Ayala v. Commissioner of Social Security Administration

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF OHIO
EASTERN DIVISION
ARACELIS AYALA,
Plaintiff,
vs.
COMMISSIONER OF SOCIAL
SECURITY ADMINISTRATION,
Defendant.
CASE NO. 1:25-cv-805
MAGISTRATE JUDGE
JAMES E. GRIMES JR.
MEMORANDUM OPINION
AND ORDER
Plaintiff Aracelis Ayala filed a complaint against the Commissioner of
Social Security seeking judicial review of the Commissioner’s decision denying
her applications for supplemental security income and disability insurance
benefits. Doc. 1. This Court has jurisdiction under 42 U.S.C. §§ 405(g) and
1383(c). The parties consented to my jurisdiction in this case. Doc. 5. Following
review, and for the reasons stated below, I affirm the Commissioner’s decision.
Procedural Background
In August 2020, Ayala filed applications for both supplemental security
income and disability insurance benefits, alleging an amended disability onset
date of December 24, 2019.1 See Tr. 2791 (noting that Ayala amended her onset
1 	“Once a finding of disability is made, the [agency] must determine the
onset date of the disability.” McClanahan v. Comm’r of Soc. Sec., 193 F. App’x
422, 425 (6th Cir. 2006).
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date); see also Tr. 109, 117 (Ayala’s benefits applications). In pertinent part,
Ayala alleged that she was disabled and unable to work due to the following
impairments: back issues, tendonitis on both wrists, carpal tunnel on both
hands, left hand surgery, leg pain, anxiety, depression, and high blood
pressure. See Tr. 109, 117.
In April 2021, Ayala requested a hearing. Tr. 167. Administrative Law
Judge (“ALJ”) Penny Loucas held a telephone hearing in September 2021. Tr.
46. Also in September 2021, ALJ Loucas issued a written decision, which found
that Ayala was not entitled to benefits. Tr. 16. In October 2021, Ayala appealed
the ALJ’s decision to the Appeals Counsel. Tr. 215. In August 2022, the
Appeals Counsel denied Ayala’s appeal of ALJ’s September 2021 decision. Tr.
2866. Ayala then filed a complaint in the District Court, but the parties
subsequently and jointly agreed to a stipulated remand. Tr. 2894.
In September 2023, ALJ Charlene P. Bellinger issued a Remand Order
that provided instructions for further evaluation of Ayala’s applications. See
Tr. 2917–2920. In February 2024, ALJ Loucas held a second telephone hearing
on remand. Tr. 2818. Ayala appeared, testified, and was represented by
counsel at the February 2024 hearing. Id. Qualified vocational expert Laura
Pizzurro also testified. Id. In March 2024, ALJ Loucas issued a written
decision, which found that Ayala was not entitled to benefits. Tr. 2787–2817.
In March 2024, Ayala appealed the ALJ’s decision to the Appeals
Counsel. See Tr. 3008. In February 2025, the Appeals Counsel denied Ayala’s
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appeal, making ALJ Loucas’s March 2024 decision the final decision of the
Commissioner. Tr. 2780; see 20 C.F.R. § 404.981.
Ayala timely filed this action in April 2025. Doc. 1. In her opening brief,
Ayala raises two issues:
1. 	Whether 	the 	ALJ 	erred 	by 	failing 	to
incorporate 	the 	Plaintiff’s 	need 	for 	an
ambulatory assistive device into her assigned
residual functional capacity.
2. 	Whether the ALJ erred by discounting the
medical opinions of the Plaintiff’s treatment
providers.
Doc. 9, at 1.
Evidence
The parties do not dispute the ALJ’s description of the medical record,
so the ALJ’s summary of the evidence is incorporated as follows:
The claimant amended the alleged onset date to
December 24, 2019. The 2017 records noted a history
of chronic right patellofemoral pain of the right
knee. Right knee examination revealed tenderness
but good range of motion without motor or sensory
deficits (Exhibit B16F 1079).
The 	October 	2017 	lumbar 	spine 	MRI 	revealed
anatomic alignment with vertebral body heights
maintained with multilevel degenerative changes
present 	with 	mild 	diffuse 	disc 	bulge 	at 	L2-L3
causing minimal neural foraminal narrowing. There
was mild facet hypertrophic in the lower lumbar
spine without any significant narrowing or neural
compression (Exhibit B2F 94).
The March 13, 2019, MRI of the cervical spine
showed spondylosis C5-C6 bulge with mild stenosis
(Exhibit B2 F 94). The claimant underwent left
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carpal tunnel carpal tunnel release in March 2019
(Exhibit B3F 343). In May 2019 claimant said her
left hand and wrist were getting better with increase
functional use of her left hand (Exhibit B3 F 287). At
physical therapy in June 2019 claimant said her
neck symptoms overall felt better with some left
upper trapezius spasms that occasionally caused
pain, but indicated she was able to manage with a
home exercise program to control pain (Exhibit B3F
275).
In January 2020 the claimant’s BMI was 41 (Exhibit
B2F 310). With Dr. Chang in April 2020, the history
noted 	September 	2017 	EMG 	showed 	mild 	left
median 	neuropathy 	and 	no 	evidence 	of
radiculopathy or polyneuropathy. The claimant was
diagnosed with mild right carpal tunnel syndrome
and right de Quervains tenosynovitis (Exhibit B2F
124).
In 	May 	2020 	the 	claimant 	said 	she 	had 	near-
complete relief with a medial branch block with
some return of right leg pain after shopping. The
claimant 	was 	prescribed 	Prednisone 	and 	the
assessment noted claimant’s left cervical radicular
pain had improved after an epidural (Exhibit B2F
131, 135). The June 2020 MRI of the lumbar spine
impression was mild lumbar spondylosis with no
significant canal or foraminal stenosis treated with
Gabapentin and Flexeril (Exhibit B3F 749).
The June 2020 examination revealed 5/5 strength of
bilateral 	extremities, 	intact 	sensation, 	and 	2+
reflexes throughout. Physical therapy indicated the
MRI did not explain the claimant’s leg symptoms
(Exhibit B4F 84; B6F 21). The claimant underwent
a 	July 	2020 	right 	hip 	with 	impression 	of 	mild
degenerative changes of the hip (Exhibit B6F 133).
In 	September 	2020 	the 	claimant 	said 	she 	had
complete resolution of her hip pain after a right hip
injection. 	The 	claimant 	said 	her 	right 	lower
extremity EMG was normal (Exhibit B7F 39).
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September 2020 with Dr. Cheng, the claimant had a
full range of motion of the bilateral wrist, 4+/5
strength, intact sensation, tenderness of the left
thumb 	at 	the 	first 	dorsal 	compartment, 	normal
stability and sensation, and mildly positive Tinel’s.
The 	assessment 	was 	right 	De 	Quervains
tenosynovitis, 	left 	wrist 	De 	Quervains
decompression February 2020, and left wrist carpal
release in March 2019 (Exhibit B7F 7). With the
claimant’s nurse practitioner in November 2020, the
claimant said she had 40% pain relief with Zanaflex.
She 	added 	that 	she 	wore 	an 	ankle 	brace 	for
tendinitis of the right ankle, but it could not be
addressed until her back was addressed (Exhibit
B9F 	313). 	However, 	there 	is 	no 	evidence 	the
claimant was putting off any ankle treatment due to
her back.
On December 10, 2020, due to left De Quervains
tenosynovitis, the claimant underwent first dorsal
compartment 	release 	(Exhibit 	B 	2F 	51). 	In 	a
February 26, 2021, surgery follow-up the claimant
had sutures removed, and she had near full range of
motion of the fingers (Exhibit B2F 75).
The January 25, 2021, MRI the right hip impression
was mild right hip osteoarthritis (Exhibit B8F 25).
March 23, 2021, right hand x-ray impression was no
significant osseous or articular abnormality of the
right hand (Exhibit B9F 289).
The 	April 	14, 	2021, 	MRI 	the 	cervical 	spine
impression 	was 	central 	disc 	protrusion 	causing
moderate to severe narrowing of the canal with mild
cord compression with no spinal cord edema. There
was mild narrowing the bilateral neural foramina.
The 	disc 	protrusion 	and 	cord 	compression 	had
progressed when compared to the prior study in
March 2019 (Exhibit 9F 288).
On April 27, 2021, with Dr. Kelly the claimant
complained of left arm pain with numbness and
tingling of the fingers, unsteady gait, and dropping
things. The claimant’s gait was antalgic with intact
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strength, sensation, and reflexes throughout. The
claimant 	was 	offered 	a 	C5-C6 	anterior 	cervical
discectomy and fusion (Exhibit B10F 65-70). The
May 	11, 	2021, 	CT 	of 	the 	cervical 	spine 	show
spondylosis at C5-C6 and large left thyroid nodule
measuring 3.1 cm (Exhibit B10F 81). On June 4,
2021, the claimant said she wanted to try another
round of epidural steroid injections prior to cervical
surgery (Exhibit B10F 166).
When the claimant underwent a thyroid biopsy on
June 17, 2021. The vitals noted BMI of 43. The
claimant’s’ s motor and sensory examination was
grossly intact, and she wore a right ankle brace and
walked with a cane. The biopsy was benign, and the
claimant 	underwent 	thyroid 	lobectomy 	(Exhibit
B12F 53, 61; B14F 34).
On September 10, 2021, claimant underwent left-
sided anterior cervical C5-C6 discectomy with plates
and screws at C5-C6 for fixation of the spine (Exhibit
B14F 2). On September 21, 2021, the claimant said
her 	presurgical 	arm 	pain 	and 	weakness 	were
improving and she had no concerns (Exhibit B29F
268). In the October 18, 2021, surgery follow-up the
claimant said she was doing well and her presurgical
arm pain and weakness were improving and she
denied 	any 	concerns. 	Her 	BMI 	was 	43 	and 	no
abnormal 	physical 	or 	psychiatric 	findings 	were
noted (Exhibit B14F 59).
On August 12, 2022, the claimant complained of left
thumb pain with some progressive symptoms over
the last several months with difficulty gripping and
grasping. The hand x-ray revealed possible basilar
joint space narrowing and small calcifications with
joint space maintained and no erosions. She had a
normal range of motion of cervical spine without
evidence 	of 	cervical 	radiculopathy 	with 	normal
range of motion of the left wrist and negative Tinel’s
and Phalen’s. She had positive CMC grind test with
no other symptomatic digits or pain. Impression was
left hand pain, trigger thumb, and arthritis of CMC
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joint. The plan was anti- inflammatory and splint
(Exhibit B13F 18-20).
At orthopedics on August 13, 2022, the claimant
complained of right hip pain. Right hip examination
revealed 100° flexion, internal rotation 10°, and
external rotation 35°. She had intact strength of the
DF, 	PF, 	EHL 	as 	well 	as 	intact 	sensation. 	The
claimant was advised that her hip joint appeared
normal with no evidence of avascular necrosis on the
MRI, and there was no intra-articular hip pathology
present (Exhibit B14F 24-26).
On August 25, 2022, the claimant was seen for right
buttocks and groin pain reporting a few hours relief
after August 2022 right gluteal bursa injection. Her
gait was slow with use of a cane. She had was right
hip 	tenderness 	with 	normal 	range 	of 	motion.
However, she said since May 2022 that after change
from Lyrica to Pregabalin her right ankle symptoms
reduced by 40%, Motrin was effective, and she had
not seen podiatry since September 2020. She used
an AFL brace on the right that allowed her to drive,
get around, and control discomfort. She said she was
doing well since her cervical surgery (Exhibit B14F
106, 107; B16F 57-58). On October 10, 2022, at
hepatology the claimant said she had no concerns,
overall doing well, and was actively trying to lose
weight. 	The 	physical 	examination 	was
unremarkable (Exhibit B16F 40, 43).
The claimant underwent another lumbar spine x-ray
on November 4, 2022, with an impression of no
compression deformity and mild lumbar spondylosis
(Exhibit 	B27F 	10). 	In 	the 	November 	4, 	2022,
primary care visit, the claimant complained of a
mass of the right forearm after IV for endoscopy. The
claimant’s BMI was 46. In the review system she
denied any swelling, spasm, numbness, tingling,
anxiety, panic, or memory loss. She was in no acute
distress 	and 	the 	physical 	examination 	was
unremarkable. 	The 	assessment 	was 	right 	wrist
mass with a plan of ultrasound (Exhibit B18F 10-
11). At physical therapy in November 2022 for left
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thumb 	CMC 	osteoarthritis 	and 	trigger 	thumb
symptoms, the claimant said her left thumb felt
much better with home program and splinting with
some locking of the thumb a couple of days ago. She
denied 	any 	significant 	paresthesia 	or 	numbness
(Exhibit B20F 10, 35).
At orthopedics on November 18, 2022, the claimant
had 	a 	full 	range 	of 	motion 	of 	the 	left 	hand,
tenderness of the A1 pulley of the left thumb with no
frank triggering on examination, and no other digits
were significant painful (Exhibit B24F 17).
The May 12, 2023, NCS and EMG showed mild left
median neuropathy cross the wrist and chronic left
C7 and C8 cervical radiculopathy without active d
enervation. 	The 	impression 	noted 	study
interpretation 	is 	difficult 	given 	the 	claimant’s
history of left carpal tunnel release surgery and a
mild left median finding may not have any clinical
significance (Exhibit B27F 31). At physical therapy
in June 2023 the claimant complained of left leg pain
and right groin pain. Her gait was antalgic with use
of a cane, but she indicated she was able to perform
steps independently at home with some difficulty
(Exhibit B28F 13-14).
In the September 2023 follow-up noted the claimant
complained of back and right hip symptoms. She
walked walk with a cane and used a right AFO
brace. She had positive straight leg raise test on the
right with severely limited right hip range of motion.
She had 5/5 strength of bilateral upper extremities
with intact sensation. The plan was MRI of the
lumbar spine, Mobic, and home exercise program
(Exhibit B29F 12-14).
The 	claimant 	complained 	of 	shoulder 	pain 	on
September 28, 2023, and some left sided neck pain.
The 	claimant 	said 	that 	after 	her 	2021 	cervical
discectomy and fusion she had complete resolution
of the symptoms, and the claimant did not require
physical 	therapy 	after 	cervical 	spine 	surgery.
Examination revealed a full range of motion of the
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neck with some left trapezius tenderness. She had a
full range of motion of forward extension of left
upper 	extremities 	90° 	with 	good 	strength 	and
sensation. The September 12, 2023, cervical spine x-
ray 	showed 	postsurgical 	changes 	from 	anterior
cervical disc fusion at C5-C6 with plate and multiple
screws. The hardware appears intact with 2.5 mm
retrolisthesis 	of 	C5 	on 	C6. 	The 	vertebral 	body
heights 	are 	preserved, 	prevertebral 	soft 	tissues
appeared 	unremarkable, 	and 	there 	was 	mild
spondylotic changes at C5-C6 and C6-C7. The plan
was to continue Mobic and Gabapentin and see
neurosurgery (Exhibit 31F 12-15; B29F 532).
The 	claimant 	was 	seen 	at 	the 	emergency
department 	November 	27, 	2023, 	complaining 	of
right leg pain for three days. She denied any frank
low extremity weakness or sensation loss and that
symptoms felt like sciatica that she had in the past.
Examination revealed full range of motion of all four
extremities and right lower extremity had intact
sensation, motor strength of 5/5, intact pulses, 2/4
reflexes, 	and 	no 	abnormal 	neurological 	findings
noted. The assessment was hemodynamically stable
with no concerning 	signs or symptoms 	of acute
spinal cord compression and examination consistent
with 	sciatica. 	The 	claimant 	was 	prescribed
Prednisone and referred to physical therapy. The
assessment was sciatica of right side (Exhibit B32F
9-12).
At Rehabilitation Medical Center on December 8,
2023, 	the 	claimant 	complained 	of 	right 	lower
extremity pain behind the right knee and prescribed
steroid from emergency department. The history
noted September 2023 complaints of left neck and
arm pain the claimant described as intermittent and
mostly when waking in the morning. The bilateral
upper EMG was described as within normal limits
in the cervical spine x-ray review as mild spondylitic
changes with hardware intact. Physical examination
listed 	limited 	gait 	with 	use 	of 	cane, 	5/5 	upper
extremity strength, intact sensation to light touch in
the 	upper 	extremities, 	2+ 	reflexes 	throughout,
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negative Hoffman, negative Spurling, limited range
of motion all planes, tenderness to palpation of the
bilateral upper trapezius, and positive Tinel of 	the
left elbow. The impression was back pain, right groin
pain, left arm pain with normal EMG, left upper
trapezius spasm, and pain of the popliteal fossa
(Exhibit B32F 1-3).
Regarding 	the 	claimant’s 	mental 	health
impairment, 	she 	had 	routine 	follow-ups 	for
counseling 	and 	medications 	with 	the 	most
significant findings regarding affect and mood of
some dysphoric, constricted, and dysthymic findings
and a few complaints of distractibility and some
problems maintaining attention and concentration.
Otherwise, 	the 	vast 	majority 	mental 	status
examinations were unremarkable. The claimant’s
medications appear very effective in managing her
anxiety and depression symptoms. Numerous visits
noted the claimant’s medications were Trazodone,
Wellbutrin, Buspar, and Sertraline. September 2020
and October 2020 mental status examination was
normal other than an anxious and dysphoric mood
and constricted affect. 	In 	the 	October 	2020 	the
claimant said her medications decreased anxiety
and improved mood (Exhibit B4F 9-10, 52; B7F 50,
57, 65, 92, 109). In the November 2020 behavior
follow-up, the clinical impression was stabilizing
with the only abnormal findings of dysphoric mood
and constricted affect. The claimant’s mood was
euthymic 	and 	mental 	status 	examination 	was
normal in the November 18, 2020, follow-up (Exhibit
B7F 155, 161).
In March 2021, the claimant reported attention and
concentration problems, but the remainder of the
mental 	status 	examination 	was 	unremarkable
(Exhibit B10F 4). In the May 2021 and June 2021,
follow-ups 	the 	mental status 	examinations 	were
normal 	other 	than 	an 	anxious 	mood 	and
constricted/dysphoric affect (Exhibit B10F 98, 129;
B12F 42, 61; B14F 23). The claimant’s depression
was described as mild in November 2021. Her mood
was 	euthymic, 	affect 	was 	constricted, 	and 	the
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remainder of the mental status examination was
normal (Exhibit B14F 70, 83).
In a July 2022 behavior follow-up, the mental status
examination was normal. The claimant said she was
doing ok in the September 2022 medication visit
with some increasing anxiety but also indicated she
was getting out more. Her mood was euthymic, and
remainder of the mental status examination was
unremarkable (Exhibit B14F 101, 108; B17F 53). In
November 2022 the claimant said her mood been ok,
stable, and anxiety had been up and down. Mental
status examination was normal in the assessment
remained depression and anxiety (Exhibit B23F 18,
23).
In the March 2023 behavior follow-up, the claimant’s
mood was dysphoric, affect was constricted, and the
remainder of the mental status examination was
normal. In the other March 2023 visit, the mental
status 	examination 	was 	unremarkable 	(Exhibit
B26F 14, 21). In May 2023 and June 2023 behavior
follow-ups 	the 	mental status 	examinations 	were
normal (Exhibit B27F 20, 39). The July 2023 and
September 2023 mental status examinations were
normal (Exhibit B29F 65; B31F 12). In November
2023 one mental status examinations revealed the
claimant’s mood was anxious and dysphoric and the
other examination was normal (Exhibit B32F 77,
19).
Tr. 2798–2802.
The ALJ’s Decision
The ALJ made the following findings of fact and conclusions of law:
1. 	The 	claimant 	meets 	the 	insured 	status
requirements 	of 	the 	Social 	Security 	Act
through December 31, 2022.
2. 	The claimant has not engaged in substantial
gainful activity since December 24, 2019, the
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alleged onset date (20 CFR 404.1571 et seq.,
and 416.971 et seq.).
3. 	The 	claimant 	has 	the 	following 	severe
impairments: generalized osteoarthritis and
other musculoskeletal conditions of the joints
(e.g., right ankle 	bursitis/tendonitis, right
patellofemoral 	disorder, 	left 	thumb
osteoarthritis, and de Quervain’s disease of
the 	bilateral 	upper 	extremities); 	cervical
degenerative disc disease status post ADFC
C5-C6; 	mild 	lumbar 	degenerative 	disc
disease; 	mild 	right 	hip 	osteoarthritis; 	left
carpal tunnel syndrome status post corrective
surgery; obesity; major depressive disorder;
and anxiety disorder (20 CFR 404.1520(c) and
416.920(c)).
4. 	The claimant does not have an impairment or
combination of impairments that meets or
medically equals the severity of one of the
listed 	impairments 	in 	20 	CFR 	Part 	404,
Subpart P, Appendix 1 (20 CFR 404.1520(d),
404.1525, 404.1526, 416.920(d), 416.925 and
416.926).
5. 	After 	careful 	consideration 	of 	the 	entire
record, 	the 	undersigned 	finds 	that 	the
claimant has the residual functional capacity
to perform light work as defined in 20 CFR
404.1567(b) and 416.967(b) except lift, carry,
push, and pull 20 pounds occasionally and 10
pounds frequently; stand and/or walk 4 hours
out of an 8-hour day; and to sit 6 hours out of
an 8-hour day; can occasionally operate foot
controls 	bilaterally; 	can 	occasionally 	climb
ramps 	and 	stairs, 	but 	can 	never 	climb
ladders, ropes, or scaffolds; can occasionally
balance, stoop, kneel, crouch, and crawl. Can
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frequently 	handle 	and 	finger 	bilaterally.
Should avoid work tasks that expose one to
hazards 	such 	as 	unprotected 	heights 	and
dangerous moving machinery like power saws
and jackhammers. Should avoid work tasks
that require hourly production quotas.
6. 	The claimant is unable to perform any past
relevant 	work 	(20 	CFR 	404.1565 	and
416.965).
7. 	The claimant was born on November 24, 1973,
and was 44 years old, which is defined as a
younger individual age 18–49, on the alleged
onset 	date. 	The 	claimant 	subsequently
changed age category to closely approaching
advanced age (20 CFR 1563 and 416.963).
8. 	The claimant has a limited education (20 CFR
404.1564 and 416.964).
9. 	Transferability of job skills is not material to
the determination of disability because using
the Medical-Vocational Rules as a framework
supports a finding that the claimant is “not
disabled,” whether or not the claimant has
transferable job skills (See SSR 82-41 and 20
CFR Part 404, Subpart P, Appendix 2).
10. 	Considering the claimant’s age, education,
work 	experience, 	and 	residual 	functional
capacity, 	there 	are 	jobs 	that 	exist 	in
significant numbers in the national economy
that 	the 	claimant 	can 	perform 	(20 	CFR
404.1569, 404.1569a, 416.969, and 416.969a).
11. 	The claimant has not been under a disability,
as defined in the Social Security Act, from
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December 42, 2019, through the date of this
decision (20 CFR 404.1520(g) and 416.920(g)).
Tr. 2793–94, 2797, 2806, 2808.
Standard for Disability
Eligibility for social security benefit payments depends on the existence
of a disability. 42 U.S.C. §§ 423(a), 1382(a). “Disability” is defined as the
“inability to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be expected
to result in death or which has lasted or can be expected to last for a continuous
period of not less than 12 months[.]” 42 U.S.C. § 423(d)(1)(A); see also 42 U.S.C.
§ 1382c(a)(3)(A).
An ALJ is required to follow a five-step, sequential analysis to make a
disability determination:
1. 	Is the claimant engaged in substantial gainful
activity? If so, the claimant is not disabled.
2. 	Does 	the 	claimant 	have 	a 	medically
determinable impairment, or a combination of
impairments, 	that 	is 	“severe”? 	If 	not, 	the
claimant is not disabled.
3. 	Does the claimant’s impairment meet or equal
one of the listed impairments and meet the
duration requirement? If so, the claimant is
disabled. If not, the ALJ proceeds to the next
step.
4. 	What is the claimant’s residual functional
capacity and can the claimant perform past
relevant 	work? 	If 	so, 	the 	claimant 	is 	not
disabled. If not, the ALJ proceeds to the next
step.
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5. 	Can 	the 	claimant 	do 	any 	other 	work
considering the claimant’s residual functional
capacity, 	age, 	education, 	and 	work
experience? If so, the claimant is not disabled.
If not, the claimant is disabled.
20 C.F.R. §§ 404.1520, 416.920; see Jordan v. Comm’r of Soc. Sec., 548 F.3d
417, 422 (6th Cir. 2008). Under this sequential analysis, the claimant has the
burden of proof at steps one through four. Jordan, 548 F.3d at 423. The burden
shifts to the Commissioner at step five “to prove the availability of jobs in the
national economy that the claimant is capable of performing.” Id. “The
claimant, however, retains the burden of proving her lack of residual functional
capacity.” Id. If a claimant satisfies each element of the analysis and meets the
duration requirements, the claimant is determined to be disabled. Walters
Comm’r of Soc. Sec., 127 F.3d 525, 529 (6th Cir. 1997).
Standard of Review
A reviewing court must affirm the Commissioner’s conclusions unless it
determines “that the ALJ has failed to apply the correct legal standards or has
made findings of fact unsupported by substantial evidence in the record.”
Jordan, 548 F.3d at 422. “‘[S]ubstantial evidence’ is a ‘term of art’” under which
“a court … asks whether” the “existing administrative record … contains
‘sufficien[t] evidence’ to support the agency’s factual determinations.” Biestek
v. Berryhill, 587 U.S. 97, 102 (2019) (citations omitted). The substantial
evidence standard “is not high.” Id. Substantial evidence “is ‘more than a mere
scintilla’” but it “means only[] ‘such relevant evidence as a reasonable mind
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might accept as adequate to support a conclusion.’” Id. at 103 (citations
omitted). The Commissioner’s “findings … as to any fact if supported by
substantial evidence [are] conclusive.” 42 U.S.C. § 405(g); Biestek, 587 U.S. at
99.
A court may “not try the case de novo, resolve conflicts in evidence, or
decide questions of credibility.” Bass v. McMahon, 499 F.3d 506, 509 (6th Cir.
2007). Even if substantial evidence or a preponderance of the evidence
supports 	a 	claimant’s 	position, 	a 	reviewing 	court 	cannot 	overturn 	the
Commissioner’s decision “so long as substantial evidence also supports the
conclusion reached by the ALJ.” Jones v. Comm’r of Soc. Sec., 336 F.3d 469,
477 (6th Cir. 2003). This is so because there is a “zone of choice within which”
the Commissioner can act, without fear of judicial “interference.” Lindsley v.
Comm’r of Soc. Sec., 560 F.3d 601, 605 (6th Cir. 2009) (quoting Felisky v.
Bowen, 35 F.3d 1027, 1035 (6th Cir. 1994)).
Discussion
1. 	The ALJ did not err by excluding a cane limitation from Ayala’s
RFC assessment.
For her first argument, Ayala argues that the ALJ erred “when she did
not incorporate [Ayala’s] need for an ambulatory device, such as a cane or a
walker, into her assigned [RFC]” and by “insist[ing]” that, despite the evidence
reporting Ayala’s use of a cane, “this cane was not a ‘medical necessity’ but
rather ‘a volitional preference.’” Doc. 9, at 18–19.
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If an assistive device is “not a necessary device for [a] claimant’s use, it
cannot be considered an exertional limitation that reduce[s] [the claimant’s]
ability to work.” Carreon v. Massanari, 51 F. App’x 571, 575 (6th Cir. 2002). To
be considered a restriction or limitation, an assistive device “must be so
necessary that it would trigger an obligation on the part of the Agency to
conclude that the [device] is medically necessary.” Murphy v. Astrue, No. 2:11-
cv-114, 2013 WL 829316, at *10 (M.D. Tenn. March 6, 2013) (citations omitted).
To be medically necessary, the record must reflect “more than just a subjective
desire on the part of the plaintiff as to the use of a[n] [assistive device].” Id.
(citation omitted). And there must be medical documentation “describing the
circumstances for which it is needed (i.e., whether all the time, periodically, or
only in certain situations; distance and terrain; and any other relevant
information).” Soc. Sec. Ruling 96-9p, 1996 WL 374185, *7 (S.S.A. July 2,
1996); see Golden v. Berryhill, No. 1:18-cv-636, 2018 WL 7079506, at *19 (N.D.
Ohio 	Dec. 	12, 	2018) 	(“a 	cane 	prescription 	[that] 	does 	not 	indicate 	‘the
circumstances 	for 	which 	[the 	cane] 	is 	needed,’ 	… 	does 	not 	fulfil 	the
requirements under SSR 96-9p”), report and recommendation adopted sub
nom. Golden v. Comm’r of Soc. Sec., 2019 WL 415250 (N.D. Ohio Feb. 1, 2019).
“If the ALJ does not find that such device would be medically necessary,
then the ALJ is not required to pose a hypothetical to the V[ocational] E[xpert]”
which includes the use of an assistive device. Murphy, 2013 WL 829316, at *10
(citing Casey v. Sec’y of Health & Human Servs., 987 F.2d 1230, 1235 (6th Cir.
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1993)). Generally, an ALJ’s finding that an assistive device is not medically
necessary is error when the claimant was prescribed an assistive device and
the ALJ didn’t include the use of the device in the RFC without providing an
explanation for omitting it. Cruz-Ridol v. Comm’r of Soc. Sec., No. 1:17-cv-
1075, 2018 WL 1136119, at *15 (N.D.Ohio Feb. 12, 2018) (citing Watkins v.
Comm’r of Soc. Sec., No. 1:16–cv–2643, 2017 WL 6419350, at *11 (N.D. Ohio
Nov. 22, 2017)), report and recommendation adopted, 2018 WL 1083252 (N.D.
Ohio Feb. 28, 2018).
To find that a “hand-held assistive device is medically required, there
must be medical documentation establishing the need for a hand-held assistive
device to aid in walking or standing, and describing the circumstances for
which it is needed.” SSR 96-9p, 1996 WL 374185, at *7. To show that an
assistive device must have been required, a claimant “must also show that his
medical records specifically document the circumstances in which he required
an assistive device—i.e., whether he required one at all times, during all
activities, and on all terrains.” Barnes v. Comm’r of Soc. Sec., No. 5:21-cv-1688,
2023 WL 2988346, at *8 (N.D. Ohio Mar. 22, 2023) (emphasis added); see SSR
96-9p, 1996 WL 374185, at *7.
Here, Ayala does not assert that she had, or cite a record showing that
she had, a cane prescription. She also does not point to any persuasive medical
evidence that specifically documents the circumstances in which she required
an assistive device. See Barnes, 2023 WL 2988346, at * 8. Instead, Ayala points
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to certain records and testimony that she believes support her position that a
cane was medically necessary. Doc. 9, at 20. Based on the records she
highlights, Ayala claims that “the record [is] filled with evidence that [she]
needed a cane to ambulate and balance” and that sometimes she “was so
unsteady that even a cane could not support her” so she “used a bilateral
walker where she could rest both of her hands.” Id. While it is clear that Ayala
believes she needed a cane, none of the evidence Ayala cites shows that the
ALJ’s decision to the contrary failed to comply with SSR 96-9p or was
unsupported by substantial evidence.
The ALJ explained her opinion that the objective findings in the record
did not support Ayala’s subjective allegations surrounding limitations for
standing, walking, and lifting, including Ayala’s allegations that she needed a
cane. See Tr. 2803 (identifying mild findings in imaging of Ayala’s lumbar spine
and hip and explaining that Ayala was “advised that there were no findings to
support her allegations of lower extremity symptoms and complaints”). So,
ultimately, the ALJ concluded that the medical findings did not support the
conclusion that a cane is medically necessary. Id. Because the ALJ found that
the record did not demonstrate a cane was medically necessary, she explained
that Ayala’s RFC did not include a limitation for use of a cane. Ayala does not
argue that this explanation was insufficient. Instead, Ayala essentially argues
that the evidence she cited supports a different outcome. Doc. 9, at 19–20. This
argument, however, does not provide a basis for remand because it is entirely
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possible for the evidence to support different conclusions. See Jones, 336 F.3d
at 477. And Ayala’s citation to other evidence in the record to support her
position is irrelevant unless she can show that the ALJ’s decision was
unsupported by substantial evidence. See Warner v. Comm’r of Soc. Sec., 375
F.3d 387, 390 (6th Cir. 2004). The ALJ identified substantial evidence,
meaning evidence “more than a mere scintilla,” Biestek, 587 U.S. at 102, to
support her conclusions that a cane was not medically necessary, see e.g., Tr.
2802–03 (explaining the evidence and testimony considered when making the
“legal inference and conclusion” that a cane was not medically necessary). So,
to the extent that Ayala is challenging whether the ALJ’s decision to exclude a
cane limitation was supported by substantial evidence, that challenge fails.
Lastly, Ayala claims that “seemingly on her own” the ALJ found that
Ayala “did not have a medical need for any assistive ambulatory device, and
that their use had been merely ‘volitional.’” Doc. 9, at 20. To this end, Ayala
claims that the ALJ “played doctor” by (1) using the word “volitional” to
describe Ayala’s use of a cane or (2) by finding that a cane was not medically
necessary. Id. at 20–21. Nothing the Ayala cites supports the idea that the
ALJ’s use of “volitional” to describe Ayala’s can use, especially without citation
to a prescription for such use, is either inaccurate or improper. Indeed, by
definition, if use of a cane is not necessary, then it is voluntary.
Instead, Ayala’s point seems to rest on the unsupported implication that
the word “volitional” has some clinical or professional import such that, by
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using that word, the ALJ “played doctor.” And, to the extent that Ayala is more
generally arguing that the ALJ’s conclusion that a cane was not medically
necessary amounted to “playing doctor,” that argument fails. It is for the ALJ
to assess the medical evidence and determine whether an assistive device is
medically necessary. See SSR 96-9p, 1996 WL 374185, at *7 (explaining what
“the adjudicator” must consider when determine whether a hand-held assistive
device is medically required).
To review, Ayala has not identified any evidence that demonstrates a
cane was medically necessary, such that it could have been error to exclude a
cane limitation from her RFC. Ayala has also failed to show that the ALJ’s
decision 	that 	a 	cane 	was 	not 	medically 	necessary 	was 	unsupported 	by
substantial evidence. Her first issue, thus, does not support remand.
2. 	The ALJ’s consideration of the medical evidence complied with
applicable regulations.
Ayala next argues that the ALJ “disregarded” two treating provider
opinions, which contradicted the ALJ’s RFC determination “despite [the]
persuasiveness” of those two opinions. Doc. 9, at 22.
Under the current regulations, the Commissioner is required to evaluate
the 	persuasiveness 	of 	all 	medical 	opinions 	using 	the 	following 	factors:
supportability; 	consistency; 	treatment 	relationship, 	including 	the 	length,
frequency, purpose, and extent; specialization; and other factors. 20 C.F.R. §§
416.920c(a), 416.920c(c)(1)–(5). Supportability and consistency are the most
important factors. 20 C.F.R. § 416.920c(a). Supportability means that “[t]he
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more relevant the objective medical evidence and supporting explanations
presented by a medical source are to support his or her medical opinion[] …
the more persuasive the medical opinions … will be.” 20 C.F.R. § 416.920c(c)(1).
Consistency means “[t]he more consistent a medical opinion[] … is with the
evidence from other medical sources and nonmedical sources in the claim, the
more persuasive the medical opinion[] … will be.” 20 C.F.R. § 416.920c(c)(2).
The Commissioner must explain the supportability and consistency factors
when discussing a medical opinion. 20 C.F.R. § 416.920c(b)(2). “[A]n ALJ need
not,” however, “specifically use the terms ‘supportability’ or ‘consistency’ in his
analysis.” Cormany v. Kijakazi, No. 5:21-cv-933, 2022 WL 4115232, at *3 (N.D.
Ohio Sept. 9, 2022) (citing cases). The Commissioner is not required to discuss
the remaining factors. Id. “A reviewing court evaluates whether the ALJ
properly considered the factors as set forth in the regulations to determine the
persuasiveness of a medical opinion.” Toennies v. Comm’r of Soc. Sec., 2020 WL
2841379, at *14 (N.D. Ohio June 1, 2020) (internal quotation marks and
citation omitted).
Nurse Practitioner Ann Harrington
Ayala first argues that the ALJ erred in her evaluation of Nurse
Harrington’s opinion. As to Nurse Harrington’s opinion, the ALJ said this:
On 	August 	4, 	2021, 	the 	claimant’s 	nurse, 	Ann
Harrington, 	indicated 	the 	claimant 	could
occasionally lift 20 pounds, frequently lift 15 pounds,
stand, and walk two hours of an eight-hour workday,
could never perform postural activity, frequently use
the upper extremities, should not have any not
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exposure to heights or temperature extremes, and
the claimant had been prescribed a cane, walker,
and brace. The report indicated the basis of the
opinion was review of imaging and the claimant’s
reports (Exhibit B11F, B17F 476). The claimant is
clearly not this limited posturally and there is no
objective evidence she is this limited in standing or
walking. 	The 	opinion 	admits 	reliance 	on 	the
claimant’s reports and the mild findings in imaging
of the hip, spine, and significant improvement of the
claimant’s 	cervical 	condition 	with 	surgery 	are
inconsistent with this level of limitations. The lifting
and carrying limitations are generally persuasive in
light of the objective evidence in the record but the
remainder the opinion is not consistent with or
supported 	by 	the 	record. 	The 	opinion 	is 	not
supported by sufficient documentation of evidence,
clear articulation for the basis of the opinions, and
with finding consistent with the records from the
nurse or other objective medical evidence of record.
Similarly, the less than sedentary work limitations
reported by a treatment provider in April 2019 and
May 2019 are not persuasive because they record
does not support the claimant is this limited (Exhibit
B16F 1544, 1549).
Tr. 2805.
Here, the ALJ showed how she considered the consistency of Nurse
Harrington’s opinion by explaining that Ayala is “clearly not this limited
posturally and there is no objective evidence she is this limited in standing or
walking.” 	Id. 	This 	comment, 	though 	the 	word 	consistency 	is 	not 	used,
references the objective evidence elsewhere in the record and compares it to
the limitations opined. See 20 C.F.R. § 404.1520c(c)(2). Importantly, the fact
that the ALJ did not use the word consistency is not fatal because there is no
requirement that the ALJ use any magic words. Cormany v. Kijakazi, No. 5:21-
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cv-933, 2022 WL 4115232, at *3 (N.D. Ohio Sept. 9, 2022) (collecting cases).
Additionally, the ALJ explained that “[t]he opinion admits reliance on the
claimant’s reports” and pointed out that “the mild findings in imaging of the
hip, spine, and significant improvement of the claimant’s cervical condition
with surgery are inconsistent with this level of limitations.” Tr. 2805. This
explanation shows that the ALJ considered how Nurse Harrington described
or cited evidence to support her opinion––i.e. the supportability factor. See 20
C.F.R. § 404.1520c(c)(1). And, to avoid any doubt, the ALJ explicitly stated that
Nurse Harrington’s opinion “is not supported by sufficient documentation of
evidence, clear articulation of the basis of the opinions, and with finding[s]
consistent with the records from the nurse or other objective medical evidence
of record.” Tr. 2805. This sentence summarizes the ALJ’s consideration of both
supportability, by identifying the lack of evidence documented or articulation
contained within the opinion, and consistency, by comparing the opinion to
other medical records.
Despite the above, Ayala argues that the “dismissal of Nurse Harrigton’s
medical opinion is unwarranted, as her findings are supportable and far more
consistent with the medical evidence than the residual functional capacity
assigned by ALJ Loucas.” Doc. 9, at 22. Ayala then continues by citing medical
records that she apparently believes support Nurse Harrington’s findings and
demonstrate a need for greater limitations. See Doc. 9, at 22–23. While the
records Ayala cites may support her alternative weighing of the evidence, they
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do 	not 	show 	that 	the 	ALJ 	failed 	to 	consider 	the 	mandatory 	factors 	of
supportability and consistency. Instead, these citations only illustrate that her
position amounts to a dispute over the ALJ’s weighing of the evidence. But
weighing the evidence is the ALJ’s responsibility, not this Court’s. See 20
C.F.R. § 404.1520c(a) (explaining how the ALJ will consider and weigh medical
opinions and prior administrative medical findings); see also Rottman v.
Comm’r of Soc. Sec., 817 F. App’x 192, 196 (6th Cir. 2020 (“[T]his court does
not weigh evidence, assess credibility, or resolve conflicts in testimony—that’s
the ALJ’s job.”) (citation omitted)). While it is entirely possible for the evidence
to support greater limitations, as Ayala insists, that possibility alone does not
support remand because a record can, and often does, support two outcomes.
See Jones, 339 F.3d at 477. In any event, Ayala’s argument heading only
indicates a challenge to the ALJ’s consideration 	of the medical opinion
evidence. Doc. 9, at 1, 20. So, to the extent that Ayala is making arguments not
indicated in her subject heading––like, for instance that the ALJ’s decision was
not supported by substantial evidence––those arguments are forfeited. See
Doc. 6, at 3 (“Each introductory heading in the Argument or Analysis section
of a brief must correspond to the argument presented under the heading.
Failure to comply with this requirement may result in … waiver of the
arguments in the heading and in the text following the heading.”)
As 	the 	above 	demonstrates, 	the 	ALJ 	properly 	considered 	Nurse
Harrington’s opinion and Ayala’s argument apparently asking the Court to
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reweigh evidence is improperly presented and otherwise does not provide a
basis to remand.
Counselor Michael Allen
Next, Ayala argues that the ALJ failed to consider the supportability
and consistency of Counselor Allen’s opinion. As to Counselor Allen’s opinion,
the ALJ explained:
The 	claimant’s 	counselor, 	Michael 	Allen, 	on
November 11, 2020, indicated the claimant had
moderate 	to 	marked 	limitations 	from 	mental
impairments 	of 	anxiety 	and 	depression 	(Exhibit
B7F). As discussed in this decision, there are no
mental status findings to support the claimant was
this limited, the claimant remains very functional,
and there is no evidence of any hospitalizations or
emergent treatment for mental health symptom.
The record simply does not support more than a
moderate limitation in concentrate, persistent, and
maintain pace. The opinion is not consistent with or
supported 	by 	the 	findings 	in 	the 	record 	and 	is
therefore not persuasive.
Tr. 2805.
Here, though her analysis was more abbreviated than in relation to the
ALJ’s consideration of other opinions, the ALJ discussed both supportability
and consistency. As to supportability, the ALJ stated that Counselor Allen’s
opinion is not “consistent with or supported by the findings in the record and
is therefore not persuasive” Tr. 2805. This statement shows that the ALJ
considered the supportability factor and, in doing so, found that Counselor
Allen’s opinion lacked sufficient support from the record for his conclusions.
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See 20 C.F.R. § 416.920c(c)(1). Moreover, Counselor Allen’s opinion is found in
a 	check-the-box 	form, 	see Tr. 	1884–85, which, 	though 	the 	ALJ 	did not
specifically discredit the opinion on this basis, renders it “patently deficient.”
See Dollinger v. Comm’r of Soc. Sec., No. 22-3359, 2023 WL 1777386, at *4 (6th
Cir. Feb. 6, 2023) (holding that a check-the-box form completed by a treating
source, 	which 	only 	contained 	a 	brief 	explanatory 	note 	for 	the 	assessed
limitations, “is the kind of ‘vague and unhelpful’ opinion that is patently
deficient and could not have been credited by the Commissioner”) (quoting
Price v. Comm’r Soc. Sec. Admin., 342 F. App’x 172, 176 (6th Cir. 2009)); Price,
342 F. App’x at 176 (holding that a doctor’s reference to “testing” to support his
conclusions on a questionnaire were “vague and unhelpful” and did not provide
”objective medical evidence to support his” conclusions)).
Next, the ALJ explained that “there are no mental status findings to
support” the opinion that Ayala “was this limited, [Ayala] remains very
functional and, there is no evidence of any hospitalizations or emergent
treatment for mental health symptom[s].” Tr. 2805. The ALJ continued by
stating that “[t]he record simply does not support more than a moderate
limitation in” Ayala’s ability to “concentrate, persist[], and maintain pace.” Id.
These explanation show that the ALJ considered how Counselor Allen’s
opinion compared to other medical evidence in the record––i.e., consistency. 20
C.F.R. § 416.920c(c)(2). As the above demonstrates, the ALJ’s consideration of
Counselor Allen’s opinion complies with the applicable regulations.
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Finally, as discussed in relation to Ayala’s arguments related to Nurse
Harrington’s opinion, Ayala’s citation to evidence elsewhere in the record that
she believes supports greater mental limitations is irrelevant to this Court’s
evaluation of whether the ALJ properly considered the opinion evidence––the
sole claim presented in Ayala’s second issue statement. See Doc. 9, at 1, 21. So
to the extent that Ayala cites additional evidence in an attempt to argue that
the ALJ’s decision is unsupported by substantial evidence, that argument is
forfeited. See Doc. 6, at 3. Even still, Ayala’s citation to evidence in an effort to
argue for a different outcome does not show that the ALJ’s decision was
unsupported by substantial evidence such that remand might be required. See
Warner, 375 F.3d at 39. In sum, none of the arguments raised in connection to
the ALJ’s evaluation of Counsel Allen’s opinion support remand.
Conclusion
For 	the 	reasons 	explained 	above, 	the 	Commissioner’s 	decision 	is
affirmed.
IT IS SO ORDERED.
Dated: December 10, 2025 	/s/ James E. Grimes Jr.
James E. Grimes Jr.
U.S. Magistrate Judge
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