Lawton v. Commissioner of Social Security Administration

OCR transcription for search; preserved printed pages are authoritative

Case: 1:25-cv-00720-CEH Doc #: 13 Filed: 11/21/25 1 of 13. PagelD #: <pagelD>

IN THE UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF OHIO

EASTERN DIVISION
LUCAS LAWTON, ) CASE NO. 1:25-CV-00720-CEH
)
Plaintiff, ) JUDGE CARMEN E. HENDERSON
) UNITED STATES MAGISTRATE JUDGE
Vv. )
) MEMORANDUM OPINION AND
COMMISSIONER OF SOCIAL ) ORDER
SECURITY ADMINISTRATION, )
)
Defendant, )

I. Introduction

Lucas Lawton (“Lawton” or “Claimant’), seeks judicial review of the final decision of
the Commissioner of Social Security denying his application for Disability Insurance Benefits
(“DIB”). This matter is before me by consent of the parties under 28 U.S.C. § 636(c) and Federal
Rule of Civil Procedure 73. (ECF No. 5). For the reasons set forth below, the Court REVERSES
the Commissioner of Social Security’s nondisability finding and REMANDS this case to the
Commissioner and the ALJ under Sentence Four of § 405(g).
II. Procedural History

On June 1, 2023, Lawton filed an application for DIB, alleging a disability onset date of
May 31, 2023. (ECF No. 9, PageID #: 278). The application was denied initially and upon
reconsideration, and Lawton requested a hearing before an administrative law judge (“ALJ”).
(Id.). On April 18, 2024, an ALJ held a hearing, during which Claimant, represented by counsel,
and an impartial vocational expert testified. (See id. at PageID #: 381-408). On May 1, 2024 the

ALJ issued a written decision finding Lawton was not disabled. (/d. at PageID #: 278-87). The

AUTHENTICATED
U.S. GOVERNMENT
INFORMATION

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ALJ’s decision became final on February 10, 2025, when the Appeals Council declined further
review. (Id. at PageID #: 29-32).
On April 10, 2025, Lawton filed his Complaint to challenge the Commissioner’s final
decision. (ECF No. 1). The parties have completed briefing in this case. (ECF Nos. 10, 12).
Lawton asserts the following assignments of error:
(1) Whether the ALJ erred in the evaluation of Mr. Lawton’s
upper extremity limitations resulting in a residual functional
capacity assessment that is not supported by substantial evidence.
(2) Whether the ALJ erred when he failed to adequately
evaluate and recognize the limiting impact of Mr. Lawton’s
hypersomnia and excessive daytime sleepiness.
(ECF No. 10 at 1).
III. Background
A. Relevant Hearing Testimony
The ALJ summarized the relevant testimony from Lawton’s hearing:
Claimant testified that he has a license and that he drives short
distances. Claimant is right handed. Claimant confirmed that he
graduated from high school. Claimant testified that he had
surgeries in May, June and October 2023 on his left upper
extremity, particularly his elbow. Claimant said that he is unable to
work because he cannot get out of bed or walk because of arthritis
in his joints. Claimant testified that he has problems with his hands
and that it hurts to brush his teeth. Claimant said that he cannot
type on a keyboard and that his ability to use his phone is limited
because of cramping in his fingers and hands. Claimant said that he
can cut a piece of meat with a knife. Claimant stated that he has
problems sleeping and that he usually sleeps about three hours at
night, then naps during the day. Claimant stated that on a typical
day, he gets his daughter up and takes her to school. Claimant
feeds the pets and does some housekeeping tasks before picking
his daughter up from school. Claimant said that he has no hobbies
or volunteer activities. Claimant testified that his fingers cramp up.
Claimant said that he cannot reach overhead or even to the front
with either arm.
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(ECF No. 9, PageID #: 282).
B. Relevant Medical Evidence
The ALJ also summarized Lawton’s health records and symptoms:
Records from the office of primary care provider Heather Mielke,
DO document claimant’s visits there dating back to January 2021,
when hypertension medication was prescribed. Claimant’s body
mass index (BMI) was over 30 (7F/1-4). Claimant saw specialist
Babu Eapen, MD for obstructive sleep apnea and CPAP in July
2021 (2F/3-7; and 20F/2-5). Claimant followed up for
hypertension and obesity with Dr. Mielke on September 1, 2022
(7F/5-9) and December 13, 2022. Claimant had been walking and
trying to eat a health diet (7F/10-14). Claimant was evaluated on
December 29, 2022 by orthopedist Mark Lembach, MD for left
shoulder and elbow pain. Dr. Lembach administered injections
(4F/2-4).
Claimant complained to Dr. Lembach on January 17, 2023 that he
now had pain in the right shoulder and elbow. Claimant deferred
injections, as they had not helped on the other side (4F/5-7). On
January 25, 2023, claimant received urgent care for asthmatic
bronchitis (1F). On January 30, 2023, claimant was evaluated by
orthopedist Mark Panigutti, MD for pain in both hands. Claimant
also complained of pain in both knees. Dr. Panigutti’s impression
included arthritis of the bilateral thumbs and carpal tunnel, bilateral
hands. Claimant was referred to rheumatology for his multiple
joint pains (4F/8-12).
Claimant underwent an initial evaluation on February 14, 2023 by
rheumatologist Gheorghe P. Ignat, MD. X-rays of the cervical
spine that day showed decreased normal cervical lordotic
curvature. X-rays of the lumbar spine showed mild lumbar
spondylosis. X-rays of the sacroiliac joints showed no evidence of
arthritis (10F/8-10; and 20F/6-8, 24-39). Claimant followed up on
February 28, 2023 with Dr. Ignat, who summarized that with
negative rheumatoid factor and other laboratory results, claimant
problems appeared to be related to osteoarthritis. Dr. Ignat
prescribed Cymbalta (10F/5-7). On February 28, 2023, Dr.
Lembach ordered physical therapy for right shoulder and elbow
pain (4F/13-15; and 20F/9-11). Claimant followed up with sleep
specialist Dr. Eapen on March 7, 2023 (2F/1-2; and 20F/12-13).
On March 7, 2023, claimant underwent an initial occupational
therapy evaluation for left shoulder and elbow pain. Claimant
attended sessions on March 14 and 21 and April 4, 2023 (3F; and
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4F/16-18).
April 18, 2023 MRI of the left shoulder showed ACL joint
arthrosis and inflammation with mild impingement and
supraspinatus and infraspinatus tendinitis. MRI of the left elbow
showed degenerative changes and small joint effusion (4F/19-22).
On April 25, 2023, Dr. Lembach endorsed proceeding with surgery
on the left shoulder and carpal tunnel, as these bothered claimant
the most. Claimant was thinking about having left elbow surgery
while he was off work as a dairy manager at a market (4F/23-25).
On May 31, 2023, Dr. Lembach performed left shoulder
arthroscopic debridement, biceps tenodesis and carpal tunnel
release surgery (4F/26- 28).
On June 15, 2023, claimant underwent an initial evaluation of his
left elbow by orthopedic specialist Harry A. Hoyen, MD, who
advised claimant to return for possible injections for osteoarthritis
once his shoulder had healed (14F/19-21). On June 16, 2023
postsurgical follow up, Dr. Lembach ordered physical therapy
(4F/29-31). Claimant underwent an initial physical therapy
evaluation on June 19, 2023 (6F/26-29) and he attended a half
dozen sessions through July 6, 2023 (6F/16-20).
Dr. Lembach’s July 7, 2023 plan included continuing physical
therapy and weaning off a left arm sling. Claimant wanted to
address his right hand issues addressed during his recovery (4F/32-
34). Claimant attended physical therapy sessions #7-9 from July
10-17, 2023 (6F/10-15).
On July 18, 2023, claimant was evaluated by neurologist Suresh
Kumar, MD for headaches. Dr. Kumar’s assessment included:
headache; excessive daytime sleepiness; idiopathic hypersomnia;
and blurry vision. Dr. Kumar ordered imaging (9F/1-4).
On July 19, 2023, Dr. Lembach performed right open carpal tunnel
and index and middle finger trigger release surgery (4F/35-36).
Claimant attended physical therapy sessions #10-11 on July 24 and
26, 2023 (6F/6-9). July 31, 2023 MRI and MRA of the brain
showed no definite emergent large vessel occlusion, arterial
dissection or aneurysm. Both cerebellar tonsils extended below the
margin of the foramen magnum, compatible with benign cerebellar
tonsillar ectopia. Paranasal sinus disease was shown, with probable
reactive lymphoid hypertrophy (5F/1- 4, 20; 6F/4-5; and 9F/11-
15).
Claimant attended physical therapy session #13 on August 3, 2023
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(6F/2-3) and he had a routine visit with Dr. Mielke that day, as
well (7F/15-16). Dr. Lembach administered a cortisone injection to
the right trigger finger on August 10, 2023. Claimant was advised
to take a two week break from physical therapy, but to continue
home stretches to avoid frozen shoulder (4F/37-39). On August 25,
2023, Dr. Kumar noted that claimant was doing well on Cymbalta
(9F/5-10). Claimant followed up with Dr. Hoyen on August 17,
2023 with continued left elbow pain (14F/17-18). August 31, 2023
CT scans of the left elbow showed moderate osteoarthritis with a
few intra-articular bodies (14F/25-27). Dr. Ignat refilled Cymbalta
and Gabapentin on September 8, 2023 (20F/14-17, 40-42).
Claimant told Dr. Hoyen on September 14, 2023 that his left elbow
was a little improved, though the pain still interfered with his
functioning (14F/16-17). Claimant followed up with Dr. Lembach
on September 21, 2023 (13F). Claimant presented as a new patient
on September 27, 2023 to an NP specialist for evaluation of his
thyroid and given a diagnosis of Hashimoto’s disease (12F).
Dr. Lembach administered injections to both knees on October 6,
2023 (13F/5). On October 11, 2023, Michael Bassett, MD
performed manipulation of the left elbow under anesthesia (14F/5-
16; and 15F/1-7). Antibiotics were prescribed for signs of possible
infection. Mary Grace Lenehan, PA removed claimant’s sutures on
October 26, 2023 (18F5-6). Claimant followed up with the thyroid
specialist on October 30, 2023 (16F) and with Dr. Eapen on
October 31, 2023 (20F/18-19). Claimant underwent an
occupational therapy evaluation on December 8, 2023 for left
elbow arthritis (19F/4-6).
Claimant had a visit on January 30, 2024 with Dr. Mielke for
sinusitis, wheezing and hypertension (17F). Claimant was
discharged from occupational therapy on January 31, 2024 as
progress had plateaued and was limited due to pain levels (19F/1-
3). Claimant told Dr. Hoyen on February 29, 2024 that he could
only lift 5-10 pounds (22F/12-14). Claimant followed up with Dr.
Ignat on March 1, 2024 (20F/20-23) and with Dr. Lembach on
March 5, 2024 (21F). On March 21, 2024, Dr. Mielke ordered
cardiac stress testing. March 26, 2024 EKG showed normal sinus
rhythm (23F).
(ECF No. 9, PageID #: 282-84).
IV. The ALJ’s Decision
The ALJ made the following findings relevant to this appeal:
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1. Claimant meets the insured status requirements of the Social
Security Act through December 31, 2028.
2. Claimant has not engaged in substantial gainful activity since May
31, 2023, the alleged onset date (20 CFR 404.1571 et seq.).
3. Claimant has the following severe impairments: arthritis; carpal
tunnel syndrome; and left shoulder rotator cuff arthropathy (20
CFR 404.1520(c)).
4. Claimant does not have an impairment or combination of
impairments that meets or medically equals the severity of one of
the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1
(20 CFR 404.1520(d), 404.1525 and 404.1526).
5. After careful consideration of the entire record, I find that claimant
has the residual functional capacity to perform sedentary work as
defined in 20 CFR 404.1567(a) except that he: can lift, carry, push
and pull 10 pounds occasionally and lesser weight frequently; in an
eight hour work day, can sit for six hours, stand for two hours and
walk for two hours; cannot push or pull with the left upper
extremity; can occasionally reach overhead with either upper
extremity and frequently in all other directions; can frequently
handle, finger and feel with either upper extremity; can
occasionally climb ramps and stairs; can never climb ladders, ropes
or scaffolds; can occasionally kneel, crouch and crawl; and can
never work at unprotected heights or near dangerous moving
machinery.
6. Claimant is unable to perform any past relevant work (20 CFR
404.1565).
…
10. Considering claimant’s age, education, work experience and
residual functional capacity, there are jobs that exist in significant
numbers in the national economy that claimant can perform (20
CFR 404.1569 and 404.1569a).
11. Claimant has not been under a disability, as defined in the Social
Security Act, from May 31, 2023 through the date of this decision
(20 CFR 404.1520(g)).
(ECF No. 9, PageID #: 280-82, 285-87).
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V. Law & Analysis
A. Standard of Review
The Court’s review “is limited to determining whether the Commissioner’s decision is
supported by substantial evidence and was made pursuant to proper legal standards.” Winn v.
Comm’r of Soc. Sec., 615 F. App’x 315, 320 (6th Cir. 2015); see also 42 U.S.C. § 405(g).
“[S]ubstantial evidence is defined as ‘more than a scintilla of evidence but less than a
preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.’” Rogers v. Comm’r of Soc. Sec., 486 F.3d 234, 241 (6th Cir. 2007)
(quoting Cutlip v. Sec’y of HHS, 25 F.3d 284, 286 (6th Cir. 1994)).
“After the Appeals Council reviews the ALJ’s decision, the determination of the council
becomes the final decision of the Secretary and is subject to review by this Court.” Olive v.
Comm’r of Soc. Sec., No. 3:06 CV 1597, 2007 WL 5403416, at *2 (N.D. Ohio Sept. 19, 2007)
(citing Abbott v. Sullivan, 905 F.2d 918, 922 (6th Cir. 1990); Mullen v. Bowen, 800 F.2d 535,
538 (6th Cir. 1986) (en banc)). If the Commissioner’s decision is supported by substantial
evidence, it must be affirmed, “even if a reviewing court would decide the matter differently.”
Id. (citing 42 U.S.C. § 405(g); Kinsella v. Schweiker, 708 F.2d 1058, 1059–60 (6th Cir. 1983)).
B. Standard for Disability
The Social Security regulations outline a five-step process that the ALJ must use in
determining whether a claimant is entitled to supplemental-security income or disability-
insurance benefits: (1) whether the claimant is engaged in substantial gainful activity; (2) if not,
whether the claimant has a severe impairment or combination of impairments; (3) if so, whether
that impairment, or combination of impairments, meets or equals any of the listings in 20 C.F.R.
§ 404, Subpart P, Appendix 1; (4) if not, whether the claimant can perform her past relevant
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work in light of her residual functional capacity (“RFC”); and (5) if not, whether, based on the
claimant’s age, education, and work experience, she can perform other work found in the
national economy. 20 C.F.R. § 404.1520(a)(4)(i)–(v); Combs v. Comm’r of Soc. Sec., 459 F.3d
640, 642–43 (6th Cir. 2006). The claimant bears the ultimate burden of producing sufficient
evidence to prove that she is disabled and, thus, entitled to benefits. 20 C.F.R. § 404.1512(a).
Specifically, the claimant has the burden of proof in steps one through four. Walters v. Comm’r
of Soc. Sec., 127 F.3d 525, 529 (6th Cir. 1997). The burden shifts to the Commissioner at step
five to establish whether the claimant has the residual functional capacity to perform available
work in the national economy. Id.
C. Discussion
Lawton raises two issues on appeal. First, he argues the ALJ “erred in the evaluation of
[his] upper extremity limitations resulting in a residual functional capacity assessment that is not
supported by substantial evidence.” (ECF No. 10 at 1). Second, he argues the ALJ “erred when
he failed to adequately evaluate and recognize the limiting impact of Mr. Lawton’s hypersomnia
and excessive daytime sleepiness.” (Id.).
1. Consideration of Upper Extremity Limitations in RFC
Plaintiff first argues that when crafting the RFC, “the ALJ erroneously interpreted raw
medical data on his own and failed to accurately evaluate and articulate all of the relevant
evidence regarding Plaintiff’s limited ability to use his upper extremities” such that the ALJ
“erred in finding that pushing and pulling was restricted only with the left, not the right upper
extremity; that Mr. Lawton could frequently reach in all other directions except for overhead;
and could frequently handle, finger, and feel with either upper extremity.” (ECF No. 10 at 11).
Plaintiff asserts that the ALJ rejected the opinions of both the State agency consultants and
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Plaintiff’s providers and instead “relied on a recitation of select portions of the evidence with a
very limited analysis” to support the RFC. (Id. at 12 (internal citation omitted)). Plaintiff’s
position is that because “the ALJ considered only selective portions of the record, did not address
the objective evidence as a whole, and reached a determination regarding Plaintiff’s upper
extremity limitations that is not supported by substantial evidence, reversal or remand is
warranted.” (Id. at 15).
The Commissioner responds that substantial evidence supports the ALJ’s decision, and
the record does not support additional limitations. (ECF No. 12 at 7). The Commissioner argues
the ALJ did not selectively cite evidence because he “repeatedly acknowledged Plaintiff’s
reports of pain in his arms, hands, and shoulders” and “referenced diagnostic images showing
objective problems and discussed Plaintiff’s various surgeries.” (Id. at 8). The Commissioner’s
position is that “given both evidence that supported Plaintiff’s allegations and evidence that
detracted from them, the ALJ reasonably crafted a restrictive RFC finding for sedentary work …
subject to additional limitations” and “it cannot be said that the ALJ’s RFC finding was
unreasonable or outside the ‘zone of choice.’” (Id. at 9).
At step four, the ALJ must determine a claimant’s RFC by considering all relevant
medical and other evidence. 20 C.F.R. § 404.1520(e). The ALJ must “consider limitations and
restrictions imposed by all of an individual’s impairments, even those that are not ‘severe.’”
Social Security Ruling (“SSR”) 98-6p, 1996 WL 374184, at *5. Further, “[t]he RFC assessment
must include a discussion of why reported symptom-related functional limitations and
restrictions can or cannot reasonably be accepted as consistent with the medical or other
evidence.” Id. at *7. Thus, “[i]n rendering his RFC decision, the ALJ must give some indication
of the evidence upon which he is relying, and he may not ignore evidence that does not support
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his decision, especially when that evidence, if accepted, would change his analysis.” Fleischer v.
Astrue, 774 F. Supp. 2d 875, 881 (N.D. Ohio 2011) (citations omitted). A court “cannot uphold
an ALJ’s decision, even if there is ‘enough evidence in the record to support the decision,
[where] the reasons given by the trier of fact do not build an accurate and logical bridge between
the evidence and the result.” Id. at 877.
After reviewing the ALJ’s decision, the Court finds Plaintiff’s argument persuasive. In
his decision, the ALJ noted Claimant’s testimony that he had “problems with his hands and that
it hurts to brush his teeth,” “he cannot type on a keyboard and … his ability to use his phone is
limited because of cramping in his fingers and hands,” and “he cannot reach overhead or even to
the front with either arm.” (ECF No. 9, PageID #: 282). The ALJ indicated he found Plaintiff’s
“medically determinable impairments could reasonably be expected to cause the alleged
symptoms” but his “statements concerning the intensity, persistence and limiting effects of these
symptoms are not entirely consistent with the medical evidence and other evidence in the record
for the reasons explained in this decision.” (Id.). However, beyond this boilerplate language, the
ALJ wholly failed to provide any explanation as to why the evidence in the record supported
discounting Plaintiff’s symptom allegations or why it justified the limitations—and only the
limitations—included in the RFC. (See id. at PageID #: 282-85). The ALJ explained that
“updated surgical and other treatment documentation” supported restricting Plaintiff to sedentary
work rather than light as opined by the State agency consultants but provided no explanation as
to why he found Plaintiff retained the ability to occasionally reach overhead and frequently in all
other directions, and frequently handle, finger, and feel with both upper extremities. (See id.).
Further, the ALJ’s summary of the medical records does not include any references or findings
that clearly contradict Plaintiff’s allegations or support the ALJ’s RFC. (Id.).
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Defendant argues that “the record contains findings on physical examination that bolster
the ALJ’s RFC finding,” including that “at times Plaintiff has exhibited normal range of motion
of the wrists, hands, and fingers and normal strength” and “[a]t a March 2024 examination,
Plaintiff displayed near full passive range of motion, but had pain with shoulder elevation, which
is consistent with the ALJ’s finding that Plaintiff could only occasionally reach overhead but
could frequently reach in other directions.” (ECF No. 12 at 8-9). The problem, however, is that
the ALJ did not mention or cite these specific findings at any point in his decision, let alone as
justification for discounting Plaintiff’s allegations or as supportive of the RFC. (See ECF No. 9,
PageID #: 282-84). Thus, the mere presence of these normal findings in the record—without any
indication that the ALJ relied on them in reaching his decision—is insufficient to uphold the
decision. See Hicks v. Comm’r of Soc. Sec., 909 F.3d 786, 808 (6th Cir. 2018) (“An agency’s
actions must be upheld, if at all, on the basis articulated the agency itself, and not based on
appellate counsel’s post hoc rationalizations.” ) (citation modified). While the Commissioner is
certainly correct that the ALJ need not specifically discuss each record if his findings show that
he considered the entire record in reaching his decision, the issue here is not whether substantial
evidence could support the ALJ’s decision but rather whether the ALJ sufficiently explained his
rationale in reaching his decision. Because the ALJ wholly failed to explain why the medical
records discussed supported his ultimate RFC finding and rejection of Plaintiff’s testimony, he
failed to build an accurate and logical bridge between the evidence and the result. See Russell v.
Comm’r of Soc. Sec. Admin., No. 1:23-cv-01748-DAC, 2024 WL 3638702, at *19 (N.D. Ohio
Aug. 2, 2024) (nothing that while an ALJ’s decision “need not be so comprehensive as to
account with meticulous specificity for each finding and limitation, nor is the ALJ required to
discuss every piece of evidence in the record,” the ALJ must still “provide sufficient explanation
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for the claimant and any reviewing court to trace the path of her reasoning and explain with
specificity how the evidence supports the RFC limitations”) (citation modified) (quoting Correa
v. Comm’r of Soc. Sec., No. 1:23-cv-685, 2023 WL 9064960, at *10, (N.D. Ohio Dec. 14, 2023)
(citations omitted), report & recommendation adopted, 2024 WL 37877 (N.D. Ohio Jan. 3,
2024)). Accordingly, remand is required. See Cox v. Comm’r of Soc. Sec., 615 F. App’x 254,
261 (6th Cir. 2015) (finding remand necessary where “neither the ALJ’s boilerplate credibility
finding nor her discussion of the evidence ma[de] clear her reasons for discrediting [claimant’s]
testimony” because such prevented the court from determining whether the RFC was supported
by substantial evidence).
2. Additional Argument
Plaintiff next argues the ALJ erred when he “did not evaluate or impose any work related
restrictions as a result of Mr. Lawton’s idiopathic hypersomnia and excessive daytime
sleepiness” because he concluded they had not interfered with Plaintiff’s work-related
functioning more than minimally for 12 months or longer. (ECF No. 10 at 15-16). However,
because the Court has already found remand necessary as explained above, the Court need not
address this argument. Rather, on remand, the ALJ should consider all relevant evidence in
evaluating Plaintiff’s disability claims in accordance with all applicable regulations.
VI. Conclusion
Based on the foregoing, the Court REVERSES the Commissioner of Social Security’s
nondisability finding and REMANDS this case to the Commissioner and the ALJ under Sentence
Four of § 405(g).
Dated: November 21, 2025
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s/ Carmen E. Henderson
CARMEN E. HENDERSON
U.S. MAGISTRATE JUDGE

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