment, the error is harmless because the ALJ proceeded past Step 2 and “noted Plaintiff’s alleged social phobia/agoraphobia and accounted for any credible limitations in the residual functional capacity.” (Dkt. 14 at 6-7.) The law is somewhat unsettled as to when an error at Step 2 is reversible. In Nicola v. Astrue, the Eighth Circuit concluded that it was reversible error for an ALJ to fail to include a diagnosis of borderline intellectual functioning as a severe impairment at Step 2. 480 F.3d 885, 887 (8th Cir. 2007). The Eighth Circuit rejected the harmless error argument that the Commissioner made in that case,16 and some district courts in this Circuit have cited Nicola for the proposition that error at Step 2 cannot be harmless. Tonya S.G. v. Berryhill, 2018 WL 4441467, at *6 (D.S.D. Sept. 17, 2018) (rejecting the argument that an error at Step 2 can be harmless) (citing Nicola, 480 F.3d at 877); Stewart v. Astrue, No. 09-cv-3170, 2011 WL 338794, at *3 (W.D. Mo. Jan. 31, 2011) (citing Nicola for a per se rule of reversal where there is an error at Step 2); Lamorte v. 16 Astrue, 480 F.3d at 887 (“The Commissioner concedes that the ALJ should have considered Nicola’s borderline intellectual functioning to be a severe impairment, but relies on Howard v. Massanari, 255 F.3d 577, 581-82 (8th Cir. 2001), in arguing that this was harmless error. The Commissioner’s reliance on Howard is misplaced. The issue in Howard was not whether the individual’s diagnosis of borderline intellectual functioning was a severe impairment; rather, the issue was whether the hypothetical question posed to a VE adequately addressed the limitations associated with the diagnosis of borderline intellectual functioning. Therefore, we reject the Commissioner’s argument of harmless error.”). CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 57 of 83
58 Astrue, No. 3:08-cv-03040, 2009 WL 3698004, at *4 (W.D. Ark. Nov. 2, 2009) (same). However, several courts in this District have distinguished Nicola and found that “an ALJ’s failure to find that an impairment is severe at Step 2 is harmless error where the ALJ otherwise finds another severe impairment exists and addresses any functional limitations caused by the overlooked impairment when determining the individual’s RFC.” Misty G. v. Berryhill, No. 0:18-CV-00587-KMM, 2019 WL 1318355, at *3 (D. Minn. Mar. 22, 2019) (collecting cases). Plaintiff argues that the ALJ’s failure to include agoraphobia as a severe impairment is not harmless because at Step 4, “the ALJ failed to account for the agoraphobia-specific symptoms of the disproportionate fears and anxieties that have more or less rendered her homebound.” (Dkt. 9 at 20.) In her argument regarding Step 4, Plaintiff only asserts: “Because appropriate impairments and limitations were not assessed earlier in this decision, the residual functional capacity assessment is not based upon the combined effects of all credible limitations, remand is warranted.” (Dkt. 9 at 29.) However, Plaintiff never identifies what limitations were omitted from the RFC that should have been included due to agoraphobia. The ALJ assessed a number of limitations associated with Plaintiff’s impairments of major depressive disorder, autism spectrum disorder, generalized anxiety disorder, and ADHD. (R. 26.) Having reviewed the record, it is not clear to the Court which, if any, of Plaintiff’s symptoms are attributable only to agoraphobia and not to any of Plaintiff’s other diagnoses as well. The Court recommends remand for an award of benefits on Step 3 grounds in Section IV.B, but in the alternative, the Court recommends remand for further proceedings so the ALJ CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 58 of 83
59 can address at Step 2 whether Plaintiff’s agoraphobia constitutes a severe impairment, and, regardless of severity, what, if any limitations should be assessed at Step 4 based on her agoraphobia. B. Whether the Step 3 Analysis is Supported by Substantial Evidence Plaintiff next argues that the ALJ’s conclusion at Step 3 that Plaintiff did not have an impairment or combination of impairments that met or medically equaled a listed impairment was not supported by substantial evidence. (Dkt. 9 at 20-27.) If it is determined at Step 3 that a claimant has an “impairment(s) that meets or equals one of our listings in appendix 1 to subpart P of part 404 of this chapter and meets the duration requirement,” the claimant must be found disabled. 20 C.F.R. § 416.920(a)(4)(iii). In general, the Listings for Mental Disorders - Adult contain three sets of criteria, a combination of which a claimant must satisfy in order to meet the Listing. See 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(A)(2). Paragraph A sets forth the relevant medical criteria, paragraph B sets forth functional criteria, and paragraph C provides the criteria used to evaluate “serious and persistent mental disorders.” Id. Here, the ALJ considered Listings 12.04 (depressive, bipolar and related disorders), 12.06 (anxiety and obsessive-compulsive disorders), 12.10 (autism spectrum disorder), and 12.11 (neurodevelopmental disorders). (R. 18.) To meet Listings 12.04 and 12.06, a claimant must satisfy either the criteria of paragraphs A and B or A and C. 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(A)(2). To meet Listings 12.10 or 12.11, a claimant must satisfy the criteria of paragraphs A and B. Id. The ALJ’s decision did not CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 59 of 83
60 discuss the paragraph A criteria.17 Rather, he concluded that neither the paragraph B nor the paragraph C criteria were satisfied. (See R. 18-19.) To satisfy paragraph B, a claimant’s mental impairments must result in either an extreme limitation of one, or a marked limitation of two of the following areas of mental functioning: (1) understanding, remembering, or apply information; (2) interacting with others; (3) concentrating, persisting, or maintaining pace; and (4) adapting or managing oneself. See 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.04(B), 12.06(B) 12.10(B), 12.11(B). To satisfy paragraph C’s criteria for a “serious and persistent” mental disorder, a claimant must have a medically documented history of the existence of the disorder over a period of at least two years, and there is evidence of both: (1) “Medical treatment, mental health therapy, psychosocial support(s), or a highly structured setting(s) that is ongoing and that diminishes the symptoms and signs of [a claimant’s] mental disorder;” and (2) “Marginal adjustment, that is, [a claimant has] minimal capacity to adapt to changes in [their] environment or to demands that are not already part of [their] daily life.” See 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.04(C), 12.06(C). The Court considers the ALJ’s decision with respect to the paragraph B and paragraph C criteria. 1. Paragraph B Beginning with paragraph B, the ALJ concluded that Plaintiff had a mild limitation in understanding, remembering, or applying information and moderate limitations in interacting with others; concentrating, persisting or maintaining pace; and 17 The Commissioner does not argue that Plaintiff does not meet the paragraph A criteria. CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 60 of 83
61 adapting or managing oneself. (R. 18.) However, Plaintiff argues that she has at least marked, if not extreme, limitations in interacting with others and adapting or managing oneself. (Dkt. 9 at 21.) A claimant has a moderate limitation if their functioning in an area “independently, appropriately, effectively, and on a sustained basis is fair.” 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(F)(2)(c). In contrast, a claimant has a marked limitation if their functioning in an area “independently, appropriately, effectively, and on a sustained basis is seriously limited.” 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(F)(2)(d). A claimant has an extreme limitation if they are not able to function in an area “independently, appropriately, effectively, and on a sustained basis.” 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(F)(2)(e). a. Interacting with Others The Court first considers Plaintiff’s limitation with respect to interacting with others. The relevant regulations define this area of function as follows: This area of mental functioning refers to the abilities to relate to and work with supervisors, co-workers, and the public. Examples include: Cooperating with others; asking for help when needed; handling conflicts with others; stating your own point of view; initiating or sustaining conversation; understanding and responding to social cues (physical, verbal, emotional); responding to requests, suggestions, criticism, correction, and challenges; and keeping social interactions free of excessive irritability, sensitivity, argumentativeness, or suspiciousness. 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(E)(2). In concluding that Plaintiff had no more than a moderate limitation in this area, the ALJ reasoned that: The claimant testified that she does not have any friends, a significant other, or belong to clubs or organizations. She reported that she struggles to interact with people. That said, the claimant reported having “no issues” getting along CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 61 of 83
62 with authority figures. Additionally, mental status examinations largely observed good eye contact. (R. 18 (citations omitted).) Plaintiff argues that her lack of “issues” with authority figures and occasional good eye contact with medical providers do not provide a substantial basis to conclude that she has only a moderate limitation, which would mean that her ability to interact with others independently, appropriately, effectively, and on a sustained basis is fair. (Dkt. 9 at 24.) Plaintiff cites evidence to the contrary, including Plaintiff’s extreme anxiety and fear about speaking with customer service staff, inability to make and attend appointments independently, and lack of friends or social connections outside of her family. (Dkt. 9 at 22-23.) In response, the Commissioner cites additional facts in the record to support the ALJ’s conclusion. (Dkt. 14 at 7.)18 Specifically, the Commissioner cites to mental status exams that the ALJ noted in his Step 4 analysis, which showed that Plaintiff “had a 18 In general, “the ALJ’s decision cannot be sustained on the basis of the post-hoc rationalizations of appellate counsel.” Ronald V. v. Kijakazi, No. 22-CV-2140 (TNL), 2023 WL 6318276, at *6 (D. Minn. Sept. 28, 2023).”) (collecting cases). The Court’s review typically “consider[s] the agency’s rationale for its decision, and if that rationale is inadequate or improper the court must reverse and remand for the agency to consider whether to pursue a new rationale for its decision or perhaps to change its decision.” Id. (quoting Shanda v. Colvin, No. 14-cv-1838 (MJD/JSM), 2015 WL 4077511, at *29 (D. Minn. July 6, 2015)). In some cases, however, “[w]here the record overwhelmingly supports a disability finding and remand would merely delay the receipt of benefits to which plaintiff is entitled, reversal is appropriate.” Thompson v. Sullivan, 957 F.2d 611, 614 (8th Cir. 1992) (citing Fowler v. Bowen, 866 F.2d 249, 253 (8th Cir. 1989)). In this case, the Court has considered all of the evidence cited by the ALJ in his decision and by the Commissioner in his brief in support of the ALJ’s Step 3 decision when determining that reversal, rather than remand, is appropriate. CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 62 of 83
63 cooperative demeanor, an euthymic or neutral mood, normal range of modulation, no abnormal thought content, intact insight and judgment, intact memory, intact attention and concentration, and thought processes that were goal-directed, organized, logical, and linear.” (Dkt. 14 at 7.) The Commissioner also pointed to Plaintiff’s statements on her functional report that she “socializes on the phone and in-person” and “had no problems getting along with others.” (Id. (citing R. 285-87, 305-07).) Finally, the Commissioner cites to the findings of the non-examining state agency psychological consultants in support of the ALJ’s Step 3 decision. (Id.) While the ALJ did not address these findings in his Step 3 analysis, he did find them persuasive as a part of his Step 4 analysis. (R. 21- 22.) Having reviewed the record in its entirety, the Court concludes that the ALJ’s determination that Plaintiff has only a moderate limitation in interacting with others is not supported by substantial evidence. The Court has considered the facts that the ALJ and the Commissioner relied on, including Plaintiff’s demeanor and mental status in medical appointments and her lack of problems with authority figures, but these facts do not rebut the extensive evidence in the record as a whole that Plaintiff’s capacity for social interactions is limited in other ways, that is, avoidance of social interactions. (See, e.g., R. 623, 1111, 1209, 1230.) For purposes of paragraph B, a claimant’s degree of functional limitation is measured by what they can do “independently, appropriately, effectively, and on a sustained basis.” 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(F)(2) (emphases added). The regulations also clarify that a claimant’s “ability to complete tasks in settings that are CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 63 of 83
64 highly structured, or that are less demanding or more supportive than typical work settings does not necessarily demonstrate your ability to complete tasks in the context of regular employment during a normal workday or work week.” 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(C)(6). Further, the regulations state that: when we evaluate the effects of your mental disorder and rate the limitation of your areas of mental functioning, we will consider the kind and extent of supports you receive, the characteristics of any structured setting in which you spend your time, and the effects of any treatment. This evidence may come from reports about your functioning from you or third parties who are familiar with you, and other third-party statements or information. Following are some examples of the supports you may receive: a. You receive help from family members or other people who monitor your daily activities and help you to function. For example, family members administer your medications, remind you to eat, shop for you and pay your bills, or change their work hours so you are never home alone. b. You participate in a . . . community support program, where you receive training in daily living and entry-level work skills. . . . f. you receive assistance from . . . social workers, or community mental health workers who help you meet your physical needs, and who may also represent you in dealings with government or community social services. 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(D)(1). The regulations recognize that the support a claimant receives may enable them to do things that they cannot do independently, and that if a claimant spends time “among only familiar people or surroundings, in a simple and steady routine or an unchanging environment, or in a highly structured setting. . . . this does not necessarily show how [they] would function in CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 64 of 83
65 a work setting on a sustained basis, throughout a normal workday and workweek.” 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(D)(3)(b). Based on the record, Plaintiff lives at home with her mother, who transitioned to telework in order to be home to support Plaintiff throughout the day. (R. 1027-32.) Plaintiff’s mother reminds Plaintiff to shower and take her medication, and handles paying the bills. (R. 315.) Plaintiff’s mother also handles communication and scheduling with Plaintiff’s medical providers and attends all her appointments with her. (E.g., R. 1715, 1759, 1782, 1793, 1800, 1811, 1842, 1875.) Plaintiff does not leave the house without her mother. (E.g., R. 43-44, 1804.) Plaintiff receives support from ARMHS workers and case managers who come to her home and help her manage her appointments, benefits, and activities of daily living. (E.g., R. 1722, 1730, 1792.) In sum, based on the record as a whole, Plaintiff lives and functions in a routine and structured environment, where her mother, ARMHS workers, and case managers provide extensive support, and Plaintiff interacts with familiar people in her own home. Further, the record is replete with evidence that Plaintiff struggles to interact with others independently, appropriately, and effectively on a sustained basis. See Wagner v. Astrue, 499 F.3d 842, 848 (8th Cir. 2007) (holding a court “do[es] not merely examine the record for the existence of substantial evidence supporting the Commissioner’s decision but also consider evidence that detracts from that decision”). The record shows that Plaintiff was overwhelmed and exhausted by frequent medical appointments, to the extent that she needed to reduce the number of appointments she attended. (E.g., R. 570, 788, 1737, 1810, 1826.) Plaintiff attempted to engage in intensive outpatient group CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 65 of 83
66 therapy but found the duration and frequency of appointments to be too draining to continue. (R. 1744.) Plaintiff’s mother reported that when Plaintiff has an appointment with her psychiatrist, “that will be it for the day,” and Plaintiff will go back to sleep. (R. 570.) Plaintiff’s mental health issues caused attendance issues at school, even after she began attending school online, and she reported issues with talking to teachers. (R. 45, 338, 344, 355-56, 605, 623, 1220, 1230, 1257.) The Commissioner cites Plaintiff’s Function Reports to support its argument that “Plaintiff admitted that she socializes on the phone and in-person, chats with her family, can follow written and spoken instructions, had no problems getting along with others, and adapted to changes in routine.” (See Dkt. 14 at 7.) But the Commissioner ignores the fact that Plaintiff’s testimony and Function Reports also make clear that Plaintiff does not go to any place on a regular basis, reported going places “[n]ot very often maybe a few times a month I don’t take part of much,” and needed someone to accompany her due to her anxiety and inability to drive. (R. 285, 305.) As to her in-person and phone interactions, she engaged in those with her family every day, but with others “not often at all – it drains me.” (R. 285, 305.) Plaintiff also reported that she did not “socialize much at all” and used to be more social. (R. 285, 305.) The Commissioner cites no evidence calling into question these self-reports. Further, even as to those interactions with her family, Plaintiff reported that calling her sister and texting other family members made her nervous and that she had to “challeng[e]” herself to do so. (R. 364-65.) Plaintiff does not leave the house without her mother. (E.g., R. 43-44, 1804.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 66 of 83
67 Finally, the Court has also considered the opinions of state agency non-examining psychological consultants Dr. DeSantis and Dr. Mylan, both of whom opined that Plaintiff had moderate limitations with respect to interacting with others. (See R. 76-77, 88-89.) As an initial matter, the Eighth Circuit “do[es] not consider the opinions of non- examining, consulting physicians standing alone to be ‘substantial evidence.’” Harvey v. Barnhart, 368 F.3d 1013, 1016 (8th Cir. 2004). But those opinions are evidence the Court must and did consider when making its decision. Here, the Court notes that these consultants’ opinions are largely based on the evidence the Court has already discussed. Dr. DeSantis explained his reasoning at Step 3 by referring to certain provider notes observing that Plaintiff’s mood was improved, she did not endorse suicidal ideation,19 homicidal ideation, or self-injurious behavior, and her mental status examination was otherwise normal. (R. 76.) As discussed above, the Court does not find Plaintiff’s occasionally normal mental status examinations, which took place while she was accompanied by her mother, to be substantial evidence that Plaintiff has a fair ability to interact with others independently and on a sustained basis. Dr. DeSantis also referred to evidence from Plaintiff’s Function Reports. (R. 77.) Specifically, Dr. DeSantis noted that Plaintiff “indicated she tries to socialize to some degree and has in-person contact with others.” (R. 77.) As discussed above, the Court does not find Plaintiff’s self-reported limited interactions with her family members to constitute substantial evidence of her ability to interact with others independently and on 19 The Court notes, and the ALJ recognized, that Plaintiff has endorsed suicidal ideation at other times. (E.g., R. 20-21, 486, 1935.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 67 of 83
68 a sustained basis. Dr. DeSantis also suggested that Plaintiff’s Function Reports are contradictory because she checked boxes to indicate that she can go out alone but also checked boxes to indicate that she needs someone to go with her when she goes places. (R. 77 (“Inconsistent allegations regarding ability to venture into public independently.”).) The Court disagrees with Dr. DeSantis’ description of Plaintiff’s Function Reports as inconsistent. In addition to Plaintiff’s statements described above, Plaintiff reported going outside “maybe about once to twice week [sic] at most”; that “I can occasionally do stuff by myself, but I try not to do things by myself”; and that she shopped by phone but not “too much.” (R. 284; see also R. 304.) None of these statements suggest that Plaintiff has more than a very limited ability to venture into public on her own. Consistent with this assessment, at the December 11, 2023 hearing, Plaintiff was asked whether she ever leaves her house alone, and she responded: “Very occasionally. Not further than the mailbox.” (R. 56.) When asked whether she ever leaves the property, Plaintiff responded that she did not. (R. 56.) Plaintiff testified that she could not remember the last time she left the property alone, and that when she does leave, her mother is with her. (R. 57.) The Commissioner cites no evidence in the record contradicting these statements, and the medical provider notes support them. (See, e.g., R. 1804 (April 28, 2022 note stating: “Says she rarely leaves the house unless its [sic] with her mother.”); R. 1821 (October 17, 2022 note stating: “Reports she still does not get out of the house on her own. Only with her Mother and only when she has a scheduled medical appt of some kind. She recognizes the struggle she’s having with motivation and getting out of the house. She wants to go to college, work and have a CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 68 of 83
69 normal life with friends, but she feels stuck and isolated and is focusing on her recent autism spectrum diagnosis and thinking working with providers will let her know her limits of what she can and can’t do.”).) The Court is not persuaded that there is some contradiction in Plaintiff’s Function Reports that provides a basis to conclude that Plaintiff has a fair ability to interact with others independently and on a sustained basis. On reconsideration, Dr. Mylan explained her Step 3 reasoning by noting Plaintiff was “alleging worsening anxiety and mental health” and a new diagnosis of autism spectrum disorder, but noted that a mental status exam from a psychiatry appointment on November 15, 2022 was within normal limits. (R. 88-89.) Dr. Mylan further observed that the Function Reports filed by Plaintiff and her mother in Fall 2022 did not show a significant change in functioning compared to Plaintiff’s April 4, 2022 Function Report. (R. 88-89.) As to the November 15, 2022 visit, Plaintiff was seen by video “both alone and with mother,” and continued to report “trying to spend more time with family, but spends a lot of time isolated.” (R. 941-42.) The provider observed that Plaintiff’s reported symptoms were “consistent with autism spectrum disorder including difficulties with social interaction and restricted behavior.” (R. 943.) For the reasons discussed above, the Court is not persuaded that Plaintiff’s mental status exam and ability to interact with a medical provider by video, in part accompanied by her mother, constitutes substantial evidence that Plaintiff has a fair ability to interact with others independently and on a sustained basis. For all these reasons, the Court concludes that there is not substantial evidence in the record as a whole that Plaintiff had at least a fair ability to function “independently, CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 69 of 83
70 appropriately, effectively, and on a sustained basis” with respect to social interactions. See Blake R. v. Berryhill, No. 0:17-CV-4273-KMM, 2019 WL 1229828, at *6 n.1 (D. Minn. Mar. 15, 2019) (“The ALJ’s evaluation of [claimant’s] daily activities as only moderately impaired appears to have relied on isolated records that do not constitute substantial evidence of an ability to function independently in a work setting.”). b. Adapting or Managing Oneself The Court next considers Plaintiff’s limitation with respect to adapting or managing oneself. This area of function is defined as follows: This area of mental functioning refers to the abilities to regulate emotions, control behavior, and maintain well-being in a work setting. Examples include: Responding to demands; adapting to changes; managing your psychologically based symptoms; distinguishing between acceptable and unacceptable work performance; setting realistic goals; making plans for yourself independently of others; maintaining personal hygiene and attire appropriate to a work setting; and being aware of normal hazards and taking appropriate precautions. 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(E)(4). In concluding that Plaintiff had no more than a moderate limitation in this area, the ALJ reasoned that: The claimant reported needing reminders for personal care such as grooming. She also testified that she has received ARMHS services for selfcare tasks such as brushing her teeth, brushing her hair, and showering. However, mental status examinations regularly observed adequate grooming and hygiene. Although she reported subjective complaints of depressed mood, sadness, and worry, she also noted feeling fine 50% of the time. Accordingly, the undersigned finds the claimant has no more than a moderate limitation in adapting or managing oneself. (R. 18 (citations omitted).) While the ALJ is correct that Plaintiff’s medical providers observed on many occasions that Plaintiff’s grooming and hygiene was adequate, they also frequently CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 70 of 83
71 observed that Plaintiff had poor hygiene and appeared poorly groomed or disheveled. (E.g., R. 626 (July 19, 2017: “Appearance: disheveled, attire appropriate and poor hygiene”), R. 1100 (June 6, 2020: “General appearance: disheaveled [sic]”), R. 1113 (April 21, 2020: “General appearance: Well appearing, disheaveled [sic]”), R. 1130 (February 25, 2020: “General Appearance: casually dressed, poorly groomed, disheaveled [sic] hair”), R. 1134 (January 23, 2020: same), R. 1141 (October 24, 2019: same), R. 1144 (September 25, 2019: same), R. 1148 (August 22, 2019: same).) Further, the Court notes that Plaintiff began receiving support with activities of daily living, including her hygiene and managing appointments and benefits, from ARMHS workers and case workers/managers in 2020, with that support continuing for years. (E.g., R. 482, 487, 770, 1094, 1722, 1730, 1775, 1782, 1792.) Plaintiff also began seeing an occupational therapist for support with activities of daily living in 2023. (E.g., R. 2038, 2046.) As one example, an August 24, 2023 note stated Plaintiff “tries to brush hair once a week, bathing 1x a week” and that Plaintiff was given worksheets “for energy conservation for ADLs tasks including feeding, grooming dressing [sic], and bathing.” (R. 2038.) A few weeks earlier, Plaintiff had a goal of learning new skills “to participate in ADLs at home.” (R. 2046.) Plaintiff’s mother reported that she needed to remind Plaintiff to shower and take her medication, and handles paying the bills. (R. 315.) All of the records that the ALJ considered regarding Plaintiff’s adequate grooming appear to be from appointments well after Plaintiff began receiving support with her activities of daily living. The ALJ cited Exhibits 5F, 7F, 10F, 15F, 22F, 23F, 24F, and 25F to support his reliance on grooming. (R. 18, 21.) The earliest of those records are CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 71 of 83
72 Plaintiff’s case management records, which are contained in Exhibit 23F and begin in September 2020. (See Dkt. 7 at 4-5 (listing dates of medical records), 1701 (Plaintiff’s first contact with case management).) Based on the Court’s review of Exhibit 23F, the first record of Plaintiff appearing with adequate grooming or hygiene in that exhibit is from an appointment in April 2023. (R. 1901-04.) The remainder of the exhibits cited by the ALJ contain no records prior to November 2021, that is, after Plaintiff began receiving support with hygiene and other ADLs at home in Fall 2020. (See Dkt. 7 at 4-5 (listing dates of medical records).) In sum, while the record indicates that Plaintiff was observed to be kempt and well-groomed at certain medical appointments, it appears (and the ALJ cited no evidence to the contrary) that this resulted from the documented services provided by Plaintiff’s mother, ARMHS workers, case managers, and occupational therapists, rather than Plaintiff’s ability to independently adapt and manage herself on an independent, appropriate, effective, and sustained basis.20 See 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(F)(2). The Court notes that even after she began receiving these supportive services, Plaintiff still appeared poorly groomed or disheveled at times. (E.g., R. 1110, 1130, 1933.) The Court also considers the ALJ’s reliance on the fact that Plaintiff once stated that she felt fine “50% of the time” when discounting Plaintiff’s reports of depressed 20 There are a few early indications of adequate grooming prior to Plaintiff’s receipt of supportive services, but they are also prior to Plaintiff’s alleged onset of disability. (E.g., R. 1335 (record of November 28, 2014 appointment, when Plaintiff was 14 years old, included in Exhibit 17F which was not cited by the ALJ).) Based on the Court’s review of the record, almost all observations of adequate grooming and hygiene took place after Plaintiff began receiving support with her activities of daily living. CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 72 of 83
73 mood, sadness, and worry in the context of her ability to adapt and manage herself. (See R. 18.) The ALJ appears to be referring to a note that psychiatric nurse practitioner Jennifer Gay made documenting a follow-up visit with Plaintiff on March 7, 2023, where the chief complaint was “everything feels weird and bad.” (R. 1977.) The note states: [Plaintiff] was last seen on 1/6; at that time she was started on bupropion XL. She started taking bupropion, and has been taking it for the last 5-6 weeks. She has not been feeling well lately and does not know if this is due to her medication. She feels that things have been “measurably worse.” She has felt more fuzzy, “everything feels weird and bad.” It is not the same but also not dissimilar to when she took venlafaxine. Irritability is a little higher but not her “biggest concern.” Overstimulation has been worse. Her sleep schedule has worsened, but she notes that this happens organically sometimes. She fluctuates between not sleeping enough to then sleeping for 14 hours. Her overall mood is “50% of the time it’s fine.” Today she feels ok as nothing stressful has happened. Denies suicidal ideation. (R. 1977 (emphasis added).) When considering the entire record as a whole, the fact that Plaintiff once reported as to her overall mood that “50% of the time it’s fine” is not substantial evidence to support the ALJ’s finding that she had no more than a moderate limitation in adapting or managing herself. Finally, the Court also considers the opinions of state agency non-examining psychological consultants Dr. DeSantis and Dr. Mylan, both of whom opined that Plaintiff had moderate limitations with respect to adapting or managing oneself. (See R. 76-77, 88-89.) In addition to the evidence from Plaintiff’s mental status exams, as discussed above, Dr. DeSantis also noted that Plaintiff’s April 4, 2022 Function Report indicated that she could handle a savings account, prepare simple meals, and perform light household chores. (R. 77.) On reconsideration, Dr. Mylan did not note any CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 73 of 83
74 additional evidence related to Plaintiff’s ability to adapt or manage herself. (R. 88.) These opinions did not acknowledge the significant support that Plaintiff received in managing her activities of daily living, and do not provide a basis to conclude that Plaintiff has a fair ability to adapt or manage herself independently and on a sustained basis. For these reasons, the Court concludes that the ALJ’s determination that Plaintiff has only a moderate limitation with adapting and managing oneself is not supported by substantial evidence. * * * The Court concludes that the record does not contain substantial evidence upon which the ALJ could find that Plaintiff has no more than a moderate limitation in the areas of interacting with others and adapting and managing oneself. In other words, Plaintiff has at least a marked limitation in these two areas. Accordingly, the Court concludes that the paragraph B criteria are met. If the paragraph A criteria are also met with respect to listing 12.04 or 12.06, Plaintiff meets the Listing and is considered disabled. See 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(A)(2). While the ALJ did not address paragraph A, there is extensive evidence in the record that Plaintiff meets the paragraph A criteria for both a depressive disorder and an anxiety disorder. Under Listing 12.04, paragraph A is satisfied if the record includes medical documentation of five or more of the following symptoms of depressive disorder: depressed mood, diminished interest in almost all activities, appetite disturbance with change in weight, sleep disturbance, observable psychomotor agitation or CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 74 of 83
75 retardation, decreased energy, feelings of guilt and worthlessness, difficulty concentrating or thinking, and thoughts of suicide. 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.04(A)(1). Plaintiff has been diagnosed with a depressive disorder since as early as 2017. (R. 1231.) Plaintiff’s medical records since that time document a depressed mood (e.g., R. 356, 380), sleep disturbance (e.g., R. 384, 396), decreased energy (e.g., R. 405, 422), feelings of guilt (e.g., R. 467, 472), difficulty concentrating (e.g., R. 502, 396), and thoughts of suicide (e.g., R. 1935). Both state agency psychological experts concluded that based on Plaintiff’s medical records, she met the paragraph A criteria for Listing 12.04. (R. 76, 88.) No party disputes that Plaintiff meets the paragraph A criteria for a depressive disorder pursuant to Listing 12.04. Accordingly, the Court concludes that Plaintiff meets the paragraph A criteria for this Listing. See Downes v. Colvin, No. 4:15-CV-00048- NKL, 2015 WL 6742123, at *11 (W.D. Mo. Nov. 2, 2015) (determining that a claimant satisfied the paragraph A criteria even where the ALJ did not make a finding as to paragraph A). Likewise, the Court concludes that Plaintiff meets the paragraph A criteria for Listing 12.06, which relates to anxiety disorders. Under Listing 12.06, paragraph A is satisfied if the record includes medical documentation of three or more of the following symptoms of anxiety disorder: restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension or sleep disturbance. 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.06(A)(1). Plaintiff has been diagnosed with an anxiety disorder since as early as 2017. (R. 1231.) Plaintiff’s medical records since that time document that she is easily fatigued (e.g., R. 760, 1244, 1342, 1935), has difficulty concentrating (e.g., R. 502, 396), CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 75 of 83
76 and experiences sleep disturbance (e.g., R. 384, 396). Both state agency psychological experts concluded that based on Plaintiff’s medical records, she met the paragraph A criteria for Listing 12.06. (R. 76, 88.) No party disputes that Plaintiff meets the paragraph A criteria for anxiety disorder pursuant to Listing 12.06. Accordingly, the Court concludes that Plaintiff meets the paragraph A criteria for this Listing. The Court concludes that Plaintiff meets both the paragraph A and B listings for both 12.04 and 12.06. Accordingly, Plaintiff must be found disabled. 20 C.F.R. § 416.920(a)(4)(iii). No further consideration on remand is necessary to reach this conclusion based on Step 3. The Eighth Circuit has held that “[w]here the record overwhelmingly supports a disability finding and remand would merely delay the receipt of benefits to which plaintiff is entitled, reversal is appropriate.” Thompson v. Sullivan, 957 F.2d 611, 614 (8th Cir. 1992) (citing Fowler v. Bowen, 866 F.2d 249, 253 (8th Cir. 1989)); see also 42 U.S.C. § 405(g) (“The court shall have power to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing.”). Having carefully reviewed the entire record in this case, there is not substantial evidence to support a conclusion that Plaintiff does not meet a Listing at Step 3. The record overwhelmingly supports the conclusion that she does, and remand would merely delay Plaintiff’s receipt of benefits. Accordingly, the Court recommends that the decision of the ALJ be reversed and benefits be awarded. While the Court need not proceed to consider Plaintiff’s remaining challenge as to the Listings, the Court does so for the sake of completeness. CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 76 of 83
77 2. Paragraph C Plaintiff also argues that the ALJ’s conclusion that she did not meet the paragraph C criteria is not supported by substantial evidence. The paragraph C criteria are an alternative to the paragraph B criteria for certain Listings, including 12.04 (depressive, bipolar and related disorders) and 12.06 (anxiety and obsessive-compulsive disorders), and take into account mental health interventions that “may control the more obvious symptoms and signs” of a mental disorder. 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00(G)(1). Under the relevant listings, paragraph C criteria are met when: Your mental disorder in this listing category is “serious and persistent;” that is, you have a medically documented history of the existence of the disorder over a period of at least 2 years, and there is evidence of both: 1. Medical treatment, mental health therapy, psychosocial support(s), or a highly structured setting(s) that is ongoing and that diminishes the symptoms and signs of your mental disorder (see 12.00G2b); and 2. Marginal adjustment, that is, you have minimal capacity to adapt to changes in your environment or to demands that are not already part of your daily life (see 12.00G2c). 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.04(C), 12.06(C). Here, the ALJ did not provide any explanation for his conclusion that Plaintiff did not meet these criteria.21 (See R. 19.) In general, “an ALJ’s failure to adequately explain 21 The ALJ only stated: The evidence also fails to establish the presence of the “paragraph C” criteria because the claimant does not have a medically documented history of mental disorder over a period of at least 2 years, with evidence of both (i) medical treatment, mental health therapy, psychosocial support, or a highly structured setting that is ongoing and that diminishes the symptoms and signs CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 77 of 83
78 his factual findings is not a sufficient reason for setting aside an administrative finding where the record supports the overall determination.” Scott ex rel. Scott v. Astrue, 529 F.3d 818, 822 (8th Cir. 2008) (citation modified). However, “remand is appropriate where the ALJ’s factual findings, considered in light of the record as a whole, are insufficient to permit this Court to conclude that substantial evidence supports the Commissioner's decision.” Id. Plaintiff argues that she has been consistently treated by psychiatrists and therapists for years, and that she receives support from an ARMHS worker and case manager who come to her home weekly to help her manage appointments, benefits, and activities of daily living. (Dkt. 9 at 25-27.) Plaintiff argues that these facts establish a highly structured setting for the purpose of C(1) criteria. (Id. at 25-27.) The Commissioner did not address Plaintiff’s arguments regarding paragraph C in its opposition. The Court notes that the administrative record contains documentation of Plaintiff’s depressive and anxiety disorders since as early as 2017. (R. 601.) Plaintiff’s treatment and support systems are also extensively documented in the record. See supra Section IV.B.1.a. The Court concludes that the ALJ’s unexplained assertion that Plaintiff does not meet the paragraph C criteria is not supported by substantial evidence, and the of the mental disorder (See 12.00(G)(2)(b)); and (ii) marginal adjustment, defined as minimal capacity to adapt to changes in the environment or to demands that are not already part of daily life (See 12.00(G)(2)(c)). (R. 19.) CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 78 of 83
79 Commissioner has presented no argument to the contrary. The Court recommends an award of benefits based on paragraphs A and B, but if that recommendation is not adopted, the Court recommends remand for reconsideration of the Paragraph C criteria. C. Whether Substantial Evidence Supports the RFC Finally, Plaintiff argues that substantial evidence does not support the RFC assessed by the ALJ at Step 4. (Dkt. 9 at 27-29.) An RFC is “an assessment of an individual’s ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis,” meaning 8 hours a day for five days a week or an equivalent schedule. Social Security Ruling (“SSR”) SSR 96-8p, 1996 WL 374184, at *1 (July 2, 1996). It is intended to quantify the “most” a claimant “can still do despite [their] limitations.” Id. at *2, 4; see also 20 C.F.R. § 416.945; Martise v. Astrue, 641 F.3d 909, 923 (8th Cir. 2011) (“RFC is defined as the most a claimant can still do despite his or her physical or mental limitations.”) (quoting Leckenby v. Astrue, 487 F.3d 626, 631 n.5 (8th Cir. 2007)). Where the claimant proves he cannot perform his past relevant work “the Commissioner has the burden of producing evidence that he has the RFC to perform other jobs.” Hensley v. Colvin, 829 F.3d 926, 32 (8th Cir. 2016). However, “the burden of persuasion to prove disability and to demonstrate RFC remains on the claimant, even when the burden of production shifts to the Commissioner.” Id. The Eighth Circuit has held that “some medical evidence must support the determination of the claimant’s RFC.” Lauer v. Apfel, 245 F.3d 700, 704 (8th Cir. 2001) (citation modified). However, “there is no requirement that an RFC finding be supported by a specific medical opinion.” Hensley, 829 F.3d at 932 (citing Myers v. Colvin, 721 CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 79 of 83
80 F.3d 521, 526 (8th Cir. 2013); Perks, 687 F.3d at 1092-93). Rather, the RFC should be “based on all of the relevant evidence, including the medical records, observations of treating physicians and others, and an individual’s own description of his limitations.” Id. (quoting Myers, 721 F.3d at 527) (citation modified). Plaintiff argues that the ALJ’s RFC should have included a limitation related to absenteeism as a result of Plaintiff’s fatigue. (Dkt. 9 at 27-28.) While ALJs are not required to “list and reject every possible limitation,” courts review the record to “ensure that an ALJ does not disregard evidence or ignore potential limitations.” McCoy v. Astrue, 648 F.3d 605, 615 (8th Cir. 2011). In assessing Plaintiff’s RFC, the ALJ did not explicitly consider an absenteeism limitation. The Commissioner argues that the ALJ did consider Plaintiff’s fatigue at Step 2, when he noted that “the medical evidence of record references a history of chronic fatigue. However, aside from prolonged sleep, the medical evidence does not contain sufficient signs, laboratory findings, or mental limitations to establish chronic fatigue syndrome as a medically determinable impairment.” (Dkt. 14 at 10 (citing R. 17).) However, the absence of chronic fatigue syndrome as a medically determinable impairment does not mean that Plaintiff did not experience symptoms related to fatigue and sleep as a result of another impairment, such as major depressive disorder. See 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.04(A)(1)(d), (f) (listing sleep disturbance and decreased energy as symptoms of depression). The record contains extensive evidence of Plaintiff’s fatigue and excessive sleep. (E.g., R. 388, 616, 495, 497, 776, 942, 1853, 1977.) These symptoms led to excessive absences from school, at one point requiring Plaintiff to repeat a year. (R. 623.) The record also CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 80 of 83
81 contains evidence that Plaintiff found her schedule of medical appointments to be overwhelming and exhausting, to the extent that she was unable to participate in some forms of treatment. (E.g., R. 570, 1737, 1744, 1810.) Having reviewed the record as a whole, the Court cannot conclude that the ALJ’s omission of an absenteeism limitation in the RFC is supported by substantial evidence. The Eighth Circuit has held that when excessive absenteeism is caused by a claimant’s impairment, they are entitled to have the VE consider that absenteeism. Baker v. Apfel, 159 F.3d 1140, 1146 (8th Cir. 1998) (citing Douglas v. Bowen, 836 F.2d 392, 396 (8th Cir. 1987)). Here, the VE did testify about the impact of absenteeism on employability. (R. 62-64.) Specifically, the VE testified that it would preclude all work for an individual to absent two days or more per month for more than six months. (R. 62.) This included arriving late to the work shift or leaving the work shift early. (R. 62- 63.) The VE clarified that missing an entire work shift and part of a second shift in the same month would be work preclusive, and a person could miss only twelve days a year and still be considered employable. (R. 63-64.) However, the hypothetical posed to the VE did not include any limitation with respect to absenteeism. (R. 60-61.) Accordingly, the Court cannot conclude that the Commissioner has carried his burden of producing evidence that Plaintiff has the RFC to perform jobs that exist in significant number in the national economy. See Hensley v. Colvin, 829 F.3d 926, 32 (8th Cir. 2016). The failure to address absenteeism in the RFC is another independent reason to reverse the decision of the Commissioner and remand for further proceedings, namely, Plaintiff’s functional limitation with respect to absenteeism. CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 81 of 83
82 V. RECOMMENDATION Based on the above, and on the files, records, and proceedings herein, IT IS RECOMMENDED that: 1. Plaintiff Victoria H.’s request that the Court reverse the Commissioner’s decision to deny her Title II Disability Insurance Benefits (Dkt. 9) or remand for further administrative proceedings be GRANTED insofar as the Court recommends that the Commissioner’s decision be reversed and benefits be awarded; 2. In the alternative, Plaintiff Victoria H.’s request that the Court reverse the Commissioner’s decision to deny her Title II Disability Insurance Benefits (Dkt. 9) or remand for further administrative proceedings be GRANTED insofar as the Court recommends that the Commissioner’s decision be reversed and remanded for further proceedings as to: a. the severity of Plaintiff’s agoraphobia and whether any limitations due to her agoraphobia should be incorporated into the RFC; b. the paragraph B criteria; c. the paragraph C criteria; d. Plaintiff’s RFC; and 3. Defendant the Commissioner of Social Security’s request (Dkt. 11) that the Court affirm the Commissioner and dismiss the Complaint be DENIED. DATED: January 30, 2026 s/Elizabeth Cowan Wright ELIZABETH COWAN WRIGHT United States Magistrate Judge CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 82 of 83
83 NOTICE This Report and Recommendation is not an order or judgment of the District Court and is therefore not appealable directly to the Eighth Circuit Court of Appeals. Under District of Minnesota Local Rule 72.2(b)(1), “a party may file and serve specific written objections to a magistrate judge’s proposed finding and recommendations within 14 days after being served a copy” of the Report and Recommendation. A party may respond to those objections within 14 days after being served a copy of the objections. D. Minn. LR 72.2(b)(2). All objections and responses must comply with the word or line limits set for in D. Minn. LR 72.2(c). CASE 0:25-cv-00847-JMB-ECW Doc. 17 Filed 01/30/26 Page 83 of 83
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