Case Name in Social Security Case - Unavailable

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF NEW MEXICO
SAMANTHA MARIE CARROLL,
Plaintiff,
v.
FRANK BISIGNANO, Commissioner
of the Social Security Administration,
Defendant.
Civ. No. 24-1211 KG/KK
PROPOSED FINDINGS AND RECOMMENDED DISPOSITION 1
Before the Court is Plaintiff Samantha Marie Carroll’s Memorandum of Law in Support of
Reversing or Remanding an Administrative Agency Decision (Doc. 15) (“Motion”), filed May 29,
2025. In her Motion, Plaintiff seeks judicial review of the decision of the Commissioner of the
Social Security Administration (“SSA”) on her Age-18 Disability Redetermination, in which the
Commissioner found that she is no longer disabled. (Id.) On July 14, 2025, the Commissioner filed
a response in opposition to the Motion, and on July 28, 2025, Plaintiff filed a reply in support of
it. (Docs. 18, 19.) Having meticulously reviewed the record and the relevant law, being otherwise
sufficiently advised, and for the reasons set forth below, I propose to find that Plaintiff’s Motion
is well-taken. I therefore RECOMMEND that the Court GRANT the Motion, REVERSE the
Commissioner’s decision, and REMAND this matter to the SSA for further proceedings.
I. FACTUAL BACKGROUND AND PROCEDURAL H ISTORY
Plaintiff 	is 	a 	thirty-three-year-old 	woman 	who 	suffers 	from 	physical 	and 	mental
impairments including rheumatoid arthritis (“RA”), degenerative disc disease of the lumbar spine,
1 By an Order of Reference (Doc. 20) entered on January 23, 2026, Chief United States District Judge Kenneth J.
Gonzales referred this case to me to conduct hearings, if warranted, including evidentiary hearings, and to perform
any legal analysis required to recommend to the Court an ultimate disposition of the case.
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a herniated intervertebral disc, inflammatory polyarthritis, piriformis syndrome, sicca syndrome
with keratoconjunctivitis, nonepileptic seizure disorder, depression, and post-traumatic stress
disorder (“PTSD”). (AR 1324.) 2 In July 2009, while still a minor, Plaintiff was awarded
Supplemental Security Income (“SSI”) due to seizures. (AR 163.)
Plaintiff turned eighteen years old in June 2010. (AR 1324.) She obtained her GED in 2012
and took some community college courses from 2012 to 2013. (AR 458, 1629.) Plaintiff has no
significant earnings from employment. (AR 446-47.) She worked briefly as a gas station attendant
in 2013 and a hotel housekeeper in 2019. (AR 76-77.) However, she testified that she was fired
from the gas station job after she had a seizure at work and that she quit the hotel housekeeping
job after she had a seizure at work and also experienced a “severe flare-up” in her hands.3 (Id.)
Beginning in 2016, Plaintiff underwent an Age 18 Disability Redetermination, in which
she alleged impairments of RA, low back pain, depression, anxiety, and PTSD. 4 (AR 103, 160-68,
457.) In March 2017, non-examining state agency consultant William Harrison, M.D., analyzed
the medical evidence of record and opined that Plaintiff can perform light work, except that she
must avoid even moderate exposure to hazards due to her history of seizures.5 (AR 864–71.) In
April 2017, the SSA notified Plaintiff of its determination that she no longer qualified for SSI
because she was “no longer disabled” as of that month. (AR 92, 136-37.)
2 Citations to “AR” refer to the Certified Transcript of the Administrative Record filed on January 28, 2025. (Doc. 10.)
3 However, a social worker noted Plaintiff’s report that she left her job as a hotel housekeeper after being “impaled by
a syringe in one of the rooms.” (AR 1039.)
4 After an individual receiving SSI as a minor turns eighteen, the Commissioner is required to redetermine the
individual’s eligibility for benefits, “either during the 1-year period beginning on the individual's 18th birthday or, in
lieu of a continuing disability review, whenever the Commissioner determines that an individual’s case is subject to a
redetermination under this clause.” 42 U.S.C. § 1382c(a)(3)(H)(iii).
5 Light work consists of “lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing
up to ten pounds.” 20 C.F.R. § 416.967(b). Additionally, it involves “a good deal of walking and standing.” Id.
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Plaintiff requested reconsideration of the agency’s determination in May 2017, and a
hearing officer held a hearing in January 2018. (AR 93, 139, 163.) The hearing officer issued an
unfavorable decision in February 2018, and the SSA again notified Plaintiff of its determination
that she no longer qualified for SSI. (AR 94, 160-68, 180-81.)
In October 2018, Plaintiff requested a hearing before an Administrative Law Judge
(“ALJ”). (AR 186.) ALJ Christopher Juge held a telephonic hearing on July 16, 2020, at which
Plaintiff and her counsel appeared. (AR 43–63.) Plaintiff and a Vocational Expert (“VE”) testified
at the hearing. (Id.) On September 4, 2020, ALJ Juge issued a partially favorable decision, finding
that Plaintiff’s
disability ended on April 30, 2017, based on [her] age-18 redetermination because
she did not satisfy the criteria for disability as an adult. However, beginning
December 4, 2019, [she] became disabled again and has continued to be disabled
through the date of this decision[.]
(AR 116.)
Plaintiff asked the SSA’s Appeals Council to review the ALJ’s decision, and on January 15,
2021, the Appeals Council remanded the case to an ALJ for further consideration. (AR 127-29.)
Pursuant to this remand, ALJ Lillian Richter held a telephonic hearing on May 11, 2021, at which
Plaintiff and her counsel appeared. (AR 64–91.) Plaintiff and a VE testified at the hearing. (AR
65.) On December 21, 2021, ALJ Richter issued an unfavorable decision, finding that Plaintiff’s
“disability ended on February 28, 2018,” and that she has not become disabled again since that
date. (AR 28.) On April 18, 2022, the Appeals Council denied Plaintiff’s request for review of ALJ
Richter’s decision. (AR 1.)
Plaintiff filed a complaint seeking judicial review of the Commissioner’s decision in this
Court on June 20, 2022. (AR 1376–77.) On April 4, 2023, the Court reversed the Commissioner’s
decision and remanded the case to the agency, concluding that the ALJ had improperly evaluated
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the medical opinion evidence. Carroll v. Kijakazi, Civ. No. 22-464 JFR, 2023 WL 2770699, at *9–
*12 (D.N.M. Apr. 4, 2023). On August 30, 2023, pursuant to the Court’s ruling, the Appeals
Council vacated the Commissioner’s decision and remanded the matter to an ALJ for further
proceedings. (AR 1437.)
Following the Appeals Council’s August 2023 remand, ALJ Michael Leppala held a
hearing on February 14, 2024, at which Plaintiff and her counsel appeared. (AR 1348–75.) Plaintiff
and VE Gloria Lasoff testified at the hearing. (Id.) On September 27, 2024, ALJ Leppala issued an
unfavorable decision, finding that Plaintiff’s disability ended on February 28, 2018, and that she
has not become disabled again since that date. (AR 1321–34.) Because Plaintiff did not file written
exceptions to the decision and the Appeals Council declined to assume jurisdiction on its own, ALJ
Leppala’s decision is the Commissioner’s final decision at issue in this case.6
II. THE ALJ’ S DECISION
ALJ Leppala decided Plaintiff’s claim pursuant to the Commissioner’s five-step sequential
evaluation process, except that he bypassed step one because “this step is not used for
redetermining disability at age 18.”7 (AR 1322–33 (citing 20 C.F.R. § 416.987(b)).) At step two,
6 “The procedure for appealing an ALJ’s decision depends on the posture of the case.” Workman v. Saul, Civ. No. 19-
326, 2020 WL 927689, at *2 (E.D. Okla. Feb. 26, 2020). If a claimant wishes to contest an ALJ’s initial decision, she
must first appeal the decision to the Appeals Council, and if the Appeals Council issues an unfavorable decision, she
may then seek judicial review. 20 C.F.R. §§ 416.1467, 416.1481. “But for cases that have been remanded by a federal
court for further proceedings, there is no requirement that the [claimant] obtain Appeals Council review of the ALJ’s
new decision prior to seeking judicial review of it.” Workman, 2020 WL 927689, at *2 (emphasis in original). Rather,
the ALJ’s decision after remand automatically becomes the Commissioner’s final decision unless the Appeals Council
assumes jurisdiction sua sponte or pursuant to the claimant’s written exceptions. 20 C.F.R. § 416.1484.
7 The Commissioner’s five-step sequential evaluation process requires the ALJ to determine whether:
(1) the claimant engaged in substantial gainful activity during the alleged period of disability;
(2) the claimant has a severe physical or mental impairment (or combination of impairments) that
meets the duration requirement;
(3) any such impairment meets or equals the severity of an impairment listed in Appendix 1 of 20
C.F.R. Part 404, Subpart P;
(4) the claimant can return to her past relevant work; and, if not,
(5) the claimant is able to perform other work in the national economy, considering her RFC, age,
education, and work experience.
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the ALJ found that Plaintiff suffers from the severe impairments of RA, degenerative disc disease
of the lumbar spine, herniated intervertebral disc, inflammatory polyarthritis, nonepileptic seizure
disorder, piriformis syndrome, sicca syndrome with keratoconjunctivitis, depression, and PTSD.
(AR 1324.) At step three, the ALJ concluded that Plaintiff does not have an impairment or
combination of impairments that meets or medically equals the criteria of listed impairments under
20 C.F.R. Part 404, Subpart P, Appendix 1. (AR 1324-26.)
At step four,8 the ALJ concluded that, since February 28, 2018, Plaintiff has had the
physical residual functional capacity (“RFC”) 9 to
perform a limited range of light work as defined in 20 CFR 416.967(b).
Specifically, the Claimant is limited to occasionally lifting and/or carrying 20
pounds, frequently lifting and/or carrying ten pounds, standing and/or walking for
about six hours in an eight-hour workday, and sitting for about six hours in an
eight-hour workday, all with normal breaks. The Claimant is further limited to
never climbing ladders, ropes, or scaffolds, occasionally balancing, stooping,
kneeling, crouching, and crawling, and frequently reaching. The Claimant is
limited to occasional exposure to extreme cold, vibration, unprotected heights,
and hazardous machinery, and she must never operate a motor vehicle.10
20 C.F.R. § 416.920(a)(4); Fischer-Ross v. Barnhart, 431 F.3d 729, 731 (10th Cir. 2005); Grogan v. Barnhart, 399
F.3d 1257, 1261 (10th Cir. 2005). The claimant has the burden of proof in the first four steps of the analysis, and the
Commissioner has the burden of proof at step five. Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007). A finding that
the claimant is disabled or not disabled at any point in the process is conclusive and terminates the analysis. Casias v.
Sec’y of Health & Hum. Servs., 933 F.2d 799, 801 (10th Cir. 1991). The SSA uses this sequential evaluation process
in Age 18 Disability Redeterminations, except that it does “not use the rule in § 416.920(b),” which mandates a finding
of non-disability if an individual has engaged in substantial gainful activity during the alleged period of disability.
Pena v. Astrue, Civ. No. 09-1015 CG, 2010 WL 11618899, at *3 (D.N.M. Dec. 20, 2010); 42 U.S.C. §
1382c(a)(3)(H)(iii)(I); 20 C.F.R. §§ 416.920(b), 416.987(b). In other words, in Age 18 Disability Redeterminations,
the adjudicator skips the first step of the five-step sequential evaluation process.
8 Step four of the sequential evaluation process has three phases. Winfrey v. Chater, 92 F.3d 1017, 1023–26 (10th Cir.
1996). In the first phase, “the ALJ must evaluate a claimant’s physical and mental residual functional capacity (RFC).”
Id. at 1023. In the second phase, “the ALJ must make findings regarding the physical and mental demands of the
claimant’s past relevant work.” Best-Willie v. Colvin, 514 F. App’x 728, 737 (10th Cir. 2013) (citation omitted). And
in the third phase, “the ALJ determines whether the claimant has the ability to meet the job demands found in phase
two despite the mental and/or physical limitations found in phase one.” Winfrey, 92 F.3d at 1023.
9 An individual’s RFC is “the most [the individual] can still do” despite the physical and/or mental limitations her
impairments cause. 20 C.F.R. § 416.945(a)(1).
10 The ALJ further found that Plaintiff has the mental RFC to
understand, carry out, and remember simple and detailed, but not complex, instructions and make
commensurate work-related decisions, respond appropriately to supervision, coworkers, and work
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(AR 1326.) Also at step four, the ALJ determined that Plaintiff does not have any past relevant
work. (AR 1332.)
At step five, the ALJ determined that Plaintiff “is capable of making a successful
adjustment to other work that exists in significant numbers in the national economy.” (AR 1332-
33.) In support, the ALJ relied on VE Lasoff’s testimony that a person with Plaintiff’s age,
education, work experience, and assigned RFC could perform the representative occupations of
cleaner, assembler, and material distributor. (AR 1333.) The ALJ therefore concluded that
Plaintiff’s disability ended on February 28, 2018, and that she has not become disabled again since
that date. (AR 1333-34.)
III. STANDARD OF REVIEW
The Court’s review of the Commissioner’s final decision is limited to determining whether
substantial evidence supports the ALJ’s factual findings and whether the ALJ applied the correct
legal standards to evaluate the evidence. 42 U.S.C. § 405(g); Hamlin v. Barnhart, 365 F.3d 1208,
1214 (10th Cir. 2004). In making these determinations, the Court must meticulously examine the
entire record but may neither reweigh the evidence nor substitute its judgment for that of the
agency. Flaherty v. Astrue, 515 F.3d 1067, 1070 (10th Cir. 2007). In other words, the Court does
not reexamine the issues de novo. Sisco v. U.S. Dep’t of Health & Hum. Servs., 10 F.3d 739, 741
(10th Cir. 1993).
situations, deal with occasional changes in [the] work setting, [and] maintain concentration[,]
persistence, and pace for up to and including two hours at a time with normal breaks throughout a
normal workday. The Claimant is limited to occasional interaction with coworkers, supervisors, and
the general public.
(AR 1326.) In her Motion, Plaintiff does not challenge the ALJ’s assessment of her mental RFC. (See generally Doc.
15.)
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The Court will not disturb the Commissioner’s decision if it correctly applies legal
standards and is based on substantial evidence in the record. Hamlin, 365 F.3d at 1214.
“Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.” Langley v. Barnhart, 373 F.3d 1116, 1118 (10th Cir. 2004) (citation
omitted). It is “more than a scintilla, but less than a preponderance.” Lax v. Astrue, 489 F.3d 1080,
1084 (10th Cir. 2007). “A decision is not based on substantial evidence if it is overwhelmed by
other evidence in the record[,]” Langley, 373 F.3d at 1118 (citation omitted), or “constitutes mere
conclusion.” Musgrave v. Sullivan, 966 F.2d 1371, 1374 (10th Cir. 1992). The Court’s examination
of the record as a whole must include “anything that may undercut or detract from the ALJ’s
findings in order to determine if the substantiality test has been met.” Grogan v. Barnhart, 399
F.3d 1257, 1262 (10th Cir. 2005).
“The failure to apply the correct legal standard or to provide this [C]ourt with a sufficient
basis to determine that appropriate legal principles have been followed is grounds for reversal.”
Jensen v. Barnhart, 436 F.3d 1163, 1165 (10th Cir. 2005) (quotation marks and brackets omitted).
Although an ALJ is not required to discuss every piece of evidence, “[t]he record must demonstrate
that the ALJ considered all of the evidence,” and “in addition to discussing the evidence supporting
his decision, the ALJ also must discuss the uncontroverted evidence he chooses not to rely upon,
as well as significantly probative evidence he rejects.” Clifton v. Chater, 79 F.3d 1007, 1009–10
(10th Cir. 1996). If the ALJ fails to do so, “the case must be remanded for the ALJ to set out his
specific findings and his reasons for accepting or rejecting evidence[.]” Id. at 1010.
IV. DISCUSSION
In her Motion, Plaintiff argues that the ALJ erred in evaluating the medical opinion of
consultative examiner Kathy Clarke, M.D., in assessing Plaintiff’s RFC at step four of the
sequential evaluation process. (Doc. 15 at 7–11; see AR 1308.) More particularly, Plaintiff asserts
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that the ALJ improperly analyzed the supportability and consistency of Dr. Clarke’s opinion and
therefore erred in rejecting it as “too restrictive.” (Doc. 15 at 8-11 (citing AR 1331).) Plaintiff
further contends that the ALJ’s errors in evaluating Dr. Clarke’s opinion are not harmless. (Id. at
10-11.) As explained below, I agree.
A. Legal Standards Governing an ALJ’s RFC Assessment and Evaluation of Medical
Opinion Evidence
An ALJ’s assessment of a claimant’s RFC must be “based on the entire case record,
including the objective medical findings and the credibility of the claimant’s subjective
complaints.” Poppa v. Astrue, 569 F.3d 1167, 1170–71 (10th Cir. 2009); see also 20 C.F.R. §
416.945(a)(3) (“We will assess your [RFC] based on all of the relevant medical and other
evidence.”). The ALJ must consider “the combined effect of all of the claimant’s medically
determinable impairments,” Wells v. Colvin, 727 F.3d 1061, 1065 (10th Cir. 2013), and the
claimant’s “ability to perform sustained work activities in an ordinary work setting on a regular
and continuing basis (i.e., 8 hours a day, for 5 days a week, or an equivalent work schedule).”
Policy Interpretation Ruling Titles II and XVI: Assessing Residual Functional Capacity in Initial
Claims, SSR 96-8P, 1996 WL 374184, at *7 (Jul. 2, 1996).
An ALJ’s “RFC assessment must include a narrative discussion describing how the
evidence supports each conclusion, citing specific medical facts… and nonmedical evidence.”
Wells, 727 F.3d at 1069 (emphasis omitted). Among other things, the ALJ’s narrative must “explain
how any material inconsistencies or ambiguities in the evidence in the case record were considered
and resolved.” SSR 96-8P, 1996 WL 374184, at *7. “[I]t is improper for the ALJ to pick and choose
among medical reports, using portions of evidence favorable to his position while ignoring other
evidence.” Carpenter v. Astrue, 537 F.3d 1264, 1265 (10th Cir. 2008) (brackets omitted); Panas
on behalf of M.E.M. v. Comm’r, SSA, 775 F. App’x 430, 436–37 (10th Cir. 2019). The ALJ “must
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make sufficiently specific findings in each of his relevant determinations so that his decision is
capable of meaningful review.” Spicer v. Barnhart, 64 F. App’x 173, 178 (10th Cir. 2003). When
an ALJ “fail[s] to make all the detailed findings required by the regulations and rulings at step four,
his RFC conclusions are not supported by substantial evidence.” Southard v. Barnhart, 72 F. App’x
781, 785 (10th Cir. 2003).
In 2017, the SSA issued new regulations regarding the evaluation of medical opinions for
claims filed on or after March 27, 2017. 82 Fed. Reg. 5844-01, 2017 WL 168819 (Jan. 18, 2017);
20 C.F.R. § 416.920c. However, the agency considers “an age 18 redetermination to be a new
claim … filed on the day a person attains age 18.” Program Operation Manuel System (“POMS”)
DI § 24503.050(D)(8).11 Thus, and because Plaintiff turned eighteen in June 2010, the previous
regulations regarding the evaluation of medical opinions apply here. 20 C.F.R. § 416.927.
Under the applicable regulations, an ALJ must consider all medical opinions in the record
and discuss the weight he gives to each opinion. Mays v. Colvin, 739 F.3d 569, 578 (10th Cir.
2014); 20 C.F.R. § 416.927(c). Factors the ALJ must consider include the source’s examining
relationship with the claimant, the source’s treatment relationship, if any, with the claimant, how
well the source supports her opinion, the consistency of the opinion with the record as a whole,
whether the source is a specialist, the source’s “understanding of [the SSA’s] disability programs
and their evidentiary requirements,” and the source’s familiarity “with the other information in
[the claimant’s] case record.” 20 C.F.R. § 416.927(c)(1)-(6). An ALJ must “provide specific,
legitimate reasons if he decide[s] to discount or dismiss an opinion from an acceptable medical
11 The POMS is “a set of policies issued by the [SSA] to be used in processing claims.” McNamar v. Apfel, 172 F.3d
764, 766 (10th Cir. 1999). Courts in the Tenth Circuit “defer to the agency interpretations stated in the POMS unless
they are ‘arbitrary, capricious, or contrary to law.’” Lee v. Colvin, 631 F. App’x 538, 541 n.1 (10th Cir. 2015) (citation
omitted).
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source.” Harrold v. Berryhill, 714 F. App’x 861, 865 (10th Cir. 2017) (quotation marks and citation
omitted); see also SSR 96-8P, 1996 WL 374184, at *7 (if ALJ’s RFC assessment conflicts with
medical opinion, ALJ must explain why he did not adopt it).
B. The ALJ Erred in Evaluating Dr. Clarke’s Opinion
1. 	Dr. Clarke’s Opinion
Dr. Clarke examined Plaintiff on September 14, 2021, “for the purpose of providing
information to the state disability office for their use in making a determination of disability[.]”
(AR 1308.) Before the examination, Dr. Clarke received and reviewed Plaintiff’s “past medical
history” from the state disability office. (Id.)
At the examination, Dr. Clarke took Plaintiff’s social, medical, and functional history and
listed her current medications. (AR 1308–10.) Among other things, Dr. Clarke noted Plaintiff’s
report that she suffers from RA, chronic low back pain, depression, anxiety, and PTSD complicated
by psychogenic nonepileptic pseudo-seizures. (AR 1308.) Dr. Clarke further noted Plaintiff’s
report that she does not use an assistive device to get around, is able to walk one block on level
ground, has difficulty standing for five to fifteen minutes or lifting more than five pounds, can turn
a doorknob, and is able to drive a car, cook, and shop for groceries for no more than fifteen minutes
at a time. (AR 1309.)
Dr. Clarke also performed a physical examination, noting that Plaintiff “cooperated well
with the examiner and gave [her] best effort.” (AR 1314.) During the examination, Dr. Clarke
observed that Plaintiff: (1) was unable to walk on her toes due to joint pain and weakness; (2) was
unable to squat due to joint pain and weakness; (3) was unable to bend over and touch her toes due
to pain and stiffness in her hips and back; (4) had mild difficulty getting up and out of a chair; (5)
had mild difficulty getting on and off the exam table; and, (6) had mild difficulty with tandem heel
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walking. (AR 1310.) Dr. Clarke further observed that Plaintiff had “spasm of the paraspinous
muscles” and straight-leg-raising tests that were “negative” but “with pain.”12 (AR 1311.)
However, Dr. Clarke also noted that Plaintiff ambulated without difficulty, did not use an assistive
device, and had a normal gait. (AR 1310.) Additionally, Dr. Clarke observed that Plaintiff had
“normal motor strength” in both arms, mild weakness in both legs, “normal grip strength” and
“normal fine and gross manipulative skills” in both hands, intact sensation, and normal reflexes.
(AR 1312.)
During her physical examination of Plaintiff, Dr. Clarke made detailed findings regarding
the range of motion of Plaintiff’s joints. With respect to Plaintiff’s lumbar spine, Dr. Clarke found
that Plaintiff had limited forward flexion, extension, lateral flexion, and rotation. (AR 1313, 1316.)
With respect to both of Plaintiff’s shoulders, Dr. Clarke observed that Plaintiff had limited
abduction, forward elevation, and internal and external rotation. (Id.) Dr. Clarke further noted
“marked bilateral … crepitus” in both shoulders. 13 (Id.)
Dr. Clarke’s examination of the joints in Plaintiff’s hands also revealed extensive
abnormalities. (AR 1313–14, 1316.) Specifically, Dr. Clarke observed: (1) limited flexion in the
metacarpophalangeal (“MCP”) joints of the second through fifth fingers of both hands 14 ; (2)
effusion and tenderness in the MCP joints of the second through fifth fingers of both hands; (3)
12 A straight-leg-raising test is positive for disk compression of a spinal nerve root if it reproduces or worsens “pain
that radiates from the buttock downward along the course of the sciatic nerve” and “firm resistance to further elevation
of the leg.” Allan H. Ropper & Ross D. Zafonte, Sciatica, THE N EW ENGLAND J OURNAL OF MEDICINE Vol. 372 No.
13 (Mar. 26, 2015), https://www.nejm.org/doi/full/10.1056/NEJMra1410151 (last accessed Jan. 22, 2026). However,
people may experience pain during the test in the absence of this positive finding due to other conditions. Id.
13 “Crepitus” refers to “[t]he crackling, crunching, grinding or grating noise that accompanies flexing a joint.” Cedars
Sinai, Crepitus, https://www.cedars-sinai.org/stories-and-insights/innovation-and-research/crepitus (last accessed Jan.
22, 2026).
14 	The 	MCP 	joints 	of 	the 	hand 	are 	the 	knuckles. 	Cleveland 	Clinic, 	Arthritis 	of 	the 	Hand,
https://my.clevelandclinic.org/health/diseases/7082-arthritis-of-the-wrist-and-hand (last accessed Jan. 22, 2026).
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limited flexion in the proximal interphalangeal (“PIP”) joints of the second through fifth fingers
of both hands 15 ; (4) effusion and tenderness in the PIP joints of the second through fifth fingers of
both hands; (5) limited flexion in the distal interphalangeal (“DIP”) joints of all five digits of both
hands 16 ; and, (6) hyperflexion deformities in the DIP joints of the second through fifth fingers of
both hands. (Id.)
Based on her examination, Dr. Clarke opined that Plaintiff has functional physical
limitations. (AR 1315.) Specifically, Dr. Clarke opined that Plaintiff: (1) can stand “occasionally,”
i.e., for up to one-third of an eight-hour workday; (2) can sit “frequently,” i.e., for up to two-thirds
of an eight-hour workday; (3) can walk “frequently”; (4) is “moderate[ly]” limited in her ability to
bend or stoop “due to [RA] affecting [her] back”; (5) is “significant[ly]” limited in her ability to
reach, handle, and grasp “due to RA affecting [her] hands”; and, (6) can lift and carry less than
five pounds “occasional[ly].”17 (AR 1315.)
2. 	The ALJ’s Evaluation of Dr. Clarke’s Opinion
The ALJ assigned “some weight” to Dr. Clarke’s opinion but did not “completely accept[]”
it because he found it to be “too restrictive based on the examination results.” (AR 1331.) In
support of this conclusion, the ALJ stated:
Claimant demonstrated she could walk unassisted with a normal gait and perform
fine/gross manipulative skills. Additionally, she had normal grip strength (5/5) in
both hands and strength was only slightly decreased (4/5) in her lower extremities
(Exhibit 32F). Furthermore, Dr. Kathy Clark[e]’s examination results did not
appear consistent with the record as a whole because other exams did not document
15 The PIP joints of the hand are the second or middle joints of the fingers. Cleveland Clinic, Arthritis of the Hand,
https://my.clevelandclinic.org/health/diseases/7082-arthritis-of-the-wrist-and-hand (last accessed Jan. 22, 2026).
16 The DIP joints of the hand are the top joints of the fingers. Cleveland Clinic, Arthritis of the Hand,
https://my.clevelandclinic.org/health/diseases/7082-arthritis-of-the-wrist-and-hand (last accessed Jan. 22, 2026).
17 Dr. Clarke also opined that Plaintiff has significant mental limitations due to her psychiatric impairments. (AR
1315.) However, the ALJ disregarded the “mental impairment related diagnoses and limitations” in Dr. Clarke’s report
“because this [area was] outside of her expertise.” (AR 1331-32.) Plaintiff does not challenge this aspect of the ALJ’s
decision. (See generally Docs. 15, 19.)
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limited range of motion in extremities or decreased strength (Exhibits 26F, pages
38 and 73; 27F, page 3; 30F, page 5; 31F, page 27; 36F, page 3; and 48F, pages 8,
12, 16, and 25–26). 18
(AR 1331-32 (footnote added).)
3. 	Analysis
As noted above, Plaintiff argues that the ALJ improperly evaluated Dr. Clarke’s opinion in
assessing her RFC at step four. (Doc. 15 at 7-11.) Specifically, according to Plaintiff, the ALJ erred
in concluding that Dr. Clarke’s examination findings do not support all of the limitations she
assessed and that her examination results are inconsistent with other medical evidence of record.
(Id.) Plaintiff claims that in reaching these conclusions, the ALJ improperly disregarded Dr.
Clarke’s examination findings that support her opinion as well as other medical evidence consistent
with it, picking and choosing among the medical reports and using portions favorable to his
position while ignoring other significantly probative evidence. (Id.)
In his response, the Commissioner counters that substantial evidence “supports the ALJ’s
conclusion that consultative examiner Dr. Clark[e]’s opinion was entitled to only some weight.”
(Doc. 18 at 6.) The Commissioner maintains the ALJ was correct when he concluded that Dr.
Clarke’s examination findings do not fully support her opinion and that the opinion is inconsistent
with other record evidence, and these were “good reasons” for his treatment of the opinion. (Id. at
6-7.) In the Commissioner’s view, Plaintiff asks the Court to reweigh Dr. Clarke’s opinion, “which
is not permissible on the deferential substantial evidence standard of review applicable here.” (Id.
at 7.)
As noted in Section IV.B.2., supra, the ALJ gave two reasons for his partial rejection of Dr.
Clarke’s opinion. First, the ALJ wrote that Dr. Clarke’s opinion “was too restrictive based on the
18 (See AR 1092, 1127, 1135, 1259, 1290, 1714, 2847, 2851, 2855, 2864–65.)
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examination results.” (AR 1331.) In other words, the ALJ concluded that Dr. Clarke’s examination
findings do not support all of the limitations she assessed. (AR 1331-32.) Second, the ALJ stated
that Dr. Clarke’s examination results appear to be inconsistent with the other medical evidence of
record. (AR 1332.) However, as explained below, the ALJ failed to demonstrate that substantial
evidence supports either of these conclusions and that he applied correct legal standards in reaching
them.
Turning first to the ALJ’s supportability analysis, 20 C.F.R. § 416.927 provides that the
“more a medical source presents relevant evidence to support a medical opinion, particularly
medical signs and laboratory findings, the more weight [the SSA] will give that medical opinion.”
20 C.F.R. § 416.927(c)(3). The regulation further states that the “better an explanation a source
provides for a medical opinion, the more weight [the SSA] will give that medical opinion.” Id.
Internal inconsistencies in a medical opinion go to the opinion’s supportability, Soderberg v.
Kijakazi, Civ. No. 20-1256 GBW, 2022 WL 884305, at *6 (D.N.M. Mar. 25, 2022), and are a
legitimate reason to accord the opinion less weight. See Pisciotta v. Astrue, 500 F.3d 1074, 1078
(10th Cir. 2007) (holding that ALJ “permissibly assigned low weight” to “unsupported and
seemingly inconsistent opinions” in source’s letter).
To support his conclusion that the limitations Dr. Clarke assessed are “too restrictive based
on the examination results,” the ALJ cited Dr. Clarke’s findings that Plaintiff “could walk
unassisted with a normal gait,” had “only slightly” decreased leg strength, could “perform normal
fine/gross manipulative skills,” and had normal grip strength. (AR 1331–32.) However, as an
initial matter, the ALJ’s bare recitation of these findings is flawed on its face because the ALJ
failed to indicate which assessed limitations the findings purportedly undermine. Of course, one
could speculate on this point by trying to connect the findings the ALJ cited to the assessed
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limitations that he excluded from Plaintiff’s RFC. But as explained below, doing so turns out to be
less illuminating than one would expect.
Comparing the limitations Dr. Clarke assessed with the RFC the ALJ assigned, the ALJ
appears to have excluded from the RFC Dr. Clarke’s assessments that Plaintiff: (1) can stand only
occasionally; (2) is significantly limited in her ability to reach, handle, and grasp; and, (3) can only
occasionally lift and carry less than five pounds. (Compare AR 1315 with AR 1326.) But trying to
connect these limitations to the findings the ALJ cited yields at least two potentially anomalous
results. First, in concluding that Dr. Clarke’s findings do not fully support her opinion, the ALJ
relied on her finding that Plaintiff can walk unassisted with a normal gait, a finding that would
most logically detract from Dr. Clarke’s assessment that Plaintiff is limited to frequent walking.
(AR 1310, 1315, 1331-32.) Yet the ALJ did not exclude Dr. Clarke’s frequent-walking limitation
from the RFC he assigned. (AR 1326.) And second, though the ALJ seems to have excluded Dr.
Clarke’s reaching, lifting, and carrying limitations from the assigned RFC, these activities appear
to involve many abilities other than or in addition to normal grip strength and manipulative skills
in the hands, the only findings the ALJ cited that could possibly apply. (AR 1326, 1331-32, 1313-
15.) Thus, the ALJ’s failure to connect the findings he cited to the assessed limitations he believed
them to undermine hinders meaningful review of his evaluation of Dr. Clarke’s opinion. Spicer,
64 F. App’x at 178.
Further, even assuming one could confidently and accurately link each cited examination
finding to the part of Dr. Clarke’s opinion the ALJ believed it to undermine, the ALJ’s explanation
for his treatment of the opinion would still be inadequate. With respect to the standing limitation
the ALJ rejected, Dr. Clarke did, as the ALJ observed, find that Plaintiff could walk unassisted
with a normal gait and had only mildly decreased leg strength. (AR 1310, 1312, 1331-32.) But the
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ALJ failed to explain why these findings undermine Dr. Clarke’s assessment that Plaintiff can
stand only occasionally. (AR 1331-32.) Moreover, such a connection is not obvious in light of Dr.
Clarke’s other findings, which appear to support her assessment that Plaintiff’s lower body joint
pain and stiffness preclude standing for more than two to three hours per day “on a regular and
continuing basis.” SSR 96-8P, 1996 WL 374184, at *7. These findings include that Plaintiff could
not walk on her toes, squat, or bend over and touch her toes, had difficulty with tandem heel
walking, getting up from a chair, and getting on and off an exam table, and had spasm of the
paraspinous muscles, pain with straight-leg-raising, and limited range of motion in the lumbar
spine. (AR 1310-14.) Yet the ALJ “fail[ed] to discuss … and resolve whether these findings could
account for the [standing limitation Dr. Clarke] assessed, or why not.” Carroll, 2023 WL 2770699,
at *10.
Likewise, with respect to the reaching, handling, grasping, lifting, and carrying limitations
the ALJ excluded, Dr. Clarke did, as the ALJ observed, find that Plaintiff demonstrated normal
grip strength and gross and fine motor manipulative skills in the hands. (AR 1312, 1331-32.) But
again, the ALJ failed to explain why these findings undermine the reaching, handling, grasping,
lifting, and carrying limitations Dr. Clarke assessed. (AR 1331-32.) And again, such a connection
is not obvious in light of Dr. Clarke’s other examination findings, which appear to support her
assessment that multiple shoulder and hand abnormalities significantly limit Plaintiff’s ability to
reach, handle, grasp, lift, and carry “on a regular and continuing basis.” SSR 96-8P, 1996 WL
374184, at *7. Most notably, these findings include that Plaintiff had limited range of motion and
“marked … crepitus” in both shoulders and effusion, tenderness, hyperflexion deformity, and
pervasively limited range of motion in both hands. 19 (AR 1313-14, 1316.) Again, however, the
19 Elsewhere in his decision, the ALJ stated that physical limitations greater than those in the assessed RFC were
unwarranted because Plaintiff exhibited not only normal gait, grip strength, and manipulative skills, but also “intact
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ALJ failed to address these findings “and resolve whether they could account for the functional
limitations assessed, or in the alternative explain why not.” Carroll, 2023 WL 2770699, at *10. In
all of the above respects, the ALJ’s evaluation of Dr. Clarke’s opinion is inadequate to permit
meaningful review of his reasons for the weight he gave it. Spicer, 64 F. App’x at 178.
Additionally, in failing to address the abnormal examination findings supportive of Dr.
Clarke’s opinion in his explanation for partially rejecting that opinion, it appears that the ALJ
improperly picked and chose among the findings, using portions favorable to his position while
ignoring other portions. Panas, 775 F. App’x at 436–37. It is true, of course, that elsewhere in his
decision, the ALJ briefly acknowledged many of Dr. Clarke’s abnormal findings. Thus, in his
initial description of her consultative examination of Plaintiff, the ALJ mentioned that Plaintiff
exhibited paraspinous muscle spasm and limited range of motion in her shoulders, hands, and
lumbar spine, and was unable to walk on her toes, squat, tandem walk, or bend over to touch her
toes. (AR 1329.) And in support of the RFC he assigned, he again pointed to Dr. Clarke’s findings
of muscle spasm, mildly reduced leg strength, and “limited range of motion in the spine and various
joints.” (AR 1331.)
However, these brief mentions do not redeem the errors in the ALJ’s supportability analysis
of Dr. Clarke’s opinion for two reasons. First, as already discussed, the ALJ never explained why
he deemed the abnormal findings he mentioned elsewhere in his decision inadequate to support
the limitations Dr. Clarke assessed, nor are his reasons obvious. (See AR 1331-32.) And second,
he wholly ignored several other abnormal findings supportive of Dr. Clarke’s opinion, including
Plaintiff’s: (1) stiffness in her back and hips; (2) difficulty getting up out of a chair; (3) difficulty
sensation,” at Dr. Clarke’s examination. (AR 1331.) However, the ALJ never stated that the finding of intact sensation
undermined Dr. Clarke’s opinion, much less explained why it might do so. (See generally AR 1321-34.)
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getting on and off of an exam table; (4) pain with straight-leg-raising; (5) marked bilateral shoulder
crepitus; (6) effusion and tenderness in the MCP and PIP joints of the second through fifth fingers
bilaterally; and, (7) hyperflexion deformity in the DIP joints of the second through fifth fingers
bilaterally. (Compare AR 1310-11, 1313-14 with AR 1321-34.) It is unclear whether the ALJ
considered these findings at all, much less factored them into his analysis of the supportability of
Dr. Clarke’s opinion. For all of the above reasons, the ALJ’s supportability analysis fails to
adequately describe specific, legitimate reasons for the weight he gave Dr. Clarke’s opinion.
Moving on to the ALJ’s analysis of the consistency of Dr. Clarke’s opinion with the other
medical evidence of record, 20 C.F.R. § 416.927 provides that “the more consistent a medical
opinion is with the record as a whole, the more weight we will give to that medical opinion.” 20
C.F.R. § 416.927(c)(4). A medical opinion’s inconsistency with other medical evidence is a valid
reason for an ALJ to accord a medical opinion less weight. See Pisciotta, 500 F.3d at 1078.
However, as explained below, here the ALJ’s consistency analysis of Dr. Clarke’s opinion fails to
demonstrate that the ALJ applied correct legal principles and that substantial evidence supports the
analysis.
In explaining his evaluation of her opinion, the ALJ stated that Dr. Clarke’s “examination
results did not appear consistent with the record as a whole because other exam results did not
document limited range of motion in extremities or decreased strength.” (AR 1332.) In support,
the ALJ cited to nine medical reports in the record. (Id. (citing AR 1092, 1127, 1135, 1259, 1290,
1714, 2847, 2851, 2855, 2864–65).)20 But the ALJ’s reliance on the cited reports is inadequate for
three reasons.
20 The ALJ listed ten record citations to support his consistency analysis of Dr. Clarke’s opinion; however, AR 1259
and AR 1714 are duplicate reports regarding Plaintiff’s June 30, 2020, visit with Julie Fitzgerald, P.A. (AR 1332; see
AR 1259, 1714.)
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First, the cited reports from October 14, 2022 (AR 2864-65), December 1, 2022 (AR 2855),
December 15, 2022 (AR 2851), and May 25, 2023 (AR 2847) make no mention of Plaintiff’s range
of motion or strength. In other words, they simply do not address whether Plaintiff’s strength and
range of motion were normal on those dates. Thus, four of the nine reports on which the ALJ relied
fail to contradict Dr. Clarke’s examination findings of mild weakness in Plaintiff’s legs and limited
range of motion in her lumbar spine, shoulders, and hands.
Second, the ALJ failed to acknowledge or discuss that symptoms of RA, the diagnosis to
which Dr. Clarke attributed the abnormal physical findings she made, often come and go. See, e.g.,
Cleveland 	Clinic, 	Rheumatoid 	Arthritis, 	https://my.clevelandclinic.org/health/diseases/4924-
rheumatoid-arthritis 	(last 	accessed 	Jan. 	22, 	2026); 	Mayo 	Clinic, 	Rheumatoid 	Arthritis,
https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms-causes/syc-
20353648 (last accessed Jan. 22, 2026). Thus, that Plaintiff was experiencing normal strength
and/or range of motion on December 3, 2019 (AR 1092), March 5, 2020 (AR 1127), June 4, 2020
(AR 1135), June 30, 2020 (AR 1259, 1714), and April 29, 2021 (AR 1290), does not, absent further
explanation, undercut Dr. Clarke’s detailed findings of weakness and pervasively limited range of
motion on September 14, 2021. (AR 1312-16.) Indeed, Plaintiff’s providers’ assessments of
ongoing RA on December 3, 2019 (AR 1093), March 5, 2020 (AR 1129), June 30, 2020 (AR 1259-
60), and April 29, 2021 (AR 1290), show that these providers continued to accept the diagnosis
even though Plaintiff did not present with weakness and/or limited range of motion on those
dates.21
21 The ALJ did not reject Dr. Clarke’s assessment that Plaintiff suffers from RA, (AR 1314), nor would substantial
evidence support such a rejection. There is currently no cure for RA, see Cleveland Clinic, Rheumatoid Arthritis,
https://my.clevelandclinic.org/health/diseases/4924-rheumatoid-arthritis (last accessed Jan. 22, 2026); and, Plaintiff
received a “confirmed” diagnosis of the disease as early as November 2016, based on her symptoms and laboratory
test results. (AR 780-82.)
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And finally, eight of the nine reports the ALJ cited include notations of other symptoms
consistent with ongoing inflammatory joint disease and thus with the results of Dr. Clarke’s
examination. On December 3, 2019, Plaintiff reported “ongoing chronic bilateral hip pain.” (AR
1091.) On June 4, 2020, Plaintiff reported bilateral wrist pain with swelling and problems writing.
(AR 1134.) On June 30, 2020, Plaintiff reported problems with her shoulders, hips, morning
stiffness, joint pain, and swelling in the extremities. (AR 1258-59.) On April 29, 2021, Plaintiff
reported pain in her shoulders, elbows, hands, and feet, morning stiffness, and swelling in her
fingers, and her provider observed that she had active synovitis in her second and third PIP joints
bilaterally on examination.22 (AR 1290.) On October 14, 2022, Plaintiff reported morning stiffness
and severe body pain. (AR 2862, 2864.) On December 1, 2022, Plaintiff reported low back spasm
and pain, and on examination her provider noted that she was “tender all over [her] low back.”
(AR 2853, 2855.) And on December 15, 2022, and May 25, 2023, Plaintiff again reported
significant low back pain. (AR 2847, 2851.) Yet the ALJ did not discuss these notations in his
consistency analysis of Dr. Clarke’s opinion. (AR 1331-32.)
Additionally, Plaintiff’s provider made findings consistent with Dr. Clarke’s opinion in at
least one report the ALJ did not cite in evaluating the opinion. (AR 1264-65, 1332.) Specifically,
in July 2019, Plaintiff’s provider found that (1) although Plaintiff had normal motor strength in her
extremities, “[s]trength maneuvers provoked diffuse pain in all her joints,” and (2) Plaintiff had
“pain on palpation of her back and neck and shoulders.” (AR 1264-65.) In sum, because the ALJ
failed to discuss whether he discounted the above significantly probative notations and records
22 “Synovitis is swelling in the synovial membrane that lines some of your joints. It’s very common in people who
have arthritis.” Cleveland Clinic, Synovitis, https://my.clevelandclinic.org/health/diseases/synovitis (last accessed Jan.
22, 2026).
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consistent with Dr. Clarke’s opinion, and if so why, his consistency analysis fails to adequately
describe specific, legitimate reasons for the weight he gave the opinion.
C. The ALJ’s Errors Were Not Harmless
In addition to asserting that the ALJ did not err in evaluating Dr. Clarke’s opinion, the
Commissioner argues that any errors in the ALJ’s evaluation were harmless. (Doc. 18 at 10.) An
error is harmless when the Court can confidently say “that no reasonable administrative factfinder,
following the correct analysis, could have resolved the factual matter in any other way.” Allen v.
Barnhart, 357 F.3d 1140, 1145 (10th Cir. 2004). In other words, errors that are “minor enough not
to undermine confidence in the determination of [a] case” will be considered harmless. Gay v.
Sullivan, 986 F.2d 1336, 1341 n.3 (10th Cir. 1993). As explained below, however, the ALJ’s errors
here do undermine confidence in his determination of the case.
As the discussion in Section IV.B., supra, makes plain, if the ALJ had properly evaluated
Dr. Clarke’s opinion, he may have accorded it greater weight. This, in turn, may have led him to
assign Plaintiff a more restrictive RFC that incorporated more of the functional limitations Dr.
Clarke assessed.
Then, a more restrictive RFC more fully aligned with Dr. Clarke’s opinion could have
resulted in a finding of disability. In concluding that Plaintiff can perform work that exists in
significant numbers in the national economy, the ALJ relied on the testimony of VE Lasoff. (AR
1333.) VE Lasoff identified representative occupations a person with Plaintiff’s characteristics
could perform based on a hypothetical the ALJ posed, which, like the RFC he assigned, excluded
some of the limitations Dr. Clarke assessed. (Compare AR 1315 with AR 1370-71.) Among other
things, this hypothetical excluded the assessed limitations that Plaintiff can only occasionally
stand, is significantly limited in her ability to reach, handle, and grasp, and can only occasionally
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lift and carry less than five pounds. (Id.) By itself, the VE’s reliance on this hypothetical suggests
that the jobs she identified may be unavailable to someone with the limitations the ALJ excluded
from it.
Moreover, on cross-examination, the VE affirmatively testified that none of the jobs she
identified in response to the ALJ’s hypothetical would be available if the hypothetical had included
the limitation of occasionally lifting and carrying no more than five pounds or the limitation of
occasionally reaching and handling. (AR 1373.) This testimony confirms that if the ALJ had
accorded Dr. Clarke’s opinion more weight and thus included one or both of these limitations in
Plaintiff’s RFC, he may have found that there are no jobs that exist in significant numbers in the
national economy that Plaintiff can perform, and thus that Plaintiff is disabled.23
Finally, in his response to Plaintiff’s Motion, the Commissioner contends that any errors in
the ALJ’s evaluation of Dr. Clarke’s opinion were harmless because “Plaintiff admitted that she
worked as a [hotel] housekeeper … during the adjudicated period, one of the exact occupations
the ALJ found she was capable of performing with the assessed workplace limitations she now
challenges.” (Doc. 18 at 10.) “The record, however, reveals that [Plaintiff] worked [as a hotel
housekeeper] for less than one month,” Carroll, 2023 WL 2770699, at *12, and earned de minimis
income at this job. (AR 446-47.) Such “[s]hort-term, intermittent work projects are not equivalent
to gainful activity.” Carroll, 2023 WL 2770699, at *12. Indeed, if anything, Plaintiff’s
unsuccessful attempt to perform this job reinforces the VE’s testimony that a person with the
reaching, handling, lifting, and carrying limitations Dr. Clarke assessed could not successfully
23 This remains true even though, as the Commissioner points out, Dr. Clarke opined that Plaintiff is “significant[ly]”
limited in her ability to reach and handle, not that Plaintiff is limited to “occasionally” reaching and handling. (Doc.
18 at 10; see AR 1315.) First, it appears reasonable to equate a significant functional limitation with the ability to
perform the function at issue only occasionally, as Plaintiff’s counsel did in his cross-examination of VE Lasoff. (AR
1373.) Second, VE Lasoff testified that not only the occasional-reaching-and-handling limitation, but also the specific
lifting-and-carrying limitation Dr. Clarke assessed, would eliminate the available jobs she identified. (AR 1373.)
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perform it. For these reasons, I cannot say that the ALJ’s errors in evaluating Dr. Clarke’s opinion
were harmless. See Harrold v. Berryhill, 714 F. App’x 861, 870 (10th Cir. 2017) (holding that
ALJ’s error was not harmless where, “if credited by the ALJ on remand, [the medical opinion]
could alter the ALJ’s RFC determination and potentially change the outcome”).
V. CONCLUSION
For the reasons explained above, I recommend that Plaintiff’s Motion (Doc. 15) be
GRANTED, and that the Commissioner’s decision finding that Plaintiff has not been disabled
since February 28, 2018, be REVERSED and this matter REMANDED to the SSA for further
proceedings in accordance with these proposed findings and recommended disposition.
Timely objections may be made pursuant to 28 U.S.C. § 636(b)(1)(C). Within fourteen
(14) days after a party is served with a copy of these proposed findings and recommended
disposition that party may, pursuant to Section 636(b)(1)(C), file written objections to such
proposed findings and recommended disposition with the Clerk of the United States District
Court for the District of New Mexico. A party must file any objections within the
fourteen-day period allowed if that party wants appellate review of the proposed findings
and recommended disposition. If no objections are filed, no appellate review will be allowed.
____________________________________
KIRTAN KHALSA
UNITED STATES MAGISTRATE JUDGE
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