Gates v. Commissioner of Social Security Administration et al

IN THE UNITED STATES DISTRICT COURT FOR THE
WESTERN DISTRICT OF OKLAHOMA
M.E.G., )
)
Plaintiff, )
)
v. ) Case No. CIV-25-665-STE
)
FRANK BISIGNANO, )
Commissioner of the )
Social Security Administration, )
)
Defendant. )
MEMORANDUM OPINION AND ORDER
Plaintiff brings this action pursuant to 42 U.S.C. § 405(g) for judicial review of the
final decision of the Commissioner of the Social Security Administration denying Plaintiff’s
application for insurance benefits under the Social Security Act. The Commissioner has
answered and filed a transcript of the administrative record (hereinafter TR. ____). The
parties have consented to jurisdiction over this matter by a United States magistrate
judge pursuant to 28 U.S.C. § 636(c).
The parties have briefed their positions, and the matter is now at issue. Based on
the Court’s review of the record and the issues presented, the Court REVERSES AND
REMANDS the Commissioner’s decision.
I. PROCEDURAL BACKGROUND
Initially and on reconsideration, the Social Security Administration denied Plaintiff’s
applications for benefits. Following an administrative hearing, an Administrative Law
Judge (ALJ) issued an unfavorable decision. (TR. 17-26). On review, the Appeals Council
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denied Plaintiff’s request for review. (TR. 1-3). Thus, the decision of the ALJ became the
final decision of the Commissioner for purposes of the instant appeal.
II. THE ADMINISTRATIVE DECISION
The ALJ followed the five-step sequential evaluation process required by agency
regulations.
See Fischer-Ross v. Barnhart, 431 F.3d 729, 731 (10th Cir. 2005); 20 C.F.R.
§ 404.1520. At step one, the ALJ determined that Plaintiff had not engaged in substantial
gainful activity from his alleged onset date of January 1, 2022 through his date last
insured of September 30, 2023. (TR. 19). At step two, the ALJ determined Plaintiff
suffered from the following severe impairments: chronic pain syndrome; kidney disease;
Raynaud's disease; neuropathy; arthritis; cervical and lumbar degenerative disc disease,
and status/post left inguinal hernia repair. (TR. 19). At step three, the ALJ found that
Plaintiff’s impairments did not meet or medically equal any of the presumptively disabling
impairments listed at 20 C.F.R. Part 404, Subpart P, Appendix 1 (TR. 21).
At step four, the ALJ concluded that Plaintiff retained the residual functional
capacity (RFC) to:
[L]ift and carry up to 10 pounds frequently and up to 20 pounds
occasionally. He could stand and/or walk in combination up to 4 hours in
an 8-hour workday. He could sit for up to 6 hours in an 8-hour workday. He
could occasionally climb ramps and stairs. He could never climb ladders,
ropes, or scaffolds. He could occasionally stoop, kneel, crouch, and crawl.
He could frequently handle and finger bilaterally. He needed to avoid
occupations that require looking over the shoulder. He needed to avoid
extreme cold weather, excessive vibrations, and unprotected heights.
(TR. 21).
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At step four, the ALJ determined that Plaintiff was unable to perform his past
relevant work. (TR. 24). Therefore, the ALJ presented the RFC limitations to a vocational
expert (VE) to determine whether there were other jobs in the national economy that
Plaintiff could perform. (TR. 55). Given the limitations, the VE identified three jobs from
the Dictionary of Occupational Titles that Plaintiff could perform. (TR. 55). The ALJ then
adopted the VE’s testimony and concluded, at step five, that Plaintiff was not disabled
based on his ability to perform the identified jobs. (TR. 25-26).
III. ISSUE PRESENTED
On appeal, Plaintiff alleges the ALJ erred in: (1) failing to consider all the relevant
evidence in determining Plaintiff’s RFC and (2) analyzing Plaintiff’s subjective allegations.
(ECF Nos. 7:4-15, 12:2-11).
IV. STANDARD OF REVIEW
This Court reviews the Commissioner’s final decision “to determin[e] whether the
Commissioner applied the correct legal standards and whether the agency’s factual
findings are supported by substantial evidence.”
Noreja v. Commissioner, SSA, 952 F.3d.
1172, 1177 (10th Cir. 2020) (citation omitted). Under the “substantial evidence” standard,
a court looks to an existing administrative record and asks whether it contains “sufficien[t]
evidence” to support the agency’s factual determinations.
Biestek v. Berryhill, 139 S. Ct.
1148, 1154 (2019). “Substantial evidence . . . is more than a mere scintilla . . . and means
only—such relevant evidence as a reasonable mind might accept as adequate to support
a conclusion.”
Biestek v. Berryhill, 139 S. Ct. at 1154 (internal citations and quotation
marks omitted).
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While the court considers whether the ALJ followed the applicable rules of law in
weighing particular types of evidence in disability cases, the court will “neither reweigh
the evidence nor substitute [its] judgment for that of the agency.”
Vigil v. Colvin, 805
F.3d 1199, 1201 (10th Cir. 2015) (internal quotation marks omitted).
V. PLAINTIFF’S FIRST PROPOSITION
Plaintiff’s first point of error is set forth as: “The ALJ failed to account for all the
relevant evidence pursuant to SSR 96-8p resulting in harmful error.” (ECF No. 7:4). Within
this allegation of error, Plaintiff argues, in part, that the ALJ erred in her consideration of
the evidence as related to Plaintiff’s ability to walk and/or stand. Specifically, Plaintiff
argues: (1) the ALJ improperly evaluated prior administrative findings from Dr. James
Metcalf and (2) the ALJ failed to consider certain evidence from consultative examiner,
Megan Ewing, APRN-CNP, which he believes is significantly probative on his ability to walk
and/or stand. The Court rejects the first argument, but finds that the second argument
has merit and constitutes reversible error.
A. The ALJ’s Evaluation of Prior Administrative Findings from Dr.
Metcalf
The Court begins its analysis of Plaintiff’s argument by noting that Plaintiff’s
counsel has presented her argument in a rambling and haphazard manner, and the Court
will do its very best to decipher it. Plaintiff first takes issue with the ALJ’s reliance on Dr.
Metcalf’s opinion in the ALJ’s RFC determination. (ECF No. 7:5). Dr. Metcalf issued a prior
administrative finding that Plaintiff was capable of “light” work,1 which “requires the
1 (TR. 87).
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ability to stand and/or walk for up to six hours a day.”
Gutierrez v. Barnhart, 109 F. App’x
321, 327, 2004 WL 2095612, at *5 (10th Cir. 2004). Plaintiff correctly notes that the ALJ
found Dr. Metcalf’s prior administrative finding supported the RFC, and that his opinion
had been based on Plaintiff’s complaints of pain and full range of motion, which Dr.
Metcalf had deemed “generally consistent with the record.” (TR. 24). Plaintiff seems to
take issue with Dr. Metcalf’s finding, citing other examples in the record which Plaintiff
apparently believes contradicts this finding. (ECF No. 7:5). But the ALJ did not end her
analysis solely relying on Dr. Metcalf’s opinion as consistent with the record. The RFC
determination alone, is evidence of that fact, as it allows only for four hours of standing
and walking instead of six.
See TR. 21. Instead, the ALJ stated:
Although [Dr. Metcalf’s] finding was generally consistent with the record, I
considered the claimant’s complaints of pain and spasms in further reducing
his standing and walking. The prior administrative medical finding was not
consistent with the same.
(TR. 24). In sum, Plaintiff argues that the ALJ failed to consider evidence which would
have contradicted the ALJ’s reliance on Dr. Metcalf’s opinion regarding Plaintiff’s ability to
walk and/or stand. But the ALJ did not solely rely on Dr. Metcalf’s opinion, as is evidenced
by the RFC itself and the ALJ’s accompanying explanation. The Court rejects this
argument.
B. The ALJ’s Evaluation of Evidence from Ms. Ewing
Next, Plaintiff challenges the ALJ’s failure to consider certain evidence in
formulating the RFC, which he believes is significantly probative on his ability to walk
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and/or stand, as set forth by consultative examiner, Ms. Ewing, APRN-CNP. The Court
agrees.2
It is well-established Tenth Circuit law that “in addition to discussing the evidence
supporting [her] decision, the ALJ also must discuss the uncontroverted evidence [she]
chooses not to rely upon, as well as significantly probative evidence [she] rejects.”
Clifton
v. Chater, 79 F.3d 1007, 1010 (10th Cir. 1996). Indeed, the Tenth Circuit has held that
failure to explain the omission of limitations found in medical opinions is legal error
requiring reversal.
Parker v. Comm'r, 922 F.3d 1169, 1172–73 (10th Cir. 2019);
see also
Haga v. Astrue, 482 F.3d 1205, 1208 (10th Cir. 2007) (finding that an ALJ is not entitled
to pick and choose through an uncontradicted medical opinion, taking only the parts that
are favorable to a finding of nondisability). Here, the ALJ did not explain why she rejected
significantly probative and uncontroverted evidence in the record related to Plaintiff’s
ability to walk and/or stand. This constitutes reversible error.
2 Plaintiff begins this argument by stating: “While assessing Claimant’s lumbar spine as a severe
impairment, the ALJ’s summary discusses little of his lower back pain and limitations that even
the Agency examiner noted.” (ECF No. 7:5-6). Plaintiff’s reference to the ALJ’s assessment of
Plaintiff’s lumbar spine as “severe” is a step two finding.
See 20 CFR § 404.1520(c); TR. 19. At
the outset, Plaintiff appears to be challenging the ALJ’s step two finding, arguing that the ALJ
failed to consider certain evidence when evaluating the severity of Plaintiff’s impairments. But the
Tenth Circuit Court of Appeals has explained that any error committed in that consideration is
rendered “harmless when the ALJ reache[s] the proper conclusion that [the claimant cannot] be
denied benefits conclusively at step two and proceed[s] to the next step of the evaluation
sequence,” as she did here.
Carpenter v. Astrue, 537 F.3d 1264, 1266 (10th Cir. 2008). However,
a further reading of Plaintiff’s argument reveals that he is
actually challenging the ALJ’s failure to
consider certain evidence in formulating the RFC, which he believes is significantly probative on
his ability to walk and/or stand, as set forth by consultative examiner, Ms. Ewing.
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According to Plaintiff, the ALJ failed to consider Ms. Ewing’s findings that Plaintiff
suffered:
• pain in his bilateral feet;
• tenderness and spasms upon palpation in the mid thoracic
region/paraspinal muscles;
• moderate to severe discomfort with flexion, extension, rotation, side-
bending of the thoracic and lumbar spine;
• pain with external hip rotation bilaterally;
• an inability to perform straight leg testing due to pain; and
• an inability to heel walk or toe walk due to instability.
(ECF No. 7:6). Plaintiff is correct, as Ms. Ewing indeed made all the forgoing findings,
see
TR. 402-406, but the ALJ failed to mention them when discussing her report. In
summarizing Ms. Ewing’s report, the ALJ stated:
During his late 2022 consultative examination, the claimant displayed
moderate discomfort with flexion, extension, rotation, and side-bending of
the cervical spine. His range of motion was full. His gait was antalgic, but
steady. The claimant reported that his hands locked at times. His bilateral
hand strength was 4/5. He had no crepitus or swelling (D4F/5-6). I have
provided bilateral handling and fingering limitations to address his
complaints. The claimant can frequently handle and finger. The limit to
lifting and carrying 10 pounds frequently and 20 occasionally also addresses
the claimant’s hand complaints. His strength and ability to make a fist
support these limitations (D4F/5). The claimant testified that he could still
use his fingers during the relevant period, supporting the residual functional
capacity’s manipulative provisions.
(TR. 21-22).
The Court finds that the ALJ failed to discuss significantly probative evidence found
by Ms. Ewing regarding her examination of Plaintiff which was directly relevant to his
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ability to walk and/or stand. The ALJ characterized Plaintiff’s gait as summarized by Ms.
Ewing as “antalgic, but steady”—this being the only reference to Plaintiff’s ability to walk
and/or stand. (TR. 22). The ALJ seems to believe that the fact that Plaintiff’s gait was
“steady” somehow “normalizes” Plaintiff’s gait, but the definition of an “antalgic gait” is
when an individual walks with a limp due to pain, which would obviously affect Plaintiff’s
ability to walk and/or stand.3 Additionally, and as discussed, the ALJ failed to even
mention Ms. Ewing’s findings that Plaintiff suffered bilateral foot pain, an inability to
perform straight leg testing due to pain, and an inability to heel walk or toe walk due to
instability. The Court finds that the ALJ’s failure to consider such significantly probative
evidence is reversible error.
See Carpenter v. Astrue, 537 F.3d at 1267 (finding reversible
error based on ALJ’s failure to discuss significantly probative evidence from a physician’s
report which limited her ability to walk).
VI. PLAINTIFF’S REMAINING ALLEGATION OF ERROR
The Court declines to consider Plaintiff’s remaining allegations of error, as they will
likely be affected “by the ALJ’s treatment of [the] case on remand.”
Watkins v. Barnhart,
350 F.3d 1297, 1299 (10th Cir. 2003).
ORDER
The Court has reviewed the medical evidence of record, the transcript of the
administrative hearing, the decision of the ALJ, and the pleadings and briefs of the parties.
3	
See https://www.webmd.com/pain-management/what-is-antalgic-gait (last visited Jan. 7,
2026).
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Based on the forgoing analysis, the Court REVERSES AND REMANDS the
Commissioner’s decision.
ENTERED on January 26, 2026.
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