Sajnog v. Commissioner, Social Security Administration

IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
CHRISTOPHER S., 1 	§
§
§
§
§
§
§
§
§
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Plaintiff,
V.
FRANK BISIGNANO,
Commissioner of Social Security,
Defendant.
No. 4:25-CV-120-P-BV
FINDINGS, CONCLUSIONS, AND RECOMMENDATION
OF THE UNITED STATES MAGISTRATE JUDGE
Plaintiff's application for disability insurance benefits was denied. He now seeks
judicial review of that denial under 42 U.S.C. § 405(g), arguing that the Administrative
Law Judge (ALJ) failed to appropriately evaluate the medical necessity of a handheld
assistive device and the medical opinion of a psychologist. After careful review, the
undersigned concludes that the ALJ did not err, and substantial evidence supports the
determination. Thus, the undersigned recommends the United States District Judge
affirm the Commissioner's decision and dismiss Plaintiff's complaint with prejudice.
1. 	Statement of the Case
Plaintiff applied for disability insurance benefits, but the Social Security
Administration denied the application initially and on reconsideration. Dkt. No. 12 at
1 To protect the privacy of plaintiffs in social security cases, the undersigned identifies Plaintiff only by
first name and last initial.
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14. 2 With the assistance of counsel, Plaintiff proceeded to a telephonic hearing before the
ALJ. Id. 	Plaintiff and a vocational expert (VE) testified. Id.
The ALJ concluded that Plaintiff is not disabled because there are jobs existing in
significant numbers in the national economy that he can perform. Id. at 28-29. Plaintiff
appealed the ALJ's determination, but the Appeals Council denied further administrative
review. See id. at 1. Plaintiff then filed this action seeking judicial review under
42 U.S.C. § 405(g). Dkt. No. 1. As a result of the denial, the ALJ's decision became the
Commissioner's final decision and is properly before the Court. Sims v. Apfel, 530 U.S.
103, 107 (2000); see also Higginbotham v. Barnhart, 405 F.3d 332, 337 (5th Cir. 2005)
(holding that the Commissioner's final decision necessarily incorporates the Appeals
Council's denial of a claimant's request for review).
In accordance with Special Order 3-350 and 28 U.S.C. § 636(b), this case was
automatically referred to the undersigned United States Magistrate Judge. See Dkt. No.
5. Not all parties have consented to proceed before a magistrate judge, so the
undersigned enters findings, conclusions, and a recommendation. See Dkt. Nos. 4, 6.
2. 	Standard of Review
A court reviewing the Commissioner's denial of social security benefits is limited
to determining whether ( 1) the decision is supported by substantial evidence in the
record, and (2) the Commissioner applied the proper legal standards. See 42 U.S.C.
2 The administrative record spans multiple subparts, all located at docket entry number 12. See Dkt. Nos.
12-1-12- 12. The Court therefore cites to the record as docket number 12, along with the record's
corresponding page number.
2
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§ 405(g) (2012); see, e.g., Higginbotham, 405 F.3d at 335. "Substantial evidence is more
than a scintilla, less than a preponderance, and is such relevant evidence as a reasonable
mind might accept as adequate to support a conclusion." Hames v. Heckler, 707 F.2d
162, 164 (5th Cir. 1983) (per curiam). A reviewing court must examine the entire record,
including evidence favorable to the Commissioner as well as contrary evidence. See Villa
v. Sullivan, 895 F.2d 1019, 1022 (5th Cir. 1990). The court "may not reweigh the
evidence in the record, nor try the issues de novo, nor substitute [the Court's] judgment
for the [Commissioner's]." Bowling v. Shala/a, 36 F.3d 431,434 (5th Cir. 1994) (per
curiam) (quoting Harrell v. Bowen, 862 F.2d 471,475 (5th Cir. 1988) (per curiam)). If
substantial evidence supports the Commissioner's findings, they are treated as conclusive
and will be affirmed. 42 U.S.C. § 405(g) (2012); Richardson v. Perales, 402 U.S. 389,
390 (1971).
Disability is defined as the "inability to engage in any substantial gainful activity
by reason of any medically determinable physical or mental impairment which can be
expected to result in death or which has lasted or can be expected to last for a continuous
period of not less than 12 months." 42 U.S.C. § 423(d)(l)(A). The Commissioner makes
a disability determination by conducting a five-step, sequential evaluation to determine
whether: ( 1) the claimant is currently working; (2) the claimant has a "severe
impairment"; (3) the impairment meets or equals an impairment listed in Appendix 1 of
the regulations; (4) the claimant is capable of performing past relevant work; and (5) the
claimant, after taking into account age, education, previous work experience, and residual
functional capacity, is capable of performing any other work. 20 C.F.R. § 404.1520(a)(4)
3
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(2016); Aud/er v. Astrue, 501 F.3d 446, 447-48 (5th Cir. 2007). If the Commissioner
makes a disability determination at any step in the process, the finding is conclusive, and
the analysis terminates. See Greenspan v. Shala/a, 38 F.3d 232, 236 (5th Cir. 1994).
The claimant bears the burden of proof in the first four steps of the analysis. Id. 	If
the claimant satisfies that burden, the Commissioner must demonstrate that the claimant
is capable of performing other work that exists in significant numbers in the national
economy. Id. 	If that showing is made, the burden shifts back to the claimant to rebut the
Commissioner's finding. 	See Newton v. Apfel, 209 F.3d 448,453 (5th Cir. 2000).
3. 	Factual Background
Plaintiff alleges he became disabled due to several health issues. 	Dkt. No. 12 at
17, 238-39, 293. Plaintiff has a college education, is a Navy SEAL veteran, and has prior
work experience as a firearms instructor. Id. at 16, 47-48.
The ALJ conducted the five-step evaluation. Id. at 16~29. At step one, the ALJ
found that Plaintiff has not engaged in substantial gainful activity for a continuous
twelve-month period. Id. at 16-17. Next, the ALJ concluded that Plaintiff has the
following severe impairments: cervical and lumbar spine degenerative disc disease; left
diaphragm paralysis; obstructive sleep apnea; osteoarthritis of left shoulder, status-post
left shoulder replacement surgery; peripheral neuropathy; osteoarthritis of hips; history of
deep vein thrombosis; attention deficit hyperactivity disorder (ADHD); post-traumatic
stress disorder (PTSD); anxiety disorder; depression; and neurocognitive disorder. Id. at
17.
4
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Despite the existence of severe impairments, the ALJ found at step three that
Plaintiff does not have an impairment or combination of impairments that meet or equal
the listings in 20 C.F.R. Part 404, Subpart P, Appendix 1. Id. at 17-20. The ALJ then
assessed Plaintiff's residual functional capacity (RFC) and concluded that Plaintiff can
perform "light work" as modified:
[H]e is able to occasionally climb ramps or stairs, balance, stoop, kneel, and
crouch. The claimant can occasionally reach overhead bilaterally. He can
have occasional exposure to dust, fumes, and pulmonary irritants. The
claimant can never climb ladders, ropes, and scaffolds or crawl. He can
understand, remember, and can-y out detailed but not complex tasks and
instmctions with occasional interaction with coworker[s], supervisors, and
the general public.
Id. at 20 (emphasis omitted). Relying on the testimony of a VE, the ALJ concluded that
there are jobs existing in significant numbers in the national economy that Plaintiff can
do despite his limitations. Id. at 28-29. Accordingly, the ALJ determined at step five that
Plaintiff is not disabled. Id.
4. 	The ALJ did not reversibly err in evaluating Plaintiff's RFC.
Plaintiff alleges that the ALJ e1Ted in developing the RFC by: ( 1) not properly
evaluating the medical necessity of Plaintiff's handheld assistive device (a walker or a
cane), and (2) failing to c01Tectly evaluate the persuasiveness of an opinion rendered by
Dr. Jessica Willis, a psychologist. 3 Dkt. No. 13 at 1, 8-14.
3 The ALJ and Plaintiff refer to this individual by different names, but the Court relies on the spelling
contained in the record evidence. E.g., Dkt. No. 12 at 3023.
s
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A. The ALJ did not err by omitting limitations in the RFC related to a
handheld assistive device.
Plaintiff argues that the ALJ erred by failing to consider whether his handheld
assistive device(s) are medically necessary. Id. at 9. According to Plaintiff, because the
evidence shows a device is medically necessary, remand is required. Id. at 9-12. In
support, Plaintiff points to a prescription for a wheeled and seated walker issued by a
physician assistant (PA). Id. ( citing Dkt. No. 12 at 2996). Plaintiff further states that he
sometimes uses a cane, but a walker provides safer ambulation. Id. at 9-10. Plaintiff
does not expressly challenge the RFC finding, but his argument is essentially that the
RFC is flawed because it lacks a limitation related to an assistive device. See id. at 11.
The Commissioner responds that "[t]he ALJ reasonably discounted Plaintiff's
report that he needed an assistive device because this allegation conflicted with the
medical record." Dkt. No. 14 at 1 (emphasis omitted). The Commissioner focuses on
Plaintiff's subjective testimony concerning the use of an assistive device without
expressly addressing the medical necessity of the device. 	See id. at 1-3.
In reply, Plaintiff argues that the Commissioner's failure to address the medical
necessity of an assistive device renders his argument unrefuted. Dkt. No. 15 at 1. In
Plaintiff's view, the Commissioner has "concede[d] there is evidence of medical
necessity and evidence describing the circumstances for which it is required." Id.
Plaintiff also reiterates that there is not substantial evidence supporting the ALJ 's
exclusion of an assistive device limitation. Id. at 1-3.
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First, the undersigned notes that the Commissioner's legal arguments are sparse,
and he does not directly address the medical necessity of Plaintiff's assistive device. Dkt.
No. 14 at 1-3. But the Commissioner contends that "the ALJ pointed to objective
medical evidence that contradict[sr "Plaintiff's allegations about his need for an assistive
device." Id. at 2. Thus, the Commissioner generally refutes Plaintiff's contention that
the ALJ erred as to the assistive device analysis. But even ifhe hadn't, the undersigned
would not recommend the result Plaintiff wants-a default reversal and remand because
based on the alleged deficiency of the Commissioner's brief. Dkt. No. 15 at 1 ("Since the
ALJ provided no evaluation of this [medical necessity] evidence ... , the Court should
reverse and remand."). Plaintiff-not the Commissioner-bears the burden of showing
that remand is warranted based on an RFC error. See Perez v. Barnhart, 415 F.3d 457,
461 (5th Cir. 2005) (explaining that plaintiff has burden to show disability under first four
steps of analysis); Jones v. Astrue, 691 F.3d 730, 734-35 (5th Cir. 2012) (holding that to
obtain remand, plaintiff must show prejudicial error).
"[A]n ALJ need not consider an assistive walking device in the RFC assessment
unless the device is medically necessary." Duenes v. Kijakazi, 578 F. Supp. 3d 859, 871
(S.D. Tex. 2022). A device is medically necessary when there is "medical documentation
establishing the need for a hand-held assistive device to aid in walking or standing, and
describing the circumstances for which it is needed (i.e., whether all the time,
periodically, or only in certain situations; distance and ten-ain; and any other relevant
information)," Social Security Ruling (SSR) 96-9P, 1996 WL 374185, at *7 (S.S.A. July
2, 1996) (emphasis added); see Staples v. Astrue, 329 F. App' x 189, 191 n.1 ( I 0th Cir.
7
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2009) (observing that SSR 96-9p applies to sedentary work but nevertheless relying on it
to evaluate plaintiff's RFC for light work, where parties agreed the standard was
appropriate); Dkt. Nos. 13 at 8; 15 at 1 (citing SSR 96-9p). The Fifth Circuit has not
defined what "medical documentation" is required to establish the necessity of an
assistive device. See Moore v. Saul, No. 3:20-cv-48-DPJ-MTP, 2021 WL 909618, at *3
(S.D. Miss. Feb. I, 2021) (observing lack of Fifth Circuit precedent), R. & R. adopted as
modified by 2021 WL 754833 (S.D. Miss. Feb. 26, 2021). Other circuits, however, have
required a statement from a medical professional describing the specific circumstances
for which the device is medically necessary. See, e.g., Tripp v. Astrue, 489 F. App'x 951,
955 (7th Cir. 2012); Howze v. Barnhart, 53 F. App'x 218,222 (3d Cir. 2002). "Neither a
prescription for a hand-held assistive device, nor a lack thereof, is 'necessarily dispositive
of medical necessity." Duenes, 578 F. Supp. 3d at 872 (citation omitted), Instead, the
ALJ "must always consider the particular facts of a case." SSR 96-9P, 1996 WL 374185,
at *7.
Plaintiff contends that the ALJ did not make a finding about the medical necessity
of an assistive device. Dkt. No. 13 at 10-12. However, at step 3, the ALJ explained that
the Plaintiff's impairments "do not preclude the use of both upper extremities to complete
work-related activities" because there was nothing showing that Plaintiff needs to use
"both upper extremities with an assistive device for mobility" or "a combination of upper
and lower extremity impairments and the need the use an assistive device for mobility."
Dkt. No. 12 at 18. Although the ALJ did not repeat this finding in the RFC discussion,
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the Court reads this finding in conjunction with the ALJ's opinion as a whole to
determine that an assistive device was not medically necessary, as discussed below.
Plaintiff also faults the ALJ for not discussing his wheeled walker prescription and
accompanying questionnaires completed by medical professionals. Dkt. No. 13 at 9-10
(citing Dkt. No. 12 at 2996, 2998, 3002, 3006). True, the ALJ did not reference
Plaintiff's prescription for a walker or the check-box questionnaires in his discussion.
See Dkt. No. 12 at 22, 24. But those documents do not show that an assistive device is
medically necessary.
First, the prescription itself does not equate to medical necessity. Duenes, 578 F.
Supp. 3d at 872 (citation omitted). The prescription does not describe the circumstances
under which the wheeled walker was necessary-e.g., when standing or walking, only
when walking longer distances, for use on uneven terrain, etc. See Dkt. No. 12 at 2996
(prescribing wheeled and seated walker due to spinal stenosis and neuropathy but not
stating when Plaintiff should use walker). 	Similarly, the PA's and physicians'
questionnaires and accompanying report-the primary documents on which Plaintiff
relies-do not state when the walker is medically necessary. See id. at 2998-3000
(opining that objective findings reflect medical need for walker and attaching report with
data collected by a physical therapist, which reflect test results but do not specify when
Plaintiff should use walker), 3002, 3006 (same). Thus, these documents fail to establish
the medical necessity of an assistive device because they are silent as to the conditions by
which the device should be used. 	See 96-9P, 1996 WL 374185, at *7; see, e.g., Hartfield
v. Kijakazi, No. I :22-cv-316-HSO-LGI, 2024 WL 1599934, at *3 (S.D. Miss. Jan. 30,
9
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2024) (rejecting plaintiff's contention that the ALJ erred by omitting consideration of her
wheeled walker in the RFC where, among other things, "[p]laintiff's prescription d[id]
not outline the circumstances for which the walker [wa]s needed, nor d[id] it provide any
of the relevant information recommended in SSR 96-9P"), R. & R. adopted sub nom. by
Hartfield v. Comm 'r of Soc. Sec., 2024 WL 1283821 (S.D. Miss. Mar. 26, 2024);
Delgadillo v. Colvin, No. EP-12-CV-00264-ATB, 2013 WL 5278495, at* 10 (W.D. Tex.
Sep. 17, 2013) (affirmingALJ's exclusion of assistive device limitation "[b]ecause there
was no medical documentation establishing claimant's need for a hand-held assistance
device to aid in walking or standing").
In his reply, Plaintiff maintains that in addition to the prescription, there is
"evidence describing the circumstances for which [an] assistive device[] is needed." Dkt.
No. 15 at 7. But Plaintiff does not direct the Court to that evidence, either in his opening
brief or reply. See Dkt. Nos. 13, 15. Because the prescription and opinions do not
specify the circumstances under which Plaintiff requires a device, and the Plaintiff has
not cited any other medical evidence explaining the circumstances, the ALJ did not err by
excluding the device from the RFC.
In any event, substantial evidence supports the ALJ's exclusion of limitations
related to an assistive device. Despite Plaintiff's argument to the contrary (Dkt. No. 13 at
10), the ALJ did review some of the evidence favorable to Plaintiff in the RFC analysis.
For example, Plaintiff testified that he needed a walker for prolonged ambulation but
otherwise walked with a cane or unassisted. Dkt. No. 12 at 21. The ALJ acknowledged
this testimony but contrasted it with PlaintifPs activities of daily living, which the ALJ
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found were inconsistent with Plaintiff's testimony. Id. at 24. Among other things,
Plaintiff traveled extensively, taking vacations to "Florida, Las Vegas, Costa Rica, and
Paris." Id. 	Further, the records showed that Plaintiff had recently played volleyball and
table tennis. Id (citing id. at 4319-4411 ). The ALJ determined that Plaintiff's "ability to
perform such a wide range of activities of daily living strongly suggests [Plaintifi] is not
as physically or mentally limited as he alleged." Id. (cleaned up).
In addition, the ALJ observed that at times, physical exams revealed "varied gait,
motor weakness[,] ... spinal tenderness, decreased spinal range of motion, and some
shortness of breath." Id. at 22; see also id. (stating that at an April 2023 consultative
exam, Plaintiff had "cervical and lumbar tenderness to palpation and decreased range of
motion''); id. at 24 (recognizing "some adverse findings, including reduced spinal, hips,
and left shoulder range of motion, intermittent tenderness, and motor weakness at times
as well as some shortness of breath and varied gait findings" (emphasis added)). But
overall, the ALJ explained that "[t]he longitudinal physical exam findings" showed
"generally normal gait, normal upper and lower extremity range of motion, 5/S motor
strength in his extremities, intact sensation, and no focal sensorial deficits." Id. at 22
(citing numerous records for support); see also id. at 24 ( citing "numerous unremarkable
or nmmal examination findings across the record"). For example, in the April 2023
consultative exam, straight leg raises were negative seated and supine bilaterally, and
Plaintiff's strength was 5/S in all extremities. Id. at 22. Plaintiff "ambulated into the
exam room without an assistive device." Id. 	Thereafter, Plaintiff attended physical
therapy, where he "made great progress with strength, core activation, and lumbar range
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of motion.'' Id. 	Because of his progress, the physical therapist discharged Plaintiff to
home exercises. Id.
The ALJ compared these documents with the medical opinions, which concluded
that Plaintiff could perform light work with some modifications. Id. at 25. Notably,
those opinions did not mention an assistive device limitation. Id. at 25. The ALJ
determined that those opinions were consistent with the other record evidence, which
reflected Plaintiff has intermittent but not sustained or debilitating conditions. See id.
As Plaintiff concedes, the ALJ need not discuss each piece of evidence. Price v.
Astrue, 401 F. App'x 985, 986 (5th Cir. 2010) (per curiam); see Dkt. No. 13 at 10. The
ALJ need only "build an accurate and logical bridge between the evidence and the final
determination." Price, 401 F. App'x at 986. Here, there is a logical bridge between the
evidence and the ALJ's decision not to account for an assistive device in the RFC.
Stated succinctly, the ALJ based his determination on the following: ( 1) he did not find
credible Plaintiff's testimony that he needed an assistive device for walking or prolonged
ambulation, particularly considering Plaintiff's activities of daily living, Dkt. No. 12 at
21, 24; (2) the objective medical evidence showed some non-disabling limitations, id. at
21-24; and (3) the medical opinions, which were consistent with that objective
information, opined that Plaintiff could perform light work with limitations that did not
include any mention of assistive device limitations. Id. at 24-25, 27. This is substantial
evidence to support the ALJ's decision. Biestek v, Benyhill, 587 U.S. 97, 103 (20 I 9)
(defining substantial evidence as "such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion'' ( citation omitted)); Madkins v. Bisignano,
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150 F.4th 657, 662 (5th Cir. 2025) (per curiam) ("A finding of no substantial evidence is
appropriate only if no credible evidentiary choices or medical findings support the
decision." (citation omitted)).
The ALJ did not err by excluding an assistive device from the Plaintiff's RFC.
The undersigned therefore recommends that the district judge overrule Plaintiff's first
point of error.
B. The ALJ properly evaluated Dr. Willis's psychological report.
Plaintiff claims that the ALJ committed legal error warranting remand in his
consideration ofDr. Willis's psychological report. Dkt. No. 13 at 13-14. TheALJ found
Dr. Willis's opinion "less persuasive because [she] did not employ language that
comports with Social Security's particular rules and regulations, such as the frequency
and/or duration of the work-related activities that [Plaintiff] could or could not perform."
Dkt. No. 12 at 27. But Plaintiff alleges that the ALJ reached this conclusion without
adequately articulating the supportability and consistency factors. Id. at 14-15.
The Commissioner, on the other hand, contends that the ALJ "rationally" found
that Dr. Willis's report does not constitute a medical opinion. Dkt. No. 14 at 3-4.
Plaintiff counters that the ALJ did not make such a finding but instead implicitly
concluded the report did constitute a medical opinion when the ALJ determined it was
"less persuasive.'' Dkt. No. 15 at 8. Plaintiff argues that "[t]he ALJ's decision must stand
or fall on the rationale set forth in the [written] opinion." Id. (citing Newton v. Apfel, 209
F.3d 455,458 (5th Cir. 2000)).
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"A medical opinion is a statement from a medical source about what [a claimant]
can still do despite [his] impairment(s) and whether [he] ha[s] one or more impairment~
related limitations or restrictions." 20 C.F.R. § 404.1513(a)(2). The ALJ evaluates every
medical opinion regardless of its source but "will 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. §§ 404.1520(a)(3), 404.1520c(a).
Under the regulations, the ALJ should review the following factors in evaluating a
medical opinion: (I) supportability; (2) consistency; (3) relationship with the claimant;
(4) specialization; and (5) other factors, including "evidence showing a medical source
has familiarity with the other evidence in the claim or an understanding of [the SSA's]
disability program's policies and evidentiary requirements." § 404.1520c(c)(I}-(5).
However, an ALJ is only required to address two factors: the supportability of a medical
opinion and the consistency of that opinion-Le., factors one and two.
§ 404.1520c(b)(2). As to supportability, "[t]he more relevant the objective medical
evidence and suppmting explanations presented by a medical source are to support ...
her medical opinion(s) ... , the more persuasive the medical opinions ... will be."
§ 404.1520c(c)(l). In addition, "[t]he more consistent a medical opinion(s) ... is with
the evidence from other medical sources and nonmedical sources in the claim, the more
persuasive the medical opinion(s) ... will be." § 404.1520c(c)(2).
Because the ALJ was only legally obligated to evaluate the persuasiveness of Dr.
Willis 's opinion if it constitutes a medical opinion, the undersigned must first answer this
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threshold question. See Winston v. Berryhill, 755 F. App'x 395, 402 (5th Cir. 2018)
(considering first whether physician's evaluation was a medical opinion "because the
legal standards allegedly violated [only] appl[ied] to medical opinions"). The
undersigned agrees with the Commissioner that Dr. Willis's report does not constitute a
medical opinion.
A medical opinion "describe[s] what [a claimant] can or cannot do during the
workday," as distinguished from "laboratory findings and clinical findings.'' Robinson v.
Comm'r of Soc. Sec., No. 22-1397, 2022 WL 17168444, at *3 (6th Cir. Nov. 22, 2022)
(internal quotation marks and citation omitted). 	Stated differently, a medical opinion
must make conclusions about the impact a claimant's conditions have on his RFC. 	See
Winston, 755 F. App'x at 402. Dr. Willis's psychological assessment does not opine to
Plaintiff's ability to perform work activities. See Dkt. No. 12 at 3023-43. Instead, she
rendered opinions on, and made recommendations about, whether Plaintiff's memory,
focus, and motivation would return and tips to help Plaintiff improve his sleep. Id. at
3023, 3042-43. Although some of these recommendations could pertain to work
activities, Dr. Willis's failure to discuss them in terms of specific work-related functions
and to opine on what Plaintiff can still do at work despite his impairments places the
evaluation outside the definition of a "medical opinion." 	Winston, 755 F. App'x at 402
(holding physician's evaluation did not constitute medical opinion under former version
of rule, where the evaluation "simply outline[d] [physician's] diagnoses and
observations, leaving other personnel to draw conclusions about the implications for
[plaintiff's] RFC)~ ?harries v. Kijakazi, No. CIV-22-750-STE, 2023 WL 3690253, at *5
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(W.D. Okla. May 26, 2023) (concluding physician's findings were not a "medical
opinion" because physician "never addressed [p]laintiff's specific work-related
limitations or what he could still do despite his impairments"); cf Kneeland v. Benyhill,
850 F.3d 749, 751, 759 (5th Cir. 2017) (concluding doctor's evaluation was a medical
opinion, "as he examined [plaintiff], noted observations from that examination, and
opined on her work limitations" by estimating that plaintiff could not "work any job that
entails standing for longer than 30 minutes or walking farther than 50 yards").
Reasonably read, the ALJts discussion could be construed as concluding that Dr.
Willis 's evaluation is not a medical opinion, given the ALJ's reference to "the frequency
and/or duration of the work-related activities." Dkt. No. 12 at 27. But even if the ALJ
did not make that finding, it makes no difference. The ALI could only have violated
§ 404.1520c ifhe was legally obligated to comply with it in the first instance. But he was
not so obligated because Dr. Willis did not render a ''medical opinion" as that term is
contemplated by the regulations and relevant case law. Thus, the ALI's failure to discuss
the consistency and supportability factors as to Dr. Willis's opinion is not error. See
Winston, 755 F. App'x at 402; Jason R. v. Comm 'r ofSoc. Sec., No. 2:23-CV-00171-BW,
2024 WL 4592377, at* 12 (N.D. Tex. Oct. 28, 2024) (concluding that physician's opinion
did not qualify as a medical opinion and therefore rejecting plaintiff's contention that the
ALI e1Ted in concluding that physician's evaluation was only somewhat persuasive
because it did not "quantify [p ]laintiff's limitations in 'vocationally-relevant terms"').
Although Dr. Willis's report is not a ''medical opinion" that required a
persuasiveness analysis, the report does constitute "other medical evidence."
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§ 404.1513(a)(3). "Other medical evidence is evidence from a medical source that is not
objective medical evidence or a medical opinion, including judgments about the nature
and severity of [the claimant's] impairments, [the claimant's] medical history, clinical
findings, diagnosis, treatment prescribed with response, or prognosis." Id. 	The ALJ must
consider "other medical evidence," but he is not required to discuss it. See§ 404.1520c.
TheALJ's mention of Dr. Willis's rep01t in the written opinion shows that he
considered it, which is all he was required to do. Pharries, 2023 WL 3690253, at *5.
Plaintiff makes no at'gument to the contrary. See Dkt. No. 13.
Moreover, a plaintiff must demonstrate prejudice to obtain remand. Jones, 691
F.3d at 734-35. "To establish prejudice, a claimant must show that he could and would
have adduced evidence that might have altered the result." Brock v. Chater, 84 F.3d 726,
728 (5th Cir. 1996) (internal quotation marks and citation omitted). Here, Plaintiff argues
that theALJ's failure to evaluate the persuasiveness of Dr. Willis's opinion was a legal
error that requires remand. Dkt. No. 13 at 14. But Plaintiff does not explain "why or
how" the RFC would have been different but for the ALJ's alleged error. 	Vasquez v.
O'Malley, No. 24-50233, 2024 WL 4381269, at *2 (5th Cir. Oct. 3, 2024). That is,
Plaintiff does not point to information within Dr. Willis's evaluation that "cast[s] into
doubt" the mental limitations the ALJ did include in the RFC. Morris v. Bowen, 864 F.2d
333, 335 (5th Cir. 1988); see Dkt. No. 12 at 20 (providing that Plaintiff"can understand,
remember, and carry out detailed but not complex tasks and instructions with occasional
interaction with coworker[s], supervisors, and the general public"). Accordingly, even if
the ALJ erred by rejecting the report solely because it did not employ work-related
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language, Plaintiff has not demonstrated that any error was prejudicial. See Devy/le C. v.
Kijakazi, No. 22-cv-01061 (GMH), 2023 WL 4864600, at* 12 (D.D.C. July 31, 2023)
(explaining that "other medical evidence" "cannot be dismissed as
inherently less persuasive" merely because it is not a "medical opinion" (citation
omitted)).
In sum, the ALJ was not required to evaluate the persuasiveness of Dr. Willis 's
opinion under § 404.1520c. And even if the ALJ erred by rejecting Dr. Willis 's
evaluation solely because it failed to discuss PlaintifY,s work-related functioning, Plaintiff
has not met his burden of showing such error was prejudicial. Thus, the undersigned
recommends the district judge overrule Plaintiff's second point of error.
5. 	Recommendation
For these reasons, the undersigned recommends that the United States District
Judge affirm the Commissioner's determination and dismiss Plaintiff's complaint with
prejudice.
6. 	Right to Object
A copy of these findings, conclusions, and recommendation shall be served on all
parties in the manner provided by law. Any party who objects to any part of these
findings, conclusions, and recommendation must file specific written objections within
fourteen days after being served with a copy. See 28 U.S.C. § 636(b)(l) (2016); Fed. R.
Civ. P. 72(b ). To be specific, an objection must identify the specific finding, conclusion,
or recommendation to which objection is made, state the basis for the objection, and
specify the place in the magistrate judge's Findings, Conclusions, and Recommendation
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where the disputed determination is found. An objection that merely incorporates by
reference or refers to the briefing before the magistrate judge is not specific. Failure to
file specific written objections will bar the aggrieved party from appealing the factual
findings and legal conclusions of the magistrate judge that are accepted or adopted by the
district court, except upon grounds of plain error. See Douglass v. United Servs. Auto.
Ass'n, 79 F.3d 1415, 1417 (5th Cir. 1996).
Dated: January 'tJ' 	, 2026.
~ 	&μWvAMANO 'AMY' R. BURCH
UNITED STATES MAGISTRATE JUDGE
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