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