Pratt v. Colvin Case remanded to SSA.

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IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF TEXAS
HOUSTON DIVISION
SHEILA P., 1
Plaintiff,
v.
FRANK BISIGNANO,
Acting Commissioner of Social
Security,
Defendant.
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§
§
§
§
§
§
§
No. 4:25-cv-764
JUDGE PALERMO’S
REPORT AND RECOMMENDATION
Plaintiff Sheila P. (“Plaintiff”) filed this suit seeking judicial review of an
administrative decision. Pl.’s Compl., ECF No. 1. Jurisdiction is predicated upon
42 U.S.C. § 405(g). Plaintiff appeals from the decision of the Commissioner of the
Social Security Administration (“Commissioner”) denying Plaintiff’s claim for
disability insurance benefits under Title II of the Social Security Act (“the Act”). 2
The parties filed cross motions for summary judgment. Pl.’s MSJ, ECF No. 12;
Def.’s MSJ, ECF Nos. 13, 14. Plaintiff seeks an order rendering benefits or
remanding for further consideration, arguing that the ALJ’s RFC determination is
1 Pursuant to the May 1, 2018 “Memorandum Re: Privacy Concern Regarding Social Security and
Immigration Opinions” issued by the Committee on Court Administration and Case Management
of the Judicial Conference of the United States, the Court uses only Plaintiff’s first name and last
initial.
2 The district judge to whom this case is assigned referred all pretrial proceedings to the
undersigned. Referral Order, ECF No. 3.
United States District Court
Southern District of Texas
ENTERED
January 08, 2026
Nathan Ochsner, Clerk
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not supported by substantial evidence. ECF No. 12. Based on the briefing, the record,
and the applicable law, the Court finds that the ALJ’s RFC determination is not based
on substantial evidence because the ALJ relies on her own lay interpretation of the
medical evidence. The Court recommends that Plaintiff’s motion for summary
judgment be granted, Commissioner’s motion for summary judgment be denied, and
the ALJ’s decision be remanded.
I. 	BACKGROUND
Plaintiff is 59 years old. R. 212, 221. 3 Plaintiff previously worked as a cashier
and a home health attendant. R. 218, 225. Plaintiff alleges a disability onset date of
February 15, 2023. R. 212, 215. Plaintiff claims to suffer from physical and mental
limitations. R. 212, 215, 221.
On November 29, 2023, Plaintiff filed an application for disability insurance
benefits under Title II of the Act. 4 R. 	350–53. Plaintiff based her application on
depression, 	bipolar 	disorder, 	neck 	pain, 	anxiety, 	high 	blood 	pressure, 	high
cholesterol, knee arthritis, headaches, and back pain. R. 212, 215, 221. The
3 “R.” citations refer to the electronically filed Administrative Record, ECF No. 7.
4 The parties agree that although the ALJ references Title XVI benefits, there is no Title XVI
supplemental security income application in the record and Plaintiff only applied for Title II
benefits. See ECF Nos. 12 at 3; 14 at n.1. For Plaintiff’s disability insurance benefits, the relevant
period is February 15, 2023—Plaintiff’s alleged onset date—through March 31, 2023—Plaintiff’s
last insured date. R. 137. The Court will consider medical evidence outside this period to the extent
it demonstrates whether Plaintiff was under a disability during this timeframe. See Williams v.
Colvin, 575 F. App’x 350, 354 (5th Cir. 2014); Loza v. Apfel, 219 F.3d 378, 396 (5th Cir. 2000).
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Commissioner denied Plaintiff’s claim initially, R. 211–19, and on reconsideration.
R. 220–26.
An administrative hearing was held before an ALJ where Plaintiff was
represented by an attorney. Plaintiff and a vocational expert (“VE”) testified.
R. 169–91. The ALJ issued a decision finding Plaintiff not disabled and denied her
request for benefits. 5 R. 132–49. The Appeals Council denied Plaintiff’s request for
review, upholding the ALJ’s decision to deny benefits. R. 5–16. Plaintiff appealed
the Commissioner’s ruling to this Court. ECF No. 1.
5 An ALJ must follow five steps in determining whether a claimant is disabled. 20 C.F.R.
§ 404.1520(a)(4). The ALJ here determined Plaintiff was not disabled at step four. R. 148. At step
one, the ALJ found that Plaintiff did not engage in substantial gainful activity since her alleged
onset date. R. 137 (citing 20 C.F.R. §§ 404.1571 et seq. and 416.971 et seq.). At step two, the ALJ
found that Plaintiff has the following severe impairments: osteoarthritis of the bilateral knees,
degenerative disc disease of the lumbar spine, migraines, obesity, major depressive disorder,
generalized anxiety disorder, and bipolar disorder. R. 138 (citing 20 C.F.R. § 404.1520(c) and
416.920(c)). At step three, 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 the regulations that would lead to a disability finding. R. 138 (citing 20 C.F.R.
§§ 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926). The ALJ then found that
Plaintiff had the RFC to perform medium work as defined in 20 CFR 404.1567(c) and 416.967(c)
except she can frequently stoop and climb ramps and stairs, occasionally kneel, crouch, and crawl,
never climb ladders, ropes, and scaffolds, cannot perform tasks involving a specific production
rate pace, such as assembly line work or an hourly production quota, but can deal with occasional
changes in a routine work setting. R. 143. At step four, the ALJ determined that Plaintiff was able
to perform past relevant work as a home health attendant and a cashier checker. R. 148 (citing 20
C.F.R. §§ 404.1565, 416.965). The ALJ concluded that Plaintiff was not disabled. R. 148.
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II. 	STANDARD OF REVIEW
The Social Security Act provides for district court review of any final decision
of the Commissioner that was made after a hearing in which the claimant was a
party. 42 U.S.C. § 405(g). In performing that review:
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 . . . , with or without remanding the cause
for a rehearing. The findings of the Commissioner . . . as to any fact, if
supported by substantial evidence, shall be conclusive[.]
Id. Judicial review of the Commissioner’s decision denying benefits is limited to
determining whether that decision is supported by substantial evidence on the record
as a whole and whether the proper legal standards were applied. Id.; Boyd v. Apfel,
239 F.3d 698, 704 (5th Cir. 2001); Loza v. Apfel, 219 F.3d 378, 393 (5th Cir. 2000).
“Substantial evidence” means “such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.” Biestek v. Berryhill, 139 S. Ct. 1148,
1154 (2019) (quotations omitted). It is “more than a scintilla but less than a
preponderance.” Carey v. Apfel, 230 F.3d 131, 135 (5th Cir. 2000). The “threshold
for such evidentiary sufficiency is not high.” Biestek, 139 S. Ct. at 1154.
The Court weighs four factors to determine “whether there is substantial
evidence of disability: (1) objective medical facts; (2) diagnoses and opinions of
treating and examining physicians; (3) subjective evidence of pain and disability;
and (4) the claimant’s age, education, and work history.” Conley-Clinton v. Saul,
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787 F. App’x 214, 216 (5th Cir. 2019) (citing Martinez v. Chater, 64 F.3d 172, 174
(5th Cir. 1995)).
A reviewing court may not reweigh the evidence in the record, try the issues
de novo, or substitute its judgment for that of the Commissioner, even if the evidence
preponderates against the Commissioner’s decision. Brown v. Apfel, 192 F.3d 492,
496 (5th Cir. 1999). Even so, judicial review must not be “so obsequious as to be
meaningless.” Id. (quotations omitted). The “substantial evidence” standard is not a
rubber stamp for the Commissioner’s decision and involves more than a search for
evidence supporting the Commissioner’s findings. Singletary v. Brown, 798 F.2d
818, 822–23 (5th Cir. 1986); Cook v. Heckler, 750 F.2d 391, 393 (5th Cir. 1985).
Rather, a reviewing court must scrutinize the record as a whole, taking into account
whatever 	fairly 	detracts 	from 	the 	substantiality 	of 	evidence 	supporting 	the
Commissioner’s findings. Singletary, 798 F.2d at 823. “Only where there is a
‘conspicuous absence of credible choices or no contrary medical evidence’ will we
find that the substantial evidence standard has not been met.” Qualls v. Astrue, 339
F. App’x 461, 464 (5th Cir. 2009) (quotation omitted).
III. 	DISABILITY INSURANCE BENEFITS UNDER THE ACT
The Act permits the payment of insurance benefits to persons who have
contributed to the program and who suffer a physical or mental disability. 42 U.S.C.
§ 423(a)(1)(D). These payments are referred to as disability insurance benefits.
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Applicants must prove “disability” to qualify for benefits. Id. § 423(d)(1)(A).
“Disability” is defined as the “inability to engage in any substantial gainful
activity by reason of any medically determinable physical or mental impairment
which can be expected to result in death or which has lasted or can be expected to
last for a continuous period of not less than 12 months.” Id. A physical or mental
impairment is defined as “an impairment that results from anatomical, physiological,
or psychological abnormalities which are demonstrable by medically acceptable
clinical and laboratory diagnostic techniques.” Id. § 423(d)(3). “The suffering of
some impairment does not establish disability; a claimant is disabled only if he is
‘incapable of engaging in any substantial gainful activity.’” Anthony v. Sullivan, 954
F.2d 289, 293 (5th Cir. 1992) (quoting Milam v. Bowen, 782 F.2d 1284, 1286 (5th
Cir. 1987)).
IV. 	THE SHIFTING BURDEN OF PROOF
The Act places the burden of establishing disability on the claimant. Perez v.
Barnhart, 415 F.3d 457, 461 (5th Cir. 2005). To be entitled to disability insurance
benefits, a claimant “must show that he was disabled on or before the last day of his
insured status.” Ware v. Schweiker, 651 F.2d 408, 411 (5th Cir. 1981).
The 	Commissioner 	applies 	a 	five-step 	sequential 	process 	to 	determine
disability status. Torres v. Colvin, No. 4:13-cv-2571, 2014 WL 4064002, at *6 (S.D.
Tex. Aug. 15, 2014). The claimant bears the burden of proof at the first four steps to
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establish that a disability exists. Farr v. Astrue, No. G-10-205, 2012 WL 6020061,
at *2 (S.D. Tex. Nov. 30, 2012). The burden shifts to the Commissioner at step five
to show that the claimant can perform other work. Id. The burden then shifts back to
the claimant to rebut this finding. Id. If at any step in the process the Commissioner
determines that the claimant is or is not disabled, the evaluation ends. Id.
V. 	PLAINTIFF IS ENTITLED TO SUMMARY JUDGMENT.
Plaintiff 	raises 	one 	issue 	for 	review, 	arguing 	that 	the 	ALJ’s 	RFC
determination is not supported by substantial evidence. Plaintiff argues that: (1) the
ALJ impermissibly relied on his own lay interpretation of the medical evidence to
develop an RFC for “medium work” that is unsupported by substantial evidence;
(2) the RFC fails to accommodate certain Paragraph B mental limitations found at
Step Two; (3) the ALJ should have incorporated prior findings from an earlier
unfavorable ALJ decision; and (4) Plaintiff’s RFC determination of “medium work”
is not supported by the record. ECF No. 12. Because the Court finds remand is
appropriate on Plaintiff’s first argument: that the ALJ’s physical RFC determination
is not supported by substantial evidence because the ALJ relies on her own lay
interpretation of the medical evidence, the Court does not address Plaintiff’s
remaining arguments.
A. 	The ALJ’s Determination of Plaintiff’s Physical RFC Is Not Supported
by Substantial Evidence.
The ALJ’s residual functional capacity (“RFC”) determination is the most a
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claimant can still do despite his limitations. 20 C.F.R. § 404.1545(a)(1). In assessing
RFC, the ALJ must consider all the evidence in the record, including the limiting
effects of all documented impairments, regardless of whether those impairments are
severe or non-severe. Id. § 404.1545(a)(1)–(3). ALJs have the “‘sole responsibility’
to make RFC determinations, and they are ‘free to reject the opinion of any physician
when the evidence supports a contrary conclusion.’” Sprowl v. Comm’r of Soc. Sec.,
No. SA-24-CV-01125-ESC, 2025 WL 2264602, at *5 (W.D. Tex. Aug. 6, 2025)
(quoting Taylor v. Astrue, 706 F.3d 600, 602–03 (5th Cir. 2012) (citing Ripley v.
Chater, 67 F.3d 552, 557 (5th Cir. 1995)); citing Newton v. Apfel, 209 F.3d 448, 455
(quoting 	Paul 	v. Shalala, 29 	F.3d 208, 211 	(5th 	Cir. 1994))). “Their 	RFC
determination need not mirror a physician’s opinion.” Id. (quoting Miller v. Kijakazi,
No. 22-60541, 2023 WL 234773, at *4 (5th Cir. Jan. 18, 2023) (per curiam)).
“Even the absence of medical opinions does not necessarily render a record
inadequate to support an ALJ’s RFC determination.” Donna A. v. Comm’r of Soc.
Sec., No. 5:22-CV-111-H-BQ, 2023 WL 5004867, at *3 (N.D. Tex. July 17, 2023),
adopted sub nom. Donna A. v. Kijakazi, No. 5:22-CV-111-H-BQ, 2023 WL 5004073
(N.D. Tex. Aug. 4, 2023) (quoting Nic R. v. Kijakazi, No. 3:22-cv-00106-K-BT,
2023 WL 2529930, at *5 (N.D. Tex. Feb. 21, 2023), adopted, 2023 WL 2531492
(N.D. Tex. Mar. 15, 2023) (citing Ripley v. Chater, 67 F.3d 552, 557 (5th Cir. 1995)
and Joseph-Jack v. Barnhart, 80 F. App’x 317, 318 (5th Cir. 2003) (per curiam))).
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The Court’s “inquiry focuses upon whether the decision of the ALJ is supported by
substantial evidence in the existing record.” Ripley, 67 F.3d at 557. “Substantial
evidence requires ‘evidence of the effects the claimant’s medical conditions have on
her ability to work.’” Donna A., 2023 WL 5004867, at *4 (quoting Moreno v. Astrue,
No. 5:09–CV–123–BG, 2010 WL 3025525, at *3 (N.D. Tex. June 30, 2010) (citing
Ripley. 67 F.3d at 557), adopted, 2010 WL 3025519 (N.D. Tex. Aug. 3, 2010)); see
Ripley, 67 F.3d at 557 (reversing because “the record d[id] not clearly establish . . .
the effect [the claimant’s] condition had on his ability to work”)).
If “the ALJ rejects the only medical opinions of record, interprets the raw
medical data, and imposes a different RFC, the ALJ has committed reversible error.”
Sprowl v. Comm’r of Soc. Sec., No. SA-24-CV-01125-ESC, 2025 WL 2264602, at
*6 (W.D. Tex. Aug. 6, 2025) (quoting Garcia v. Berryhill, No. EP-17-cv-00263-
ATB, 2018 WL 1513688, at *2 (W.D. Tex. Mar. 27, 2018) (citing Williams, 355 F.
App’x at 831); citing Beachum v. Berryhill, No. 1:17-cv-00095-AWA, 2018 WL
4560214, at *4 (W.D. Tex. Sept. 21, 2018) (citing Garcia, 2018 WL 1513688, at *2)
(vacating the Commissioner’s decision where the ALJ rejected all medical opinions
and relied solely on “raw medical data” in crafting an RFC)); see also Fitzpatrick v.
Colvin, No. 3:15-CV-3202-D, 2016 WL 1258477, at *8 (N.D. Tex. Mar. 31, 2016)
(“[T]he ALJ improperly made an independent RFC finding after declining to rely on
any of the medical opinions addressing the effects of [the plaintiff’s] mental
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impairments on his ability to work.”); Thornhill v. Colvin, No. 3:14-CV-335-M,
2015 WL 232844, at *10 (N.D. Tex. Jan. 16, 2015) (“While the ALJ may choose to
reject medical sources’ opinions, he cannot then independently decide the effects of
Plaintiff’s mental impairments on her ability to perform work-related activities, as
that is prohibited by Ripley. . . .”).
Here, the ALJ determined Plaintiff’s physical RFC “to perform medium
work 6 as defined in 20 CFR 404.1567(c) and 416.967(c) except she can frequently
stoop and climb ramps and stairs. She can occasionally kneel, crouch, and crawl.
She can never climb ladders, ropes, and scaffolds. . . .” R. 143. In determining
Plaintiff’s RFC, the ALJ considered Plaintiff’s testimony, summarizing that Plaintiff
testified to “difficulties managing migraine headaches, knee pain, standing for
longer than 15 minutes, sitting for longer than five minutes, dealing with back pain,
and managing medication side effects, including stiffness, nausea, and drowsiness.”
R. 144. The ALJ also noted that Plaintiff “submitted an adult function report
indicating she has difficulties with activities of daily living and functions including
lifting, squatting, bending, walking, kneeling, climbing stairs, taking medications
without reminders from her daughter, completing tasks, concentrating, and handling
stress and change.” R. 144. The ALJ found that although Plaintiff’s medically
6 “Medium work involves lifting no more than 50 pounds at a time with frequent lifting or carrying
of objects weighing up to 25 pounds.” 20 C.F.R. § 404.1567(c).
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determinable impairments could be expected to cause these alleged symptoms,
Plaintiff’s testimony regarding the intensity, persistence, and limiting effects of her
symptoms was not “entirely consistent with the medical evidence and other
evidence.” R. 144.
The ALJ reviewed Plaintiff’s medical records, noting Plaintiff consistently
complained of knee and back pain with examinations and images showing crepitus
and osteoarthritis in her knees and decreased range of motion and degenerative disc
disease in her back. R. 144. The ALJ then noted that the overall record shows grossly
normal findings of her knees and back, along with normal motor skills and sensation
despite a painful range of motion and normal gait—all of which the ALJ concluded
“indicates [Plaintiff’s] reports of pain do not affect her ability to walk or stand.”
R. 144. The ALJ next noted that Plaintiff’s migraine headaches were helped with
medication and her neurological examinations showed grossly normal findings.
R. 145. The ALJ stated that when she decided Plaintiff’s RFC, she took Plaintiff’s
orthopedic issues and migraines into account and thus:
restricted her to the medium exertional range limiting the amount of
exertion or weight lifted or carried. Further limitations were also
afforded to the claimant limiting her ability to frequently stoop and
climb ramps and stairs but only occasionally kneel, crouch, and crawl
with a restriction from climbing ladders, ropes, and scaffolds, also due
to the level of exertion required by such tasks, with evidence showing
some range of motion issues combined with crepitus to her knees, as
well as persistent pain requiring medication management.
R. 145.
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Importantly, none of the medical evidence relied on by the ALJ made any
mention of Plaintiff’s lifting abilities, how long she could stand or walk, how
(in)frequently 	she 	could 	stoop, 	climb, 	kneel, 	crouch, 	and 	crawl—important
components to finding Plaintiff capable of medium work, which requires standing
or walking for 6 out of 8 hours a day and lifting of 50 pounds with frequent carrying
of 25 pounds, and the additional imposed limitations. See 20 C.F.R. § 404.1567(c).
Next, the ALJ noted Plaintiff’s obesity and stated that her medical records
show a BMI that qualifies Plaintiff as obese. Then, without citation to the record, the
ALJ noted:
an individual may have limitations in any of the exertional functions,
postural functions, in the ability to manipulate objects, or to tolerate
extreme heat, humidity, or hazards because of obesity. The claimant’s
weight, including the impact on the ability to ambulate as well as the
other 	body 	systems, 	has 	been 	considered 	within 	the 	functional
limitations determined herein and specifically, her obesity has been
found to contribute to her exertional and postural limitations found
herein.
R. 145. Again, nothing within the ALJ’s consideration of Plaintiff’s obesity included
medical opinions or examination findings regarding Plaintiff’s ability to work or
determinations of Plaintiff’s functional abilities—instead, the ALJ appears to rely
upon her own understanding of how obesity affects functional ability.
And finally, the ALJ noted of the record’s medical opinions:
in November 2023, Patty Rowley, M.D., examined the evidence and
opined the claimant could perform work at the light exertional level
with limitations in frequently climbing ramps and stairs, balancing, and
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stooping, but only occasionally climbing ladders, ropes, and scaffolds,
kneeling, 	crouching, 	and 	crawling. 	As 	an 	initial 	matter, 	the
Administrative Law Judge finds this opinion not persuasive because it
is not well supported by even the citations provided, which show the
claimant exhibited grossly normal findings upon examination of her
gait and station, as well as normal range of motion and negative
findings on SLR testing. This opinion is also inconsistent with the
overall evidence. Specifically, despite a one-time finding of knee
crepitus and range of motion issues to her spine, the overall record
shows grossly normal findings, including a normal gait, normal motor
skills, and normal sensation throughout. As such, the Administrative
Law Judge is not persuaded by Dr. Rowley’s limitation to work at the
light exertional level as the evidence does not support such limitations.
In fact, there is no evidence to suggest the claimant would have
limitations in lifting, carrying, pushing, and/or pulling to the light level
when her symptoms are well managed with medication and prescription
gel. Regardless, to account for the claimant’s subjective complaints and
the findings of range of motion issues and crepitus to her knees, the
Administrative Law Judge finds the claimant would be limited to work
at the medium level, which also accounts for the claimant’s migraine
headaches, which could be exacerbated by her overall exertion. This is
consistent with the finding of decreased range of motion and crepitus.
However, later, in January 2024, Larry Wilson, M.D., also reviewed the
record but found [insufficient evidence] to make a determination (Ex.
B5A). 	The 	Administrative 	Law 	Judge 	finds 	this 	opinion 	to 	be
inherently neither valuable nor persuasive in accordance with 20 CFR
404.1520b(c) 	and 	416.920b(c) 	because 	there 	were 	no 	functional
limitations set forth by Dr. Wilson when, at the hearing level, there is,
in fact, sufficient evidence to evaluate the severity of the claimant’s
impairments. Accordingly, the Administrative Law Judge has provided
the claimant physical limitations to account for the combination of her
impairments and their associated symptoms, as discussed above.
Finally, in June 2023, the claimant’s treating physician, Dominic
Joseph, M.D., recommended the claimant, “get back to work in home
health agency” and provided her with a referral to employment services.
While 	this 	statement 	does 	not 	provide 	any 	specific 	functional
limitations related to the claimant’s mental or physical abilities, the
Administrative 	Law 	Judge 	has 	considered 	it. 	Specifically, 	the
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Administrative Law 	Judge notes 	that 	this 	statement 	is 	from 	the
claimant’s treating physician who has specific knowledge of the
claimant’s mental and physical impairments and limitations. Not only
that, Dr. Joseph has had the benefit of personally examining the
claimant and did not find it necessary to provide her limitations, but
instead recommended she return to work.
R. 147–48 (internal citations omitted).
The ALJ rejected both medical opinions, finding instead that her independent
review of the medical examination record supported a greater level of physical work.
In finding support for her higher physical RFC, she relied on a statement from
Plaintiff’s treating mental health physician at the Harris Center for Mental Health,
Dominic M. Joseph, M.D. On June 27, 2023, Plaintiff presented to Dr. Joseph with
the chief complaint that her anxiety was worse because she was going to be homeless
because she can no longer work in home healthcare. R. 669. Due to “[t]he complexity
and risks of this case includ[ing] dual diagnosis and comorbid psychosocial stressors
including being unemployed and fear of getting evicted over not paying rent,”
Dr. Joseph counseled Plaintiff to seek housing ahead of being evicted and “to get
back to work in home health agency” and seek employment at the Harris Center.
R. 672. 7 Dr. Joseph performed a mental status examination on Plaintiff but did not
7 Dr. Joseph’s statement in a treatment record is arguably neither a medical opinion nor medical
source statement under the regulations. See Anderson v. Berryhill, No. 4:18-CV-03058, 2019 WL
3252934, at *5 (S.D. Tex. July 19, 2019) (“A medical opinion is an opinion from an ‘acceptable
medical source’ ‘about what [a claimant] can still do despite [her] impairments,’ 20 C.F.R.
§ 404.1527(a)(1), 20 C.F.R. §§ 404.1513(a)(2)(i-iv). A ‘medical source statement’ is a ‘medical
opinion[ ] submitted by [an] acceptable medical source[ ], including treating sources, . . . about
what an individual can still do despite a severe impairment(s), in particular about an individual’s
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perform any physical examination. R. 670–71. Nothing in Dr. Joseph’s mental health
treatment record touches on Plaintiff’s physical functional abilities.
In rejecting all medical opinions in the record, the ALJ’s physical RFC finding
rests only on the ALJ’s lay interpretation of observation and examination notes from
treatment records and clinical test results—none of which address Plaintiff’s
functional ability to perform the ALJ’s determined RFC. But, “[t]he problem with
this approach is that an ALJ may not ‘draw [her] own medical conclusions from
some of the data, without relying on a medical expert’s help.’” Donna A., 2023 WL
5004867, at *5 (quoting Frank v. Barnhart, 326 F.3d 618, 621–22 (5th Cir. 2003)
(per curiam); citing Fitzpatrick v. Colvin, No. 3:15-CV-3202-D, 2016 WL 1258477,
at *8 (N.D. Tex. Mar. 31, 2016) (finding error where the ALJ “attempted to
compensate for” the claimant's disorder, “[b]ut other than the opinions of the two
SAMCs (which the ALJ rejected), the record lack[ed] medical evidence that would
support a determination that” the claimant could work despite that impairment)).
“An ALJ is free to reject medical opinions provided that [she] does not ‘then
independently decide the effects of a claimant’s impairments on her ability to
perform work-related activities.’” Id. (quoting Greer v. Comm’r of Soc. Sec., No.
7:21-cv-00032-O-BP, 2022 WL 4239356, at *7 (N.D. Tex. Aug. 9, 2022), adopted,
physical or mental abilities to perform work-related activities on a sustained basis.’ SSR 96-5p,
1996 WL 374183 at *4.”).
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2022 WL 4240948 (N.D. Tex. Sept. 14, 2022)).
The ALJ relied on evidence that merely describes Plaintiff’s conditions rather
than demonstrating her ability to work despite those impairments. See id. at *6
(citing Jim S. v. Saul, No. 3:18-CV-2179-BH, 2019 WL 4694943, at *9 (N.D. Tex.
Sept. 25, 2019) (finding error where the ALJ relied on medical records to assess the
claimant's RFC without identifying the medical opinions that were the source of the
imposed limitations); Turner v. Colvin, No. 3:13–CV–1458–B, 2014 WL 4555657,
at *5 (N.D. Tex. Sept. 12, 2014) (“[E]vidence which merely describes Plaintiff’s
medical conditions is insufficient to support the ALJ’s RFC determination.”)).
Nothing relied upon by the ALJ addressed Plaintiff’s functional abilities like how
much she can lift or how long she can walk or stand—rather, the ALJ interpreted
herself that grossly normal findings of Plaintiff’s gait, station, and range of motion
meant Plaintiff had the ability to lift up to 50 pounds at a time with frequent lifting
or carrying of objects weighing up to 25 pounds. This is error.
The record does not “clearly establish how Plaintiff’s conditions impact her
ability to perform medium work and there are no medical opinions to otherwise serve
as a foundation for that decision,” and “appears the ALJ relied on [her] own
interpretation of the medical and other evidence, which [she] may not do.” 	See id.
(citing Cary G. T. v. Comm’r, Soc. Sec. Admin., No. 3:20-CV-1948-BK, 2022 WL
954341, at *3 (N.D. Tex. Mar. 29, 2022) (concluding that although “the RFC is
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ultimately the ALJ’s determination,” there was no apparent “foundational basis for
that decision” where “no treating, examining, or consultative resource reviewed the
impact of [p]laintiff’s conditions on his ability to work”); Alexander v. Saul, No.
7:19-CV-00127-M-BP, 2020 WL 4573847, at *4 (N.D. Tex. July 9, 2020), adopted
by 2020 WL 4569034 (N.D. Tex. Aug. 7, 2020)). The ALJ erred in making a physical
RFC determination without evidence in the record clearly establishing the impact of
Plaintiff’s impairments on her ability to work. See Donna A., 2023 WL 5004867, at
*6. 8
Likewise, the ALJ erred in making accommodations for Plaintiff’s mental
impairments in the RFC without evidence establishing the impact of Plaintiff’s
mental impairments on her ability to work. Thornhill, 2015 WL 232844, at *10. The
ALJ cannot “independently decide the effects of Plaintiff’s mental impairments on
her ability to perform work-related activities, as that is prohibited by Ripley. . . .”.
Id.
8 Commissioner argues that the ALJ’s RFC determination need not mirror a medical opinion, but
rather the ALJ is responsible for interpreting the medical evidence to determine Plaintiff’s RFC.
ECF No. 14 at 10. But what is missing from the ALJ’s determination is any evidence in the record
to establish “the effect [Plaintiff’s] condition had on [her] ability to work.” See Tiede, 770 F. Supp.
3d at 972 (emphasis in original) (quoting Ripley, 67 F.3d at 557); see also Donna A., 2023 WL
5004867, at *5–6 (RFC not supported by substantial evidence where ALJ rejected SAMCs’
opinions, but relied on the plaintiff’s testimony, clinical test results, and medical records finding
normal strength, gait, and range of motion because this evidence described the plaintiff’s
conditions, but did not make clear what effect the plaintiff’s condition had on the plaintiff’s ability
to work).
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B. 	The ALJ’s Error Was Harmful.
“A court will not vacate a judgment unless the ‘substantial rights of a party
have been affected.’” Giles R., 2021 WL 4502842, at *9 (quoting Mays v. Bowen,
837 F.2d 1362, 1364 (5th Cir. 1988)). Plaintiff must demonstrate that she was
prejudiced 	from 	the 	ALJ’s 	errors 	by 	showing 	that, 	absent 	the 	error, 	the
Commissioner might have reached a different conclusion. See id. (citing Jones v.
Astrue, 691 F.3d 730, 735 (5th Cir. 2012) (“The party seeking to overturn the
Commissioner’s decision has the burden to show that prejudice resulted from an
error.”); Newton v. Apfel, 209 F.3d 448, 453 (5th Cir. 2000)). “Prejudice can be
established by showing that additional evidence would have been produced if the
ALJ had fully developed the record, and that the additional evidence might have led
to a different decision.” Ripley, 67 F.3d at 557 n.22.
Here, the ALJ determined that Plaintiff could “perform medium work,
meaning she could lift up to 50 pounds and frequently lift 25 pounds, stand or walk
for 6 out of 8 hours every day, “except she can frequently stoop and climb ramps
and stairs” and “occasionally kneel, crouch, and crawl.” R. 143. The only other
medical opinion addressing Plaintiff’s physical RFC, Dr. Rowley, stated that
Plaintiff was only capable of light work, which the VE testified would prevent
Plaintiff from returning to her past relevant work as a home health aide. R. 188. It is
not out of the realm of possibilities that a medical opinion could have determined
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Plaintiff incapable of the physical functions demanded of medium work and that
Plaintiff would therefore be unable to perform her past relevant work. If she was
limited to light work, Plaintiff is correct that, the regulations would require a finding
of disabled for a person of advanced age with only a high school education and no
transferable skills. 20 C.F.R. Pt. 404, Subpt. P, App. 2, Rule 201.04 & 201.06.
Therefore, the ALJ’s failure to develop the record was not harmless. Remand for
further proceedings is required on this issue. See Donna A., 2023 WL 5004867, at
*6 (citing Kirkland v. Comm’r of Soc. Sec., No. 4:22-cv-759-O-BP, 2023 WL
3357597, at *6 (N.D. Tex. Apr. 25, 2023), adopted, 2023 WL 3362633 (N.D. Tex.
May 10, 2023); Lozano v. Comm’r, Soc. Sec. Admin., No. 4:21-CV-1365-P, 2023
WL 2618132, at *6 (N.D. Tex. Mar. 2, 2023), adopted, 2023 WL 2619311 (N.D.
Tex. Mar. 23, 2023); Graves v. Kijakazi, No. 3:22-CV-0107-L-BH, 2023 WL
2025247, at *17 (N.D. Tex. Jan. 31, 2023), adopted, 2023 WL 2025052 (N.D. Tex.
Feb. 15, 2023); Martinez v. Kijakazi, No. 3:20-CV-3282-BH, 2022 WL 4590577, at
*22 (N.D. Tex. Sept. 29, 2022).
VI. 	CONCLUSION
The Court RECOMMENDS that Plaintiff’s motion for summary judgment,
ECF No. 12, be GRANTED, the Commissioner’s motion for summary judgment,
ECF No. 13, be DENIED, that the Commissioner’s determination that Plaintiff is
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not disabled be REVERSED and REMANDED to the Commissioner for further
proceedings, and that the Court enter a separate final judgment.
The 	Parties 	have 	fourteen 	days 	from 	service 	of 	this 	Report 	and
Recommendation to file written objections. 28 U.S.C. § 636(b)(1)(C); F ED. R.
C IV . P. 72(b). Failure to file timely objections will preclude review of factual
findings or legal conclusions, except for plain error. Quinn v. Guerrero, 863 F.3d
353, 358 (5th Cir. 2017).
Signed at Houston, Texas, on January 8, 2026.
______________________________
Dena Hanovice Palermo
United States Magistrate Judge
______________________________
Dena Hanovice Palermo
United States Magistrate Judge
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