Case Name in Social Security Case - Unavailable

UNITED STATES DISTRICT COURT
DISTRICT OF MINNESOTA
Alan L.,1
Plaintiff, 	Case No. 25-cv-2377 (JMB/LIB)
v. 	REPORT AND RECOMMENDATION
Frank Bisignano,
Commissioner of Social Security Administration,
Defendant.
Plaintiff, Alan L. (hereafter “Plaintiff”), seeks judicial review of the decision of the
Commissioner of Social Security (hereafter “Defendant”) denying his application for disability
benefits. This matter is before the undersigned United States Magistrate Judge for disposition
pursuant to 28 U.S.C. § 636 and Local Rules 7.2(a)(1). This Court has jurisdiction over the claims
under 42 U.S.C. § 405(g).
Pursuant to the Federal Supplemental Rules of Civil Procedure which govern actions
seeking judicial review of a decision of the Commissioner of Social Security, the present action
“is presented for decision by the parties’ briefs.” Fed. R. Civ. P. Supp. SS Rule 5. Plaintiff filed a
brief requesting reversal of the Commissioner’s final decision and the immediate award of
benefits, or in the alternative, remand to the Social Security Administration for further
administrative proceedings. [Docket No. 12]. Defendant filed a brief asking this Court to affirm
the Commissioner’s decision denying Plaintiff’s request for disability benefits. [Docket No. 22].
1 This District has adopted the policy of using only the first name and last initial of any nongovernmental parties in
Social Security opinions such as the present Report and Recommendation. Thus, when the Court refers to Plaintiff by
his name only his first name and last initial are provided.
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For the reasons discussed herein, the undersigned recommends that Plaintiff’s request for
relief, [Docket No. 12], be GRANTED, and Defendant’s request for relief, [Docket No. 22], be
DENIED.
I. 	BACKGROUND
On June 15, 2023, Plaintiff filed a Title II application for a period of disability and disability
insurance benefits. (Tr. 10, 194, 195).2 In his application, Plaintiff alleged that his disability began
on April 26, 2022. (Tr. 10, 194).3 The Commissioner initially denied Plaintiff’s claims on June 11,
2024, and again, upon reconsideration, on August 22, 2024. (Tr. 10, 114–122). On September 9,
2024, Plaintiff filed a written request for a hearing before an Administrative Law Judge. (Tr. 10,
125, 126).
Administrative Law Judge Corey Ayling (hereafter “ALJ”) conducted a telephonic hearing
on February 14, 2025. (Tr. 10, 42–64). Plaintiff testified at the hearing, along with an independent
vocational expert, Brian Womer, (hereafter “IVE Womer”). (Tr. 10, 57–63). At the hearing,
Plaintiff was represented by counsel. (Tr. 10, 44).
On February 25, 2025, the ALJ issued a decision denying Plaintiff’s request for a period
of disability and disability insurance benefits. (Tr. 10–27). The ALJ concluded that Plaintiff was
not disabled within the meaning of the Social Security Act. (Tr. 27).
Plaintiff thereafter sought review of the decision by the Appeals Council. (Tr. 1–6, 181,
182). Subsequently, on April 9, 2025, the Appeals Council denied Plaintiff’s request for review.
2 Throughout this Report and Recommendation, the Court refers to the Administrative Record, [Docket No. 6], by the
abbreviation “Tr.” The Administrative Record is consecutively paginated across 61 exhibits. (See, Administrative
Record [Docket No. 6]). Where the Court cites to the Administrative Record, it refers to the page numbers found in
the bottom-right corner of these exhibits.
3 The ALJ noted that Plaintiff has amended his alleged onset date of April 26, 2022, to April 30, 2022. The ALJ’s
findings, however, address the period from April 26, 2022, through the date of the ALJ’s decision. (Tr. 10, 12, 27).
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(Tr. 1–6). As a result, the ALJ’s decision became the final decision of the Commissioner. See, 20
C.F.R. §§ 404.981, 416.1481.
On June 9, 2025, Plaintiff filed this action. (Compl. [Docket No. 1]). Thereafter, this matter
was presented to the Court for review pursuant to the parties’ briefs, [Docket Nos. 12, 22], and the
Court took the matter under advisement on the written submissions.
II. STANDARDS OF REVIEW
A. Administrative Law Judge’s Five-Step Analysis
If a claimant’s initial application for disability benefits is denied, he may request
reconsideration of the decision. 20 C.F.R. §§ 404.907–404.909. A claimant who is dissatisfied
with the reconsidered decision may then obtain administrative review by an administrative law
judge (“ALJ”). 42 U.S.C. § 405(b)(1); 20 C.F.R. § 404.929.
To determine the existence and extent of a claimant’s disability, the ALJ must follow a
five-step sequential analysis. This analysis requires the ALJ to make a series of factual findings
about the claimant’s impairments, residual functional capacity, age, education, and work
experience. See, 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4); Locher v. Sullivan, 968 F.2d 725,
727 (8th Cir. 1992). The Eighth Circuit has described this five-step process as follows:
The Commissioner of Social Security [through the ALJ] must evaluate: (1) whether
the claimant is presently engaged in a substantial gainful activity; (2) whether the
claimant has a severe impairment that significantly limits the claimant’s physical
or mental ability to perform basic work activities; (3) whether the claimant has an
impairment that meets or equals a presumptively disabling impairment listed in the
regulations; (4) whether the claimant has the residual functional capacity to
perform his or her past relevant work; and (5) if the claimant cannot perform the
past work, the burden shifts to the Commissioner to prove that there are other jobs
in the national economy that the claimant can perform.
Dixon v. Barnhart, 353 F.3d 602, 605 (8th Cir. 2003).
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B. Appeals Council Review
If the claimant is dissatisfied with the ALJ’s decision, he may request review by the
Appeals Council, although the Appeals Council need not grant that request for review. See, 20
C.F.R. §§ 404.967–404.982. The decision of the Appeals Council (or, if the request for review is
denied by the Appeals Council, then the decision of the ALJ) is final and binding upon the
claimant, unless the matter is appealed to federal court within sixty days after notice of the Appeals
Council’s action. See, 42 U.S.C. § 405(g); 20 C.F.R. § 404.981. In this case, the Appeals Council
declined to review the ALJ’s decision finding that Plaintiff was not disabled. (Tr. 1).
C. Judicial Review
If a claimant remains dissatisfied with the final decision of the Commissioner following
the resolution of claimant’s request for review to the Appeals Council, the claimant may seek
judicial review in federal court. Judicial review of the administrative decision generally proceeds
by considering the decision of the ALJ at each of the five steps discussed above.
The claimant bears the burden under the Social Security Act of proving that they are
disabled. See, 20 C.F.R. § 404.1512(a); Whitman v. Colvin, 762 F.3d 701, 705 (8th Cir. 2014).
Once the claimant has demonstrated he cannot perform any of their prior, relevant work due to a
disability, the burden then shifts to the Commissioner to show that the claimant retains the residual
functional capacity (“RFC”) to engage in some other substantial, gainful activity. Goff v. Barnhart,
421 F.3d 785, 790 (8th Cir. 2005).
Judicial review of the Commissioner’s decision (through the ALJ) to deny disability
benefits, however, is constrained to a determination of whether the decision is supported by
substantial evidence in the record as a whole. 42 U.S.C. § 405(g); Bradley v. Astrue, 528
F.3d 1113, 1115 (8th Cir. 2008); Tellez v. Barnhart, 403 F.3d 953, 956 (8th Cir. 2005); Buckner
v. Apfel, 213 F.3d 1006, 1012 (8th Cir. 2000). “Substantial evidence is less than a preponderance,
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but is enough that a reasonable mind would find it adequate to support the Commissioner’s
conclusion.” Buckner, 213 F.3d at 1012 (quoting Prosch v. Apfel, 201 F.3d 1010, 1012 (8th Cir.
2000)); see, Coleman v. Astrue, 498 F.3d 767, 770 (8th Cir. 2007).
In reviewing the record for substantial evidence, the Court may not substitute its own
judgment or findings of fact for that of the ALJ. Hilkemeyer v. Barnhart, 380 F.3d 441, 445 (8th
Cir. 2004). The possibility that the Court could draw two inconsistent conclusions from the same
record does not alone prevent a particular finding from being supported by substantial evidence.
Culbertson v. Shalala, 30 F.3d 934, 939 (8th Cir. 1994). The Court should not reverse the ALJ’s
finding merely because evidence exists in the administrative record to support a conclusion
contrary to the Commissioner’s findings. Woolf v. Shalala, 3 F.3d 1210, 1213 (8th Cir. 1993).
After balancing the evidence, if it is possible to reach two inconsistent positions from the
evidence and one of those positions represents the ALJ’s decision, the Court must affirm the
decision. Robinson v. Sullivan, 956 F.2d 836, 838 (8th Cir. 1992); Medhaug v. Astrue, 578
F.3d 805, 813 (8th Cir. 2009). Thus, the Court will not reverse the ALJ’s “denial of benefits so
long as the [ALJ’s] decision falls within the ‘available zone of choice.’” Bradley, 528 F.3d at 1115.
The decision of the ALJ “is not outside the ‘zone of choice’ simply because [the Court] might have
reached a different conclusion had [it] been the initial finder of fact.” Id.
III. DECISIONS UNDER REVIEW
The ALJ made the following determinations during the five-step disability evaluation
process.
At step one, the ALJ concluded that Plaintiff had not engaged in substantial gainful activity
since April 26, 2022, the alleged onset date. (Tr. 12). Plaintiff does not challenge this finding. The
Court will refer to the time period between Plaintiff’s alleged onset date and the date of the ALJ’s
decision as “the adjudicated period.”
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At step two, the ALJ concluded that Plaintiff had “the following severe impairments:
bilateral knee pain secondary to service-related traumatic knee osteoarthritis on each knee; mild
lumbar degenerative disc disease; bilateral elbow cubital tunnel syndrome status post-surgery on
each elbow; plantar fasciitis status post bilateral gastrocnemius recession; chronic pain syndrome;
irritable bowel syndrome (IBS); and obesity.” (Tr. 13). Plaintiff does challenge the findings made
by the ALJ at step two in so far as the ALJ concluded that Plaintiff’s determinable mental
impairments of major depressive disorder (hereafter “MDD”), generalized anxiety disorder
(hereafter “GAD”), and panic disorder with agoraphobia were not severe.
At step three, the ALJ concluded that Plaintiff did not have any impairment or combination
of impairments that met or medically equaled the severity of one of the listed impairments in 20
C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 16–18). Specifically, the ALJ found that Plaintiff did
not have any impairment or combination of impairments which met or equaled listings 1.18 for
bilateral knee osteoarthritis; 1.15 for lumbar degenerative disc disease; 11.14 for bilateral cubital
tunnel syndrome; 5.06 for IBS; and SSR 19-2p for obesity. (Tr. 16). Plaintiff does not challenge
the ALJ’s findings at step three.
At step four, the ALJ made the following RFC determination:
[C]laimant has the residual functional capacity to perform sedentary work as
defined in 20 CFR 404.1567(a) except can occasionally climb ramps and stairs; no
climbing of ladders, ropes, or scaffolds; occasional balancing as that term is defined
in the Selected Characteristics of Occupations (SCO); occasional stooping,
kneeling and crouch; no crawling; no work at unprotected heights; no work near
moving mechanical parts; no exposure to extremes of cold; no hand power tools or
similar direct and sustained physical contact with heavy vibrating machinery; can
ambulate with the assistance of a cane.
(Tr. 18). Plaintiff challenges this RFC determination made by the ALJ. Plaintiff does not challenge
the ALJ’s credibility determination, but does challenge the RFC on the grounds that it is not
supported by substantial evidence given the ALJ’s alleged improper evaluation of evidence on the
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record in finding Plaintiff’s mental impairments of MDD, GAD, and panic disorder with
agoraphobia to be non-severe; and the ALJ’s improper consideration of Dr. Karayusuf’s March
11, 2024, medical opinion.4 In making this RFC determination, the ALJ found that Plaintiff’s
“medically determinable impairments could reasonably be expected to cause the alleged
symptoms;” however, the ALJ also concluded that Plaintiff’s “statements concerning the intensity,
persistence and limiting effects of these symptoms are not entirely consistent with the medical
evidence and other evidence in the record for the reasons explained in [the ALJ’s] decision.” (Tr.
19).
At step five, based on his RFC determination and relying on the testimony from the
independent vocational expert, IVE Womer, the ALJ determined that Plaintiff was capable of
performing the requirements of such representative occupations as a document preparer, with
approximately 14,000 jobs in the national economy; Food Order Clerk, with approximately 3,400
jobs in the national economy; and a sack repair, with approximately 1,400 jobs in the national
economy. (Tr. 26, 27).
Based on his findings at each step of the sequential analysis, the ALJ concluded that
Plaintiff was not under a disability, as that term is defined by the Social Security Act, at any time
during the adjudicated period. (Tr. 27).
IV. ANALYSIS
Plaintiff asserts one overarching argument in his appeal of the ALJ’s decision: the ALJ’s
RFC determination is not supported by substantial evidence in the record. (See gen., Mem. in Supp.
4 “Social Security Ruling 16-3p eliminates the use of the term ‘credibility’ and clarifies that the Commissioner’s
review of subjective assertions of the severity of symptoms is not an examination of a claimant’s character, but rather,
is an examination for the level of consistency between subjective assertions and the balance of the record as a whole.”
Noerper v. Saul, 964 F.3d 738, 745 n.3 (8th Cir. 2020). SSR 16-3p applies to the present case, “but it largely changes
terminology rather than the substantive analysis to be applied,” and in discussing said determination, Courts have
continued to use the “credibility” terminology. Noerper, 964 F.3d at 745 n.3.
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[Docket No. 12]). In support of this argument, Plaintiff contends that: (1) the ALJ failed to consider
Plaintiff’s mental impairments of MDD, GAD, and panic disorder with agoraphobia as severe; and
(2) the ALJ improperly rejected Dr. Karayusuf’s medical opinion. (Id.).
The Commissioner contends that the ALJ’s opinion is supported by substantial evidence
in the record as a whole and the ALJ properly evaluated Dr. Karayusuf’s medical opinion. (See
gen., Mem. in Opp. [Docket No. 22]).
A. The ALJ’s Finding That Plaintiff’s MDD, GAD, and Panic Disorder with
Agoraphobia were Non-Severe.
Plaintiff maintains that the ALJ’s finding that Plaintiff’s MDD, GAD, and panic disorder
with agoraphobia disorder were non-severe was not supported by substantial evidence in the record
as a whole. (Mem. in Supp. [Docket No. 12] at 6–9).
At step two, the ALJ must consider whether the claimant has any impairments or a
combination of impairments that are “severe.” 20 C.F.R. §404.1520(c). The purpose of step two
is to provide de minimus screening to dispose of groundless claims. See, Bowen v. Yuckert, 482
U.S. 137, 107 S. Ct. 2287 (1987); see also Dewald v. Astrue, 590 F. Supp. 2d 1184, 1199 (D.S.D.
2008) (citing Hudson v. Bowen, 870 F.2d 1392, 1395-96 (8th Cir. 1989)). Where a claimant cannot
establish the existence of a severe impairment, he is not disabled, and the ALJ will not evaluate
the last three steps in the sequential evaluation. See, Dixon, 353 F.3d at 605; 20 C.F.R.
§404.1520(a)(4).
An impairment, or combination of impairments, is “severe” within the meaning of the
regulations if it significantly limits an individual’s ability to perform basic work activities. Id. “An
impairment is not severe if it amounts only to a slight abnormality that would not significantly
limit the claimant’s physical or mental ability to do basic work activities.” Kirby v. Astrue, 500
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F.3d 705, 707 (8th Cir. 2007). The regulations define “basic work activities” as “the abilities and
aptitudes necessary to do most jobs.” 20 C.F.R. § 416.922(b).
The claimant bears the burden of establishing that a given impairment is severe. Kirby, 500
F.3d at 707–08 (citing Mittelstedt v. Apfel, 204 F.3d 847, 852 (8th Cir. 2000)). However, this
burden is not a great one. Caviness v. Massanari, 250 F.3d 603, 605 (8th Cir. 2001). Instead, the
claimant must show at least a slight abnormality that would have a minimal impact on the
claimant’s ability to work. Caviness, 250 F.3d at 605; SSR 96-3p, 1996 SSR LEXIS 10; SSR 85-
28, 1985 SSR LEXIS 19. Any doubt as to whether the requisite showing of severity has been made
is to be resolved in favor of the claimant. SSR 85-28, 1985 SSR LEXIS 19; see also Newell v.
Commissioner of Social Security, 347 F.3d 541, 547 (3d Cir. 2003) (reasonable doubts on severity
are to be resolved in favor of the claimant); Gilbert v. Apfel, 175 F.3d 602, 605 (8th Cir. 1999)
(“contradictory evidence in the administrative record” did not support the ALJ’s decision to stop
the sequential analysis at step two).
“[S]everal district courts in the Eighth Circuit, including the District of Minnesota, have
concluded that an ALJ’s failure to find that an impairment is severe at step two is harmless error
where the ALJ otherwise finds another severe impairment exists and addresses any functional
limitations caused by the overlooked impairment when determining the individual’s RFC.” Misty
G. v. Berryhill, No. 18-cv-00587, (KMM), 2019 U.S. Dist. LEXIS 47619, 2019 WL 1318355, at
*3 (D. Minn. Mar. 22, 2019) (citing cases).5 However, a “step two error cannot be dismissed as
5 In some Circuits, the finding of a single severe impairment, whether or not it qualifies as a disability and whether or
not it results from a single severe impairment or combination of impairments that together qualify as severe, is enough
to satisfy the requirement at step two. See, e.g., Heatly v. Commissioner of Social Security, 382 Fed. Appx. 823 (11th
Cir. 2010); Swartz v. Barnhart, 188 Fed. Appx. 361, 368 (6th Cir. 2006) (where ALJ finds at least one “severe”
impairment and proceeds to assess claimant’s RFC based on all alleged impairments, any error in failing to identify
particular impairment as “severe” at step two is harmless); Lewis v. Astrue, 498 F.3d 909, 911 (9th Cir. 2007) (finding
even if the ALJ fails to identify a severe impairment at step two, the error is harmless so long as he considers all the
claimant’s impairments at subsequent steps of the analysis); Stanton v. Astrue, 370 Fed. Appx. 231, 233 n.1 (2d Cir.
Mar. 24, 2010).
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harmless if the RFC finding omits the claimant’s relevant functional limitations, and a remand
would be necessary to correct the analysis.” Shane T. v. Saul, No. 18-634 (BRT), 2019 U.S. Dist.
LEXIS 148381, at *7 (D. Minn. Aug. 30, 2019) (citing Misty G., 2019 U.S. Dist. LEXIS 47619,
2019 WL 1318355, at *4); see, e.g., Lewis, 498 F.3d at 911 (finding that while the ALJ may have
failed to consider claimant’s bursitis at step two, such error was harmless because “the ALJ
extensively discussed [claimant’s] bursitis at Step 4”); Carpenter v. Astrue, 537 F.3d 1264, 1266
(10th Cir. 2008) (finding that the ALJ’s failure to consider the combined effects of the claimant’s
impairments at step two was a harmless error, but remanded the case due to the ALJ’s failure to
consider important evidence at the later steps of the sequential evaluation).
The Court will evaluate the ALJ’s determination that Plaintiff’s MDD, GAD, and panic
disorder with agoraphobia disorder were not severe to the extent that the step-two evaluation, when
combined with any evaluation at step four, shows whether the ALJ properly considered the record
when determining the RFC. This is because once a severe impairment is found, the ALJ must
consider the “combined effect” of all the medically determinable severe and non-severe
impairments in assessing a claimant’s RFC. See, Swartz, 188 Fed. App’x. at 368 (where ALJ finds
at least one “severe” impairment and proceeds to assess claimant’s RFC based on all alleged
impairments, any error in failing to identify particular impairment as “severe” at step two is
harmless); Elmore v. Astrue, 2012 U.S. Dist. LEXIS 44844, 2012 WL 1085487 at *12 (E.D. Mo.
Mar. 5, 2012); see also 20 C.F.R. §416.945(a)(2) (in assessing RFC, the ALJ must consider “all of
[a claimant’s] medically determinable impairments …, including ... impairments that are not
‘severe’”); §416.923 (ALJ must “consider the combined effect of all [the claimant’s] impairment
without regard to whether any such impairment, if considered separately, would be of sufficient
severity”).
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Plaintiff alleges the RFC was flawed because the ALJ erred in finding that Plaintiff’s MDD,
GAD, and panic disorder with agoraphobia were not “severe.” (Mem. in Supp. [Docket No. 12] at
6). Plaintiff bolsters this assertion through citing his subjective complaints regarding his symptoms
of MDD, GAD, and panic disorder with agoraphobia. (Tr. 54, 222). Plaintiff goes on in his brief
to discuss evidence contained in the record, specifically the Veteran Affairs Medical Center’s
(hereafter “VA”) finding that Plaintiff’s depression was linked to his physical impairments, and
Dr. Karayusuf’s finding that Plaintiff suffered from numerous mental health disorders, to assert
that Plaintiff has satisfied his burden of making the prerequisite showing that his MDD, GAD, and
panic disorder with agoraphobia are, in fact, severe. (Mem. in Supp. [Docket No. 12] at 7–9; Tr.
712, 1008).
“At step two of the analysis under 20 C.F.R. §404.1520(c), the ALJ must take into account
all of the evidence . . . to determine whether the functionally limiting effects of a claimant’s
impairments have an effect on their ability to perform basic work activities. Troy v. Comm’r of
Soc. Sec., No. 10-cv-6827 (DMC), 2012 U.S. Dist. LEXIS 43439, 2012 WL 1067739, at *12
(D.N.J. Mar. 28, 2012) (internal quotations and alterations removed) (citing SSR 96-3p, 1996 SSR
Lexis 4 (1996)). The Court finds the ALJ adequately considered all of the evidence when
determining Plaintiff’s RFC.
For mental impairments, the Social Security Administration follows the psychiatric review
technique (“PRT”). Programs Operations Manual System (“POMS”) DI 24583.005(A). The PRT
involves the ALJ evaluating mental impairments by rating the claimant’s limitations attributable
to her mental impairments on a five-point scale (none, mild, moderate, marked, or extreme) across
four broad categories of mental functioning called the “paragraph B” criteria. See, 20 C.F.R. §
404.1520a(c)(4); § 404 subpart P, App’x 1 (hereafter “Appendix 1”), 12.00(E) (listing the
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paragraph B criteria).6 The four “paragraph B” criteria are claimant’s ability to: (1) understand,
remember, or apply information; (2) interact with others; (3) concentrate, persist, or maintain pace;
and (4) adapt and manage oneself. Id.
In the case now before the Court, the ALJ applied the PRT in evaluating Plaintiff’s alleged
mental impairments. (Tr. 14–16). In this process, the ALJ considered the broad functional areas of
mental functioning set out in Appendix 1. (Id.).
In the first functional area of understanding, remembering, or applying information, the
ALJ considered Plaintiff’s March 11, 2024, mental status evaluation with Dr. Karayusuf where
Plaintiff reported diminished memory and was able to remember only two out of three unrelated
objects after five minutes. (Tr. 15, 711). However, Plaintiff did not report any memory difficulties
during his hearing testimony or in his Function Report. (Tr. 15, 42–64, 225–218).7 The ALJ also
referenced the findings from Plaintiff’s March 11, 2024, and December 13, 2024, mental status
evaluations, which were “largely unremarkable” and showed no problems with memory or
cognition. (Tr. 15, 1020–1023). The ALJ then described Plaintiff’s reported activities of daily
living which included caring for himself, playing video games, watching television, using
Facebook, driving part-time for Lyft, occasionally driving his mother to her job, and spending
months in Arizona “helping his grandfather.” (Tr. 15, 48, 49, 711, 1020–1023, 1034). The ALJ
finally considered how Plaintiff answered questions appropriately and displayed no evidence of
difficulty in understanding the content of the ALJ hearing. (Tr. 15, 45–57). As a result, the ALJ
6 The term “paragraph B criteria” comes from the structure of Appendix 1. Each listed mental disorder in Appendix 1
has two or three paragraphs of listed criteria; satisfaction of at least two criteria typically render the claimant disabled
under that listing. See, Appendix 1 at 12.00(A)(2). Those paragraphs are labeled A, B, and C. Id. Paragraph B always
lists the same four categories of mental functioning and states that an “[e]xtreme limitation of one, or marked limitation
of two, of the following areas of mental functioning” will satisfy that paragraph. Id. Those categories are thus called
the “paragraph B criteria.”
7 Plaintiff did indicate, in his Function Report, that he needed reminders to complete housework such as loading the
dishwasher, sweeping, and vacuuming, but indicated he did not need reminders to take care of his personal needs and
grooming, or to take his medications. (Tr. 220).
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ultimately found that Plaintiff has a mild limitation in the domain of understanding, remembering,
or applying information. (Tr. 15).
In the second functional area of interacting with others, the ALJ also considered Plaintiff’s
Function Report, where he alleges difficulty getting along with others and leaving his home. (Tr.
15, 222, 223). The ALJ noted that Plaintiff has indicated he works part-time as a Lyft driver, plays
video games with friends, goes out to dinner about every two months, and spent months in Arizona
“helping his grandfather.” (Tr. 15, 222, 1023, 1034). In addition, the ALJ reiterated Plaintiff’s
reports that stated he experiences anxiety and panic attacks when leaving his home and has
difficulty being around others. (Tr. 15, 710–713, 1020–1023). Outside of Plaintiff’s subjective
reports, the ALJ took into account the findings from Plaintiff’s mental status evaluations on March
11, 2024, and December 13, 2024, which were “largely unremarkable” and showed Plaintiff is
cooperative and exhibits “good behavior.” (Tr. 15, 710–713, 1020–1023). As a result, the ALJ
ultimately found that Plaintiff has a mild limitation in the domain of interacting with others. (Tr.
15).
In the third functional area of concentrating, persisting, or maintaining pace, the ALJ
ultimately found the claimant had a mild limitation. (Tr. 15). The ALJ considered Plaintiff’s
subjective complaints in his Function Report which described his difficulties with concentration,
attention, and completing tasks. (Tr. 15, 218–225). At his March 11, 2024, mental status
evaluation, Plaintiff described diminished concentration, racing thoughts, and poor sleep. (Tr. 15,
710–713). At his December 13, 2024, mental status evaluation, Plaintiff described low mood and
interest in activities, difficulty in pacing his activities, and daytime fatigue and tiredness. (Tr. 15,
1020–1025). Despite Plaintiff’s subjective reports, the findings from his March 11, 2024, and
December 13, 2024, mental status evaluations were “largely unremarkable” and showed no signs
of issues with attention and concentration. (Tr. 15, 710–713, 1020–1023). The ALJ lastly
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considered Plaintiff’s reported daily activities of caring for himself, playing video games, watching
television, using Facebook, driving part-time for Lyft, occasionally driving his mother to her job,
and spending months in Arizona “helping his grandfather.” (Tr. 15, 48, 49, 711, 1020–1023, 1034).
As a result, the ALJ ultimately found that Plaintiff has a mild limitation in his ability to concentrate,
persist, or maintain pace. (Tr. 15).
Finally, in the fourth functional area of adapting or managing oneself, the ALJ found that
Plaintiff has only a mild limitation. (Tr. 16). The ALJ noted that Plaintiff’s Function Report
describes difficulty handling stress and changes in routine. (Tr. 16, 224). Plaintiff’s March 11,
2024, and December 13, 2024, mental status evaluations additionally noted difficulties handling
stressors such as finances and his marriage. (Tr. 16, 710–713, 1020, 1023). The ALJ additionally
considered that Plaintiff, outside of the aforementioned mental status evaluations, has received
little treatment for his mental health. (Tr. 16). The ALJ specifically noted that, in April 2022,
Plaintiff stopped pursuing mental health care at the VA, stating he was stable when he stopped
using his prescribed psychotropic medications, and would not pursue recommended cognitive
behavioral therapy to address his chronic pain. (Tr. 16, 645–648). Further, the ALJ referenced
Plaintiff’s reports of stable housing and support from his mother; and his ability to care for himself,
clean his home, do laundry, engage in his hobbies such as watching television and playing video
games, and work as a Lyft driver. (Tr. 15, 48, 49, 710–713, 366, 367).
Because none of Plaintiff’s mental impairments cause at least two “marked” limitations or
one “extreme” limitation, the ALJ ultimately concluded that the “paragraph B” criteria were not
satisfied. (Tr. at 16). Based on that conclusion, the ALJ further concluded that Plaintiff’s MDD,
GAD, and panic disorder with agoraphobia were not severe. (Tr. 16).
Plaintiff asserts the ALJ improperly considered Plaintiff’s lack of mental health treatment
in determining Plaintiff’s MDD, GAD, and panic disorder with agoraphobia were not severe.
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(Mem. in Supp. [Docket No. 12] at 7). Specifically, Plaintiff argues the ALJ failed to adequately
develop the record to establish why, exactly, Plaintiff did not pursue further mental health
treatment. (Id. at 7, 8).
“In determining the severity of Plaintiff's impairments, the ALJ has a duty to develop the
record sufficiently to permit meaningful review on appeal.” Ronald V. v. Kijakazi, No. 22-cv-2140
(TNL), 2023 WL 6318276, at *4 (D. Minn. Sept. 28, 2023); (citing Noerper, 964 F.3d at 747).
This duty to develop the record “arises from the simple fact that the disability determination
process is not an adversarial process,” and thus, the duty to develop the record “exists alongside
the claimant's burden to prove [his] case.” Noerper, 964 F.3d at 747. Moreover, the ALJ’s duty
exists even when a claimant is represented by counsel. Id. The Eighth Circuit Court of Appeals
has “repeatedly recognized this duty,” and it has “remanded for further development of the record
not only where evidence of functional limitations is lacking, but also where the record presents
conflicting medical opinions as to which the Commissioner fails to explain a choice.” Id. “There
is no brightline test for determining when the [ALJ] has . . . failed to develop the record. The
determination in each case must be made on a case by case basis.” Battles v. Shalala, 36 F.3d 43,
45 (8th Cir. 1994).
At the February 14, 2025, hearing, the ALJ inquired into Plaintiff’s mental health status,
and whether or not Plaintiff was seeking treatment:
[ALJ]: . . . . Are you having any mental health problems that affects your ability to
work?
[Plaintiff]: Depression and Anxiety.
[ALJ]: Do you see a therapist for that?
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[Plaintiff]: I have been seeing – I don’t know if it’s a therapist. I’ve been seeing
multiple people at the VA, and I have talked with a therapist. We’ve done a few
sessions and tried some different medications that have not helped.
(Tr. 54). Later, in the ALJ’s decision, the ALJ concluded that “the entirety of the [Plaintiff’s]
mental health treatment since the [alleged onset date] . . . consists entirely of two evaluations and
discontinuation of mental health care through the VA in April 2022” due to being “stable off
psychotropic medications.” (Tr. 14, 16). Plaintiff argues that, if the ALJ was planning to “discredit
[Plaintiff’s] mental health impairments” on the basis of lack of treatment, then the ALJ should
have asked Plaintiff, at the February 14, 2025, hearing, (1) why Plaintiff’s therapy sessions and
mental 	health 	medications 	were 	not 	helpful; 	(2) 	if 	Plaintiff 	was 	having 	problems 	with
transportation or insurance; or (3) whether Plaintiff had difficulty obtaining treatment due to his
difficulties in being around others. (Mem. in Supp. [Docket No. 12] at 7, 8). Plaintiff additionally
contends that the VA, where Plaintiff receives medical care, is not equipped with the “necessary
resources” to address mental health issues. (Id.).
Importantly, however, Plaintiff’s reasoning for discontinuing mental health treatment was
already apparent from the record. During Plaintiff’s April 26, 2022, VA mental health medication
management follow up, Plaintiff denied having any mental health related concerns or mental health
symptoms since he had “self-discontinued” taking his prescribed psychiatric medications. (Tr.
645–647). Plaintiff further declined any need or interest in medication initiation or any mental
health medication follow up. (Tr. 647). The ALJ specifically cited this in his opinion, stating, “[i]n
April 2022, [Plaintiff] discontinued mental health care at the VA due to being stable off
psychotropic medications.” (Tr. 16). As such, the ALJ’s conclusion that Plaintiff’s only mental
health treatment consisted of two mental health evaluations, and that Plaintiff was “stable” after
discontinuing his use of prescribed psychiatric medications, is supported by the present record.
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Further, on the record now before the Court, there is no evidence to suggest that Plaintiff’s
lack of mental health treatment was due to any issues with transportation, insurance, Plaintiff’s
difficulties in being around others, or resource shortages at the VA. As a result, the Court cannot
say that the ALJ erred in failing to further develop the record on this issue. See, Hollingsworth v.
Astrue, No. 11-cv-955 (DSD/FLN), 2012 WL 2119255, at *10 (D. Minn. May 24, 2012), report
and recommendation adopted, 2012 WL 2119205 (D. Minn. June 11, 2012) (“Given the absence
of any evidence to suggest that [Plaintiff’s] noncompliance with his medication was attributable
to his bipolar disorder, the Court cannot say that the ALJ erred by not eliciting testimony on this
issue.”).
Plaintiff does not point to any other specific evidence showing that the ALJ failed to
properly consider Plaintiff’s MDD, GAD, or panic disorder with agoraphobia. Rather, Plaintiff
argues the ALJ, in finding Plaintiff’s MDD, GAD, and panic disorder with agoraphobia to be non-
severe, “significantly prejudiced [Plaintiff’s] disability claim.” (Mem. in Supp. [Docket No. 12] at
9). Given the ALJ did consider Plaintiff’s MDD, GAD, and panic disorder with agoraphobia
symptoms, Plaintiff’s argument is akin to requesting the Court reweigh the evidence. Plaintiff’s
disagreement with the ALJ’s conclusion does not necessarily mean the ALJ erred in evaluating the
evidence. See, Schmitt v. Kijakazi, 27 F.4th 1353, 1361 (8th Cir. 2022)) (“Despite [claimant’s]
dissatisfaction with how the ALJ weighed the evidence, it is not this Court’s role to reweigh the
evidence”). The Court may not reverse the ALJ simply because evidence exists to support an
opposite conclusion. See, Schmitt, 27 F.4th at 1361; see also Milam v. Colvin, 794 F.3d 978, 983
(8th Cir. 2015). Nor can this Court substitute its own judgment or findings of fact for those of the
ALJ. See, Woolf, 3 F.3d at 1213.
Moreover, even if the Court found that the ALJ did not consider all of the evidence, this
error would be harmless because the ALJ found at least one “severe” impairment and proceeded
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to steps three and four to ultimately have the opportunity to assess Plaintiff’s RFC based on all
alleged impairments. 20 C.F.R. §416.945(a)(2) (in assessing RFC, ALJ must consider “all of [a
claimant’s] medically determinable impairments . . . 	including . . . impairments that are not
‘severe’”); §416.923 (the ALJ must “consider the combined effect of all [the claimant’s]
impairment without regard to whether any such impairment, if considered separately, would be of
sufficient severity”).
As such, insofar as Plaintiff argues that the Commissioner’s decision requires a reversal as
the result of the ALJ’s error in step two, Plaintiff’s argument is unpersuasive.
B. The ALJ’s Consideration of Dr. Karayusuf’s March 11, 2024, Medical Opinion.
As observed above, Plaintiff additionally argues that the ALJ failed to properly evaluate
Dr. Karayusuf’s March 11, 2024, medical opinion using the supportability and consistency factors
under 20 C.F.R. § 404.15209(c). (Mem. in Supp. [Docket No. 12] at 8–11).
The relevant regulations governing the weighing of opinion evidence were revised for
claims filed on or after March 27, 2017. See, 20 C.F.R. § 404.1520c(a). Because Plaintiff filed his
application for disability benefits on June 16, 2023, the new regulations apply here. See, Id.
The new regulations eliminate the “treating physician” rule. Id.; see, Austin v. Kijakazi, 52
F.4th 723, 728 (8th Cir. 2022). Under the new regulations, the administrative law judge does “not
defer or give any specific evidentiary weight, including controlling weight, to any medical
opinion(s) or prior administrative medical finding(s), including those from [the claimant's] medical
sources.” 20 C.F.R. § 404.1520c(a). 	Instead, 	the administrative law judge evaluates the
persuasiveness of all medical opinions in the record by considering the following five factors: (1)
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supportability;8 (2) consistency;9 (3) relationship with the claimant; (4) specialized training of the
medical source; and (5) other factors. 20 C.F.R. § 404.1520c(c).
The 	two 	most 	important 	factors 	are 	supportability 	and 	consistency. 	20 	C.F.R. 	§
404.1520c(b)(2); Austin, 52 F.4th at 728. The ALJ is required to explain how these two factors
were considered. 20 C.F.R. § 404.1520c(b)(2); Bonnett v. Kijakazi, 859 F. App’x 19, 20 (8th Cir.
2021). The ALJ may also, but is not required to, explain how the remaining factors were
considered. See, 20 C.F.R. § 404.1520c(b)(2). However, where the ALJ “find[s] that two or more
medical opinions or prior administrative medical findings about the same issue are both equally
well-supported . . . and consistent with the record . . . but are not exactly the same,” the ALJ “will
articulate how [they] considered the other” enumerated factors “for those medical opinions or prior
administrative medical findings[.]” 20 C.F.R. § 404.1520c(b)(3).
Dr. Karayusuf was hired by Social Security to examine Plaintiff and author the March 11,
2024, 	mental status evaluation. (Mem. in Supp. [Docket No. 12] at 9; Tr. 710). This was Dr.
Karayusuf’s first and last time examining Plaintiff. Plaintiff highlights that Dr. Karayusuf had
access to “certain aspects” of his medical records; diagnosed Plaintiff with “elements” of PTSD,
generalized anxiety, and a panic disorder with agoraphobia; and opined that Plaintiff could
maintain pace and persistence if limited to simple, routine, repetitive, concrete, and tangible tasks
and could understand, retain, and follow simple instructions, but should be restricted to brief,
superficial, and infrequent interactions with others. (Mem. in Supp. [Docket No. 12] at 9; Tr. 710–
712).
8 “Supportability. The more relevant the objective medical evidence and supporting explanations presented by a
medical source are to support his or her medical opinion(s) or prior administrative medical finding(s), the more
persuasive the medical opinion(s) or prior administrative medical finding(s) will be.” 20 C.F.R. § 1520c(c)(1).
9 “Consistency. The more consistent a medical opinion(s) or prior administrative medical finding(s) is with the
evidence from other medical sources and nonmedical sources in the claim, the more persuasive the medical opinion(s)
or prior administrative medical finding(s) will be.” 20 C.F.R. § 1520c(c)(2).
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In the present case, the ALJ found Dr. Karayusuf’s opinion to be unpersuasive. (Tr. 24).
The ALJ first considered Dr. Karayusuf’s opinion in determining whether Plaintiff’s MDD, GAD,
and panic disorder with agoraphobia were severe. (Tr. 15, 16). The ALJ mentioned Dr.
Karayusuf’s opinion for each of the four functional areas, noting that Dr. Karayusuf’s report
contained no mention of any memory issues; the evaluation was “largely unremarkable;” and the
findings indicated Plaintiff was “cooperative” and exhibited “good behavior.” (Tr. 15, 16). The
ALJ additionally noted that Dr. Karayusuf reported Plaintiff had mentioned experiencing
diminished concentration, racing thoughts, and poor sleep, as well as, some difficulty relating to
finances and his marriage. (Tr. 15, 16).
The ALJ then, when determining Plaintiff’s RFC, again discussed Dr. Karayusuf’s March
11, 2024, opinion. The ALJ summarized and evaluated the opinion as follows:
As for additional opinion evidence, Dr. Karayusuf provided a mental medical
source 	statement 	as 	part 	of 	the 	claimant’s 	March 	11, 	2024 	psychological
consultative examination. He found the claimant to be able to understand, retain,
and following[sic] simple instructions, able to maintain pace and persistence for
simple, routine and repetitive tasks, and able to interact with coworkers, supervisors
and the public on a brief, superficial and infrequent basis . . . . Dr. Karayusuf’s
medical source statement is not consistent with or supported by the record discussed
above under Finding #3, which shows the claimant as having little to no mental
health treatment outside of two mental health evaluations since the AAOD . . . .
Further, language use by Dr. Karayusuf such as brief, superficial, concrete, and
tangible are not vocationally defined, and thus, do not adequately articulate the
limitations for use in a residual functional capacity assessment. Overall, I do not
find Dr. Karayusuf’s opinion persuasive.
(Tr. 24).
The ALJ did not find Dr. Karayusuf’s March 11, 2024, opinion to be as equally well-
supported as any other opinion. (Tr. 24). To the contrary, the ALJ clearly found that Dr.
Karayusuf’s medical opinion was unsupported by the record. (Tr. 24). Because the ALJ did not
find Dr. Karayusuf’s opinion to be equally well-supported as any other opinion about the same
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issues, the ALJ is required here to explain only how the supportability and consistency factors
were considered. 20 C.F.R. § 404.1520c(b).
In his discussion of Dr. Karayusuf’s opinion, the ALJ addressed only the consistency
factor. (Tr. 24). In other words, the ALJ’s discussion of Dr. Karayusuf’s opinion addressed only
whether the opinion was consistent with the other evidence in the record, specifically, Plaintiff’s
lack of mental health treatment. (Tr. 24). The ALJ failed to proffer any discussion of the
supportability factor, to wit: whether Dr. Karayusuf’s opinion was supported by Dr. Karayusuf’s
own treatment notes within the March 11, 2024, opinion, and whether there was any objective
medical evidence presented by Dr. Karayusuf himself.
Defendant attempts to save the ALJ’s decision by arguing the ALJ expressly referred back
to “Finding #3,” which addresses the supportability factor. (Mem. in Supp. [Docket No. 12] at 8,
9; Tr. 13–16, 24). Defendant specifically argues that, in continuously stating Plaintiff’s mental
status examination findings were “largely unremarkable,” followed by a general citation to Dr.
Karayusuf’s March 11, 2024, opinion, the ALJ adequately considered “the objective medical
evidence from the medical source who provided the opinion.” (Mem. in Opp. [Docket No. 22] at
9 (citing § 404.1520c(c)(1)). However, the ALJ’s language coupled with a generic citation does
not equate to a discussion on whether or not Dr. Karayusuf’s March 11, 2024, opinion is well-
supported. See, Lucus v. Saul, 960 F.3d 1066, 1069–70 (8th Cir. 2020) (“. . .while an ALJ’s
explanation need not be exhaustive, boilerplate or ‘blanket statement[s]’ will not do.”) (quoting
Walker v. Comm’r, Soc. Sec. Admin., 911 F.3d 550, 553 (8th Cir. 2018)).
The ALJ’s failure to discuss the supportability factor regarding Dr. Karayusuf’s opinion
represents a sufficient, independent legal error warranting remand of the present action. See, e.g.,
Lucus, 960 F.3d at 1069 (finding remand required where the ALJ discredited a physician’s opinion
without discussing factors contemplated in the regulation; stating, “[t]he failure to comply with
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SSA regulations is more than a drafting issue, it is legal error.”); Bonnett, 859 F. App’x at 20
(finding remand required because “while the ALJ adequately evaluated the supportability of [the
plaintiff’s physician’s] opinion, she did not address whether his opinion was consistent with the
other evidence of record, as required by the applicable regulation”); Samantha A. v. O’Malley,
No. 22-cv-3119 (TNL), 2024 WL 841270, at *5–6 (D. Minn. Feb. 28, 2024); Violet G. v. Kijakazi,
No. 21-cv-2105 (TNL), 2023 WL 2696594, at *6–7 (D. Minn. Mar. 29, 2023).
Although Defendant is correct that the ALJ can expressly refer back to the ALJ’s earlier
findings within his decision, (Mem. in Opp. [Docket No. 22] at 9), still, “it must be clear [the
required factors] were addressed.” Kimm W. v. O’Malley, No. 23-cv-2497 (JMB/DLM), 2024 WL
3896613, at *6 (D. Minn. July 15, 2024) (quoting Diane W. v. Kijakazi, No. 20-cv-2651
(SRN/ECW), 2022 WL 4377731, at *5 (D. Minn. Sept. 22, 2022)), report and recommendation,
2024 WL 3890913 (D. Minn. Aug. 21, 2024); see, Samantha A., 2024 WL 841270, at *5. In the
present case, the ALJ’s decision fails to demonstrate that the “supportability” factor was
considered in the ALJ’s evaluation of Dr. Karayusuf’s opinion. The ALJ’s decision simply lacks
any discussion regarding whether Dr. Karayusuf’s opinion is supported by the medical evidence
and treatment notes from Dr. Karayusuf himself.
In sum, the ALJ failed to adequately explain how supportability was considered with
regards to Dr. Karayusuf’s March 11, 2024, opinion.
Accordingly, 	the 	Court 	recommends 	that 	the 	present 	case 	be 	remanded 	to 	the
Commissioner so that a determination may be made in a manner consistent with this Report and
Recommendation. On remand, the ALJ should evaluate Dr. Karayusuf’s opinion in accordance
with 20 C.F.R. § 404.1520c, specifically relating to the supportability factor.10
10 Plaintiff additionally argues that the ALJ’s mention of Dr. Karayusuf’s use of non-vocationally defined language
did not adequately articulate the limitations for use in an RFC assessment should have had “minimal impact, if any at
all,” on the resulting RFC determination. (Mem. in Supp. [Docket No. 12] at 13). Given the Court has already found
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V. CONCLUSION
Therefore, based on the foregoing, and all the files, records, and proceedings herein, IT IS
HEREBY RECOMMENDED THAT:
1. 	Plaintiff’s request for relief, [Docket No. 12], be GRANTED, as set forth herein;
2. 	Defendant’s request for relief, [Docket No. 22], be DENIED, as set forth herein; and
3. 	The above captioned matter be REMANDED to the Social Security Administration,
pursuant to sentence four of 42 U.S.C. § 405(g), for further administrative proceedings
consistent with this Report and Recommendation.
Dated: April 30, 2026 	s/Leo I. Brisbois
Hon. Leo I. Brisbois
United States Magistrate Judge
NOTICE
Filing Objections: This Report and Recommendation is not an order or judgment of the District
Court and is therefore not appealable directly to the Eighth Circuit Court of Appeals.
Under Local Rule 72.2(b)(1), “a party may file and serve specific written objections to a magistrate
judge's proposed findings and recommendations within 14 days after being served a copy” of the
Report and Recommendation. A party may respond to those objections within 14 days after being
served a copy of the objections. LR 72.2(b)(2). All objections and responses must comply with the
word or line limits set forth in LR 72.2(c).
that the ALJ did not properly consider Dr. Karayusuf’s March 11, 2024, opinion, the ALJ’s assertion that Dr.
Karayusuf’s March 11, 2024, opinion did not use vocationally defined language does not impact this Court’s ruling.
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