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UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF FLORIDA
CASE NO. 2:24-CV-14395-KMM/REID
LIZENA DAVIS,
Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
___________________________________________/
REPORT AND RECOMMENDATION
ON CROSS-MOTIONS FOR SUMMARY JUDGMENT
THIS CAUSE is before the Court upon a Motion for Summary Judgment filed by Plaintiff
Lizena Davis (“Plaintiff”), and a Motion for Summary Judgment filed by Defendant Commissioner
of Social Security (“Defendant”), [ECF Nos. 12, 16]. These motions were referred to the
Undersigned by the Honorable K. Michael Moore for a Report and Recommendation. [ECF No.
8]. For the reasons stated below, the Undersigned RECOMMENDS Plaintiff’s Motion for
Summary Judgment be DENIED, Defendant’s Motion for Summary Judgment be GRANTED,
and the Administrative Law Judge’s (“ALJ”) decision be AFFIRMED.
PROCEDURAL BACKGROUND
Plaintiff appeals the denial of her Title II application for a period of disability and disability
insurance benefits. [ECF Nos. 1, 4 at 22]. The application was originally filed on February 15,
2022, alleging an onset date of October 10, 2021. [ECF No. 4 at 22]. Plaintiff’s application was
initially denied on April 25, 2022, and again upon reconsideration on June 20, 2023. [Id.]. Plaintiff
subsequently filed a written request for hearing before an ALJ on July 24, 2023. [Id.]. ALJ Valencia
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Jarvis conducted the hearing by telephone on November 14, 2023. [Id.]. Plaintiff, her counsel, and
impartial vocational expert, Ghari Shirley (“VE”), attended the hearing. [Id.]. Following the
hearing, the ALJ issued a decision and concluded Plaintiff was not disabled within the meaning of
the Social Security Act and retained the residual functional capacity to do sedentary work with
certain stated exceptions. [Id. at 37]. Plaintiff’s appeal of the ALJ’s decision to the Appeals Council
was denied. See [ECF No. 4 at 6–10]. Thereafter, Plaintiff appealed to the district court initiating
this instant action. See [ECF No. 1].
Plaintiff contends the ALJ’s decision is flawed. Plaintiff contends that in assessing her
residual functional capacity, the ALJ failed to account for her cognitive limitations noted in the
opinion of consultative examiner Sterling Haws, M.D., without providing an explanation for this
omission. For the following reasons, I disagree.
RELEVANT LAW
A. Standard of Review
The scope of this Court’s review is limited to whether the ALJ applied the correct legal
standards and whether substantial evidence supports the ALJ’s decision. Monroe v. Comm’r of Soc.
Sec. Admin., 569 F. App’x 833, 835 (11th Cir. 2014). “Under the substantial-evidence standard, a
court looks to an existing administrative record and asks whether it contains sufficient evidence to
support the agency’s factual determinations.” Biestek v. Berryhill, 587 U.S. 97, 102 (2019) (internal
quotations omitted). Evidence is substantial when it is “more than a mere scintilla” but one which
“reasonable mind[s] might accept as adequate to support a conclusion.” Id. at 103 (citations
omitted). The court must not “find facts ‘anew,’ reweigh evidence, or substitute [its] own judgment
for that of the ALJ, even if [the court] find[s] [that] the evidence preponderates against the ALJ’s
decision.” Wright v. Barnhart, 153 F. App’x 678, 683 (11th Cir. 2005) (citing Martin v. Sullivan,
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894 F.2d 1520, 1529 (11th Cir.1990)). Accordingly, remand is appropriate only when “the record
reveals evidentiary gaps which result in unfairness or clear prejudice.” Henry v. Comm’r of Soc.
Sec., 802 F.3d 1264, 1267 (11th Cir. 2015) (internal quotations omitted). Prejudice requires a
showing that the ALJ did not consider all the relevant evidence in the record in reaching her
decision. Kelley v. Heckler, 761 F.2d 1538, 1540 (11th Cir. 1985).
B. Regulatory Framework
“[T]he overall burden of demonstrating the existence of a disability as defined by the Social
Security Act unquestionably rests with the claimant.” Washington v. Comm’r of Soc. Sec., 906 F.3d
1353, 1359 (11th Cir. 2018) (quoting Doughty v. Apfel, 245 F.3d 1274, 1280 (11th Cir. 2001)); 20
C.F.R. §§ 404.1512(a). To meet this definition, the claimant must have a severe impairment that
makes him unable to do past relevant work or any other substantial gainful work that exists in the
national economy. 20 C.F.R. § 404.1505. The Social Security Act outlines a five-step sequential
evaluation process to determine whether a claimant is disabled. 20 C.F.R. § 404.1520(a).
First, a claimant engaged in “substantial gainful activity,” is not disabled. 20 C.F.R. §
404.1520(b). Second, if a claimant does not have an “impairment or combination of impairments”
that significantly limits the claimant’s physical or mental ability to do basic work activities, he is
not disabled. Id. at § 404.1520(c). Third, if a claimant’s impairments do not “meet or equal” an
impairment listed in a provided appendix, he is not disabled. Id. at § 404.1520(d). Fourth, if a
claimant’s impairments do not meet or equal an impairment in a provided appendix, the ALJ must
assess the claimant’s residual functional capacity (“RFC”). Id. at § 404.1520(e). Fifth, using the
claimant’s RFC, the ALJ will embark on a two-level analysis. The ALJ will first determine if the
claimant can perform the physical and mental demands of his past relevant work. Id. at §
404.1520(f). If the claimant cannot, the ALJ will then determine whether, in light of claimant’s
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age, education, and work experience, he can still perform other types of work. Id. at §
404.1520(g)(1). If the claimant can do other work, the claimant is not disabled. Id.
Regarding the burden of proof, the claimant must prove he has a severe impairment or
combination of impairments to establish a disability at steps one to four of the evaluation. See
Williams v. Astrue, 416 F. App’x 861, 862 (11th Cir. 2011). At step five, however, the burden shifts
to the ALJ to show there are other jobs the claimant may still perform despite his condition. See
id.
THE RECORD
A. Plaintiff’s Testimony
Plaintiff testified before the ALJ by telephone on November 14, 2023. [ECF No. 4 at 44].
Plaintiff has a high school education and was fifty-eight years old at the time of the hearing. [Id.
at 51–52]. Plaintiff testified that she receives financial support through a pension and assistance
from her mother and boyfriend. [Id. at 63]. Her boyfriend does not work, and all three reside
together in their home. [Id. at 52, 65]. Before she stopped working, Plaintiff described her past
jobs as a bus traffic controller and box packager. [Id. at 52–53, 60–62].
Plaintiff last worked in October 2021 as a bus traffic controller. [Id. at 52]. In that role, she
was responsible for scheduling, monitoring, and coordinating the movement of more than 200
buses, responding to incidents around bus garages, and communicating with both the public and
employees. [Id. at 53]. Her duties included making emergency calls to police, fire, and ambulance
services, and she spent most of her workday seated at a desk with limited breaks. [Id.]. Her
employment ended after she suffered a hemorrhagic stroke that left her disabled. [Id.]. Plaintiff
also reported working as a box packager at a warehouse for about six months between 2008 and
2009. [Id. at 60–61]. She carried boxes weighing up to forty pounds at that time. [Id. at 62.].
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Plaintiff testified the stroke she suffered in October 2021 damaged the right side of her
body, preventing her from using her right hand and returning to work. [Id. at 53]. She further
testified that the lasting effects of the stroke resulted in pain from her right shoulder down to her
fingertips, making it difficult for her to type, and lift and carry items. [Id. at 53–54]. Plaintiff also
stated that she experienced constant pain on the right side of her body, extending from her shoulder
to her fingertips, with persistent tingling, numbness, and neuropathic sensations in her hand and
fingers, as well as cramping in her legs. [Id. at 54]. She explained she can sit for only fifteen
minutes before her right leg becomes numb and painful, stand for ten minutes, and walk for about
ten minutes with a cane, which she uses inside and outside the home. [Id. at 56–57]. She estimated
that she can lift less than ten pounds with her right hand. [Id. at 57]. She reported difficulty bending,
twisting, or climbing stairs beyond five or six steps. [Id. at 57–58]. Her right arm movement is also
significantly limited, and she cannot raise it overhead. [Id. at 58].
In addition to complications from her stroke, Plaintiff also testified that she experiences
daily seizures, sometimes occurring multiple times a day, triggered by stress, bright lights, and
strong odors. [Id. at 54–55]. Plaintiff stated that while she is sometimes aware of her seizures,
other times she experiences them as a “daydream” from which she has trouble recovering. [Id. at
55]. Her neurologist recently increased her seizure medication dosage following an EEG that
indicated worsening seizure activity. [Id. at 54–55]. Plaintiff also testified that she has
hypertension, diabetes, and depression. [Id. at 55–56]. She described difficulty regulating her
blood pressure, sometimes requiring both high and low blood pressure medication. [Id. at 55].
Plaintiff explained she became severely depressed following her daughter’s death in 2022. [Id. at
56]. She reported withdrawing from others, isolating in her bedroom, and experiencing memory
and concentration problems. [Id.]. Plaintiff sees a therapist by telehealth every two to three weeks
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and is prescribed Sertraline by her psychiatrist, which was increased to 150 mg in 2023. [Id. at 66–
67].
As to daily activities, Plaintiff testified she requires assistance from her mother and
boyfriend with hygiene, dressing, and mobility. [Id. at 59]. She begins the day resting after waking,
often in a recliner that adjusts her legs to relieve pain and numbness. [Id. at 63]. She reported
spending much of the day lying down, resting, and occasionally sitting on the porch for short
periods. [Id. at 63–64]. Lastly, she does not perform household chores or cook for herself. [Id. at
59].
Plaintiff acknowledged that her twelve-year-old granddaughter briefly stayed with her
during the summer but was largely self-sufficient and took care of herself. [Id. at 71]. She testified
that she has taken two trips since her stroke: (1) a four-day trip to Jamaica in July 2023, and (2) a
nine-day cruise beginning in September 2023. [Id. at 72–73]. The Jamaica trip was recommended
by her therapist as a form of relaxation. [Id. at 73–74]. She flew to Jamaica from Fort Lauderdale
with her boyfriend and stayed at a resort, relying on golf carts for transportation around the
property. [Id. at 74–75]. She reported doubling her medication to tolerate the flight due to pain
while sitting but did not inform her doctors of the adjustment. [Id. at 75]. The September cruise
departed from Fort Lauderdale and ended in Boston. [Id.]. While at one of the cruise’s stops in
Curaçao, Plaintiff testified participating only in a thirty-minute bus tour and otherwise remained
on the ship. [Id. at 76–77]. She testified that she did not participate in other excursions due to cost
and limitations from her impairments. [Id. at 77].
B. Medical Evidence
a. Dr. Edward Kellenberger, M.D.
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On November 17, 2021, after her stroke, Plaintiff contacted neurologist Dr. Edward
Kellenberger, M.D. (“Dr. Kellenberger”), and scheduled a discharge follow-up via video
appointment with him for January 4, 2022. See [ECF No. 4 at 541]. Dr. Kellenberger reported that
Plaintiff’s cranial nerves were intact, and she was alert and oriented, but she still showed signs of
right-side weakness and reduced stride while walking. See [id. at 470]. Furthermore, Dr.
Kellenberger reported Plaintiff was taking gabapentin to treat nerve pain but was reluctant to
increase dosage due to its tendency to make her dizzy. [Id. at 466.].
b. Dr. Delvis Celdran, M.D.
Plaintiff’s treatment history with Dr. Delvis Celdran, M.D. (“Dr. Celdran”) consists of
visits from February 2022 through February 2023 for neurological management following her
October 2021 hemorrhagic stroke. See [id. at 306]. On February 1, 2022, autonomic testing
revealed abnormal blood pressure responses when Plaintiff stood, indicating autonomic
dysfunction and orthostatic hypotension. [Id. at 92]. On February 28, 2022, Plaintiff reported
persistent right-sided numbness, spasticity, and balance difficulties, and used a walking cane after
experiencing two falls. [Id.]. Examination showed mild right hemiparesis, decreased sensation to
pinprick and light touch in the right extremities, and an abnormal gait with left circumduction,
though overall muscle strength remained intact. [Id.].
Throughout the remainder of 2022, Plaintiff continued to receive regular neurological,
psychiatric, and primary care follow-up examinations documenting ongoing complaints of
numbness, spasticity, and gait instability. See [id. at 306]. On January 28, 2023, Plaintiff was
reported to be feeling better yet still experiencing pain and numbness on her right side. [Id. at 995].
Plaintiff was walking with a cane and had no other falling episodes but still stated she was
experiencing issues with balance. [Id.].
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c. Dr. Fausto De La Cruz, M.D.
Dr. Fausto De La Cruz, M.D. (“Dr. De La Cruz”) is Plaintiff’s primary care physician. [Id.
at 34]. Plaintiff was typically examined by Dr. De La Cruz’s physician assistant, Ximena Guimet,
P.A. (“Ms. Guimet”). [Id.]. Plaintiff first saw Dr. De La Cruz in 2011 and had been seeing him for
routine internal medicine visits and chronic disease management such as blood pressure,
cholesterol, depression, and breast cancer follow-up. [Id. at 297, 375–407]. She returned to him
following her stroke and saw him multiple times between November 2021 and February 2023. [Id.
at 306].
During these follow-up visits, Dr. De La Cruz and Ms. Guimet consistently documented
Plaintiff’s status as medically stable while continuing her long-standing prescriptions. See [id. at
375–407]. In these reports, Dr. De La Cruz found Plaintiff was in “no acute distress” as well as
normal range in her extremities and full range of motion in her musculoskeletal system. [Id.]. On
May 9, 2022, Dr. De La Cruz reported Plaintiff should be limited to both sitting and standing for
0–2 hours in an eight-hour working day and that she uses a cane. [Id. at 884–85].
d. Ventre Medical Associates
Plaintiff saw multiple doctors within Ventre Medical Associates (“Ventre”) from May 2022
to March 2023. [Id. at 306]. Ventre engaged with Plaintiff through telemedicine meetings and
focused on managing her mental health and medication. See generally [id. at 806–929, 956–89,
1053–81]. Regarding an appointment on August 29, 2022, Dr. Ernesto Lajara, M.D. reported
Plaintiff was oriented to “self, time, place, and situation[,]” and her concentration was within
normal limits. [Id. at 899]. Earlier evaluations reflected significant depressive symptoms,
psychosocial stressors, and untreated mental health conditions. See [id. at 984, 988]. Nevertheless,
subsequent reports from Ventre consistently noted Plaintiff was stable, tolerating medication, and
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exhibiting no substantial variation or acute psychiatric symptoms over time. See [id. at 806–929,
956–89, 1053–81]. Additionally, follow-up notes describe the patient as stable, tolerating Zoloft,
continuing therapy, and reporting only mild anxiety and sleep difficulties, with no material
variation in symptoms or treatment plan. See [id. at 1053–81].
e. State Agency Consultants
i. Dr. Donald Morford, M.D.
On April 22, 2022, Dr. Donald Morford (“Dr. Morford”) reviewed the evidence of
Plaintiff’s record and concluded that her recorded disabilities were “not inconsistent” considering
the total medical and non-medical evidence on file. [Id. at 93]. Specifically, Dr. Morford found
Plaintiff could occasionally lift or carry up to twenty pounds, stand or walk for approximately six
hours in an eight-hour workday, and perform postural activities on an occasional basis. [Id. at 91].
However, he determined Plaintiff should never climb ladders, ropes, or scaffolds, and she should
avoid concentrated exposure to extreme heat and cold as well as even moderate exposure to
workplace hazards. [Id. at 91–92].
ii. Dr. Steven Arkin, M.D.
On June 11, 2023, Dr. Steven Arkin (“Dr. Arkin”) reviewed Plaintiff’s medical and non-
medical evidence of record at the reconsideration level and concluded the evidence was
“consistent” with physical findings. [Id. at 105.]. Specifically, Dr. Arkin opined Plaintiff could
occasionally lift or carry up to ten pounds and frequently lift or carry less than ten pounds. [Id. at
102]. He further found that on a typical eight-hour workday, Plaintiff could sit for about six hours
but could stand or walk for only about four hours and would require the use of a hand-held assistive
device for ambulation. [Id.]. Dr. Arkin noted Plaintiff could perform postural activities
occasionally but should never climb ladders, ropes, or scaffolds, and should avoid concentrated
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exposure to extreme heat and cold as well as even moderate exposure to workplace hazards. [Id.
at 103]. Regarding neurological disorders, Dr. Arkin found Plaintiff to have severe impairments
from vascular insult to the brain, epilepsy, and neuropathy. [Id. at 100].
f. Consultative Examiner, Dr. Sterling Haws, M.D.
On May 13, 2023, Dr. Sterling Haws, M.D. (“Dr. Haws”) performed an initial consultative
examination of Plaintiff. [Id. at 1013]. Generally, Dr. Haws observed Plaintiff was “oriented to
herself, but not to place or time.” [Id. at 1015]. On examination, Dr. Haws opined Plaintiff’s right
upper and lower extremities were found to show weakness. [Id.]. Furthermore, Plaintiff’s right
upper and lower extremity strength was estimated to be a 4/5. [Id. at 1017].
During the exam, Dr. Haws reported Plaintiff did not use a cane or walker but instead relied
on her partner for assistance with ambulation. [Id. at 1015]. Dr. Haws further recorded that
Plaintiff’s gait and station were abnormal as “[she was] able to stand with a stable posture[,]” but
upon closing her eyes “she exhibit[ed] significant disability and disorientation.” [Id. at 1016]. He
concluded Plaintiff’s gait instability was mostly due to cognitive difficulties. [Id. at 1015]. Dr.
Haws concluded Plaintiff would “require assistance and guidance during her ambulation to ensure
she did not become disoriented and become a danger to herself or to others[,]” which in Dr. Haws
opinion “would limit [Plaintiff] to four hours of active standing.” [Id. at1017].
Lastly, Dr. Haws observed that during the mental examination, Plaintiff had difficulty with
word comprehension and required frequent reorientation. [Id. at 1018]. He also cautioned that her
reduced verbal acuity and disorientation rendered her unsafe to travel independently or work
around hazards, and he specifically documented that she is unable to drive. [Id.].
C. Vocational Expert’s Testimony
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The Vocational Expert (the “VE”) reviewed Plaintiff’s records and listened to her testimony
prior to classifying her work history. [Id. at 78.]. Based on all evidence on the record, the VE
classified each of Plaintiff’s past work experience as follows: her employment at Miami Dade
Transit was classified as a Dispatcher, Bus and Trolley, while her part-time employment at Federal
Express was classified as Laborer, Stores. [Id. at 79].
Based upon these classifications, the ALJ cross-examined the VE framing three
hypotheticals. The ALJ first asked whether an individual who performs at the sedentary work level
can do Plaintiff’s past relevant work considering that:
The individual would have the ability to form -- perform a full range of work at the
light exertional level but can only occasionally climb ramps and stairs, never climb
ladders, scaffolds. The individual could occasionally balance, occasionally stoop,
occasionally kneel, occasionally crouch, occasionally crawl, would avoid
concentrated exposure to extreme heat and cold, would have occasional exposure
to unprotected heights.
[Id. at 82–83.]. The VE responded that such an individual could not work as a laborer but could
work as a dispatcher. [Id. at 83]. The ALJ then described an individual with the same
characteristics, except they could “occasionally lift and carry up to ten pounds, frequently lift and
carry less than ten pounds[,]” and could “stand and walk four hours of an eight-hour day, [and] sit
six hours in an eight-hour day.” [Id.]. When evaluating this hypothetical, the VE testified that such
an individual could not perform the job of bus dispatcher as described in the Dictionary of
Occupational Titles but could perform it as Plaintiff did. [Id. at 83–84]. Finally, when presented
with the same hypothetical but with the added use of a handheld assistive device for ambulation,
the VE testified that the job of dispatcher position as performed by Plaintiff would be appropriate,
but all other past work would be precluded. [Id. at 84].
D. The ALJ’S Decision
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The ALJ follows a five-step sequential process in evaluating a claim for disability benefits.
See 20 C.F.R. § 404.1520. At step one, the ALJ concluded Plaintiff has not engaged in substantial
gainful activity since October 10, 2021. [ECF No. 4 at 25]. At step two, the ALJ found Plaintiff
has five severe impairments that significantly limit her ability to perform basic work activities as
required by SSR 85-28: (1) post cerebrovascular accident with orthostatic hypotension; (2)
seizures; (3) peripheral neuropathy; (4) hypertension; and (5) gastroesophageal reflux disease
(“GERD”) with esophagitis. [Id.]. Additionally, the ALJ found Plaintiff had the medically
determinable impairments of diabetes with chronic kidney disease and blindness or low vision.
[Id.]. The ALJ determined that the former “caused no more than a minimal impact on [Plaintiff’s]
ability to complete basic work activities,” while the latter “did not constitute a severe vision-related
impairment.” [Id.].
Lastly, the ALJ also found that Plaintiff had the medically determinable mental impairment
of major depressive disorder without psychotic features. [Id. at 26]. However, the ALJ noted this
impairment “does not cause more than minimal limitation in [Plaintiff’s] ability to perform basic
mental work activities and is therefore nonsevere.” [Id.]. In reaching this conclusion, the ALJ used
a psychiatric review technique (“PRT”) to evaluate the severity of Plaintiff’s symptoms across four
broad areas of mental functioning set in 20 CFR, Part 404, Subpart P, Appendix 1. These areas
include: (1) understanding, remembering, or applying information; (2) interacting with others; (3)
concentrating, persisting, or maintaining pace; and (4) adapting or managing oneself. [Id. at 26–
27]. The ALJ employs a five-point scale to rate the increasing degree of limitation across given
functional areas from none, mild, moderate, marked, and extreme. 20 C.F.R. § 404.1520a(c)(4).
Limitations of “none” or “mild” are generally considered non-severe, unless the evidence
otherwise indicates that there is more than a minimal limitation in one’s ability to do basic work
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activities. 20 C.F.R. § 404.1520a(d)(1). In this case, the ALJ rated Plaintiff’s medically
determinable mental impairments as “mild” and moved on to the next step.
At step three, the ALJ found that despite Plaintiff’s severe physical impairments, she did
not have an impairment or combination of impairments that met or medically equaled the severity
of an impairment listed in applicable regulations. [ECF No. 4 at 28]. The ALJ noted Plaintiff’s
seizure “disorder d[id] not meet the frequency requirements of listing 11.02.” [Id.]. Specifically,
the ALJ found that Plaintiff’s testimony regarding her seizures was not generally consistent with
the objective evidence. [Id.]. Further, the ALJ stated “the medical evidence d[id] not document
motor aphasia resulting in ineffective speech or communication persisting for at least 3 consecutive
months after the insult as required by listing 11.04(A)[;]” and “there [was] also not medical
documentation of disorganization of motor function in two extremities resulting in an extreme
limitation in the ability to stand up from a seated position, balance while standing or walking, or
use the upper extremities, persisting for at least 3 consecutive months after the insult[,]” as required
by listing 11.04(B). [Id.]. Regarding listing 11.04(C), the ALJ found Plaintiff did not “have a
marked limitation in understanding, remembering, or applying information, interacting with
others, concentrating persisting, or maintaining pace, or adapting or managing oneself[.]” [Id.].
Lastly, the ALJ noted Plaintiff’s peripheral neuropathy did not meet 11.14. [Id.].
At step four, the ALJ carefully assessed all of Plaintiff’s records and concluded she had the
RFC to perform sedentary work and further qualified it with the following limitations:
[T]he claimant has the residual functional capacity to perform sedentary work as
defined in 20 CFR 404.1567(a) except occasionally lift/carry 10 pounds and
frequently lift/carry less than 10 pounds, stand/walk for 4 hours in an 8-hour day,
and sit for 6 hours in an 8-hour day. The claimant would use a hand-held assistive
device for ambulation. She can occasionally climb ramps or stairs, balance, stoop,
kneel, crouch, and crawl, but never climb ladders, ropes, or scaffolds. She can have
occasional exposure to extreme cold, extreme heat, and to unprotected heights.
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[Id. at 29]. In explaining the RFC, the ALJ noted that while Plaintiff’s medically determinable
impairments could be reasonably expected to cause the alleged symptoms, “[Plaintiff’s] statements
concerning the intensity, persistence and limiting effects of these symptoms are not entirely
consistent with the medical evidence and other evidence in the record for the reasons explained in
this decision.” [Id. at 31]. When discussing the medical record, the ALJ found the conclusions
reached by Dr. Morford somewhat persuasive because it was “generally reasonably supported by
the consultant’s review of the record[.]” [Id. at 34]. Nonetheless, the ALJ found Plaintiff’s
“neurology exams showing mild right hemiparesis with decreased sensation [] more consistent
with sedentary work as the claimant would not be able to lift/carry 20 pounds occasionally[.]”
[Id.].
Additionally, the ALJ acknowledged the examination conducted by Dr. Arkin and
concluded it was the most persuasive since it was well supported by the records. [Id.]. The ALJ
stated that:
Dr. Arkin explained that the evidence showed that the claimant had normal range
of motion and strength, but her gait was circumducted and unsteady requiring an
assistive device (Ex. 4A, pg. 8). Dr. Arkin’s finding is reasonably consistent with
other substantial evidence. For example, this finding is consistent with the
claimant’s neurology exams showing mild right hemiparesis, decreased sensation
in the right upper and lower extremity, and a circumducted gait with a cane (Ex. 4F,
11F). However, musculoskeletal exams also showed that the claimant had full range
of motion globally with no muscle weakness or paralysis[.]
[Id.]. The ALJ also considered Dr. De La Cruz’s conclusions after a May 9, 2022, consultation
where Dr. De La Cruz’s opined:
[Plaintiff] was limited to standing/walking for 0-2 hours in an 8-hour day and sitting
for 0-2 hours in an 8-hour day (Ex. 7F). She required an assistive device for
occasional standing/walking (Ex. 7F). [Plaintiff] could rarely lift/carry less than 10
pounds (Ex. 7F). She could never twist or crouch/squat and rarely stoop or climb
stairs (Ex. 7F). [Plaintiff] could use her right hand for reaching, handling, or
fingering 0% of the day, but has no limitations in using the left upper extremity (Ex.
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7F). She is incapable of even low stress jobs and would miss more than 4 days of
work per month (Ex. 7F).
[Id.]. The ALJ found Dr. De La Cruz’s opinion not persuasive and not supported by his treatment’s
notes where Ms. Guimet’s “exams typically show[ed] [Plaintiff] was in no acute distress, had full
range of motion, normal extremities, and was alert and oriented with 2+ deep tendon reflexes[.]”
[Id.].
Finally, the ALJ explained Dr. Haws examination of Plaintiff’s was “somewhat
persuasive.” [Id. at 35]. The ALJ noted that Dr. Haws found Plaintiff required assistance or
guidance during ambulation, could “lift/carry [ten] pounds occasionally and frequently and
occasionally climb ramps or stairs, ladders, ropes, or scaffolds, balance, stoop, kneel, crouch, and
crawl[.]” [Id.]. Dr. Haws also opined Plaintiff had “limitations on verbal acuity, is unsafe to travel
unaided, should do no commercial driving, and her disorientation and cognitive decline would
make working around any type of hazards completely contraindicated . . . . [Plaintiff] ha[d]
limitations in extreme temperatures and working around chemicals, dust, fumes, or gases[.]” [Id.].
The ALJ noted Dr. Haws findings with respect to standing, walking, sitting, lifting, and
postural limitations were generally persuasive since they were reasonably supported by his exam
and reasonably consistent with Plaintiff’s neurologist’s exams and Dr. Arkin’s findings. [Id.].
However, the ALJ stated Dr. Haws’ opinion that Plaintiff had limitations in verbal acuity was not
persuasive as not supported by objective examination findings and inconsistent with Plaintiff’s
“treatment records noting she has clear speech and intact cognitive functioning[.]” [Id.]. The ALJ
also concluded Dr. Haws’ findings regarding total avoidance of hazards was not persuasive and
noted:
While Dr. Haws supported his opinion by explaining that [Plaintiff] ha[d]
disorientation and cognitive decline, he largely based this opinion on the
[Plaintiff’s] subjective reports and did not perform a formal mental status exam or
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other cognitive testing. This portion of his opinion is inconsistent with [Plaintiff’s]
neurology and psychiatry records which consistently note that [she] is alert and
oriented, with intact memory, intact attention, and intact cognition[.]
[Id.]. Lastly, the ALJ found “Dr. Haws’ opinion that [Plaintiff] is limited in working around
chemicals, dust, fumes, or gases [] not persuasive as it [was] not well supported[,]” Dr. Haws did
not provide a reason for his opinion, and it was inconsistent with Plaintiff’s treatment records and
with the findings of the state agency medical consultants. Regarding, Dr. Haws’ cognitive findings,
the ALJ specifically stated “[t]he objective evidence does not support that [Plaintiff] would have
cognitive impairments.” [Id. at 33].
Lastly, at step five, the ALJ considered the VE’s testimony to conclude that Plaintiff could
perform her past work as a Dispatcher, Bus and Trolley. [Id. at 35]. Thus, the ALJ found Plaintiff
“has not been under a disability, as defined in the Social Security Act, from October 10, 2021,
through the date” of the decision. [Id.].
DISCUSSION
The RFC is the ALJ’s assessment, based on all relevant evidence, of a claimant’s ability to
work despite his or her impairments. Lewis v. Callahan, 125 F.3d 1436 (11th Cir. 1997). “Error
arises only when the ALJ rejects medical evidence from the RFC ‘without (at least) providing a
good reason for doing so.’” Felker v. Comm’r of Soc. Sec., No. 2:22-CV-221-KCD, 2023 WL
2986246, at *5 (M.D. Fla. Apr. 18, 2023) (quoting Sneed v. Comm’r of Soc. Sec., No. 6:13-CV-
1453-ORL-TBS, 2015 WL 1268257, at *7 (M.D. Fla. Mar. 19, 2015)). “Even if the evidence
preponderates against the Secretary, we must affirm if the decision is supported by substantial
evidence.” Sewell v. Bowen, 792 F.2d 1065, 1067 (11th Cir. 1985). In addition, “[t]he ALJ is not
required to specifically discuss each piece of evidence so long as the decision shows that [s]he
considered the claimant’s condition as a whole.” Robinson v. Kijakazi, No. 21-21603-CIV, 2022
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WL 18155656, at *2 (S.D. Fla. Dec. 21, 2022), report and recommendation adopted sub nom.
Robinson v. Comm’r of Soc. Sec., No. 21-21603, 2023 WL 136556 (S.D. Fla. Jan. 9, 2023) (quoting
Alvarez v. Comm’r of Soc. Sec., 848 F. App’x 823, 824 (11th Cir. 2021)). Here, Plaintiff raises one
argument for why the case should be remanded. See generally [ECF No. 12].
Plaintiff argues the ALJ erred by failing to incorporate into the RFC evaluation Dr. Haws’s
finding that, due to cognitive issues, Plaintiff requires human assistance and guidance during
ambulation. [Id. at 3–8] (emphasis added). Dr. Haws observed Plaintiff ambulate into the
examination room with the help of her partner, and noted her instability was primarily cognitive
rather than balance related. [ECF No. 12-1 at 2]. Although the ALJ found Dr. Haws’ opinion
“somewhat persuasive” and consistent with other providers’ findings, the ALJ omitted the human
ambulation assistance limitation from the RFC. [ECF No. 12 at 6]. According to Plaintiff, the RFC
was rendered incomplete because it reflected only the use of a hand-held assistive device, without
incorporating the examiner’s limitation that she needed human assistance. [Id. at 3].
Defendant, in turn, asserts the ALJ adequately evaluated Dr. Haws’ opinion, and the record
supports the finding that a cane addressed Plaintiff’s ambulation issues. [ECF No. 16 at 5–7].
Moreover, Defendant argues that substantial evidence from the record supports the ALJ’s finding
that Plaintiff did not have a severe mental impairment, or combination of impairments, that limits
her capacity to do sedentary work with limitations. [Id.]. Specifically, Defendant argues that
“[r]eading the ALJ’s decision as a whole, considering that the ALJ found Plaintiff’s cognitive
issues not reflected in the medical records, but finding a need for a hand-held assistive device
because of balance to be supported by the record, the ALJ properly incorporated Dr. Haws’
persuasive parts of her opinion into the RFC.” [Id. at 7]. In response, Plaintiff contends Defendant
is attempting to make a post-hoc argument to support the ALJ’s finding. [ECF No. 18 at 2].
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Here, there is substantial evidence in the record supporting the ALJ’s findings. Substantial
evidence from the record shows the ALJ considered all of Plaintiff’s medically determinable
impairments, both severe and non-severe, in concluding that Plaintiff was not disabled and has the
RFC to perform sedentary work with specific limitations because her medically determinable
impairments did not render her disabled as defined by 20 C.F.R. pt. 404, subpt. P, appx. 1. [ECF
No. 4 at 29]. “An ALJ is not required to adopt every finding made by a doctor whose opinion is
found to have any modicum of persuasiveness.” Mesa v. Kijakazi, No. 21-20424-CIV, 2022 WL
4369733, at *15 (S.D. Fla. May 11, 2022), report and recommendation adopted, No. 21-20424-
CIV, 2022 WL 4366950 (S.D. Fla. Sept. 21, 2022); see also Watson v. Kijakazi, No. 21-CV-60516-
RUIZ/STRAUSS, 2022 U.S. Dist. LEXIS 95024, at *15 (S.D. Fla. May 3, 2022) (quoting League
v. Comm’r of Soc. Sec., No. 2:20-CV-650-SPC-NPM, 2022 U.S. Dist. LEXIS 42037, 2022 WL
1085540, at *6 (M.D. Fla. Feb. 7, 2022), report and recommendation adopted, 2022 U.S. Dist.
LEXIS 41962, 2022 WL 703011 (M.D. Fla. Mar. 9, 2022)) (“At any rate, ‘the regulations do not
require an ALJ to adopt into the RFC every part of an opinion that he otherwise finds
persuasive.’”).
Contrary to Plaintiff’s assertion that the ALJ ignored Dr. Haws’s recommendation for
human assistance during ambulation, the decision reflects that the ALJ considered this opinion but
reasonably declined to adopt it based on inconsistencies with the broader medical record. See 20
C.F.R. § 404.1529. The ALJ gave due consideration to Plaintiff’s testimony, as well as medical
opinions from consultative examinations and prior administrative assessments in evaluating her
limitations. [ECF No. 4 at 25–35]. Fundamentally, the ALJ noted that although Plaintiff alleged,
she could not perform chores or personal care without help, treatment notes consistently
documented that she was independent in bathing, dressing, toileting, feeding, and medication
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management. [Id. at 30]. The ALJ also observed that Plaintiff reported traveling internationally,
caring for her grandchild, and participating in family outings—activities inconsistent with an
ongoing need for human assistance. [Id.].
Moreover, Plaintiff’s argument that her gait instability was caused by cognitive issues is
not supported by evidence. Notably, the ALJ explicitly addressed the mild limitations in mental
functioning identified at step two and found them consistent with the objective clinical findings
when assessing Plaintiff’s RFC. [ECF No. 4 at 26–27]. The ALJ must rate a claimant’s degree of
limitation in four broad areas of mental functioning. See 20 C.F.R. § 404.1520. As to the third
functional area—“concentrating, persisting, or maintaining pace”—the ALJ determined that
Plaintiff had only a “mild” limitation, citing her psychiatrist’s observations that she was “oriented
to person, time and place [and] able to use decision making strategies.” See [id. at 27]. Additionally,
Plaintiff’s psychiatrist with Ventre documented that Plaintiff was “cooperative and oriented,” with
“goal-directed thought processes” and “fair judgment and insight.” [Id. at 1056]. Furthermore, Dr.
Celdran’s reports demonstrate Plaintiff’s cognitive function as normal. See e.g., [id. at 506, 520].
In light of these repeated normal findings, the ALJ reasonably concluded that Plaintiff’s mental
impairments caused no more than mild limitations in any functional area and that her alleged
cognitive difficulties did not contribute to her physical symptoms or gait instability.
Although finding some aspects of Dr. Haws’ opinion persuasive, the ALJ found
unpersuasive Dr. Haws’ opinion that Plaintiff had limitations in verbal acuity, should avoid
hazards, and had cognitive impairments. [ECF No. 4 at 35]. Notably, the ALJ found persuasive Dr.
Haws’ opinion that Plaintiff needed assistance or guidance to ambulate. [Id.]. The ALJ found that
conclusion consistent with Dr. Arkin’s who opined Plaintiff “would require a hand-held assistive
device for ambulation.” [Id. at 34, 35]. Thus, in accordance with the medical record, the ALJ
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included the need of an assistive device to ambulate in Plaintiff’s RFC. In addition, when
discussing Dr. Haws’ opinion, the ALJ also stated that “[w]hile Dr. Haws supported his opinion by
explaining that the claimant has disorientation and cognitive decline, he largely based this opinion
on the claimant’s subjective reports and did not perform a formal mental status exam or other
cognitive testing.” [Id. at 35].
It is true that the ALJ did not explicitly reject the idea that Plaintiff needed human assistance
to ambulate, but the ALJ was not required to do so. See Mena v. Kilolo Kijakazi Acting Comm’r of
Soc. SEC, No. 1:22-cv-24098 SCOLA/GOODMAN, 2023 U.S. Dist. LEXIS 228532, at *14-15
(S.D. Fla. Nov. 17, 2023) (striking down plaintiff’s implication that if the ALJ found a medical
opinion to be persuasive but either disagrees with or rejects “certain parts of that opinion, then the
ALJ is required to discuss it in her rationale.” The court determined that “[p]laintiff’s position
[was] void of any supporting caselaw and [was] seemingly based on attorney rhetoric.”).
Accordingly, the ALJ did not improperly omit the ‘human assistance’ limitation from the RFC
because the ALJ provided support from record evidence and properly articulated the reasons for
discounting Dr. Haws’ opinion that Plaintiff’s need for guidance or assistance while ambulating
was due to cognitive issues.
Moreover, in reviewing the record as a whole, the ALJ put forth a clear rationale in
concluding that Dr. Celdran’s opinion and Plaintiff’s psychiatrist’s findings were more persuasive
with respect to Plaintiff’s cognitive abilities because they were consistent with other evidence from
Plaintiff’s own testimony and records. [ECF No. 4 at 33]. Thus, there is sufficient evidence to find
that the ALJ properly considered the combined impact of Plaintiff’s limitations in the ultimate
RFC determination.
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Given the substantial evidence standard, and prohibition for this Court to reweigh the
record evidence, the ALJ’s decision must be affirmed.
CONCLUSION
For the foregoing reasons, it is RECOMMENDED that Plaintiff’s Motion for Summary
Judgment [ECF No. 12] be DENIED, the Defendant’s Motion for Summary Judgment [ECF No.
16] be GRANTED, and the ALJ’s decision be AFFIRMED.
Objections to this Report may be filed with the district judge within FOURTEEN (14)
days of receipt of a copy of the Report. Failure to timely file objections will bar a de novo
determination by the district judge of anything in this Report and shall constitute a waiver of a
party’s “right to challenge on appeal the District Court’s order based on unobjected-to factual and
legal conclusions.” 11th Cir. R. 3-1; see also Harrigan v. Metro-Dade Police Dep’t Station #4, 977
F.3d 1185, 1191–92 (11th Cir. 2020); 28 U.S.C. § 636(b)(1)(C).
SIGNED this 5th day of January, 2026.
LISETTE M. REID
UNITED STATES MAGISTRATE JUDGE
cc: United States District Judge K. Michael Moore;
All Counsel of Record
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