Case Name in Social Security Case - Unavailable

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UNITED STATES DISTRICT COURT
DISTRICT OF MINNESOTA
Richard B.,1
Plaintiff,
v.
Frank Bisignano, Commissioner of Social
Security,
Defendant.
Case No. 25-cv-928 (SGE)
ORDER
This matter is before the Court on the parties’ respective briefing addressing the
Commissioner’s final decision denying benefits. (See Pl.’s Br. (Dkt. 14); Def.’s Br.
(Dkt. 27); Pl.’s Reply (Dkt. 28).) Plaintiff Richard B. (“Mr. B”) argues that the
Commissioner of Social Security’s denial of an application for disability benefits should
be reversed because the Agency’s Administrative Law Judge (“ALJ”) committed legal
error and the resulting decision is not supported by substantial evidence. For the reasons
set forth below, the Court concludes that the Commissioner’s decision should be remanded
for further administrative proceedings as set forth below.
1 This District has adopted the policy of using only the first name and last initial of any
nongovernmental parties in Social Security opinions such as the present Report and
Recommendation. Thus, when the Court refers to Plaintiff, it is by his or her first name and
last initial only.
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I. 	Background
The Social Security regulations set forth a sequential method of evaluating disability
claims. 20 C.F.R. §§ 404.1520(a). The first step is to determine whether the claimant
engages in substantial gainful activity. At the second step, the ALJ determines whether the
claimant suffers from a severe impairment—i.e., an impairment that significantly limits the
ability to perform basic work activities. 20 C.F.R. §§ 404.1520(c). If not, the claim is
denied. If so, at the third step, the ALJ determines whether the claimant’s impairment meets
or equals one of the impairments listed in 20 C.F.R. Part 404, Subpart P, App. 1. 20 C.F.R.
§ 404.1520(d). If the claimant’s impairment meets or equals a listed impairment, then the
claim will be granted. If not, at the fourth step, the ALJ determines whether the claimant
has an impairment which precludes the performance of past relevant work. 20 C.F.R.
§ 404.1520(e). This includes evaluating the claimant’s residual functional capacity
(“RFC”), which is the claimant’s ability to do physical and mental work on a
sustained basis despite limitations from any impairments. If the claimant’s
impairments do not preclude performance of past relevant work, then the claim will
be denied. If the claimant’s impairments do preclude performance of past relevant
work, then at the fifth step, the ALJ determines whether the claimant’s impairments
prevent the performance of any other work, considering the claimant’s residual
functional capacity, age, education, and work experience. 20 C.F.R. § 404.1520(f).
Mr. B applied for disability insurance benefits under Title II of the Social Security
Act on August 9, 2023. (See R. 59.) His initial application was denied, as was the request
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for reconsideration. (R. 59-65, 90-92.) An audio hearing was held before an ALJ on
February 3, 2025, and the ALJ issued a determination that Mr. B was not disabled on
February 12, 2025. (R. 11-27.) Mr. B asked the Appeals Council to review the ALJ’s
decision, and the Appeals Council declined. (R. 1-5.) Mr. B filed the Complaint in this
matter on March 12, 2025. (Compl., Dkt. 1.)
II. 	Legal Standard
Federal courts will uphold the Commissioner’s denial of a disability claim if
substantial evidence supports the ALJ’s findings and if the decision is not based on legal
error. See Noerper v. Saul, 964 F.3d 738, 744 (8th Cir. 2020); Collins v. Astrue, 648 F.3d
869, 871 (8th Cir. 2011). “Legal error may be an error of procedure, . . . the use of erroneous
legal standards, or an incorrect application of the law,” and courts review whether an ALJ
based a decision on legal error de novo. Collins, 648 F.3d at 871 (internal citations
omitted).
Judicial review of the final decision of the Commissioner is restricted to a
determination of whether the decision is supported by substantial evidence in the record as
a whole. See 42 U.S.C. § 405(g); Qualls v. Apfel, 158 F.3d 425, 427 (8th Cir. 1998); Gallus
v. Callahan, 117 F.3d 1061, 1063 (8th Cir. 1997); Wilson v. Sullivan, 886 F.2d 172, 175
(8th Cir. 1989). Substantial evidence is “such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.” Biestek v. Berryhill, 587 U.S. 97, 103 (2019)
(citation omitted); Krogmeier v. Barnhart, 294 F.3d 1019, 1022 (8th Cir. 2002). A court
determining whether evidence is substantial must also consider whatever is in the record
that fairly detracts from its weight. See Warburton v. Apfel, 188 F.3d 1047, 1050 (8th Cir.
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1999); see also Cruse v. Bowen, 867 F.2d 1183, 1184 (8th Cir. 1989) (citing Universal
Camera Corp. v. NLRB, 340 U.S. 474, 488 (1951)).
The substantial-evidence standard is deferential, and courts should not reverse the
Commissioner’s findings simply because evidence may exist in the administrative record
that would support a different conclusion. Milam v. Colvin, 794 F.3d 978, 983 (8th Cir.
2015). Instead, a court should reverse only when the ALJ’s decision is outside the
reasonable “zone of choice” created by the evidentiary record. Bradley v. Astrue, 528 F.3d
1113, 1115 (8th Cir. 2008). Therefore, the law requires that this Court review the ALJ’s
factual determinations with deference, neither re-weighing the evidence nor reviewing the
factual record de novo. See Flynn v. Chater, 107 F.3d 617, 620 (8th Cir. 1997); Roe v.
Chater, 92 F.3d 672, 675 (8th Cir. 1996). However, the Court’s deference to the ALJ is not
absolute. Where an ALJ fails to adequately support their determination, the Court may
remand. See, e.g., Weber v. Colvin, No. 16-cv-332 (JNE/TNL), 2017 WL 477099 at *26
(D. Minn. Jan. 26, 2017) (noting that the ALJ must demonstrate some “logical bridge”
between the evidence and their conclusions).
Courts reviewing ALJ decisions must read and consider the decision in its entirety.
See, e.g., Wiese v. Astrue, 552 F.3d 728, 733-34 (8th Cir. 2009) (determining the basis of
the ALJ’s finding was “apparent from the opinions entirety”). An ALJ is not required to
evaluate the medical opinions in any particular section of her opinion See, e.g., Jones v.
Astrue, 619 F.3d 963, 970 (8th Cir. 2010) (ALJ’s narrative explanation in different section
of decision can support findings throughout the decision).
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III. ALJ’s Decision
The ALJ began his analysis by determining that Mr. B remains insured through
December 31, 2026, and has not engaged in substantial gainful activity since May 7, 2021.
(R. 13.) The ALJ next determined that Mr. B has the following severe impairments:
degenerative disc disease of the lumbar spine with thoracic compression deformity; right
ankle trimalleolar fracture, status-post open reduction and internal fixation; obstructive
sleep apnea; and mental conditions variously diagnosed as depressive disorder, dysthymic
disorder, anxiety disorder, and posttraumatic stress disorder. (R. 13-14.) At step three, the
ALJ determined that Mr. B’s impairments did not meet or medically equal the criteria of
any listed impairment in 20 CFR Part 404, Subpart P, Appendix 1. (R. 15-18.)
At step four, the ALJ determined that Mr. B had the RFC to perform medium work
as defined by 20 C.F.R. § 404.1567(c) with the following limitations:
occasionally operate foot controls with the right lower extremity;
occasionally push and pull with the right lower extremity; frequently
climb ramps and stairs; occasionally climb ladders, ropes, and
scaffolds; frequently balance, stoop, kneel, crouch, and crawl; no
exposure to unprotected heights and moving mechanical parts; carry
out simple instructions; deal with occasional changes in a routine
work setting; and occasionally interact with supervisors, coworkers,
and the public.
(R. 18.) Using this RFC, the ALJ determined that Mr. B was unable to perform any past
relevant work. (R. 25-26.) At step five, the ALJ determined that Mr. B could still perform
other jobs that exist in significant numbers in the national economy, including a hand
packager, a machine packager, and a package sealer machine tender. (R. 26-27.)
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ANALYSIS
Mr. B argues that the ALJ’s RFC determination was not supported by substantial
evidence. Specifically, Mr. B argues that (1) the ALJ failed to address the supportability
and consistency of medical opinions he relied on, and (2) the ALJ’s RFC determination is
not supported by substantial evidence because the ALJ mischaracterized evidence in the
record.
I. 	Supportability and Consistency of Medical Opinions
A. Regulations require the ALJ to evaluate the supportability and
consistency of medical opinions.
An ALJ must consider all medical opinions in the record. 20 C.F.R. § 404.1527(c).
The Social Security regulations require the ALJ to explain how persuasive each medical
opinion is and to explain the “supportability and consistency” of each opinion. 20 C.F.R.
§ 404.1520c(a). “ALJs evaluate the persuasiveness of medical opinions by considering
[factors including] (1) whether they are supported by objective medical evidence, (2)
whether they are consistent with other medical sources, (3) the relationship that the source
has with the claimant, (4) the source’s specialization, and (5) any other relevant factors.”
Bowers v. Kijakazi, 40 F.4th 872, 875 (8th Cir. 2022).
The first two factors of supportability and consistency “are the most important
factors” to consider when determining the persuasiveness of a medical source’s medical
opinions and, therefore, an ALJ must explain how she considered the factors of
supportability and consistency in her decision. 20 C.F.R. § 404.1520c(b)(2). “The ALJ’s
brevity is not reversible error.” Grindley v. Kijakazi, 9 F.4th 622, 631 (8th Cir. 2021). At
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the same time, although an explanation “need not be exhaustive,” “boilerplate or blanket
statements will not do.” Lucus v. Saul, 960 F.3d 1066, 1069 (8th Cir. 2020) (cleaned up).
An ALJ’s failure to explain either supportability or consistency is reversible error. Id.
Additionally, an ALJ may “accept some, but not all, of a medical opinion.” Austin
v. Kijakazi, 52 F.4th 723, 729 (8th Cir. 2022). The ALJ is not required to identify each and
every scrap of evidence that supports or detracts from the medical opinions, but she must
at least set forth reasoning “clear enough to allow for appropriate judicial review.”
Grindley, 9 F.4th at 631; see also Diane M. W. v. Kijakazi, Case no. 20-cv-2651
(SRN/ECW), 2022 WL 4377731, at *5 (D. Minn. Sept. 22, 2022) (“The ALJ need not use
the magic words of ‘supportability’ and ‘consistency,’ but it must be clear they were
addressed.”). The regulations require that the ALJ explain how she considered the
supportability and consistency factors in evaluating a psychological expert’s administrative
medical findings. 20 C.F.R. § 416.920c(b)(2); Bonnett v. Kijakazi, 859 F. App’x 19, 20
(8th Cir. 2021) (per curiam) (failure to articulate consistency is a legal error that requires
remand); Michael B. v. Kijakazi, Case no. 21-cv-1043 (NEB/LIB), 2002 WL 4463901, at
*2 (D. Minn. Sept. 26, 2022) (failure to articulate supportability is a legal error that requires
remand). The ALJ does not need to use the words “supportability” and “consistency,” but
“it must be clear” that the ALJ addressed the factors. Diane M.W., 2022 WL 4377731, at
*5 (citing Svendsen v. Kijakazi, No. 1:21-cv-1029 (CBK), 2022 WL 2753163, at *8 (D.S.D.
July 14, 2022); Goss v. Kijakazi, No. 4:21-cv-0663 (LPR/JJV), 2022 WL 1511521, at *3
(E.D. Ark. May 12, 2022)). An ALJ’s failure to articulate how he considered the
supportability and consistency factors is legal error requiring remand. Susan H. v. Kijakazi,
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Case no. 21-cv-2688 (ECT/ECW), 2023 WL 2142786, at *3 (D. Minn. Feb. 21, 2023);
Michael B., 2022 WL 4463901, at *2; Joel M. B. v. Kijakazi, Case no. 21-cv-1660
(PAM/ECW), 2022 WL 1785224, at *3 (D. Minn. June 1, 2022) (citing Lucus, 960 F.3d at
1070).
The regulations define supportability and consistency. Although “supportability”
and “consistency” are terms of art, the regulations indicate that the words mirror their
everyday meaning: supportability means that a prior administrative medical finding will be
considered more persuasive the more it is supported by objective medical evidence;
consistency means that a prior administrative medical finding will be more persuasive if it
is consistent with the other medical and nonmedical sources relevant to Plaintiff’s claim.
20 C.F.R. § 416.920c(c)(1), (2).
A reviewing court’s inquiry is not whether it disagrees with the ALJ’s explanation
of the supportability and consistency factors based on the record because that would be an
improper reweighing of the evidence. See Hensley v. Colvin, 829 F.3d 926, 934 (8th Cir.
2016) (citing Cox v. Astrue, 495 F.3d 614, 617 (8th Cir. 2007)). Rather, a court reviews
only whether the ALJ explained the required factors, and if so—and even if the reviewing
court disagrees with the ALJ’s explanation—it must find no legal error. See, e.g., Berry v.
Kijakazi, Case no. 20-cv-0890 (RLW), 2021 WL 4459699, at *8 (E.D. Mo. Sept. 29, 2021).
B. ALJ’s evaluation of State agency medical consultants’ opinions satisfied
regulatory obligations.
Mr. B first argues that the ALJ failed to evaluate the supportability and consistency
of the state agency medical consultants’ opinions as required by the regulations. The record
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contained two medical opinions by state agency medical consultants: Dr. Gregory Salmi,
M.D., at the initial level, and Dr. Stacy Holberg, D.O., at the reconsideration level. Dr.
Gregory Salmi, the initial-level medical consultant, determined that Mr. B was capable of
full-time work at a medium exertional level, meaning he could occasionally lift and/or
carry up to 50 pounds and frequently lift and/or carry up to 25 pounds, and he could stand,
walk, or sit for about 6 hours in an 8-hour workday. (R. 62-63.) He further determined that
Mr. B should have no repetitive use of foot controls on with his right foot, but frequent use
of foot controls was allowed. (R. 63.) Dr. Salmi further determined that Mr. B could
frequently climb ramps or stairs; occasionally climb ladders, ropes or scaffolds; and
frequently balance, stoop, kneel, crouch, and crawl. (R. 63.)
The ALJ addressed the supportability of this opinion, noting that Dr. Salmi’ s
conclusions were “supported with citations and a reasonable explanation.” (R. 24.) Dr.
Salmi referred to and relied on Mr. B’s medical records and noted that Mr. B had
transitioned to a CAM boot and taking daily walks a few months after surgery. (R. 63.)
The ALJ cited to other evidence supporting Dr. Salmi’s conclusion, including that Mr. B
demonstrated fluid and active range of motion of his right ankle with no crepitus
appreciated in July 2023, and that he demonstrated a normal gait at multiple examinations.
(R. 21-22.)
The ALJ also addressed the consistency factor of Dr. Salmi’s conclusions, stating
that they were “consistent with the overall record, including the overall physical clinical
findings and signs, the claimant’s courses of and responses to physical treatments, and the
claimant’s daily and other activities.” (R. 24.) The ALJ also noted that Dr. Salmi’s
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conclusion was “consistent with [Mr. B’s] subjective statements about numbness in his
right foot and statements in his adult functional reports about medication side effects.” (R.
24.) This is sufficient to satisfy the obligations of the regulations. See Daniels v. Kijakazi,
617 F. Supp. 3d 180, 188-89 (S.D.N.Y. 2002). The ALJ recited the limitations that Dr.
Salmi found and examined the evidence on which he based those findings, ultimately
finding that his opinion was supported by the evidence. (R. 19-24.)
The reconsideration-level medical consultant, Dr. Stacy Holberg, D.O., made a
similar determination regarding Mr. B’s ability to work. (R. 76-77.) Dr. Holberg
determined that Mr. B was capable of full-time work at a medium exertional level, meaning
he could occasionally lift and/or carry up to 50 pounds and frequently lift and/or carry up
to 25 pounds, and he could stand, walk, or sit for about 6 hours in an 8-hour workday. (R.
76.) She further determined that Mr. B could frequently climb ramps or stairs; occasionally
climb ladders, ropes or scaffolds; and frequently balance, stoop, kneel, crouch, and crawl.
(R. 76.) Dr. Holberg also determined that a minor limitation on overhead reaching was
appropriate to address shoulder pain. (R. 76-77.)
Like with Dr. Salmi, the ALJ addressed the supportability of Dr. Holberg’s opinion,
stating that her conclusions are “also supported with citations and a reasonable
explanation.” (R. 24.) Dr. Holberg referred to and relied on Mr. B’s medical records and
noted that Mr. B’s IBS-C and osteoporosis are non-severe. (R. 78.) The other evidence that
the ALJ cited supporting Dr. Salmi’s conclusion also supports Dr. Holberg’s conclusion,
including that Mr. B demonstrated fluid and active range of motion of his right ankle with
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no crepitus appreciated in July 2023, and that he demonstrated a normal gait at multiple
examinations. (R. 21-22.)
The ALJ also addressed the consistency factor of Dr. Holberg’s conclusions, stating
that they were “mostly consistent with the overall record,” but noting that the record did
not support the need for any overhead reaching restrictions. (R. 24.) As such, the ALJ found
Dr. Holberg’s conclusions were “mostly consistent” with the record and declined to adopt
the overhead reaching limitation. (R. 24.) This satisfies the ALJ’s obligations to evaluate
the consistency of the medical opinions in the record. See Daniels, 617 F. Supp. 3d at 188-
89. The ALJ recited the limitations that Dr. Holberg found and examined the evidence on
which she based those findings. (R. 25-29.) The ALJ then made her own determinations
regarding Mr. B’s limitations, and in doing so, she identified evidence in the record that
supported and was consistent with his determinations.
Based on the above, the Court concludes that the ALJ evaluated the supportability
and consistency of the state agency medical consultants’ opinions. Although the experts
did not have access to all of the medical records, the ALJ reviewed Mr. B’s entire medical
file and found that the opinions were supported by and consistent with the record. This
satisfies the ALJ’s obligations under the regulations.
II. 	Mischaracterized Evidence
Mr. B also argues that the ALJ erred in assessing his subjective complaints and self-
reported symptoms in violation of SSR 16-3p by mischaracterizing the evidence in the
record. SSR 16-3p requires an ALJ to take into account the claimant’s reported symptoms
and evaluate the intensity, persistence, and limiting effects of those symptoms when
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determining whether a claimant is disabled. 2017 WL 5180304; see, e.g., Bryant v. Colvin,
861 F.3d 779, 782 (8th Cir. 2017) (“Part of the RFC determination includes an assessment
of the claimant’s credibility regarding subjective complaints.”). In determining the
intensity, persistence, and limiting effects of those symptoms, the ALJ
examine[s] the entire care record, including the objective medical
evidence; an individual’s statements about the intensity, persistence,
and limiting effects of symptoms; statements and other information
provided by medical sources and other persons; and any other relevant
evidence in the individual’s case record.
SSR 16-3p, 2017 WL 5180304, at *4. This evaluation includes consideration of “(i) the
claimant’s daily activities; (ii) the duration, frequency, and intensity of the claimant’s pain;
(iii) precipitating and aggravating factors; (iv) the dosage, effectiveness, and side effects
of medication; and (v) the claimant’s functional restrictions.” Vance v. Berryhill, 860 F.3d
1114, 1120 (8th Cir. 2017) (citing Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1984))
(citation omitted); see also SSR 16-3p, 2017 WL 5180304, at *7-8.
The ALJ summarized Mr. B’s subjective complaints related to his ankle and back
pain and concluded that they were not consistent with the objective medical evidence and
other evidence in the record. (R. 19-23.) The ALJ noted that despite an alleged onset of
disability date of May 2021, Mr. B did not present for an evaluation of low back pain until
September 2023 (which he stated began in March 2023); he engaged only in “routine,
conservative, and outpatient-only” back-pain treatment during the relevant period; and his
overall physical clinical signs have been “fairly minimal.” (R. 20.) As for Mr. B’s ankle
pain, the ALJ found that after his January 2023 surgery and hardware placement, Mr. B
had a well-corrected fracture; his ankle was healing without complication; an EMG nerve
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conduction study was only “mildly abnormal”; and although he used a cane and crutches,
no records indicated they were a medical necessity, and Mr. B had no documented
treatments for fall-related injuries. (R. 21). The ALJ also summarized Mr. B’s medical
appointment notes, noting that by July 2023 Mr. B had fluid and active range of motion of
his right ankle, with no crepitus appreciated, no obvious orthopedic abnormalities, and no
regularly presenting gait defects. (R. 21-22.) The ALJ also noted that by June 2024, Mr. B
had “comfortable” ambulation. (R. 22.)
The ALJ also stated that Mr. B’s described daily activities were not strong evidence
in favor of finding him disabled because they could not be “objectively verified with any
reasonable degree of certainty,” and it is difficult to attribute the stated degree of limitation
to Mr. B’s medical condition “in light of the relatively weak medical evidence and other
factors.” (R. 23.) The ALJ continued that Mr. B’s admitted participation in certain activities
is ”not nearly limited to the extent one would expect, given the complaints of disabling
symptoms and limitations.” (R. 23.) The ALJ specifically noted that Mr. B’s activities
included independently tending to his personal care, walking for up to 10 minutes,
preparing meals, doing some housework, caring for pet dogs, reading, and watching
television. (R. 23.) The ALJ determined that Mr. B’s participation in these activities was
sufficient to discount evidence and allegations of disability.
The Court sees at least two problems with this determination. First, the ALJ’s
evaluation of Mr. B’s daily activities is circular. The ALJ determined both that Mr. B’s
allegations of limitation were incapable of being objectively verified and that Mr. B’s
stated activities showed that he was not disabled. This dichotomy leaves Mr. B in an
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impossible position. If he reports that he engages in any activities, the ALJ will use that to
show that he is not disabled; but the ALJ also will not believe his reports that his activities
are as limited as he reports. The ALJ has him coming and going.
Second, the ALJ’s determination that discounted Mr. B’s activities of daily living
“are not nearly limited to the extent one would expect, given the complaints of disabling
symptoms and limitations” implies that Mr. B’s activities are equivalent to medium work,
which is inconsistent with the ALJ’s eventual finding that Mr. B could no longer perform
medium work that he performed in the past. And none of the activities that the ALJ
identifies demonstrate that he can endure the requirements of medium work, including for
example lifting up to 50 pounds or walking up to 6 hours a day. The Eighth Circuit has
repeatedly held that “‘the ability to do activities such as light housework and visiting with
friends provides little or no support for the finding that a claimant can perform full-time
competitive work.’” Baumgarten v. Chater, 75 F.3d 366, 369 (8th Cir. 1996) (quoting
Hogg v. Shalala, 45 F.3d 276, 278 (8th Cir. 1995)). To establish disability, Mr. B need not
prove that his pain “precludes all productive activity and confines [him] to life in front of
the television.” Id.
Furthermore, the ALJ’s recitation of Mr. B’s medical records mischaracterizes the
record. For instance, the ALJ states Mr. B had comfortable ambulation at a June 2024
appointment (R. 22)—but that description concerned the fit of Mr. B’s orthotics, not his
unassisted ambulation. (R. 1408.) The ALJ also cited to appointments in September 2023
as showing no gait deficits, but those records do not mention Mr. B’s gait whatsoever. (R.
21, 446, 514-15.) And although the ALJ repeatedly states that Mr. B alleges an onset of
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disability on May 7, 2021, the records unambiguously show that he alleges his disability
began on January 17, 2023. (R. 177.)
Based on the above, the Court cannot conclude that the ALJ’s RFC determination
is supported by substantial evidence. It is not this Court’s role “to reweigh the evidence or
review factual record de novo.” Masterson .v Barnhardt, 363 F.3d 731, 736 (8th Cir. 2004).
The ALJ might have had good reasons for discounting Mr. B’s reported symptoms based
on his medical records, and making this determination is the ALJ’s prerogative.
Nonetheless, this Court is unable to determine whether there is substantial evidence in the
record as a whole to support the ALJ’s conclusion when the ALJ has not adequately
explained the evidence on which he relied. See Boettcher, 652 F.3d at 863; Scott, 529 F.3d
at 822; see also Masterson, 363 F.3d at 736 (courts “must simply determine whether the
quantity and quality of evidence is enough so that a reasonable mind might find it adequate
to support the ALJ’s conclusion”). Accordingly, remand is appropriate.
CONCLUSION
Based on the foregoing, and all the files, records, and proceedings herein, IT IS
HEREBY ORDERED that:
1. Mr. B’s request for relief (Dkt. 14) be GRANTED;
2. The Commissioner’s request for relief (Dkt. 27) be DENIED; and
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3. This matter be REMANDED to the Commissioner pursuant to sentence
four of 42 U.S.C. § 405(g) for further administrative proceedings consistent
with this order.
Date: March 23, 2026
s/Shannon G. Elkins
SHANNON G. ELKINS
United States Magistrate Judge
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