Case Name in Social Security Case - Unavailable

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION
CARRIE R.W.,
Plaintiff,
v.
COMMISSIONER OF SOCIAL
SECURITY,
Defendant.
Civil Action 2:25-cv-159
Magistrate Judge Chelsey M. Vascura
OPINION AND ORDER
Plaintiff, Carrie R.W., brings this action under 42 U.S.C. § 405(g) for review of a final
decision of the Commissioner of Social Security (“Commissioner”) denying her application for
Supplemental Security Income (“SSI”). This matter is before the Court on Plaintiff’s Statement
of Errors (ECF No. 10), the Commissioner’s Memorandum in Opposition (ECF No. 15),
Plaintiff’s Reply (ECF No. 16), and the administrative record (ECF No. 9). For the reasons that
follow, the Commissioner’s non-disability determination is AFFIRMED.
I. 	BACKGROUND
Plaintiff protectively filed her application in January 2022, alleging that she became
disabled beginning January 1, 2019. After Plaintiff’s application was denied initially and upon
reconsideration, an Administrative Law Judge (“ALJ”) held a telephonic hearing on October 19,
2023, at which Plaintiff, represented by counsel, appeared and testified. A vocational expert
(“VE”) also appeared and testified. On January 23, 2024, the ALJ issued an unfavorable
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determination, which became final on December 19, 2024, when the Appeals Council declined
review. (R. at 17–25, 1–6.)
Plaintiff seeks judicial review of that unfavorable determination. She contends that the
ALJ erred when determining that none of her medically determinable impairments (“MDIs”)
were severe. (Pl.’s Statement of Errors 9–12, 16–18, ECF No. 10.) She also relatedly contends
that the ALJ erred when evaluating medical opinions and prior administrative findings. (Id. at 9,
12–16, 19.) 1 Defendant contends that Plaintiff’s contentions of error lack merit. (Def.’s Mem. in
Opp’n 3–9, ECF No. 16.)
1 Plaintiff also states that the ALJ erred when performing a subjective symptom assessment
(f.k.a., a “credibility determination”). (Pl.’s Statement of Errors 9, ECF No. 10.) But she fails to
develop this argument and has thus forfeited it. See McPherson v. Kelsey, 125 F.3d 989, 996–96
(6th Cir. 1997) (“[I]ssues adverted to in a perfunctory manner, unaccompanied by some effort at
developed argumentation, are deemed waived. It is not sufficient for a party to mention a
possible argument in the most skeletal way, leaving the court to . . . put flesh on its bones.”
(internal quotation marks and citations omitted) ); Hollon v. Comm’r of Soc. Sec., 447 F.3d 477,
490–91 (6th Cir. 2006) (“This challenge warrants little discussion, as Hollon has made little
effort to develop this argument in her brief on appeal, or to identify any specific aspects of the
Commissioner’s determination that lack support in the record.”).
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II. 	THE ALJ’s DECISION
The ALJ issued the unfavorable determination on January 23, 2024. (R. at 17–25.) At
step one of the sequential evaluation process,2 the ALJ found that Plaintiff had not engaged in
substantial gainful activity since her January 25, 2022 application date. (Id. at 19.) At step two,
the ALJ found that Plaintiff had the following MDIs: borderline obesity; urinary tract infection;
viral syndrome; sinusitis; covid; constipation; two small lesions on arm; sunburns; hemorrhoids;
ear infection; vision impairment; gastroesophageal reflux disease (“GERD”); hyperlipidemia;
diverticulitis; thyroid nodule; bruxism; heel spur; osteoarthritis, right knee; anxiety; and
depression. (Id.) The ALJ also found that none of these MDIs were severe, either on their own or
combined. (Id. at 20.) Finally, the ALJ determined that Plaintiff’s irritable bowel syndrome and
constipation, asthma, and disorders of the spine were not MDIs. (Id. at 21–22.)
2 Social Security Regulations require ALJs to resolve a disability claim through a five-step
sequential evaluation of the evidence. See 20 C.F.R. §§ 404.1520(a)(4). Although a dispositive
finding at any step terminates the ALJ’s review, see Colvin v. Barnhart, 475 F.3d 727, 730 (6th
Cir. 2007), if fully considered, the sequential review considers and answers five questions:
1. Is the claimant engaged in substantial gainful activity?
2. Does the claimant suffer from one or more severe impairments?
3. Do the claimant’s severe impairments, alone or in combination, meet or equal the
criteria of an impairment set forth in the Commissioner’s Listing of Impairments, 20
C.F.R. Subpart P, Appendix 1?
4. Considering the claimant’s residual functional capacity, can the claimant perform his
or her past relevant work?
5. Considering the claimant’s age, education, past work experience, and residual
functional capacity, can the claimant perform other work available in the national
economy?
See 20 C.F.R. §§ 404.1520(a)(4); see also Henley v. Astrue, 573 F.3d 263, 264 (6th Cir.
2009); Foster v. Halter, 279 F.3d 348, 354 (6th Cir. 2001).
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Because the ALJ found that Plaintiff had no severe MDIs, she determined that Plaintiff
was not disabled during the relevant time frame without proceeding to consider the remaining
steps in the sequential evaluation process. (Id. at 25.)
III. 	STANDARD OF REVIEW
When reviewing a case under the Social Security Act, the Court “must affirm a decision
by the Commissioner as long as it is supported by substantial evidence and was made pursuant to
proper legal standards.” DeLong v. Comm’r of Soc. Sec., 748 F.3d 723, 726 (6th Cir. 2014)
(cleaned up); see also 42 U.S.C. § 405(g) (“The findings of the Commissioner of Social Security
as to any fact, if supported by substantial evidence, shall be conclusive . . . .”). While this
standard “requires more than a mere scintilla of evidence, substantial evidence means only such
relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Moats
v. Comm’r of Soc. Sec., 42 F.4th 558, 561 (6th Cir. 2022) (cleaned up) (quoting Biestek v.
Berryhill, 139 S. Ct. 1148, 1154 (2019)).
Although the substantial evidence standard is deferential, it is not trivial. The Court must
“examine[ ] the record as a whole and take[ ] into account whatever in the record fairly detracts
from the weight” of the Commissioner’s decision. Golden Living Ctr.-Frankfort v. Sec’y Of
Health And Hum. Servs., 656 F.3d 421, 425 (6th Cir. 2011) (citing Universal Camera Corp. v.
NLRB, 340 U.S. 474, 487 (1951)).
Nevertheless, where “substantial evidence supports the Secretary’s determination, it is
conclusive, even if substantial evidence also supports the opposite conclusion.” Emard v.
Comm’r of Soc. Sec., 953 F.3d 844, 849 (6th Cir. 2020) (quoting Crum v. Sullivan, 921 F.2d 642,
644 (6th Cir. 1990)). Finally, even if the ALJ’s decision meets the substantial evidence standard,
“a decision of the Commissioner will not be upheld where the SSA fails to follow its own
regulations and where that error prejudices a claimant on the merits or deprives the claimant of a
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substantial right.” Rabbers v. Comm’r Soc. Sec., 582 F.3d 647, 651 (6th Cir. 2009) (quoting
Bowen v. Comm’r of Soc. Sec., 478 F.3d 742, 746 (6th Cir. 2007)).
IV. 	ANALYSIS
As explained above, Plaintiff contends that the ALJ erred by finding that none of her
MDIs were severe and by improperly evaluating medical opinions and prior administrative
findings. The Court addresses each contention in turn and concludes that neither has merit.
A. 	The ALJ’s Step-Two Determinations
As a preliminary matter, Plaintiff appears at times to conflate impairments the ALJ
determined were not MDIs with impairments the ALJ found were MDIs but not severe. The
Court therefore addresses both the ALJ’s step-two MDI findings and her step-two severity
determinations.
1. 	Step-Two Standards
At step two, an ALJ must determine if a claimant has an impairment that is medically
determinable—i.e., one resulting from anatomical, physiological or psychological abnormalities
that can be shown by medically acceptable clinical and laboratory diagnostic techniques. 20
C.F.R. §§ 416.920; 416.921. Such “impairment[s] must be established by objective medical
evidence from an acceptable medical source.” 20 C.F.R. § 416.921. They must also meet the
durational requirement in 20 C.F.R. § 416.909, which provides that “[u]nless your impairment is
expected to result in death, it must have lasted or be expected to last for a continuous period of at
least 12 months.” A plaintiff bears the burden of establishing that an impairment meets the
duration requirement at step two. Harley v. Comm’r of Soc. Sec., 485 F. App’x 802, 803 (6th Cir.
2012).
If an impairment is medically determinable, an ALJ must then determine whether it is
severe. 20 C.F.R. § 416.920(a)(4)(ii). A “severe impairment” is defined as “any impairment or
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combination of impairments which significantly limits [a claimant’s] physical or mental ability
to do basic work activities.” 20 C.F.R. § 416.920(c). If a claimant has at least one severe MDI,
an ALJ must consider the limiting effects of all a claimant’s MDIs, severe and not, when
formulating a claimant’s RFC. 20 C.F.R. § 416.923.
Although a claimant bears the burden of proving that an impairment is medically
determinable at step two, the United States Court of Appeals for the Sixth Circuit has explained
that the step two inquiry is “employed as an administrative convenience to screen out claims that
are ‘totally groundless’ solely from a medical standpoint.” Higgs v. Bowen, 880 F.2d 860, 863
(6th Cir. 1988) (quoting Farris v. Sec’y of Health & Hum. Servs., 773 F.2d 85, 90 n.1 (6th Cir.
1985)). Accordingly, a claimant’s burden at step two is “a de minimis hurdle in the disability
determination process” requiring a claimant to show only that an impairment has more than a
minimal impact on his ability to perform work-related functions. Id. at 862. Still, an impairment
must be medically determinable, severe, and of sufficient duration or there will be a finding of
non-disability. 20 C.F.R. § 416.920(a)(4)(ii).
2. 	The ALJ’s MDI Determinations
a. 	IBS with Chronic Constipation
Plaintiff challenges the ALJ’s determination that her IBS with chronic constipation was
not an MDI. (Pl.’s Statement of Errors 17–18, ECF No. 10.) She specifically contends that the
ALJ improperly concluded that her condition failed to satisfy the 12–month durational
requirement. (Id.) That contention mischaracterizes the ALJ’s reasoning.
The ALJ discussed Plaintiff’s IBS with chronic constipation as follows:
The record also shows non-medically determinable impairments. The claimant
reported having irritable bowel syndrome (IBS) (Ex. 3F-2), but she was not
diagnosed with this condition based on objective signs and findings. This was noted
as a diagnosis at Exhibit 12F-7 but there are no objective signs or findings (e.g. CT
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or x-ray of her abdomen). She was seen for constipation and noncompliant with
prescribed regimen of laxatives. (Ex. 16F-4, 64). Regardless, even if her complaints
of constipation amount to IBS, the record does not support any functional
limitations from her constipation. Physical exams are also within normal limits, as
she was in no distress with normal bowel sounds and no guarding. She also had a
diagnosis from a chiropractor who is not an acceptable medical source. (Exs. 4F,
13F).
As this discussion demonstrates, the ALJ did not determine that Plaintiff’s IBS with chronic
constipation did not constitute a MDI because it failed to meet the 12–month duration
requirement. Rather, the ALJ determined it was not an MDI because it was not diagnosed by an
acceptable medical source who used objective signs and findings.
Substantial evidence supports that determination. The record reflects that Plaintiff
regularly told providers that she had IBS or that her IBS was included in descriptions of her past
medical history. (See e.g., R. at 374, 549.) But Plaintiff does not point to any medical record
demonstrating that an acceptable medical source diagnosed her with IBS based on objective
evidence. As the ALJ noted, the record contains one treatment note in which Plaintiff was
assessed by a doctor as having IBS, but that assessment was not based on any objective signs or
findings such as a CT scan or an X-Ray. (Id. at 485–86.) Indeed, that note does not indicate that
Plaintiff’s abdomen was physically examined that day.
More importantly, the ALJ further determined that even if Plaintiff’s chronic constipation
constituted IBS, the record did not demonstrate any resulting functional limits (i.e., the record
did not demonstrate that her IBS was severe). Substantial evidence supports that determination as
well. In March 2021, Plaintiff denied abdominal pain or a change in her bowel habits; an
examination that day found that her abdomen was normal, soft, nontender, and nondistended and
that she had no guarding or rigidity, palpable masses, or rebound tenderness. (Id. at 314, 316.)
Later that month, Plaintiff’s abdomen was soft, nontender, nondistended, and had no palpable
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masses. (Id. at 627.) In February 2022, Plaintiff’s abdominal examination was benign. (Id. at
374.) In April 2022, Plaintiff’s abdomen was soft, nontender, nondistended, with no masses
palpable, her bowel sounds were normal, and she had no guarding or rigidity. (Id. at 454.) In
May 2022, Plaintiff reported that “her bowel movement sometimes occasionally good and other
times [. . . ] constipated.” (Id. at 444.) Plaintiff had surgery in July 2022 to remove hemorrhoids,
but abdominal examinations during that time were also routinely normal. (Id. at 695, 715, 732,
680, 738.) In August 2022, Plaintiff reported constipation but that she did well on MiraLAX.
(Id. at 486.) In October 2022, Plaintiff denied abdominal pain and a change in bowel habits, and
an examination again found that her abdomen was normal, soft, nontender, and nondistended
with no guarding or rigidity, palpable masses, or rebound tenderness. (Id. at 549, 551.) In
November 2022, a gastroenterologist wrote: “There are no alarm findings at this time.” (Id. at
572–73.) At a follow up visit in February 2023, the same gastroenterologist found that Plaintiff’s
abdomen was nondistended and that she had normal bowel sounds. (Id. at 849.)
Moreover, the ALJ reasonably relied on evidence that Plaintiff was non-compliant with
prescribed treatment for her constipation. In May 2022, Plaintiff complained of slow transit
constipation but admitted that she had not followed a prescribed regimen. (Id. at 444 (noting that
Plaintiff “failed use of order regimen”).) In November 2022, Plaintiff’s gastroenterologist wrote
that Plaintiff symptoms reportedly improved when she took MiraLAX and Metamucil as
directed, but that she had been “slacking off of the meds” more recently. (Id. at 570) Although
she was instructed to increase her MiraLAX dosage at that time, she later reported taking less
than directed. (Id. at 573, 847–48.) Even so, she reported improvements in bowel function. (Id. at
848.)
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Accordingly, substantial evidence supports the ALJ’s determination that Plaintiff’s IBS
with chronic constipation was not an MDI and, even if it was, it was not severe. Plaintiff’s
contention of error lacks merit.
b. 	“Disorders of the Spine”
Plaintiff also contends that the ALJ erred when finding that her alleged spinal disorder
was not an MDI at step two. (Pl.’s Statement of Errors 18–19, ECF No. 10.) Plaintiff specifically
contends that the ALJ erred because she rejected this condition as a MDI because the record did
not contain an X-Ray. (Id. at 18.) This contention also mischaracterizes the ALJ’s reasoning.
The ALJ discussed Plaintiff’s spinal issues as follows:
The state agency Disability Determination Services (“DDS”) consultants found a
severe impairment of “disorders of the spine,” but, as noted by the representative
brief, which cites to all of the medical evidence in the file, she has no diagnosis of
any spine related condition in this record from an acceptable medical source. She
sees a chiropractor, but they cannot diagnose for purposes of our program. The
consultative examiner likewise does not diagnose any condition, and simply notes
back and neck pain as part of the history. I note that at Exhibit 2A, they reference
x-rays from a consultative examiner from a 2020 prior claim. However, even
assuming that these x-rays showed a condition to support a medically determinable
impairment, it would nevertheless be non-severe considering the lack of any
treatment other than chiropractic care, as well as her overwhelmingly normal
physical exam findings throughout this record.
(R. at 21–22.) As this discussion demonstrates, the ALJ did not determine that Plaintiff’s spinal
complaints were not an MDI because the record lacked an X-Ray. Rather, the ALJ determined
that Plaintiff’s spinal disorder was not an MDI because she was not diagnosed with any spinal
condition by an acceptable medical source.
Substantial evidence supports that determination. Plaintiff does not point to evidence that
an acceptable medical source diagnosed her with a spinal condition based on objective evidence.
As the ALJ noted, the record contains notes from Plaintiff’s chiropractor, but a chiropractor is
not an acceptable medical source. See 20 C.F.R. § 416.902(a) (excluding chiropractors from the
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list of acceptable medical sources). And a claimant must point to “objective medical evidence
from an acceptable medical source to establish the existence of a [MDI] that could reasonably be
expected to produce [her] alleged symptoms.” SSR 16-3p, 2017 WL 5180304, at *3.
The ALJ also correctly noted that the consultative examiner did not diagnose Plaintiff
with any spinal issue. (R. at 466–78.) Moreover, the ALJ explained that the state agency
reviewers referenced an X-Ray from a prior claim. (Id. at 21–22.) But even if that X-Ray could
have supported a MDI finding during the relevant period, the ALJ determined that Plaintiff’s
MDI would not have been severe given that Plaintiff only sought chiropractic treatment. (Id.)
Substantial evidence also supports this explanation. Plaintiff does not point to any evidence that
she sought treatment for her spine from any healthcare professional other than her chiropractor.
The ALJ also based her severity determination on Plaintiff’s routinely normal
examination findings. Substantial evidence supports this explanation too because Plaintiff’s
musculoskeletal examinations were often benign. For instance, at an exam in March 2021,
Plaintiff denied muscle weakness. (Id. at 315.) In July 2022, Plaintiff’s back examination was
normal, and she had no tenderness. (Id. at 696.) At that time, she also denied an abnormal gait,
back pain, joint swelling, limited range of motion, or muscle weakness. (Id. at 713.) At her
consultative examination in August 2022, Plaintiff had only mild lumbar spinal tenderness and
no evidence of muscular asymmetry, atrophy, or acute joint findings. (Id. at 470.) She also had
normal strength and range of motion bilaterally and was able to sit, stand, walk, and rise from an
exam table multiple times without problems or assistance. (Id.) Plaintiff denied muscle weakness
and gait abnormalities in October 2022, and her spine examination was normal with no
costovertebral angle tenderness. (Id. at 549, 551.) In November 2022, and February 2023, she
denied weakness or falls. (Id. at 572, 849.)
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Plaintiff points to chiropractic findings of pain and restricted motion in her cervical,
thoracic, and lumbar spine. (Pl.’s Statement of Errors 19, ECF No. 10.) But where substantial
evidence supports an ALJ’s determination it will be upheld, even if substantial evidence could
support a different conclusion. See Emard, 953 F.3d at 849. In any event, those same chiropractic
notes appear to show that Plaintiff’s spine-related complaints did not meet the 12-consecutive
month durational requirement. Plaintiff sought chiropractic treatment for back pain for ten
months–from December 13, 2021, until October 11, 2022. (R. at 391, 389, 387, 385, 383, 514,
516, 518, 520, 522, 524, 526, 528, 530, 532, 534.) She did not return for treatment again until a
year later, on October 13, 2022. (Id. at 536.) Plaintiff has not pointed to, and the Court has not
found, evidence that Plaintiff complained about back pain to any healthcare professional outside
of these two discrete periods, neither of which lasted for twelve consecutive months. Thus, she
has failed to show that her condition met the durational requirement.
In short, substantial evidence supports the ALJ’s determination that Plaintiff’s spinal
disorder was not an MDI and, even if it was, it was not severe. Plaintiff’s contention to the
contrary lacks merit.
3. 	The ALJ’s Severity Determinations
a. 	Osteoarthritis in the Right Knee
Plaintiff further contends that the ALJ reversibly erred when assessing osteoarthritis in
her right knee at step two. (Pl.’s Statement of Errors 16–17, ECF No. 10.) The Court agrees that
the ALJ erred when discussing this impairment, but concludes that the error was harmless.
The ALJ initially determined that Plaintiff’s osteoarthritis in her right knee was a MDI.
(R. at 19.) But the ALJ further determined that it was not severe because it was one of several
“chronic conditions that [did] not limit [Plaintiff’s] functioning.” (Id. at 21.) The ALJ explained
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that it, and the several other chronic conditions, caused only transient and mild symptoms, were
well controlled with treatment, did not met the 12-month durational requirement, or were
otherwise not adequately supported by the medical evidence of record. (Id.) As part of this
discussion, the ALJ expressly noted that Plaintiff had “osteoarthritis in the right knee . . . , which
was seen for treatment only after she bruised it.” (Id.)
Plaintiff correctly contends that the ALJ erred, at least in part, on this point. Imaging in
April 2022 revealed that Plaintiff had mild osteoarthritis in her right knee. (Id. at 415.) Plaintiff
also reported right knee pain during her August 2022 consultative examination. (Id. at 466.) But,
contrary to what the ALJ wrote, Plaintiff did not seek treatment for her right knee after injuring
it.3 Indeed, it appears that Plaintiff never sought treatment for her right knee. Accordingly, the
ALJ’s error was harmless.
Moreover, the ALJ’s determination that this condition was not severe was supported by
substantial evidence. As the ALJ explained, the record showed that it caused only transient
symptoms and was not otherwise adequately supported by the record. For example, during her
August 2022 consultative examination, Plaintiff’s strength and ranges of motion were normal in
both of her knees. (Id. at 470, 472, 475.) Likewise, an examination in March 2023 found that had
normal range of motion in her right knee and normal strength bilaterally. (Id. at 801.)
Medical records also noted that Plaintiff had no problems walking. On several occasions,
Plaintiff reported that she was ambulatory without assistance and that she had “[n]ormal
walking/striding without hesitation.” (Id. at 346, 456, 583.) In July 2022, she had no abnormal
gait. (Id. at 713.) Plaintiff also had a normal, reciprocal gait pattern without an assistive device
3 Plaintiff sought treatment for her left knee after she injured it. The records indicate that she may
sustained that injury while cleaning out a burn barrel or throwing a tool into her shed. (R. at 800,
875.)
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during her August 2022 consultative examination. (Id. at 469.) And even though Plaintiff had an
abnormal gait in February 2023, it was attributed to her left leg, which she had recently bruised,
and not her right knee. (Id. at 875, 800.)
For these reasons, the Court concludes that the ALJ did not reversibly err when
determining that Plaintiff’s osteoarthritis in her right knee was not severe. Plaintiff’s contention
of error, therefore, lacks merit.
b. 	Anxiety and Depression
Finally, Plaintiff contends that the ALJ erred when determining that her anxiety and
depression were not severe. (Pl.’s Statement of Errors 11–16, ECF No. 10.) This contention of
error also lacks merit.
The ALJ discussed Plaintiff’s depression and anxiety as follows:
Concerning the claimant’s mental health, DDS found “severe” impairments, but
there is little to no evidence outside of the consultative exam at 7F. For example,
before the protective filing date she reported some anxiety “due to stresses at home”
but wanted to “hold off” on any treatment (Ex. 2F-1-2). Her objective examination
at this time was normal as she was in no apparent distress, “sound][ed] well” and
was alert and oriented with normal speech (id). She sought no mental health
treatment on/after the protective filing date. When seen for her physical complaints
her mental status was consistently normal (Exs. 8F-1, 5; 10F-5, 9, 14, 17; 12F-5, 8;
15F-6-8, 16-27, 31, 84; 17F).
(R. at 22.)
As this discussion shows, the ALJ determined that Plaintiff’s depression and anxiety
were not severe for at least two reasons. First, the ALJ explained that although the state agency
reviewers found that Plaintiff’s mental health impairments were severe, they had little evidence
to support that conclusion aside from the consultative examiner’s report. Substantial evidence
supports that explanation. As the ALJ noted, Plaintiff declined to pursue mental health treatment
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before or after filing her applications. (Id.) Accordingly, the record lacks a longitudinal treatment
history.
Second, the ALJ explained that Plaintiff’s mental status was consistently normal during
examinations for her physical health. (Id.) Substantial evidence supports that explanation.
Examiners often found that Plaintiff had normal or appropriate mood and/or affect (Id. at 642,
621, 583, 696, 720, 687, 469, 840.) She was also found to have good eye contact, insight, and
judgment. (Id. at 454, 552.) She was described as pleasant (id. at 316, 427, 590, 470) or
cooperative (id. at 427, 597, 454, 590, 424, 469, 486, 552, 572, 849, 801). Her appearance was
noted to be normal (id. at 316, 840, 823) or that she did not appear ill (id. at 823). Her speech
was clear (id. at 454) or normal (id. at 469) or spontaneous with normal articulation or no
appreciable deficits (id. at 348, 344, 336, 334, 328, 457, 441, 668, 657, 483). She was also
routinely described as being in no acute or apparent distress. (Id. at 347, 641, 316, 344, 627, 427,
620, 336, 334, 328, 374, 457, 597, 454, 590, 449, 424, 445, 581, 441, 667, 486, 657, 483, 650,
572, 849, 792.)
Consequently, substantial evidence supports the ALJ’s determination that Plaintiff’s
anxiety and depression were not severe. Thus, this contention of error also lacks merit.
B. 	The ALJ’s Evaluation of Medical Opinions4 and Prior Administrative Findings
Plaintiff relatedly challenges the ALJ’s evaluation of opinion evidence and prior
administrative findings. (Pl.’s Statement of Errors 9, 12–15, 19, ECF No. 10.) She contends that
4 Plaintiff does not challenge the ALJ’s evaluation of medical opinions from consultative
physical examiner Dr. Kahn but instead cites Dr. Kahn’s report in support of other contentions of
error. (Pl.’s Statement of Errors 17, 19, ECF No. 10.) To the extent she intended to challenge the
ALJ’s assessment of Dr. Kahn’s opinion, her arguments are forfeited because they were not
sufficiently developed. See McPherson, 125 F.3d at 996–96; Hollon, 447 F.3d at 490–91.
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the ALJ improperly discounted opinions and findings that showed that her MDIs were severe.
This contention of error lacks merit.
1. 	The Evaluation of Medical Opinions and Prior Administrative Findings
An ALJ’s RFC determination must be “based on all the relevant evidence” in a
claimant’s case record. §§ 404.1545(a)(1); 416.945(a)(1). The governing regulations5 describe
five categories of evidence: (1) objective medical evidence, (2) medical opinions, (3) other
medical evidence, (4) evidence from nonmedical sources, and (5) prior administrative medical
findings. 20 C.F.R. §§ 404.1513(a)(1)–(5); 416.913(a)(1)–(5). An ALJ need not “defer or give
any specific evidentiary weight, including controlling weight, to any medical opinion(s) or prior
administrative finding(s) including those from [the claimant’s] medical sources.” 20 C.F.R.
§ 404.1520c(a); 416.920c(a). Instead, an ALJ must use the following factors when considering
those categories of evidence: (1) “[s]upportability”; (2) “[c]onsistency”; (3) “[r]elationship with
the claimant”; (4) “[s]pecialization”; and (5) other factors, such as “evidence showing a medical
source has familiarity with the other evidence in the claim or an understanding of [the SSA’s]
disability program s policies and evidentiary requirements.” §§ 404.1520c(c)(1)–(5);
416.920c(c)(1)–(5). Although there are five factors, supportability and consistency are the most
important, and the ALJ must explain how they were considered. Id. And even though an ALJ
may discuss how he or she evaluated the other factors, he or she is not generally required to do
so. Id.
2. 	State Agency Physical Reviewers—Drs. McKee and Siddiqui
5 Because Plaintiff’s application was filed in 2022, it is subject to regulations governing
applications filed after March 27, 2017.
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Plaintiff challenges the ALJ’s evaluation of prior administrative findings from Drs.
McKee and Siddiqui, who reviewed Plaintiff’s file at the initial and reconsideration stages
respectively. (R. at 50–58, 60–68.) Both reviewers found that Plaintiff had severe physical
impairments and that she was limited to a range of light work that included some postural limits.
(Id. at 54–55, 64–65.)
The ALJ discussed those prior administrative findings as follows:
The DDS physical findings limiting the claimant to a range of light work are not
persuasive. First, the only impairments they note are “disorders of the spine”
(which, as noted, is not a medically determinable impairment in the current period,
as we only have chiropractic records and nothing from an acceptable medical
source, with no significant treatment or physical exam findings since the protective
filing date), disorders of the urinary tract (here, as noted, she has had some urinary
tract infections, but nothing chronic lasting 12 months or longer) and “other and
unspecified arthropathies” (which typically means some form of degenerative joint
disease, though the DDS fails to identify where). However, on this record, we see
only mild/tiny abnormalities in the left knee and some limited range of motion
without any related diagnosis in the shoulders at the consultative exam. Therefore,
barring evidence of a severe and medically determinable impairment in these areas,
it was inappropriate for the DDS to find limits, and these limits are not well
supported. The DDS findings of fact and analysis of evidence does not support
finding severe physical impairments (see Ex. 4A-3 all noted exams are normal).
DDS also inappropriately relied on a consultative examination from 2020 (Ex. 2A-
3), which included some x-rays. While those x-rays reportedly showed some
abnormalities, finding these conditions to be severe on and after 1/25/22 is still
inappropriate, as it is inconsistent with the collateral record showing no recent
imaging and only minimal treatment in the form of chiropractic care, as well as no
current diagnosis in the period under review. For these reasons, and the reasons
explained as to why her impairments are non-severe, the DDS findings are
unpersuasive, as they are not supported by the overall evidence of record.
(Id. at 24–25.) As this discussion demonstrates the ALJ considered the supportability and
consistency factors and found them lacking.
When considering supportability, the ALJ determined that the reviewers’ “findings of
fact and analysis of evidence [did] not support finding severe physical impairments.” (Id. at 24.)
When making that determination, the ALJ cited Dr. Siddiqui’s “Physical Summary,” and
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explained that “all noted exams are normal.” (Id. (citing R. at 62).) Substantial evidence supports
that explanation. That “Physical Summary” discussed information from eight medical records,
including the results of three physical examinations. (Id. at 62.) The summary discussion
indicated that Plaintiff’s physical examinations were normal during her November 17, 2022
office visit with a gastroenterologist and at an October 26, 2022 treatment after her hemorrhoid
surgery. (Id.) The summary discussions also indicated that a September 13, 2022 examination
found that Plaintiff had “no appreciable motor deficits.” (Id.) The ALJ reasoned that these
normal examination results did not substantiate Dr. Siddiqui’s finding of severe impairments,
and thus, that severity finding lacked support.
Plaintiff nevertheless urges that the ALJ erred when she wrote that “all noted
examinations are normal,” presumably because other examinations in the record were not.
(Pl.’s Reply 2, ECF No. 16.) But the ALJ wrote that “all noted exams are normal,” and she
cited Dr. Siddiqui’s summaries. (R. at 24 (emphasis added).) She did not write “all exams are
normal” and cite to the record. Notably, supportability refers to the degree to which a medical
source presents relevant, objective medical evidence and supporting explanations to support his
or her opinion. See 20 C.F.R. § 1520c(c)(1). Thus, when considering supportability, the ALJ
did not err by observing that that the noted exams—the ones that were summarized in the
“Physical Summary”—were normal.
When considering consistency, the ALJ also explained that Dr. McKee relied on a
consultative examination from 2020 that included cervical and lumbar X-Rays that may have
shown some abnormalities. (R. at 24–25 (citing id. at 52).) The ALJ determined that even if
those images from a prior period showed some abnormalities, the reviewers’ finding that they
showed severe impairments in the relevant period was “inconsistent with the collateral record
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showing no recent imaging and only minimal chiropractic care.” (Id.) Substantial evidence
supports that consistency determination. The record does not contain any imaging of Plaintiff’s
spine during the relevant period or any record of treatment for her back issues aside from
chiropractic care, which she pursued for ten months before taking a year-long break.
More globally, the ALJ determined that reviewers’ finding were unpersuasive because
the only physical impairments that they identified were disorders of the spine, urinary tract
disorders, and other unspecified arthropathies that were apparently related to Plaintiff’s
osteoarthritis in her right knee. (Id. at 24–25, 52, 63.) The ALJ explained that because none of
these impairments constituted severe MDIs, it was inappropriate for the reviewers to find that
they caused any functional limits. Substantial evidence supports that explanation. As discussed
above, the ALJ did not err by finding that Plaintiff’s disorders of the spine did not constitute a
MDI and that her osteoarthritis in her right knee was not severe. And Plaintiff does not
challenge the ALJ’s assessment of her urinary tract infections.
Because the ALJ’s supportability and consistency determinations were supported by
substantial evidence, the ALJ did not err when evaluating prior administrative findings from
Drs. McKee and Siddiqui. Plaintiff’s contention of error lacks merit.
3. 	Consultative Psychological Examiner—Dr. Arnold
Plaintiff also challenges the ALJ’s evaluation of medical opinions from Dr. Arnold, who
consultatively examined Plaintiff on April 18, 2022. (Id. at 417–22.) The ALJ summarized and
discussed Dr. Arnold’s examination report as follows:
At the consultative examination, she reported a variety of symptoms. Her mental
status exam was normal, except that she reported that her mood was down, irritable
and overwhelmed, and the consultative examiner found her affect was congruent.
Her speech and orientation were normal. She recalled 2/3 words after a delay and
performed better on digit span forward than backward. Her fund of knowledge was
limited. She could not perform serial 7s but was not tested on serial 3s. She could
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spell “world” forward and not backward but had no difficulty following the
conversation. Her abstract thinking was intact, as were insight and judgment. The
consultative examiner opined to no limits in understanding, remembering or
applying information. I note that at this exam her delayed recall was 2/3 and her
“digits backward” performance was only 2/6. however, the collateral record shows
no deficits with memory. Therefore, while the consultative examiner noted no
limits here, I find a mild limit based on the specific testing performed at the exam.
The consultative examiner opined to no limits in concentration, persistence, or
maintaining pace under “functional information” but, later, indicated that she was
distractible and fatigued. On exam, the claimant could not perform serial 7’s or
spell “world” backward, which are measures of concentration. While there is no
collateral evidence of any deficits in this domain in her treatment records, I
considered her performance on mental testing on this one date to find a mild limit.
The consultative examiner did not offer specific functional opinions related to the
social domain but simply restated the claimant’s subjective reports of spending time
with family and people at church as well as caretaking other family members yet
feeling lonely and isolating. She interacted appropriately with the examiner, though
the examiner found her affect to be congruent with her depressed and irritable
mood, she did not describe any objective signs to support this. I therefore find a
mild limit here as well. Finally, the consultative examiner opined that the claimant
has a “reduced ability” to do many activities and “reduced tolerance for things being
unsanitary or unsafe for her son” and that she adapted to her limits on managing
stressors by self-isolating. These are better characterized as restatements of the
claimant’s subjective reports than medical opinions, as they do not express opinions
in functional terms based on any objective signs or findings in the exam. The
claimant was able to complete the mental testing at the exam without any evidence
of decompensation or being overwhelmed or unable to continue. The collateral
record does not support the claimant’s subjective assertions. She can take care of
her family and herself, including seeking appropriate medical care when reason
exists to do so. While the consultative examination findings were minimally
supported in part by some findings on this one-time exam, they are generally not
expressed in functional terms (e.g., the consultative examiner noted the claimant
was able to sustain concentration and show persistence for simple tasks for a short
period of time but did not actually opine that the claimant would be unable to
understand, remember or apply instructions for detailed or complex tasks).
Additionally, the consultative examiner’s findings are not well supported due to the
internal inconsistencies between the “functional information” and the “functional
assessment”. More importantly, the consultative examiner’s opinions, to the extent
they could be treated as such, are inconsistent with the collateral record, which does
not reflect either the frequency or severity of symptoms or objective findings
reported and/or found at this exam. For these reasons the consultative examiner’s
opinions are not persuasive to support even a moderate limit in any area.
(R. at 22–23.) As this discussion demonstrates, the ALJ considered the supportability and
consistency factors and found them both to be lacking.
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First, the ALJ determined that Dr. Arnold’s opinion lacked support because of internal
inconsistencies in her examination report. Substantial evidence supports that determination. The
ALJ explained that Dr. Arnold noted no limits in Plaintiff’s ability to understand, remember, and
apply information. (Id. at 22, 421.) But, as the ALJ explained, Dr. Arnold also wrote that during
testing, Plaintiff’s delayed word recall was only 2/3 and her ability to recite digits backwards was
only 2/6. (Id. at 22, 419.) Given Plaintiff’s performance on these memory tests, the ALJ
concluded that she had mild impairments instead of no impairments in this area and that she was
more limited than Dr. Arnold seemingly opined. (Id. at 22.)
Similarly, the ALJ noted inconsistencies in Dr. Arnold’s opinions about Plaintiff’s
concentration, persistence, and pace. As the ALJ explained, Dr. Arnold opined no limits in this
area in the “functional information” section of her report. (Id. at 22.) In that section, Dr. Arnold
wrote that Plaintiff was “able to sustain concentration and show persistence for up to an hour or
more while taking care of and being with her son, daughter and mother. [She] is able to do these
activities in a timely manner and at a reasonable pace.” (Id. at 420.) But elsewhere Dr. Arnold
also wrote that Plaintiff was distractable and fatigued. (Id. at 421.) The ALJ also noted that
during concentration testing, Plaintiff was unable to perform serial 7s or spell “world”
backwards. (Id. at 22.) Accordingly, the ALJ determined that Plaintiff had a mild limit, rather
than no limit, as seemingly opined in at least one part of the examination report.
With regard to Plaintiff’s social interaction abilities, the ALJ correctly explained that Dr.
Arnold did not opine specific functional limits in this area. (Id. at 22.) But the ALJ also correctly
noted that although Dr. Arnold determined that Plaintiff’s affect was congruent with her
depressed and irritable mood, Dr. Arnold did not describe any objective signs to support that
finding. (Id. at 22, 419.) Accordingly, the ALJ determined that Dr. Arnold’s opinions were,
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overall, only “minimally supported in part by some findings on this one-time exam . . . ” (Id. at
22.)
When considering the consistency factor, the ALJ determined that Dr. Arnold’s opinion
was inconsistent with the collateral record, which did not “reflect the frequency or severity of
symptoms or objective findings reported and/or found” during Dr. Arnold’s examination. (Id. at
23.) Substantial evidence supports that explanation. The ALJ explained elsewhere in her
determination that Plaintiff’s mental status was consistently noted to be normal. (Id. at 22.) And
the record shows that examiners often found that Plaintiff had normal or appropriate mood
and/or affect (id. at 642, 621, 583, 696, 720, 687, 469, 840).
Plaintiff nonetheless contends that the ALJ erred when assessing Dr. Arnold’s opinion
because she found that Dr. Arnold limits were restatements of Plaintiff’s subjective reports. (Pl.’s
Statement of Errors 15–16, ECF No. 10.) But this mischaracterizes the ALJ’s evaluation of Dr.
Arnold’s opinion, which was that some of the limits Dr. Arnold opined “were better
characterized as restatements of Plaintiff’s subjective reports rather than medical opinions, as
they do not express opinions in functional terms based on objective signs or findings in the
exam.” (R. at 22.) Thus, the ALJ did not discount Dr. Arnold’s opined limits simply because
they were based on Plaintiff’s subjective reports. Instead, the ALJ explained that some of Dr.
Arnold’s “limits” did not truly constitute opinions because they were not stated in concrete
functional terms.
The cases cited by Plaintiff on this point are unavailing because they discuss that clinical
observations can be used to support a medical opinion about the limits caused by a plaintiff’s
mental health impairments. (Pl.’s Statement of Errors 9–12, 15–16, ECF No. 10.) And to be sure,
when mental illness is the basis of a disability claim, clinical and laboratory data may consist of
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diagnoses and observations from trained professionals rather than more objective clinical
manifestations. But even where an opinion is based on professional observations rather than
something more tangible, like an X-Ray, an opined limit must still be stated in concrete
functional terms.
Here, some of Dr. Arnold’s limits lacked that requisite functionality. For instance, and as
the ALJ explained, Dr. Arnold opined that Plaintiff had a “reduced ability to do many physical
activities and mental tasks.” (R. at 420, 22.) But Dr. Arnold failed to describe or quantify that
reduced ability. What mental tasks were impacted? Understanding? Memory? Concentration?
And to what extent were they reduced—to six hours in an eight-hour workday? Four hours?
In short, the ALJ’s supportability and consistency determinations were supported by
substantial evidence and the ALJ did not err by noting that some of Dr. Arnold’s opinions were
not stated as functional limits. Plaintiff’s contention of error lacks merit.
4. 	State Agency Psychological Reviewers—Drs. Swain and Fernandez
Plaintiff’s file was reviewed initially and on reconsideration by Drs. Swain and
Fernandez respectively. (Id. at 50–58, 60–68.) Both reviewers found that Plaintiff’s mental
impairments were severe and that she had moderate social interaction and adaptation limits. (Id.
at 52, 56, 64, 66.)
The ALJ discussed those prior administrative findings as follows.
The DDS, which interpreted the consultative examiner’s opinions to support
moderate limits in the social and adapt/manage domains, is unpersuasive for the
same reasons. The DDS findings were supported by reference to the consultative
exam, which in itself was neither well supported nor consistent and, therefore, the
same conclusion applies to the DDS findings.
(Id. at 23.) As this discussion demonstrates, the ALJ explained that the reviewers’ findings were
largely based on Dr. Arnold’s consultative examination. (Id.) The ALJ further explained that
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because Dr. Arnold’s opinions were unsupported and inconsistent with the rest of the record, the
reviewers’ findings also lacked support and consistency.
Substantial evidence supports the ALJ’s determination. As the ALJ accurately wrote
elsewhere, the reviewers found that Plaintiff had severe impairments, but there was “little to no
evidence” for them to make that finding aside from Dr. Arnold’s consultative examination. (Id.
at 22.) As the ALJ also correctly noted elsewhere, this was because Plaintiff did not pursue
mental health treatment during the relevant period and thus the record lacked treatment records.
(Id.) Moreover, and as the ALJ also wrote elsewhere, Plaintiff’s mental status was consistently
normal during examinations for her physical health—examiners often found that she had normal
or appropriate mood and/or affect (Id. at 642, 621, 583, 696, 720, 687, 469, 840.)
Accordingly, the Court does not find that the ALJ reversibly erred when evaluating the
reviewers’ prior administrative findings. Plaintiff’s contention lacks merit.
V. 	CONCLUSION
For all the foregoing reasons, the Court finds that the ALJ did not reversibly err at step
two when determining that Plaintiff did not have any severe MDIs or when evaluating medical
opinions and prior administrative findings. The Commissioner’s non-disability determination is,
therefore, AFFIRMED and Plaintiff’s Statement of Errors is OVERRULED.
IT IS SO ORDERED.
/s/ Chelsey M. Vascura
CHELSEY M. VASCURA
UNITED STATES MAGISTRATE JUDGE
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