Leija v. Commissioner, Social Security Administration

IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
ABILENE DIVISION
BRANDI L., 	§
Plaintiff, 	§
§
v. 	§ 	No. 1:25-CV-043-BW
§
COMMISSIONER OF THE SOCIAL 	§
SECURITY ADMINISTRATION, 	§
Defendant. 	§
MEMORANDUM OPINION AND ORDER
Plaintiff Brandi L. brings this action pursuant to the Social Security Act (the
“Act”), seeking review of the final decision of the Commissioner of Social Security
(the “Commissioner”) denying her application for Disability Insurance Benefits
(“DIB”) under Title II of the Act. (See Dkt. No. 1.) The Court has jurisdiction over
this action under 42 U.S.C. §§ 405(g), 1383(c), and the parties consented to proceed
before the undersigned in accordance with 28 U.S.C. § 636(b) and Special Order No.
3-350. (See Dkt. Nos. 4, 12.)
Plaintiff filed a brief on appeal (Dkt. No. 13) (“P. Br.”), to which the
Commissioner filed a brief in response (Dkt. No. 17 (“D. Br.”)), and Plaintiff filed a
reply brief (Dkt. No. 18) (“Reply”). After considering the pleadings, briefs, and
administrative record, the Court concludes that the Commissioner's decision must be
AFFIRMED.
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 1 of 27 PageID <pageID>

2
I. BACKGROUND
On October 19, 2022, Plaintiff protectively filed an application for DIB,
alleging disability beginning October 1, 2018. (See Transcript (“Tr.”) 178-79.)
Plaintiff later amended her alleged onset date to April 16, 2021. (Tr. 14, 203.) In her
application, Plaintiff alleges disability due to “(1) Parkinson's Disease; (2) blind or
low vision; (3) Trigemenal Neuralgia; (4) Epstein Barr- chronic; (5) Chronic
Fati[g]ue Syndrome; (6) currently wearing a heart monito[r]; (7) Migraine
[headaches]; (8) Gait Instab[i]lity; (9) insomnia; and (10) depression/anxiety.” (See
Tr. 218.) Plaintiff’s claim was denied initially on August 24, 2023, (Tr. 91), and
again upon reconsideration on March 20, 2024, (Tr. 92), after which Plaintiff timely
requested an administrative hearing (Tr. 126).
On May 12, 2022, Administrative Law Judge Edward L. Thompson (“the
ALJ”) held a telephonic hearing, at which all participants appeared by telephone.
(Tr. 14.) Plaintiff was represented at the hearing by two non-attorney
representatives, William John Wright and Walter Hermann. (Id.) Clifton A. King,
an impartial vocational expert, also appeared and testified at the hearing. (Id.) The
ALJ issued an unfavorable decision on November 6, 2024, finding Plaintiff not
disabled between April 16, 2021, and September 30, 2022, the date she was last
insured. (Tr. 11-38.) On January 10, 2025, the Appeals Council denied Plaintiff’s
request for further review. (Tr. 1-3.) The ALJ’s November 6, 2024 decision thus
became the “final decision” of the Commissioner subject to judicial review under 42
U.S.C. § 405(g).
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 2 of 27 PageID <pageID>

3
II. 	LEGAL STANDARDS
A. 	District Court Review
Judicial review of the Commissioner's denial of benefits is limited to whether
the Commissioner’s position is supported by substantial evidence and whether the
Commissioner applied the proper legal standards in evaluating the evidence. See 42
U.S.C. § 405(g); Copeland v. Colvin, 771 F.3d 920, 923 (5th Cir. 2014); Ripley v. Chater,
67 F.3d 552, 555 (5th Cir. 1995). Substantial evidence is “more than a mere scintilla.
It means such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971); accord
Copeland, 771 F.3d at 923. To determine whether substantial evidence of disability
exists, four elements of proof must be weighted: (1) objective medical facts;
(2) diagnoses and opinions of treating and examining physicians; (3) claimant’s
subjective evidence of pain and disability; and (4) claimant’s age, education, and
work history. See Wren v. Sullivan, 925 F.2d 123, 126 (5th Cir. 1991) (citing DePaepe
v. Richardson, 464 F.2d 92, 94 (5th Cir.1972)).
The Commissioner, rather than the courts, must resolve conflicts in the
evidence, including weighing conflicting testimony and determining witnesses’
credibility, and the Court does not try the issues de novo. See Martinez v. Chater, 64
F.3d 172, 174 (5th Cir. 1995); Greenspan v. Shalala, 38 F.3d 232, 237 (5th Cir. 1994).
Thus, the court may not reweigh the evidence or substitute its judgment for the
Commissioner’s but must scrutinize the entire record to ascertain whether substantial
evidence supports the hearing decision. See Copeland, 771 F.3d at 923; Hollis v.
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 3 of 27 PageID <pageID>

4
Bowen, 837 F.2d 1378, 1383 (5th Cir. 1988). The Court “may affirm only on the
grounds that the Commissioner stated for [the] decision.” Copeland, 771 F.3d at 923.
“Absent an error that affects the substantial rights of a party, administrative
proceedings do not require ‘procedural perfection.’” Wilder v. Colvin, No. 13-CV-
3014-P, 2014 WL 2931884, at *5 (N.D. Tex. June 30, 2014) (quoting Taylor v. Astrue,
706 F.3d 600, 603 (5th Cir. 2012)). “The ALJ is not required to discuss every piece
of evidence in the record nor must the ALJ follow formalistic rules of articulation.”
Hunt v. Astrue, No. 4:12-CV-244-Y, 2013 WL 2392880, at *7 (N.D. Tex. June 3,
2013) (citing Castillo v. Barnhart, 151 F. App’x 334, 335 (5th Cir. 2005)). “Procedural
errors affect the substantial rights of a claimant only when they ‘cast into doubt the
existence of substantial evidence to support the ALJ’s decision.’” Wilder, 2014 WL
2931884, at *5 (quoting Morris v. Bowen, 864 F.2d 333, 335 (5th Cir. 1988)).
“Remand is required only when there is a realistic possibility that the ALJ would
have reached a different conclusion absent the procedural error.” Id. (citing January
v. Astrue, 400 F. App’x 929, 933 (5th Cir. 2010)).
B. 	The Sequential Evaluation Process
“In order to qualify for disability insurance benefits or [supplemental security
income], a claimant must suffer from a disability.” Copeland. 771 F.3d at 923 (citing
42 U.S.C. § 423(d)(1)(A)). The Act defines “disability” as the inability to engage in
substantial gainful activity by reason of any medically determinable physical or
mental impairment that can be expected to result in death or last for a continued
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 4 of 27 PageID <pageID>

5
period of 12 months. See id. § 423(d)(1)(A); see also Copeland, 771 F.3d at 923; Cook v.
Heckler, 750 F.2d 391, 393 (5th Cir. 1985).
An ALJ must follow a five-step sequential evaluation to determine whether a
claimant is disabled within the meaning of the Act. See Wren, 925 F.2d at 125
(summarizing 20 C.F.R. § 404.1520(b)-(f)). On the first four steps of the analysis, the
claimant has the initial burden of proving she is disabled. Bowen v. Yuckert, 482 U.S.
137, 146 n. 5 (1987). The burden shifts to the Secretary on the fifth step to show that
the claimant is capable of performing work in the national economy and is therefore
not disabled. Id. “A finding that a claimant is disabled or is not disabled at any
point in the five-step review is conclusive and terminates the analysis.” Lovelace v.
Bowen, 813 F.2d 55, 58 (5th Cir.1987).
At step one, the ALJ must determine whether the claimant is engaged in
substantial gainful work activity. See 20 C.F.R. § 404.1520(b). If so, the claimant is
not disabled. If the claimant is not engaged in substantial gainful work activity, the
ALJ proceeds to step two and determines whether the claimant has an impairment,
or combination of impairments, that is “severe” within the meaning of the Act,
meaning that it imposes significant restrictions on the claimant’s ability to perform
basic work activities. Id. § 404.1520(c). If the claimant does not have a severe
impairment or combination of impairments, the analysis concludes with a finding of
“not disabled.” If the claimant does, the ALJ continues to step three.
At step three, the ALJ examines whether a claimant’s impairment meets or
medically equals the criteria of a listed impairment in Appendix 1 of Subpart P of
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 5 of 27 PageID <pageID>

6
Regulation No. 4 (the “Listings”). Id. § 404.1520(d). If the impairment meets or
medically equals the criteria of a Listing and meets the durational requirement, the
claimant is disabled. Id. § 404.1509. If not, the ALJ determines the claimant’s
residual functional capacity (“RFC”), which is the ability to perform physical or
mental work activities on a sustained basis notwithstanding limitations for the
collective impairments. See id. § 404.1520(e)-(f).
The ALJ then proceeds to step four and determines whether the claimant’s
RFC permits her to perform the requirements of her past relevant work. 20 C.F.R.
§ 404.1520(f). If the claimant can perform such requirements, then she is not
disabled. Id. If an individual’s impairment precludes her from performing past
work, the analysis proceeds to the fifth and final step, wherein the burden shifts to
the Commissioner to show that there is other gainful employment available in the
national economy that the claimant is capable of performing. Greenspan, 38 F.3d at
236. This burden may be satisfied either by reference to the Medical-Vocational
Guidelines of the regulations or by expert vocational testimony or other similar
evidence. Fraga v. Bowen, 810 F.2d 1296, 1304 (5th Cir. 1987).
III. ALJ’s FINDINGS
The ALJ analyzed Plaintiff's claim for benefits under the process described
above and made the following findings in his November 6, 2024 decision:
1. 	The claimant’s insured status expired on September 30, 2022.
2. 	The claimant did not engage in substantial gainful activity during the
period from her amended alleged onset date of disability of April 16, 2021,
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 6 of 27 PageID <pageID>

7
through her date last insured of September 30, 2022 (20 CFR 404.1571 et
seq.).
3. 	Through the date last insured, the claimant had the following severe
impairments: Parkinson’s disease and migraine headaches (20 CFR
404.1520(c)).
4. 	Through the date last insured, the claimant did not have an impairment or
combination of impairments that met or medically equaled the severity of
one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1
(20 CFR 404.1520(d), 404.1525 and 404.1526).
5. 	Through the date last insured, the claimant had the residual functional
capacity to perform light work as defined in 20 CFR 404.1567(b)1 except
the claimant could frequently balance, stoop, and climb ramps/stairs; and
the claimant could occasionally kneel, crouch, crawl, and climb
ladders/ropes/scaffolds. Mentally, the claimant could understand,
remember, and carry out simple and detailed instructions, but complex
instructions. The claimant could make judgements on simple and detailed
work-related decisions, but not on complex work-related decisions. The
claimant had the concentration, persistence, and pace to focus for normal
eight-hour workdays (with normal work breaks that occur about every two
hours throughout normal eight-hour workdays) and normal forty-hour
workweeks on an ongoing basis. The claimant was able to interact
appropriately with co-workers, supervisors, and the public. The claimant
was able to respond appropriately to usual work situations and to changes
in a routine work setting. The claimant did not have any other physical or
mental limitation or restrictions through the date the claimant's insured
status expired.
6. 	The ALJ relies on the Social Security Administration’s Expedited
Vocational Assessment and makes no finding concerning the claimant’s
1 20 C.F.R. § 404.1567(b): Light work involves lifting no more than 20 pounds at a
time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the
weight lifted may be very little, a job is in this category when it requires a good deal of
walking or standing, or when it involves sitting most of the time with some pushing and
pulling of arm or leg controls. To be considered capable of performing a full or wide range
of light work, [the claimant] must have the ability to do substantially all of these activities.
If someone can do light work, [the SSA] determine[s] that he or she can also do sedentary
work, unless there are additional limiting factors such as loss of fine dexterity or inability to
sit for long periods of time.
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 7 of 27 PageID <pageID>

8
past relevant work; and proceeds to step five of the sequential evaluation
process. (20 CFR 404.1565).
7. 	The claimant was . . . 45 years old, which is defined as a younger
individual age 18-49, on the date last insured (20 CFR 404.1563).
8. 	The claimant has at least a high school education (20 CFR 404.1564).
9. 	Transferability of job skills is not an issue under the Social Security
Administration’s Expedited Vocational Assessment. (20 CFR 404.1568).
10. Through the date last insured, considering the claimant’s age, education,
and residual functional capacity, there were jobs that existed in significant
numbers in the national economy that the claimant could have performed
(20 CFR 404.1569 and 404.1569a).
11. The claimant was not under a disability, as defined in the Social Security
Act, at any time from April 16, 2021, the alleged onset date, through
September 30, 2022, the date last insured (20 CFR 404.1520(g)).
(Tr. 17-38.)
Accordingly, the ALJ determined that, for the application for a period of
disability and disability insurance benefits, protectively filed on October 19, 2022, the
claimant is not disabled under sections 216(i) and 223(d) of the Act through
September 30, 2022, the last date insured. (Tr. 38.)
IV. ANALYSIS
Plaintiff raises two arguments on appeal—both contending that the ALJ failed
to account for the “total limiting effects” of Plaintiff’s migraine headaches and
Parkinson’s disease, and that the ALJ’s decision therefore is not supported by
substantial evidence. (See P. Br. at 13-24.) More specifically, Plaintiff complains that
the ALJ erred by failing to incorporate off-task time limitations related to her
migraines and additional standing/walking limitations and
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 8 of 27 PageID <pageID>

9
reaching/handling/fingering limitations related to her Parkinson’s disease into his
RFC finding. 	(See id. at 13-21.)
The Commissioner argues in response that the RFC finding is supported by
substantial evidence, including the medical evidence, Plaintiff’s subjective
complaints, and her activities of daily living. (D. Br. at 9-14.) According to the
Commissioner, the ALJ discussed treatment records documenting Plaintiff’s
improvement with treatment for her chronic migraine headaches, physical
examination findings that were inconsistent with Plaintiff’s statements about her
limitations, prior administrative medical findings that Plaintiff’s statements were
only “partially consistent” with the evidence, and Plaintiff’s reports of her subjective
complaints and limited daily activities. (Id. (citing Tr. 26-33, 36).)
The Court has reviewed the briefing and the administrative record and
determines that the ALJ weighed “all the relevant evidence in [Plaintiff’s] case
record,” 20 C.F.R. § 404.1545(a), and reasonably determined that Plaintiff had the
RFC to perform a reduced range light with additional limitations, including mental
limitations limiting her to simple and detailed instructions and work-related
decisions. (Tr. 23.) Accordingly, the ALJ’s decision is supported by substantial
evidence.
A. 	Relevant Medical Evidence
Plaintiff was diagnosed with chronic migraines and early-onset Parkinson’s
disease prior to her amended alleged onset date of April 16, 2021. (See Tr. 828,
2511.) Medical records prior to the alleged onset date, however, reveal that
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 9 of 27 PageID <pageID>

10
Plaintiff’s migraines were controlled by injections and that her Parkinson’s disease
had not substantially progressed. Upon physical examination during a February
2021 visit, Plaintiff was observed to have no focal, motor, or sensory deficits, with
speech, memory and expressions within normal limits. (Tr. 829.) During visits in
February and March 2021 for injections of Aimovig (a migraine preventive
medication), Plaintiff reported a history of migraines uncontrolled by oral
medication, but she was doing well on injections and her number of migraine days
had decreased. (Tr. 2477, 2496.) On physical examination, Plaintiff was observed to
have 5/5 muscle strength in the upper and lower extremities bilaterally. (Tr. 2478,
2497.)
On March 22, 2021, Plaintiff reported to the Emergency Room at Hardeman
County Memorial Hospital, complaining of dizziness and weakness beginning two
days earlier. (Tr. 2487.) 	Physical examination results showed cranial nerves grossly
intact, 5/5 muscle strength and symmetrical deep tendon reflexes in the upper and
lower extremities, and normal sensation to pain, touch, and proprioception. (Tr.
2490.) Plaintiff returned to Hardeman County Memorial Hospital for follow-up in
April 2021. (Tr. 2470.) She was reportedly doing well on Aimovig injection with
reduced number of migraine days reported. (Id.) Physical examination showed
cranial nerves II through XII grossly intact; muscle strength was 5/5 in the upper and
lower extremities bilaterally; Plaintiff was oriented to person, place, time, and
situation with appropriate mood and affect; intact short-term and long-term memory;
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 10 of 27 PageID <pageID>

11
and normal judgment and insight. (Tr. 2471.) She was assessed with chronic
migraine headache, and Aimovig injection was administered. (Id.)
Medical records thereafter in 2021 and 2022 showed relatively controlled
migraines and Parkinson’s disease. Plaintiff received more Aimovig injections in
May, June, and July 2021, and physical examination results again showed grossly
intact cranial nerves and 5/5 strength in her upper and lower extremities (Tr. 2443,
2459, 2464.) During a June 2021 follow-up visit with Dianne M. Cooper, M.D.,
Plaintiff noted that she was taking amantadine for her Parkinsons and “overall she
[was] doing better” except for severe leg aches especially in the feet. (Tr. 826.) Dr.
Cooper observed that Plaintiff had no acute musculoskeletal findings and no focal
motor sensory deficits present. (Tr. 827.)
Plaintiff returned to Hardeman County Memorial Hospital on June 28, 2021,
with chief complaint of chronic migraine to be treated with Aimovig injection. (Tr.
2443.) Plaintiff’s “longstanding history of chronic migraines uncontrolled by oral
medications” was noted, but she was reportedly “doing well on [Aimovig] injections
and her number of migraine days ha[d] decreased.” (Tr. 2442.) Neurological
findings on examination showed cranial nerves II through XII grossly intact; muscle
strength was 5/5 in the upper and lower extremities bilaterally; Plaintiff was oriented
to person, place, time, and situation with appropriate mood and affect; intact short-
term and long-term memory; and normal judgment and insight. (Tr. 2443.)
In a December 2021 follow-up visit with Dr. Cooper, Plaintiff reported she
was “doing ok[,] Parkinson’s-wise” but complained of constipation. (Tr. 824.) Dr.
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 11 of 27 PageID <pageID>

12
Cooper observed that Plaintiff had moderate musculoskeletal stiffness and
neurological findings consistent with Parkinsons, and that her exam was also
consistent with Parkinson’s. (Tr. 825.)
In January 2022, Plaintiff consulted with Sandia Neurology Group regarding
her Parkinson’s disease; she reported that her right side did not move as well as well
as her left, and she had suffered a fall in September 2021 because she missed a step
with her right foot. (Tr. 891.) Plaintiff reported arthralgias (joint pain), back pain,
and joint stiffness; ataxia (poor muscle control), headache, and weakness, but denied
dizziness, fainting, memory loss, paresthesia (tingling/numbness), seizures, tremor,
or vertigo; and stated that she did not use a cane, walker, or wheelchair. (Tr. 892.)
Regarding activities of daily living, Plaintiff and her family reported that she was
independent in ambulation, bathing, dressing, personal hygiene, and feeding. (Id.)
Objective findings from physical examination showed no apparent distress;
neurological findings showed visual fields intact to confrontation; sensation intact;
and motor strength intact. (Tr. 893-94). Active tremor was noted although there
were no signs of bradykinesia; cogwheeling was absent; and postural stability was
fair. (Id.) 	Plaintiff rose from a chair with one-to-two rocks; her blink rate was
normal; and her range of expression was good. (Id.) Assessment included
Parkinson’s disease; migraine without aura, not intractable, without status
migrainosus; and anxiety disorder, unspecified. (Tr. 894.)
During a follow-up visit with Sandia Neurology Group in late February 2022,
Plaintiff reported independence in bathing, dressing, personal hygiene, and feeding;
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 12 of 27 PageID <pageID>

13
anxiety, depression, constipation, and excessive urination; and ataxia, headaches,
tremors, and weakness. (Tr. 896.) Objective examination findings again showed
normal strength in all extremities, no cogwheel rigidity, normal blink rate, and a
normal rage of expression. (Tr. 897.)
A brain MRI in March 2022 showed no evidence of acute infarct, mass, or
hydrocephalus; subtle abnormal signal in the bilateral substantia nigra; differential
was artifact or stigmata of Parkinson’s disease; and there was no evidence of volume
loss in the bilateral hemisphere with mild chronic microvascular ischemic change in
the white matter. (Tr. 922-23.)
During a follow-up with Sandia Neurology Group on April 25, 2022, Plaintiff
reported similar activities of daily living and symptoms but also reported her
concerns of insomnia. (Tr. 900.) Objective examination results were similar to the
January and February 2022 examinations except Plaintiff was observed to rise from a
chair without difficulty. (Tr. 900-01.) Assessment included Parkinson’s disease with
continuation of current medications; migraine without aura with continuation of
medications; and primary insomnia with new prescription for trazodone. 	(Tr. 902.)
Physical examination by Thomas C. Darter, M.D., in May 2022 showed full
range of motion of the neck; normal breath sounds; regular cardiac rate and rhythm;
normal bowel sounds; normal gait; no focal neurological deficits; and appropriate
affect and demeanor. (Tr. 1735-36.) In a June 2022 examination with Sandia
Neurology Group, Plaintiff reported increased headaches and noted that Fioricet was
not working but sumatriptan was effective. (Tr. 904.) Plaintiff again reported that
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 13 of 27 PageID <pageID>

14
she was independent in ambulation, bathing, personal hygiene, and feeding. (Id.)
She also reported ataxia, headaches, tremors, and weakness, but she was not using a
walker, cane, or wheelchair. (Id.) Physical examination noted similar findings to the
April 2022 examination. (Tr. 904-05.) Plaintiff was continued on previously
prescribed medications for Parkinson’s disease and anxiety; Qulipta was added;
trazodone was discontinued for insomnia; and samples of Belsomra were provided.
(Tr. 906.)
On July 18, 2022, Plaintiff went to Hardeman County Clinic complaining of a
migraine that had lasted several days. (Tr. 1288.) She reportedly had missed her
Aimovig injection for two weeks. (Id.) On physical examination, Plaintiff was
observed to be well appearing, well nourished, and in no apparent distress; cranial
nerves were grossly intact with positive photophobia; psychiatric examination
findings were normal. (Tr. 1289.)
During an examination with Sandia Neurology Group on August 15, 2022,
Plaintiff reported that her headaches “have been better” and that she had one fall but
that she did not hurt herself. (Tr. 912). Plaintiff again reported that she was
independent in ambulation, bathing, personal hygiene, and feeding, but also reported
ataxia, headaches, tremors, and weakness. (Tr. 912.) Physical examination findings
were similar to the April and July examinations. (Tr. 912-13.)
Medical evidence after September 30, 2022, the date Plaintiff’s insured status
expired, shows physical examination by Dr. Darter in October 2022 with largely
normal physical findings (Tr. 1739); follow-up visit at Sandia Neurology Group on
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 14 of 27 PageID <pageID>

15
November 14, 2022, that was positive for reports of fatigue, headaches, ataxia,
tremor, weakness, and joint stiffness but otherwise showed unremarkable findings
(Tr. 920); routine medical care at Hardeman County Clinic on January 6, 2023, with
largely unremarkable examination results, but Plaintiff complained of weight gain
and wanted to explore medication options (Tr, 1294-95) ); and on January 9, 2023,
Dr. Darter assessed major depressive disorder; generalized anxiety disorder;
adjustment insomnia; and unspecified tachycardia and prescribed medication for
treatment of major depressive disorder (Tr. 1743).
Thereafter, in February 2023 and March 2023, examination findings at
Hardeman County Clinic similarly showed largely normal physical findings. (Tr.
1298); and in March 2023, Dr. Darter, described Plaintiff as moderately obese and
diagnosed Parkinson’s disease, major depressive disorder, generalized anxiety
disorder; and mixed hyperlipidemia (Tr. 1509, 1747).
B. 	Relevant Opinion Evidence
On August 8, 2023, State Agency Medical Consultant Laurence Ligon, M.D.,
independently examined the evidence of record as of that date and opined that,
through the date last insured, Plaintiff had the physical ability to perform light
exertion work, except she could frequently stoop and climb ramps/stairs and
occasionally kneel, crouch, crawl, and climb ladders/ropes/scaffolds. 	(Tr. 83-90.)
Dr. Ligon further opined that, through the date last insured, Plaintiff did not have
any other physical or mental limitation or restriction. (Id.)
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 15 of 27 PageID <pageID>

16
On March 4, 2024, State Agency Medical Consultant Kavitha Reddy, M.D.,
independently examined the evidence of record as of that date and opined that,
through Plaintiff’s date last insured, she had the physical ability to perform light
exertion work, except she could frequently balance, stoop, kneel, crouch, crawl, and
climb ramps/stairs; and she could occasionally climb ladders/ropes/scaffolds. (Tr.
93-102.) Dr. Reddy further opined that, through the date last insured, Plaintiff did
not have any other physical or mental limitation or restriction. (Id.)
C. The ALJ’s RFC Finding was Supported by Substantial Evidence.
RFC is what an individual can still do despite her limitations. Social Security
Regulation (“SSR”) 96-8p, 1996 WL 374184, at *2 (S.S.A. July 2, 1996). It reflects
the individual's maximum remaining ability to do sustained work activity in an
ordinary work setting on a regular and continuing basis. Id.; see Myers v. Apfel, 238
F.3d 617, 620 (5th Cir. 2001). A regular and continuing basis is an eight-hour day,
five days a week, or an equivalent schedule. SSR 96-8p, 1996 WL 374184, at *2.
RFC is not the least an individual can do but the most. Id. The RFC is a function-
by-function assessment, with both exertional and nonexertional factors to be
considered, and it is based upon all of the relevant evidence in the case record. Id. at
3-6. The ALJ has the sole responsibility for evaluating a claimant’s RFC based on
the record. 20 C.F.R. § 404.1546(c); see also Villa v. Sullivan, 895 F.2d 1019, 1023
(5th Cir. 1990). The ALJ must discuss the claimant's ability to perform sustained
work activity on a regular and continuing basis and resolve any inconsistencies in the
evidence. SSR 96-8p, 1996 WL 374184, at *7.
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 16 of 27 PageID <pageID>

17
In making the RFC assessment, the ALJ must consider all symptoms,
including pain, and the extent to which these symptoms can be reasonably accepted
as consistent with objective medical evidence and other evidence. See 20 C.F.R.
§ 404.1529; SSR 16-3p, 2017 WL 5180304, at *2 (Oct. 25, 2017); SSR 96-8p, 1996
WL 374184, at *5. The ALJ must also consider limitations and restrictions imposed
by all of an individual’s impairments, even impairments that are not severe. See SSR
96-8p, 1996 WL 374184, at *5. The ALJ may draw reasonable inferences from the
evidence in making his decision, but the social security ruling also cautions that
presumptions, speculation, and supposition do not constitute evidence. See, e.g., SSR
86-8, 1986 WL 68636, at *8 (1986), superseded by SSR 91-7c, 1991 WL 231791, at *1
(Aug. 1, 1991) (changing the ruling only to the extent the SSR discusses the former
procedures used to determine disability in children).
The ALJ is not required to incorporate limitations in the RFC that he did not
find the record supported. See Muse v. Sullivan, 925 F.2d 785, 790 (5th Cir. 1991)
(“The ALJ as factfinder has the sole responsibility for weighing the evidence and
may choose whichever physician’s diagnosis is most supported by the record.”). In
reviewing the ALJ’s decision, a finding of no substantial evidence is appropriate only
if no credible evidentiary choices or medical findings support the decision. Boyd v.
Apfel, 239 F.3d 698, 704 (5th Cir. 2001).
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 17 of 27 PageID <pageID>

18
1. The ALJ appropriately applied SSR 19-4p to evaluate the consistency of
Plaintiff’s headache symptoms with the objective medical evidence.
At step two, the ALJ found that Plaintiff had a medically determinable
impairment of primary headache disorder. (Tr. 17.) Plaintiff asserts that the ALJ
erred in evaluating her primary headache disorder because his RFC finding failed to
consider “the most obvious effect of Plaintiff’s headaches, that she is off task during
them.” (P. Br. at 17-21.)
The definition of medically severe impairment at step two “has a specific—if
somewhat surprising—meaning.” Salmond v. Berryhill, 892 F.3d 812, 817 (5th Cir.
2018). “Phrased in the negative, an ‘impairment can be considered as not severe
only if it is a slight abnormality [having] such minimal effect on the individual that it
would not be expected to interfere with the individual's ability to work, irrespective
of age, education or work experience.’” Keel v. Saul, 986 F.3d 551, 555 (5th Cir.
2021) (alteration in original) (quoting Stone v. Heckler, 752 F.2d 1099, 1101 (5th Cir.
1985)). “This second step requires the claimant to make a de minimis showing.”
Salmond, 892 F.3d at 817.
In support of her argument, Plaintiff first faults the ALJ for not referencing
SSR 19-4p in his RFC analysis. (See id. at 17.) SSR 19-4p details how ALJs establish
that a person has a medically determinable impairment of primary headache disorder
and how the ALJ should evaluate primary headache disorders in disability claims.
SSR 19-4p, 2019 WL 4169635 (Aug. 26, 2019). Although Plaintiff acknowledges
that the ALJ referenced SSR-19-4p to support his finding that migraine headaches
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 18 of 27 PageID <pageID>

19
was a medically determinable impairment and that her mental impairments were
primarily the result of her migraine headaches, Plaintiff contends that the ALJ erred
because he failed to discuss SSR 19-4p in his RFC analysis. (P. Br. at 17.) SSR 19-
4p provides the following guidance regarding how ALJs consider primary headache
disorder when assessing a claimant’s RFC:
We consider the extent to which the person's impairment-related
symptoms are consistent with the evidence in the record. For example,
symptoms of a primary headache disorder, such as photophobia, may
cause a person to have difficulty sustaining attention and concentration.
Consistency and supportability between reported symptoms and
objective medical evidence is key in assessing the RFC.
SSR 19-4p, 2019 WL 4169635, at *8.
Contrary to Plaintiff’s argument, this is precisely that the ALJ did. The ALJ
weighed Plaintiff’s statements about her headache symptoms and limitations and
considered whether these statements were consistent with the objective medical
evidence and the other evidence of record. 20 C.F.R. § 404.1529(c). Ultimately, the
ALJ found that Plaintiff’s statements were inconsistent with “the treatment records
on physical examination for the period from April 16, 2021, the amended alleged
onset date, and September 30, 2022, the date last insured.” (Tr. 27.) See SSR 96–7p,
1996 WL 374186, at *2 (“whenever the individual's statements . . . [regarding her]
symptoms are not substantiated by objective medical evidence, the adjudicator must
make a finding on the credibility of the individual's statements based on a
consideration of the entire case record”); 20 C.F.R. §§ 404.1529(c)(4), 416.929(c)(4);
see also James v. Bowen, 793 F.2d 702, 706 (5th Cir.1986) (An “ALJ's findings
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 19 of 27 PageID <pageID>

20
regarding the debilitating effect of the subjective complaints are entitled to
considerable judicial deference”).
First, the ALJ noted that Plaintiff’s “history of migraine headaches [was] well
documented in her treatment records,” and while oral medications were generally
not effective for treating her migraine headaches, she “repeatedly reported
effectiveness of Aimovig injections for headache relief as well as reduction in the
number of headache events well on his medication.” (Tr. 17.) The ALJ went on to
cite the treatment records that documented Plaintiff’s reports of favorable response to
Aimovig injections for treatment of her chronic migraine headaches. (Tr. 29-33, 36.)
Specifically, Plaintiff reported that her migraines were uncontrolled by oral
medication, but she was doing well on Aimovig injections, and her number of
migraine days had decreased. (Tr. 2442, 2458, 2477, 2496, 2510.) Notably, medical
records documenting Plaintiff’s treatment with Aimovig injections did not specify the
intensity, duration, or frequency of her headaches. (Id.) Plaintiff reported suffering
from headaches during neurology visits regarding her Parkinson’s disease, but the
record is likewise silent on the intensity, duration, and frequency of the headaches.
(Tr. 892, 896, 904, 912.)
The ALJ also noted treatment records indicating that Plaintiff reported
“worsening and frequent” headaches during a neurology visit in June 2022; however,
she also reported that although Fioricet was not working, sumatriptan was effective.
(Tr. 33, 904.) Plaintiff also visited Hardeman County Clinic in July 2022,
complaining of a migraine that had lasted several days, but in that instance, she had
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 20 of 27 PageID <pageID>

21
reportedly missed two weeks of Aimovig injections and received IV medication
during the visit. (Tr. 1288-90.) Plaintiff also reported improvement with headaches
during a neurology visit in August 2022. (Tr. 33, 912.)
The ALJ also relied on the findings of Dr. Ligon and Dr. Reddy, both of
whom opined that Plaintiff could perform light work with noted limitations. (Tr. 22,
35-36.) The ALJ found that Dr. Ligon’s and Dr. Reddy’s opinions were “well-
supported by the evidence; [] consistent with the evidence; and [] persuasive.” (Tr.
22.) The ALJ also found that to the extent Dr. Ligon’s and Dr. Reddy’s opinions
differed, any differences were resolved in Plaintiff’s favor, and the more restrictive
physical functional limitations were adopted. (Tr. 36.)
Plaintiff also contends that the ALJ erred in evaluating her subjective
complaints by failing to discuss her evidence of more limited daily activities as
required by 20 C.F.R. § 404.1529(c). (P. Br. at 23.) But the ALJ’s decision reveals
that he evaluated Plaintiff’s more limited daily activities when he described her
alleged change in activities and noted that daily activities were one factor to be
considered. (Tr. 26-27.) The regulations do not require a more expansive discussion.
See Guillory v. Saul, 2021 WL 1600283, at *11 (E.D. Tex. Apr. 23, 2021) (ALJ
decision reflected compliance with § 404.1529(c) when ALJ cited pertinent
regulations, summarized evidence relevant to the factors, and articulated legitimate
reasons for his decision). Thus, the ALJ correctly evaluated Plaintiff’s subjective
complaints under the factors set forth in 20 C.F.R. § 404.1529(c).
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 21 of 27 PageID <pageID>

22
But even if the ALJ did not explicitly cite SSR 19-4p in the RFC analysis, this
is not legal error. See Keel, 986 F.3d at 556 (“A case will not be remanded simply
because the ALJ did not use ‘magic words.’”) (citing Hampton v. Bowen, 785 F.2d
1308, 1311 (5th Cir. 1986)). SSR 19-4p’s requirement that the ALJ consider “the
extent to which the person’s impairment-related symptoms are consistent with the
evidence in the record” is effectively identical to the standard for evaluating
subjective complaints generally, set forth in in 20 C.F.R. § 404.1529 and SSR 16-3p,
also cited by the ALJ. 	(See Tr. 24.) As discussed above, the ALJ’s decision makes
clear that, irrespective of whether he cited SSR 19-4p, he applied the correct standard
by considering whether Plaintiff’s subjective complaints of debilitating migraines
were consistent with the evidence for the relevant time period. (Tr. 25-36.) Thus,
the ALJ complied with the requirements of 20 C.F.R. 404.1529, SSR 19-4p, and SSR
16-3p, even if he did not explicitly cite SSR 19-4p in the process of doing so.
2. The ALJ reasonably concluded that the RFC did not require off-task-
time limitations related to Plaintiff’s headaches.
Plaintiff next argues that the ALJ erred by failing to include limitations for off-
task time in the RFC to account for her primary headache disorder. (See P. Br. at 18-
21.) 	Specifically, Plaintiff contends that: the ALJ: (1) failed to provide a required
explanation on why he failed to include time-off-task limitations; (2) ignored
negative findings that supported time-off-task limitations; and (3) failed to account
for the “good days/bad days” nature of the migraine disorder. (Id.) Without citing
any legal authority, Plaintiff appears to argue that off-task time is an “obvious effect”
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 22 of 27 PageID <pageID>

23
of headaches, and therefore the ALJ should have included it in the RFC. (Id. at 18.)
But there is simply no objective medical evidence to support Plaintiff’s contention
that the ALJ should have included a time-off-task limitation for in the RFC. Nor
does Plaintiff cite any record evidence suggesting that any of her providers assigned
any limitations based on her headaches. (See generally id.) An ALJ does not have to
assign limitations in the RFC unless the medical providers, examiners, or consulting
physicians assigned such limitations.” Stewart v. Comm’r Soc. Sec., No. 3:23-CV-134-
DAS, 2024 WL 1747649, at *3 (N.D. Miss. Apr. 23, 2024).
As discussed above, medical records during the relevant time period noted
that Plaintiff reported headaches but did not specify the severity, frequency, or
duration of the headaches, aside from reporting that Aimovig was effective at
reducing the number of headaches. (Tr. 892, 896, 904, 912, 2442, 2458, 2477, 2496,
2510.) Thus, contrary to Plaintiff’s assertion that the ALJ “picked and chose” only
those record references that supported the ALJ’s RFC finding (see P. Br. at 21), the
record was essentially devoid of any information from which the ALJ could have
determined that an off-task time limitation was required and, if so, how much time
off task was necessary. Instead, given the lack of information record information
regarding the severity of Plaintiff’s migraine disorder, the ALJ reasonably concluded
that no off-task time limitations were necessary. See Cooper v. Kijakazi, No. 4:22-CV-
118-DAS, 2023 WL 2467880, at *2 (N.D. Miss. Mar. 10, 2023) (affirming the
Commissioner's denial of benefits where the plaintiff received treatment for
headaches but her examination findings were normal, she indicated that over-the-
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 23 of 27 PageID <pageID>

24
counter medications helped relieve her symptoms, and her complaint of the
aggravating effects of noise and stress was only documented once in the record and
not corroborated by any objective medical evidence); Esperanso G. v. Comm'r, Soc. Sec.
Admin., No. 1:24-CV-20-BK, 2025 WL 919390, at *8 (N.D. Tex. Mar. 26, 2025)
(affirming Commissioner's denial of benefits and finding that the ALJ’s decision not
to assign limitations due to headaches was supported by substantial evidence).
Although Plaintiff maintains in her reply that the ALJ failed to adequately
consider the evidence regarding her ongoing headaches (see generally Reply),
substantial evidence, including the clinical findings and objective medical records,
the opinions of two state agency consultants, Plaintiff’s subjective statements
regarding her headache symptoms and limitations, and her reports of her daily
activities, supports the ALJ’s disability decision. See Wren, 925 F.2d at 126. While
Plaintiff may disagree with the ALJ’s conclusions, her arguments amount to nothing
more than an invitation for the court to reweigh the evidence and second-guess the
ALJ’s decision not to include an off-task limitation, which is not proper under the
substantial evidence standard of review. Carey v. Apfel, 230 F.3d 131, 135 (5th Cir.
2000) (providing that a reviewing court may not reweigh the evidence or substitute
its judgment for the ALJ’s judgment even if the evidence weighs against the ALJ’s
determination); Garcia v. Berryhill, 880 F.3d 700, 704 (5th Cir. 2018); see also Bowling
v. Shalala, 36 F.3d 431, 434 (5th Cir. 1994); Harrell v. Bowen, 862 F.2d 471, 475 (5th
Cir. 1988); Hollis v. Bowen, 837 F.2d 1378, 1383 (5th Cir. 1988). Accordingly, the
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 24 of 27 PageID <pageID>

25
Court finds no error in the ALJ’s RFC decision not to include off-task time
limitations in the RFC finding.
3. The ALJ reasonably concluded that the RFC did not require additional
standing/walking limitations and reaching/handling/fingering
limitations related to Plaintiff’s Parkinson’s disease.
Plaintiff’s argument that the ALJ erred by failing to add additional
standing/walking limitations and reaching/handling/fingering limitations related to
her Parkinson’s disease into her RFC (see P. Br. at 21-22) fails for similar reasons.
Plaintiff asserts, in essence, that evidence of self-reported stiffness, observed tremors,
and exhaustion warranted additional limitations in reaching, handling, and fingering
and self-reported falls and observed shuffling gait warranted greater standing and
walking limitations. (See P. Br. at 21-22.) But in addition to noting the above
reported and observed symptoms, the ALJ also considered the medical evidence in
making his RFC assessment, including largely normal objective musculoskeletal and
neurological findings during the relevant period. (Tr. 23-36.)
For example, throughout 2021 and 2022, treatment records show that
Plaintiff’s providers routinely observed that she had grossly intact cranial nerves,
normal strength in all extremities, and intact reflexes and sensation. (Tr. 829, 893-
94, 897, 1735-36, 2478, 2490, 2497.) Her neurologist also observed no cogwheel
rigidity, fair postural stability, ability to rise from a chair; normal blink rate; and
normal range of expression. (Tr. 894, 897, 912-13.) The ALJ also noted reports that
Plaintiff was independent with bathing, dress, personal hygiene, and feeding. (Tr.
32-33, 892, 896, 904, 906.)
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 25 of 27 PageID <pageID>

26
Finally, although Plaintiff insinuates that the ALJ found that she “never has
Parkinson’s -related symptoms” (see P. Br. at 22), the decision clearly shows that the
ALJ found that Plaintiff’s Parkinson’s disease warranted limiting her to light work
with additional postural limitations as described in the RFC. (Tr. 23-36). Although
Plaintiff contends that the restrictions in the RFC are inadequate, the RFC need only
include limitations that the ALJ found supported by the evidence. Moore v. Barnhart,
182 F. App'x 321, 323 (5th Cir. 2006); Surgi v. Barnhart, 168 F. App’x 555, 558, (5th
Cir. 2006) (it is the ALJ’s responsibility to determine an individual’s RFC). Here,
other than citing a few reports of stiffness, exhaustion, and falls and observations of
tremors and shuffling gait, Plaintiff cites no objective medical evidence to support
any additional limitations beyond those included in the RFC. (See P. Br. at 21-22.
(citing Tr. 30-33).)
As the ALJ explained, “[n]eurological examinations from a variety of
clinicians, including neurologist[s], do not document abnormalities that could
reasonably be expected to explain the limitations alleged and described by
[Plaintiff].” (Tr. 36.) Accordingly, the record does not demonstrate that further
limitations were necessary. See Wilson v. Barnhart, 210 F. App’x 448, 450-51 (5th Cir.
2006). As explained above, Plaintiff’s arguments amount to a request to re-weigh the
evidence to reach a different conclusion, which is not allowed under the substantial
evidence standard. Bowling, 36 F.3d at 434.
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 26 of 27 PageID <pageID>

27
Based on the foregoing, Plaintiff has failed to demonstrate either that improper
standards were used to evaluate the evidence or that the final decision was not
supported by substantial evidence.
CONCLUSION
The Commissioner's decision is AFFIRMED, and this case is DISMISSED
WITH PREJUDICE.
SO ORDERED on January 26, 2026.
____________________________________
BRIAN McKAY
UNITED STATES MAGISTRATE JUDGE
Case 1:25-cv-00043-BW Document 19 Filed 01/26/26 Page 27 of 27 PageID <pageID>