Catey v. Commissioner of Social Security

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF MICHIGAN
SOUTHERN DIVISION
BILLIE C.,
Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
____________________________________/
Hon. Jane M. Beckering
Case No. 1:24-cv-1217
REPORT AND RECOMMENDATION
This is an action pursuant to Section 205(g) of the Social Security Act, 42 U.S.C. § 405(g),
to review a final decision of the Commissioner of Social Security denying Plaintiff’s claim for
Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI) under Titles II and
XVI of the Social Security Act.
Section 405(g) limits the Court to a review of the administrative record and provides that,
if the Commissioner’s decision is supported by substantial evidence, it shall be conclusive. The
Commissioner has found that Plaintiff is not disabled within the meaning of the Act. Plaintiff seeks
review of the Commissioner’s decision, arguing that it is not supported by substantial evidence.
Pursuant to 28 U.S.C. § 636(b)(1)(B), authorizing United States Magistrate Judges to
submit proposed findings of fact and recommendations for disposition of social security appeals,
I recommend that the Commissioner’s decision be affimed.
STANDARD OF REVIEW
The Court’s jurisdiction is confined to a review of the Commissioner’s decision and of the
record made in the administrative hearing process. See Willbanks v. Sec’y of Health and Human
Servs., 847 F.2d 301, 303 (6th Cir. 1988). The scope of judicial review in a social security case is
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limited to determining whether the Commissioner applied the proper legal standards and whether
there exists in the record substantial evidence supporting the decision. See Brainard v. Sec’y of
Health and Human Servs., 889 F.2d 679, 681 (6th Cir. 1989). The Court may not conduct a de
novo review of the case, resolve evidentiary conflicts, or decide questions of credibility. See
Garner v. Heckler, 745 F.2d 383, 387 (6th Cir. 1984). Fact finding is the Commissioner’s province,
and those findings are conclusive provided substantial evidence supports them. See 42 U.S.C. §
405(g).
Substantial evidence is more than a scintilla but less than a preponderance. See Cohen v.
Sec’y of Dept. of Health & Human Servs., 964 F.2d 524, 528 (6th Cir. 1992). It is such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion. See Richardson
v. Perales, 402 U.S. 389, 401 (1971); Bogle v. Sullivan, 998 F.2d 342, 347 (6th Cir. 1993). In
applying this standard, a court must consider the evidence as a whole, while accounting for any
evidence that fairly detracts from its weight. See Richardson v. Sec’y of Health & Human Servs.,
735 F.2d 962, 963 (6th Cir. 1984). The substantial evidence standard contemplates a zone within
which the decision maker can properly rule either way without judicial interference. See Mullen v.
Bowen, 800 F.2d 535, 545 (6th Cir. 1986). This standard affords the administrative decision maker
considerable latitude and precludes reversal simply because the evidence would have supported a
contrary decision. See Bogle, 998 F.2d at 347; Mullen, 800 F.2d at 545.
PROCEDURAL POSTURE
Plaintiff filed applications for DIB and SSI on November 26, 2021, alleging that she
became disabled as of July 1, 2021, due to hypertension, diabetes mellitus-type 2, asthma, anxiety,
gastroesophageal reflux disease, arthritis (both feet, both hands), depression, and migraine
headaches. (PageID.83–84, 106–07, 258–67, 271–72.) Plaintiff was 51 years old on her alleged
onset date and at the time she filed her applications. (PageID.83.) She had earned a high school
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diploma and had past work as a bench assembler, a flagger, a janitor, and a machine feeder.
(PageID.50, 306–07.) Plaintiff’s application was denied initially and on reconsideration, and she
requested a hearing before an Administrative Law Judge (ALJ).
On February 6, 2024, ALJ Paul W. Jones held a hearing and received testimony from
Plaintiff and impartial vocational expert (VE) Dewey Franklin. (PageID.58–81.) On March 29,
2024, ALJ Jones issued a written decision finding that Plaintiff was not disabled from her alleged
onset date through the date of decision. (PageID.37–52.) The Appeals Council denied Plaintiff’s
request for review on October 7, 2024. (PageID.21–23.) 	ALJ Jones’s ruling thus became the
Commissioner’s final decision. See Cook v. Comm’r of Soc. Sec., 480 F.3d 432,434 (6th Cir. 2007).
Plaintiff timely initiated this civil action for judicial review on November 15, 2024.
ANALYSIS OF THE ALJ’S DECISION
The social security regulations articulate a five-step sequential process for evaluating
disability. See 20 C.F.R. §§ 404.1520(a-f), 416.920(a-f).1 If the Commissioner can make a
1 1. 	An individual who is working and engaging in substantial gainful activity will not be found
to be “disabled” regardless of medical findings (20 C.F.R. §§ 404.1520(b), 416.920(b));
2. 	An individual who does not have a “severe impairment” will not be found “disabled” (20
C.F.R. §§ 404.1520(c), 416.920(c));
3. 	If an individual is not working and is suffering from a severe impairment which meets the
duration requirement and which “meets or equals” a listed impairment in Appendix 1 of
Subpart P of Regulations No. 4, a finding of “disabled” will be made without consideration
of vocational factors (20 C.F.R. §§ 404.1520(d), 416.920(d));
4. 	If an individual is capable of performing her past relevant work, a finding of “not disabled”
must be made (20 C.F.R. §§ 404.1520(e), 416.920(e));
5. 	If an individual’s impairment is so severe as to preclude the performance of past work, other
factors including age, education, past work experience, and residual functional capacity
must be considered to determine if other work can be performed (20 C.F.R. §§ 404.1520(f),
416.920(f)).
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dispositive finding at any point in the review, no further finding is required. See 20 C.F.R. §§
404.1520(a), 416.920(a). The regulations also provide that, if a claimant suffers from a
nonexertional impairment as well as an exertional impairment, both are considered in determining
residual functional capacity. See 20 C.F.R. §§ 404.1545, 416.945.
The burden of establishing the right to benefits rests squarely on Plaintiff’s shoulders, and
she can satisfy her burden by demonstrating that her impairments are so severe that she is unable
to perform her previous work, and cannot, considering her age, education, and work experience,
perform any other substantial gainful employment existing in significant numbers in the national
economy. See 42 U.S.C. § 423(d)(2)(A); Cohen, 964 F.2d at 528. While the burden of proof shifts
to the Commissioner at step five of the sequential evaluation process, Plaintiff bears the burden of
proof through step four of the procedure, the point at which her residual functional capacity (RFC)
is determined. See Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987); Walters v. Comm’r of Soc.
Sec., 127 F.3d 525, 528 (6th Cir. 1997) (ALJ determines RFC at step four, at which point claimant
bears the burden of proof).
After determining that Plaintiff met the insured status requirements of the Act through
December 31, 2023, and the non-disability requirements for disabled widow’s benefit set forth in
section 202(e) of the Act, and had not engaged in substantial gainful activity since her alleged
onset date of July 1, 2021, the ALJ found that Plaintiff suffered from severe impairments of
depression, anxiety, and posttraumatic stress disorder. (PageID.39.) At step three, the ALJ
determined that Plaintiff did not have an impairment or combination of impairments that met or
medically equaled any impairment identified in the Listing of Impairments detailed in 20 C.F.R.,
Part 404, Subpart P, Appendix 1. (PageID.43–44.) The ALJ considered listings 12.04 (Depressive,
Bipolar, and Related Disorders), 12.06 (Anxiety and Obsessive-Compulsive Disorders), and 12.15
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(Trauma and Stressor-Related Disorders). In applying these listings, the ALJ considered the
“paragraph B” criteria that address four broad areas of mental functioning. See 20 C.F.R., Part 404,
Subpart P, Appendix 1. The ALJ found that Plaintiff had mild limitations in the areas of
understanding, remembering, or applying information and adapting or managing oneself and
moderate limitations in the areas of interacting with others and concentrating, persisting, or
maintaining pace. (PageID.43–44.)
The ALJ then found that Plaintiff retained the RFC to perform “simple, routine, repetitive
work; with only occasional supervisor and public interaction.” (PageID.44.) At step four, the ALJ
determined that Plaintiff was able to perform her past relevant work of janitor, machine feeder,
bench assembler, and flagger. (PageID.50–51.) Alternatively, the ALJ found that based on
testimony from the VE, Plaintiff was able to perform three additional jobs existing in the national
economy, including industrial cleaner, warehouse worker, and salvage worker, approximately
1,145,000 of which existed in the national economy. (PageID.51–52.) This represents a significant
number of jobs. See, e.g., Taskila v. Comm’r of Soc. Sec., 819 F.3d 902, 905 (6th Cir. 2016) (“[s]ix
thousand jobs in the United States fits comfortably within what this court and others have deemed
‘significant’”). Therefore, the ALJ concluded that Plaintiff was not disabled.
DISCUSSION
Plaintiff raises two issues in her appeal: (1) the ALJ failed to reconcile his mental findings
in the paragraph “B” criteria at steps two and three of the sequential evaluation process with the
mental limitations assessed in the RFC which she ultimately adopted, and the discrepancy was not
explained; and (2) the ALJ violated 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2), by rejecting
key portions of the opinion of agency psychologist Jonathon D. Shy, Ph.D., without adequate
explanation 	and 	without 	properly 	discussing 	the 	regulatory 	factors 	of 	supportability 	and
consistency. (ECF No. 13 at PageID.1207.)
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I. 	ALJ’s RFC Finding
A claimant’s RFC represents the “most [a claimant] can still do despite [her] limitations.”
Sullivan v. Comm’r of Soc. Sec., 595 F. App’x 502, 505 (6th Cir. 2014); see also SSR 96-8P, 1996
WL 374184 at *1 (Social Security Administration, July 2, 1996) (a claimant’s RFC represents her
ability to perform “work-related physical and mental activities in a work setting on a regular and
continuing basis,” defined as “8 hours a day, for 5 days a week, or an equivalent work schedule”).
“An RFC is an ‘administrative finding,’ and the final responsibility for determining an individual’s
RFC is reserved to the Commissioner.” Shepard v. Comm’r of Soc. Sec., 705 F. App'x 435, 442
(6th Cir. 2017). In determining a claimant’s RFC, the ALJ considers medical source statements
and all other evidence of record. 20 C.F.R. §§ 404.1545(a)(3) and 416.945(a)(3). While the ALJ
makes the RFC determination, that determination must be supported by substantial evidence.
Torres v. Comm'r of Soc. Sec., 490 F. App’x 748, 754 (6th Cir. 2012).
The regulation set forth in 20 C.F.R. §§ 404.1520a and 416.920a “requires adjudicators to
assess an individual’s limitations and restrictions from a mental impairment(s) in categories
identified in the ‘paragraph B’ and ‘paragraph C’ criteria of the adult mental disorders listings.”
SSR 96-8P, 1996 WL 374184, at *4. These findings, which examine four broad areas of
functioning, are used to rate the severity of the claimant’s mental impairment(s) at steps two and
three of the sequential evaluation process. Id. As set forth above, at step three,2 the ALJ found that
Plaintiff had mild limitations in the areas of understanding, remembering, or applying information
and adapting and managing oneself and moderate limitations in the areas of interacting with others
and concentrating, persisting, or maintaining pace.
2 Plaintiff erroneously suggests in her statement of errors and brief that the ALJ made paragraph
B findings at step 2 as well as step 3. (ECF No. 13 at PageID.1207, 1217.)
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Plaintiff contends that the ALJ erred in three respects by failing to explain “the conflict”
between his paragraph B findings and his RFC finding. First, she contends that in spite of the
ALJ’s finding of moderate limitation in the area of concentrating, persisting, and maintaining pace,
the ALJ failed to include any limitation addressing this area. Second, in spite of the ALJ’s finding
of a moderate limitation in interacting with others, the ALJ found that Plaintiff can interact with
the public for up to one-third of the workday. Finally, Plaintiff contends that in spite of the ALJ’s
finding of mild limitation in ability to adapt or manage oneself, the ALJ failed to include any
limitation in this area. (Id. at PageID.1216.)
The ALJ’s paragraph B findings do not conflict with his RFC finding. To the extent that
Plaintiff asserts that the ALJ’s RFC finding was required to mirror his step-three findings, the
argument lacks merit. As the ALJ explained in his decision, paragraph B findings are not an RFC
assessment because “[t]he mental RFC assessment used at steps 4 and 5 of the sequential
evaluation process requires a more detailed assessment of the areas of mental functioning.”
(PageID.44.) See SSR 96-8p, 1996 WL 374184, at *4. In other words, an ALJ is not required to
include a paragraph B finding as part of his RFC determination. Vaughan v. Comm’r of Soc. Sec.,
No. 1:13-cv-1266, 2015 WL 5691003, at *5 (W.D. Mich. Sept. 28, 2015); Fellows v. Comm’r of
Soc. Sec., No. 1:14-cv-506, 2015 WL 4134699, at *6 (W.D. Mich. July 8, 2015). Thus, “a
[moderate] limitation is not synonymous with a specific functional restriction or RFC.” Haggard
v. Berryhill, No. 3:17-CV-99, 2018 WL 6003862, at *8 (E.D. Tenn. Nov. 15, 2018); see also
Pinkard v. Comm’r of Soc. Sec. Admin., No. 1:13-cv-1339, 2014 WL 3389206, at *10 (N.D. Ohio
July 9, 2014) (“Hence, the ALJ was correct in finding that Plaintiff had moderate limitations in
evaluating her mental impairment under the listings at step three of the sequential evaluation
process, and in not including a ‘moderate limitation in concentration, persistence, and pace’ in his
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residual functional capacity finding at steps four and five. At step four of the sequential evaluation
process, the ALJ correctly considered the effect of Plaintiff’s symptoms on her concentration,
persistence, and pace when he allowed Plaintiff to be off task five percent of the time.”).
In evaluating Plaintiff’s RFC, the ALJ appropriately considered the evidence as a whole,
including Plaintiff’s allegations that her mental impairments limit her ability “to concentrate,
remember, complete tasks, maintain work pace, maintain work attendance, and handle stress.”
(PageID.45.) The ALJ also discussed Plaintiff’s treatment records reflecting mostly normal mental
status examinations showing that Plaintiff “presented as alert, oriented, calm, cooperative, pleasant
and well-groomed with normal affect, normal mood, normal behavior, good eye contact, normal
speech, 	logical 	thought 	processes, 	appropriate 	concentration, 	[and] 	normal 	judgment.”
(PageID.46–47.) For example, during a September 2021 visit with her primary care physician,
Plaintiff denied any active symptoms of depression, and the doctor noted that she appeared alert
and oriented with normal mood and affect. (PageID.437.) A record from a January 2022
emergency room visit for abdominal pain indicated that Plaintiff was alert with normal mood and
affect, speech, behavior, cognition, and memory. (PageID.532–34.) During a March 2022
appointment with her primary care physician, although Plaintiff reported symptoms of her
depression, the doctor observed that Plaintiff appeared alert and oriented, with normal mood and
affect. The doctor increased her Effexor dose and recommended that she follow up with a
counselor, but she apparently never did. (PageID.45, 454–55.) In December 2023, Plaintiff
reported difficulties concentrating and interacting with others. However, her doctor noted that
“[t]his has been improving and last visit with us we even [had] plans to decrease her depression
medication.” (PageID.1186.) The ALJ also considered Plaintiff’s reported daily activities of
driving, preparing meals, washing dishes, housecleaning, doing laundry, caring for her personal
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hygiene, using a cell phone, managing her own money, spending time with her family and friends,
speaking with others on the phone, exchanging text messages with others, reading, and watching
television, many of which, the ALJ observed, “require a fair degree of concentration, persistence,
and pace.” (PageID.44, 47.) Finally, the ALJ considered the opinion evidence, including the prior
administrative findings of State agency psychologists Alvin Smith, Ph.D., and Colin King, Ph.D.,
whose opinions he found persuasive as to Plaintiff’s moderate limitations in the areas of interacting
with others and concentrating, persisting, and maintaining pace. (PageID.48.) Likewise, the ALJ
found the opinions of psychological consultative examiner Jonathan Shy, Ph. D., persuasive
regarding moderate limitations in Plaintiff’s abilities to concentrate, persist, and maintain pace and
interact with others. (PageID.47–48.)
Contrary to Plaintiff’s argument, the ALJ addressed Plaintiff’s moderate limitation in
concentrating, persisting, and maintaining pace in his RFC finding by limiting her to “simple,
routine, repetitive work.” (PageID.44.) Numerous cases from the Sixth Circuit, as well as from
this district, have held that limitations similar to those the ALJ included in Plaintiff’s RFC here
adequately addressed the claimant’s moderate limitations in concentration, persistence, or
maintaining pace. See Smith-Johnson v. Comm’r of Soc. Sec., 579 F. App’x 426, 437 (6th Cir.
2014) (concluding that a “limitation to simple, routine, and repetitive tasks” adequately accounted
for the plaintiff’s “moderately-limited ability ‘to maintain attention and concentration for extended
periods’”); Wood v. Comm'r of Soc. Sec., No. 19-1560, 2020 WL 618536, at *2–4 (6th Cir. Jan.
31, 2020) (RFC limitation to “performing simple and routine tasks” was not inconsistent with
ALJ’s step three finding that the plaintiff had moderate limitations in concentration, persistence,
and pace because the plaintiff failed to show that the evidence warranted additional limitations);
Farmer v. Comm’r of Soc. Sec., No. 1:20-cv-562, 2022 WL 2526946, at *3–4 (W.D. Mich. July
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7, 2022) (additional limitations not warranted as limitation to “simple, routine, repetitive work”
fully accounted for moderate limitations in concentrating, persisting, or maintaining pace);
Johnson v. Comm’r of Soc. Sec., No. 1:19-cv-1024, 2021 WL 1085006, at *3, 5–6 (W.D. Mich.
Mar. 22, 2021) (limitation to “simple, routine and repetitive tasks” and “simple work-related
decisions 	with 	normal 	break[s]” 	properly 	accounted 	for 	the 	plaintiff’s 	moderate 	mental
limitations); Potter v. Comm’r of Soc. Sec., No. 1:19-cv-837, 2021 WL 1049871, at *4–5 (W.D.
Mich. Mar. 19, 2021) (the ALJ’s finding that the plaintiff could “perform simple, routine, repetitive
tasks” adequately addressed her moderate limitations in concentrating, persisting, and maintaining
pace); Hycoop v. Comm’r of Soc. Sec., No. 1:15-CV-795, 2016 WL 4500794, at *3 (W.D. Mich.
Aug. 29, 2016) (“[T]he ALJ found that Plaintiff had only moderate limitations with regard to
concentration, persistence or pace. Such limitations could be accommodated by performing
‘simple, routine work.’” (record citation omitted)). Plaintiff fails to show that any additional
limitation is warranted in this area.
As for interacting with others, the ALJ translated Plaintiff’s moderate limitation into “only
occasional 	supervisor 	and 	public 	interaction,” 	consistent 	with 	Dr. 	King’s 	opinion 	on
reconsideration. (PageID.48, 161.) This limitation properly accounted for Plaintiff’s moderate
limitation in interacting with others. See Reeves v. Comm’r of Soc. Sec., 618 F. App’x 267, 275
(6th Cir. 2015) (noting that the ALJ accounted for the plaintiff’s moderate limitation in his ability
to interact with the public by limiting him to “occasional interaction with the public”); Cummings
v. Comm’r of Soc. Sec., No. 3:24-CV-1368, 2025 WL 1949499, at *13 (N.D. Ohio July 16, 2025)
(affirming the ALJ’s decision that “accounted for [the claimant’s] moderate limitations in
interacting with others by limiting her to ‘occasional interaction with the public, coworkers, and
supervisors.’”); Bryan v. Comm’r of Soc. Sec., No. 2:18-cv-554, 2019 WL 2912089, at *3-4 (S.D.
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Ohio July 8, 2019) (affirming the ALJ’s decision where the plaintiff had moderate limitations in
interacting with others and the ALJ limited the RFC to occasional interactions with others);
Beemer v. Comm’r of Soc. Sec., No. 1:14-cv-678, 2015 WL 4546520, at *6 (W.D. Mich. July 28,
2015) (“[T]he Court finds no inconsistency between the doctor’s opinion that plaintiff had . . .
moderate limitations related to interacting with others . . . and the ALJ’s RFC, which limited
plaintiff ‘to simple, routine, and repetitive tasks’ and ‘occasional interaction with coworkers,
supervisors, and the public[.]’”). Plaintiff fails to show that she was more limited in interacting
with the public than the ALJ found.
Last, the ALJ was not required to include a limitation in his RFC finding to account for
Plaintiff’s mild limitation in adapting or managing oneself. The ALJ’s decision shows that he fully
considered the extent of Plaintiff’s limitation due to her impairments, specifically her depression,
anxiety, and posttraumatic stress disorder, and found that the limitations in his RFC finding
accounted for her work limitations. (PageID.50.) In fact, the ALJ found that Plaintiff has no
“significant limitation in this area.” (PageID.44.) This determination is supported by substantial
evidence. See Webb v. Comm’r of Soc. Sec., No. 1:20-cv-1206, 2022 WL 4545508, at *8 (W.D.
Mich. Sept. 29, 2022). Thus, Plaintiff fails to meet her burden of showing that she is more limited
than what the RFC assessed. See Casey v. Sec'y of Health & Human Servs., 987 F.2d 1230, 1233
(6th Cir. 1993) (“Plaintiff has the ultimate burden of establishing the existence of a disability.”).
II. 	Opinion Evidence
The ALJ evaluated the medical opinions pursuant to 20 C.F.R. §§ 404.1520c and
416.920c. Under that regulation, the ALJ “will not defer or give any specific evidentiary weight,
including controlling weight, to any medical opinion(s) or prior administrative medical finding(s),”
even an opinion from a treating source. 20 C.F.R. §§ 404.1520c(a) and 416.920c(a). Instead, an
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ALJ will articulate his or her determination of the persuasiveness of a medical opinion “in a single
analysis using the factors listed in paragraphs (c)(1) through (c)(5) of this section, as appropriate.”
20 C.F.R. §§ 404.1520c(b)(1) and 416.920c(b)(1). Those factors include: (1) supportability; (2)
consistency; (3) relationship with the claimant; (4) specialization; and (5) other factors which tend
to support or contradict the opinion. 20 C.F.R. §§ 404.1520c(c)(1)–(5) and 416.920c(c)(1)–(5). In
general, the ALJ must explain his or her consideration of the supportability and consistency
factors, but is not required to explain how the remaining factors were considered. 20 C.F.R. §§
404.l520c(b)(2) and (3) and 416.920c(b)(2) and (3). The regulations explain “supportability” and
“consistency” as follows:
(1) 	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 opinions or prior administrative medical finding(s) will be.
(2) 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. §§ 404.1520c(c)(1)–(2) and 416.920c(c)(1)–2.
Plaintiff contends that the ALJ erred in evaluating the opinion of consultative examiner
Jonathon Shy, Ph.D., who conducted a psychiatric/psychological examination of Plaintiff on April
5, 2023. (PageID.1139–42.). The ALJ summarized Dr. Shy’s evaluation as follows:
In April 2023, claimant attended a psychological consultative examination with
Jonathon Shy, Ph.D. At this evaluation, claimant reported experiencing symptoms
of depression, anxiety, and posttraumatic stress disorder (PTSD) due to being
molested as a child. Despite this history, claimant acknowledged that “she has not
been 	in 	treatment 	for 	years.” 	Claimant 	also 	denied 	any 	history 	of 	being
psychiatrically hospitalized. Dr. Shy noted that claimant demonstrated diminished
memory, 1 math calculation error, and variable insight, but observed that she
remained oriented, cooperative, and pleasant with full range of affect, appropriate
grooming, normal speech, logical thought processes, appropriate concentration, no
significant anxiety, and no suicidal ideation. Ultimately, Dr. Shy diagnosed
claimant with major depressive disorder and PTSD (Ex. 7F).
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(PageID.46.) The ALJ later evaluated Dr. Shy’s opinion as follows:
After his April 2023 psychological consultative examination, Dr. Shy suggested
that claimant had moderate limitations in her abilities to understand, remember, and
apply complex information; interact with others; concentrate, persist, and maintain
pace; and adapt or manage herself. Dr. Shy also noted that claimant had no
limitations in her abilities to understand, remember, and apply simple information
(Ex. 7F).
Dr. Shy’s opinion is partially persuasive because his conclusions regarding
claimant’s abilities to interact with others and to concentrate, persist, and maintain
pace are consistent with the medical evidence and the record as a whole, including
claimant’s history of mental health treatment, the mental status examination
findings, claimant’s medication regimen, and claimant’s reported activities of daily
living, as detailed above. Furthermore, Dr. Shy is an impartial psychological expert
who had an opportunity to examine claimant in person prior to providing his
opinion, and his examination findings and narrative statements support these
conclusions. In not finding Dr. Shy’s opinion more persuasive, I note that his
conclusions regarding claimant’s abilities to understand, remember, and apply
information, and to adapt or manage herself, are inconsistent with the medical
evidence and the record as a whole, which does not contain sufficient evidence of
treatment 	reports 	or 	mental 	status 	examination 	abnormalities 	to 	provide 	a
corroborative basis for such restrictions.
(PageID.47–48.)
Plaintiff contends that the ALJ failed to comply with the regulation because his discussion
as to Dr. Shy’s opined moderate limitations in abilities to understand, remember, and apply
information and to adapt and manage herself does not adequately address either supportability or
consistency. More specifically, Plaintiff contends that the analysis regarding the consistency factor
is too conclusory to permit review of whether the ALJ’s evaluation is supported by substantial
evidence. Plaintiff further contends that the ALJ wholly failed to articulate his consideration of the
supportability factor with regard to these areas of functioning. (ECF No. 13 at PageID.1221–22.)
Last, Plaintiff contends that the ALJ’s error was not harmless because the VE testified that being
off-task ten percent of the workday and/or missing more than one day per month on a regular and
ongoing basis would be work preclusive. (Id. at pageID.1222–23.)
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Defendant responds that the ALJ properly evaluated Dr. Shy’s opinion as to the limitations
at issue because, as to consistency, his rationale is illuminated by his earlier RFC discussion noting
that Effexor was effective in treating Plaintiff’s symptoms, her mental status examinations by
doctors other than Dr. Shy were almost entirely normal, including no memory deficits, and Plaintiff
engaged in a wide range of activities. (ECF No. 14 at PageID.1236.) Defendant further contends
that the ALJ’s observation that Dr. Shy’s opinions were supported by “his examination findings
and narrative statements”—referring to Dr. Shy’s previously-discussed notes that Plaintiff had one
calculation error in performing a serial 7’s sequence and demonstrated variable insight—satisfied
the regulation’s required articulation of the supportability factor. Defendant asserts that pursuant
to 20 C.F.R. §§ 404.1520c(b)(1), 416.92c(b)(1), the ALJ was not required to address supportability
and consistency for each of Dr. Shy’s individual opinions. (Id. at PageID.1237.) Finally, Defendant
contends that Plaintiff fails to identify any specific restriction Dr. Shy opined that can be
incorporated into an RFC finding. (Id.)
In applying the regulation, “the ALJ must explain h[is] conclusions enough for a reviewing
court to trace the path of h[is] reasoning.” Whalen v. Comm’r of Soc. Sec., No. 1:24-CV-1928,
2025 WL 1452713, at *12 (N.D. Ohio May 21, 2025), report and recommendation adopted, 2025
WL 1756524 (N.D. Ohio June 25, 2025) (citing Russell v. Comm’r of Soc. Sec. Admin., No. 1:23-
CV-1748, 2024 WL 3638702, at *19 (N.D. Ohio Aug. 2, 2024)). The regulations do not require
“a specific level of detail” from an ALJ. Timothy B. v. Comm’r of Soc. Sec., No. 2:22-cv-3834,
2023 WL 3764304, at *7 (S.D. Ohio June 1, 2023) (internal quotation marks omitted). Rather, “the
appropriate level of articulation will necessarily depend on the unique circumstances of each
claim.” Id. (internal quotation marks omitted). Still, the regulation requires a “minimum level of
articulation,” the absence of which “frustrates this court’s ability to determine whether [the ALJ’s]
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disability determination was supported by substantial evidence.” Warren I. v. Comm’r of Soc. Sec.,
No. 5:20-CV-495, 2021 WL 860506, at *8 (N.D.N.Y. Mar. 8, 2021).
Here, the ALJ failed sufficiently to articulate his consideration of the supportability and
consistency factors to allow a reviewing court to trace the path of his reasoning. As to consistency,
the ALJ’s references to “the medical evidence and the record as a whole,” as well as the lack of
“sufficient evidence of treatment reports or mental status abnormalities to provide a corroborative
basis for such restrictions,” do not explain the ALJ’s rationale. For example, the ALJ said that Dr.
Shy’s opinion regarding moderate limitations in the areas of interacting with others and
concentrating, persisting, and maintaining pace was consistent with Plaintiff’s “history of mental
health treatment, the mental status examination findings, [her] medication regimen, and [her]
reported activities of daily living” (PageID.47–48), but he failed to explain what about these same
considerations was inconsistent with Dr. Shy’s other opined moderate limitations. While it is true,
as Defendant argues, that a court is permitted to look elsewhere in a decision for an ALJ’s support
for his rationale, see Norris v. Comm'r of Soc. Sec., 461 F. App’x 433, 440 (6th Cir. 2012) (“So
long as the ALJ's decision adequately explains and justifies its determination as a whole, it satisfies
the necessary requirements to survive this court's review.”), the ALJ still failed to provide a readily
discernable basis for his finding. Similarly, even though one could surmise that the ALJ found Dr.
Shy’s opinion unsupported by his examination findings and narrative statements as to these areas
of functioning, the ALJ did not say so. Defendant’s reliance on 20 C.F.R. §§ 404.1520c)(b)(1) and
416.920c(b)(1) is unpersuasive because this provision applies only when a medical source submits
multiple medical opinions. Here, Dr. Shy provided only one opinion. (PageID.1139–42.) See
Lindsey v. Comm’r of Soc. Sec., No. 3:20cv1127, 2021 WL 4472211, at *2 (N.D. Ohio Sept. 30,
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2021) (holding that 20 C.F.R. § 404.1520c(b)(1) did not apply because the claimant’s treating
psychiatrist “submitted only a single medical source statement”).
Notwithstanding the ALJ’s failure to comply with the regulation, the ALJ’s error may not
necessitate remand if it was harmless. “[A]n agency’s violation of its procedural rules will not
result in reversible error absent a showing that the claimant has been prejudiced on the merits or
deprived of substantial rights because of the agency’s procedural lapses.” Connor v. U.S. Civil
Serv. Comm’n, 721 F.2d 1054, 1056–57 (6th Cir. 1983); see also American Farm Lines v. Black
Ball Freight Serv., 397 U.S. 532, 539 (1970) (holding that the agency’s failure to follow its own
regulations did not require reversal absent a showing of substantial prejudice by the affected party).
Here, Plaintiff fails to show how she was prejudiced by the ALJ’s failure to comply with the
regulation. Specifically, Plaintiff fails to identify any functional limitation Dr. Shy supported that
the ALJ did not include in his RFC finding. See Tracy F. v. Comm’r of Soc. Sec., No. 2:23-CV-
188, 2023 WL 8614065, at *7 (S.D. Ohio Dec. 13, 2023), report and recommendation adopted,
2024 WL 689322 (S.D. Ohio Feb. 20, 2024) (“In the absence of identifying any specific limitation
that Dr. Rowland supported that the ALJ omitted, Plaintiff can show no prejudice even if the ALJ’s
articulation of the ‘supportability’ and ‘consistency’ factor was overly cursory.”). Plaintiff
mentions limitations of being off-task ten percent of the workday and missing more than one day
per month on a regular and ongoing basis, but these are not Dr. Shy’s opined limitations. Rather,
these are limitations from Plaintiff’s treating provider, Dr. Schafer (PageID.1191), whose opinion
the ALJ found unpersuasive. (PageID.49.) Because Plaintiff does not challenge this determination
on appeal, she fails to demonstrate any prejudice warranting remand, especially because no other
medical source supported these limitations. See Shinseki v. Sanders, 556 U.S. 396, 407 (2009)
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(recognizing that the harmless error doctrine is intended to prevent reviewing courts from
becoming “impregnable citadels of technicality”). Therefore, this argument lacks merit.
CONCLUSION
For the foregoing reasons, I recommend that the Commissioner’s decision be affirmed.
Dated: November 14, 2025 	/s/ Sally J. Berens
SALLY J. BERENS
U.S. Magistrate Judge
NOTICE
OBJECTIONS to this report and recommendation must be filed with the Clerk of Court
within 14 days of the date of service of this notice. 28 U.S.C. § 636(b)(1)(C). Failure to file
objections within that time waives the right to appeal the District Court’s order. See Thomas v.
Arn, 474 U.S. 140 (1985); United States v. Walters, 638 F.2d 947 (6th Cir. 1981).
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