“We note that the task of determining a claimant’s residual functional capacity and ability to work is within the province of the ALJ, not of doctors.”
How later courts described this case
- “We note that the task of determining a claimant’s residual functional capacity and ability to work is within the province of the ALJ, not of doctors.”
- “Contrary to the district court’s reasoning, the ALJ did not ‘play doctor’ in assessing Mr. Castle’s RFC, but instead properly carried out his regulatory role as an adjudicator responsible for assessing Mr. Castle’s RFC.”
Written by the judges who cited it.
The opinion
UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF FLORIDA
FORT MYERS DIVISION
JOSEPH WILLIAM BOISVERT,
Plaintiff,
v. Case NO.: 2:21-cv-35-KCD
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
_________________________________________/
ORDER1
Joseph William Boisvert appeals the Commissioner of Social Security’s
final decision denying his application for a period of disability and Disability
Insurance Benefits. (Doc. 1.) For the reasons below, the Commissioner’s final
decision is affirmed.
I. Background
In July 2018, Boisvert filed an application for social security benefits.
(Tr. 15, 190-97.) His application was denied initially and again upon
reconsideration. He then requested further administrative review. (Tr. 15,
108, 123, 138.) A hearing was held before the assigned administrative law
1 Disclaimer: Documents hyperlinked to CM/ECF are subject to PACER fees. By using
hyperlinks, the Court does not endorse, recommend, approve, or guarantee any third parties
or the services or products they provide. The Court is also not responsible for a hyperlink’s
availability and functionality, and a failed hyperlink does not affect this Order.
judge on April 16, 2020, during which Boisvert was represented by an attorney.
(Tr. 15, 29-74.) Boisvert and a vocational expert (“VE”) testified. (Tr. 15, 29-
74.)
After assembling the record, the ALJ performed the five-step sequential
evaluation process as set forth in 20 C.F.R. § 404.1520(a). (Tr. 16-24.)2 First,
the ALJ found Boisvert last met the insured status requirements of the Social
Security Act on March 31, 2020. (Tr. 18.) The ALJ also concluded that Boisvert
had not engaged in substantial gainful activity from his alleged onset date of
June 23, 2018, through the date last insured. (Tr. 18.)
At step two, the ALJ found that Boisvert suffered from the following
severe impairments: degenerative disc disease, degenerative joint disease,
anxiety disorder, panic disorder, and ADHD. (Tr. 18.) Turning to step three,
the ALJ concluded Boisvert did not have an impairment or combination of
impairments that met or medically equaled the severity of one of the listed
impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 18-19.)
2 An individual claiming Social Security disability benefits must prove that he or she is
disabled. Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005). “The Social Security
Regulations outline a five-step, sequential evaluation process used to determine whether a
claimant is disabled: (1) whether the claimant is currently engaged in substantial gainful
activity; (2) whether the claimant has a severe impairment or combination of impairments;
(3) whether the impairment meets or equals the severity of the specified impairments in the
Listing of Impairments; (4) based on a residual functional capacity (“RFC”) assessment,
whether the claimant can perform any of his or her past relevant work despite the
impairment; and (5) whether there are significant numbers of jobs in the national economy
that the claimant can perform given the claimant’s RFC, age, education, and work
experience.” Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1178 (11th Cir. 2011).
Based on the record presented, the ALJ found that through the date last
insured, Boisvert had the RFC to perform sedentary work as defined in the
Social Security regulations,3 except that he:
can stand and/or walk for a total of four hours during
an eight-hour workday. The claimant can sit for a total
of six hours during an eight-hour workday. The
claimant can never climb ladders, ropes, or scaffolds,
can frequently balance and stoop, and can occasionally
climb ramps and stairs, kneel, crouch and crawl. The
claimant is limited to performing simple SVP-2 tasks.
The claimant can have occasional interaction with
supervisors, coworkers and the public.
(Tr. 19-20.)
After considering the evidence, the ALJ found at step four that Boisvert
was unable to perform his past relevant work as a chef. (Tr. 23.) However,
considering Boisvert’s age (younger individual), education, work experience,
RFC, and the testimony of the VE, the ALJ concluded that there were jobs
existing in significant numbers in the national economy that he could have
3 The social security regulations define sedentary work to include:
lifting no more than 10 pounds at a time and occasionally lifting
or carrying articles like docket files, ledgers, and small tools.
Although a sedentary job is defined as one which involves
sitting, a certain amount of walking and standing is often
necessary in carrying out job duties. Jobs are sedentary if
walking and standing are required occasionally and other
sedentary criteria are met.
20 C.F.R. § 404.1567(a).
performed, including table worker, final assembler, and fruit sorter. (Tr. 23-
24.)
The ALJ issued an unfavorable decision finding Boisvert not disabled at
any time from June 23, 2018 (the alleged onset date) through March 31, 2020
(the date last insured). The Appeals Council denied Boisvert’s request for
review, and this action followed. (Doc. 1.)
II. Legal Standard
Because Boisvert has exhausted his administrative remedies, the Court
has jurisdiction to review the Commissioner’s decision pursuant to 42 U.S.C. §
405(g). The scope of the Court’s review is limited to determining whether the
Commissioner applied the correct legal standards and whether the factual
findings are supported by substantial evidence. Winschel v. Comm’r of Soc.
Sec., 631 F.3d 1176, 1178 (11th Cir. 2011).4 The Commissioner’s findings of
fact are conclusive if they are supported by substantial evidence, 42 U.S.C. §
405(g), which is defined as “more than a scintilla and is such relevant evidence
as a reasonable person would accept as adequate to support a conclusion.”
Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997).
The Court must view the evidence as a whole, taking into account
evidence favorable as well as unfavorable to the Commissioner, when
4 Unless otherwise indicated, all internal quotation marks, citations, and alterations have
been omitted in this and later citations.
determining whether the decision is supported by substantial evidence. Foote
v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995). The Court may not reweigh
evidence or substitute its judgment for that of the Commissioner. And even if
the evidence preponderates against the Commissioner’s decision, the
reviewing court must affirm if the decision is supported by substantial
evidence. Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983).
III. Discussion
A. Boisvert’s Shoulder Impairment
Boisvert contends the ALJ erred in the evaluation process—first at step
two by not finding Boisvert’s shoulder impairment severe, and second, at step
four by not including limitations caused by his shoulder impairment in the
RFC determination. (Doc. 26 at 15-18.) The Commissioner argues the ALJ
adequately determined that the shoulder impairment was severe at step two.
(Doc. 26 at 18-19.) Further, according to the Commission, even if the shoulder
impairment was not included in the list of severe impairments at step two, the
error was harmless because the ALJ considered it when assessing the RFC.
(Doc. 26 at 20-22.)
The Court agrees with the Commissioner. The ALJ included Boisvert’s
shoulder impairment at step two of the analysis when he found that Boisvert
suffered from degenerative joint disease, as well as in the RFC determination
when he restricted Boisvert to sedentary work.
At step two of the sequential evaluation process, the ALJ must determine
whether the claimant has a medically determinable impairment that is
“severe” or a combination of impairments that is “severe.” 20 C.F.R. §§
404.1520(c), 416.920(c). The Eleventh Circuit has described this analysis “as a
screening or filter to eliminate groundless claims.” Tuggerson-Brown v.
Comm’r of Soc. Sec., 572 F. App’x 949, 951 (11th Cir. 2014). Important for
present purposes, an ALJ is not required to identify every severe impairment.
Id. “The finding of any severe impairment, based on either a single impairment
or a combination of impairments, is enough to satisfy step two because once
the ALJ proceeds beyond step two, he is required to consider the claimant’s
entire medical condition, including impairments the ALJ determined were not
severe.” Burgin v. Comm’r of Soc. Sec., 420 F. App’x 901, 902 (11th Cir. 2011).
At step four of the sequential evaluation process, the ALJ assesses a
claimant’s RFC and ability to do past relevant work. See 20 C.F.R. §§
404.1520(a)(4)(iv), 416.920(a)(4)(iv). RFC is defined as the most the claimant
can still do despite his limitations and is based on an evaluation of all the
relevant evidence in the record. See 20 C.F.R. §§ 404.1520(e), 404.1545(a)(1)
and (a)(3); Social Security Ruling (“SSR”) 96-8p, 1996 WL 374184 (July 2,
1996). The task of determining a claimant’s RFC and ability to work rests with
the ALJ, not a medical source. See Moore v. Soc. Sec. Admin., Comm’r, 649 F.
App’x 941, 945 (11th Cir. 2016); Castle v. Colvin, 557 F. App’x 849, 853 (11th
Cir. 2014) (“Contrary to the district court’s reasoning, the ALJ did not ‘play
doctor’ in assessing Mr. Castle’s RFC, but instead properly carried out his
regulatory role as an adjudicator responsible for assessing Mr. Castle’s RFC.”);
Robinson v. Astrue, 365 F. App’x 993, 999 (11th Cir. 2010) (“We note that the
task of determining a claimant’s residual functional capacity and ability to
work is within the province of the ALJ, not of doctors.”).
Here, at step two, the ALJ found that Boisvert’s degenerative disc
disease and degenerative joint disease constituted severe impairments. (Tr.
18.) While the ALJ did not specifically mention shoulder pain, the impairments
listed implicitly included shoulder complaints, as is evident from his discussion
of the medical evidence in the RFC analysis. (Tr. 21.) Nevertheless, even if
shoulder complaints were not included in the severe impairments at step two,
the error was harmless because the ALJ considered Boisvert’s shoulder
impairments at subsequent steps.
In the RFC assessment, the ALJ specifically considered Boisvert’s
shoulder impairment. Referring to Boisvert’s degenerative disc disease and
degenerative joint disease, the ALJ noted that Boisvert “underwent numerous
scans, including MRIs and X-rays, which showed cervical spondylosis, thoracic
disc protrusions, surgical history with stable hardware of the right knee, and
right shoulder small tear supraspinatus[.]” (Tr. 21.) The ALJ also referred to a
July 2, 2018, examination by Dr. Lian Jen, D.O., who found that Boisvert had
decreased shoulder range of motion, and diagnosed him with a right shoulder
cuff tear. (Tr. 21.) The ALJ further noted that on October 15, 2018, “claimant
was seen at Iona Cannabis Clinic for continued complaints of right shoulder
pain and back pain[,]” and that he “was diagnosed with chronic pain and
neuropathy and prescribed an oral tincture of THC[.]” (Tr. 21.) Continuing on,
the ALJ referred to a consultative examination performed by Dr. Michael
Rosenberg, M.D., who noted, in regards to the shoulder impairment, that
Boisvert had reduced shoulder range of motion and diagnosed mild bilateral
shoulder pain. (Tr. 21.)
The ALJ also considered the opinions of Dr. Shakra Junego, M.D., and
Dr. Jolita Burns, M.D., state agency consulting physicians who reviewed
Boisvert’s medical records. (Tr. 22, 95-105, 109-20.) They noted Boisvert’s
shoulder impairment and opined that he could perform sedentary exertion
level work, could stand and walk for 4 hours during an 8-hour workday, could
occasionally climb, balance, stoop, kneel, crouch, and crawl, but “was limited
to frequently overhead reaching with the right arm[.]” (Tr. 22, 103-04, 118-19.)
The ALJ found “[t]hese opinions persuasive,” but still afforded “more
restrictions . . . in the residual functional capacity.” (Tr. 22-23.)
Boisvert states that his shoulder impairment originated with a motor
vehicle accident in 2016, which was further aggravated by a fall several years
later. (Doc. 26 at 16-17.) Boisvert refers to physical examinations after these
incidents that “are also consistent with [his] testimony at the . . . hearing that
he is right-handed and has a ‘major problem’ with his right shoulder in terms
of reaching above his head or out in front of him.” (Doc. 26 at 17.) Citing this
evidence, Boisvert argues that the RFC determination does not account for his
muscle weakness and limited range of motion. (Doc. 26 at 18.)
Contrary to Boisvert’s contention, the ALJ considered his accident and
resulting shoulder pain. (Tr. 20.) The ALJ referenced an emergency room
report noting that Boisvert “appeared in no acute distress and reported should
[sic] pain was a 4 on a scale of 1-10, with 10 being the worse pain.” (Tr. 22.) A
shoulder X-ray showed no fracture, and Boisvert “was diagnosed with shoulder
pain/acute right shoulder sprain/strain and a possible rotator cuff tear . . . and
was prescribed Ibuprofen.” (Tr. 22.) The ALJ also referred to a medical report
dated September 30, 2019, and a subsequent December 20, 2019 report, and
stated:
On September 30, 2019, the claimant went to Family
Health Center to establish care. The claimant reported
having chronic pain, right shoulder pain, repeated
falls, dyslexia and alexia, and nicotine dependence.
Due to complaints of shoulder pain an MRI was
ordered for the claimant. On examination, the
claimant had normal gait, stance, balance, strength,
and range of motion, except for limited range of motion
of both shoulders and right shoulder pain on testing.
The claimant returned on December 20, 2019,
complaining of continued shoulder pain. The claimant
had not undergone a shoulder MRI. The claimant
underwent x-rays in the office, which showed no
fractures, no dislocations, no significant arthritis, and
no acute changes. Physical exam showed no deformity,
no erythema, and no swelling. The claimant had full
shoulder flexion and external rotation. The claimant
was noted as having right cuff tendinitis, underwent
an injection, and was given exercises to do at home.
(Tr. 20.)
Considering all of the medical evidence, the ALJ concluded that Boisvert
had the RFC to perform sedentary work, and substantial evidence supports
this finding. As the ALJ discussed in his opinion, after the onset date, Boisvert
was seen by Dr. Jen with complaints of right knee, back, and right shoulder
pain. (Tr. 551.) Medical notes from that visit indicate “motor 4+/5 with right
shoulder girdle 4-/5,” and tight range of motion in the right shoulder, decreased
internal rotation, and uneven and forward shoulder, and his diagnosis included
right shoulder cuff tear. (Tr. 551.) A follow-up examination was consistent with
these findings. (Tr. 550.)
Dr. Rosenberg later performed a consultative examination. (Tr. 633.)
Boisvert’s reported activities of daily living included simple cooking, cleaning
counters and tables, light laundry and light shopping. (Tr. 634.) He reported
being able to shower and dress himself, do childcare, and tend to orchids. (Tr
634.) As the Commissioner persuasively argues, these activities are consistent
with the ALJ’s determination that Boisvert is capable of a reduced range of
sedentary work. (Doc. 26 at 21.) Dr. Rosenberg further noted that Boisvert
needed no help changing for the exam or getting on and off the exam table, and
was able to rise from a chair without difficulty. (Tr. 635.) He had pain with
range of motion of bilateral shoulders, but 5/5 strength in the upper and lower
extremities. (Tr. 635.)
As for Boisvert’s post-accident fall that allegedly aggravated his shoulder
injury, he was examined in the emergency room with complaints of leg, hip and
knee pain, and a small laceration under his right eye. (Tr. 692, 696.) His
symptoms were noted to be mild. (Tr. 696.) Other than pain in the right leg,
extremities were grossly normal, and range of motion was intact in all
extremities. (Tr. 697.) A right shoulder X-ray revealed normal findings. (Tr.
710.)
Boisvert returned to the emergency room in September 2019 with
complaints of right shoulder pain after tripping over his dog. (Tr. 642.) The
physical examination indicated grossly normal extremities, except for
decreased range of motion in the right shoulder, pain, and tenderness. (Tr.
646.) Circulation and sensation were intact, and Compartment Syndrome
exam of the affected extremity was normal. (Tr. 646.) The radiology test
revealed no acute fracture or dislocation, and no joint effusion. (Tr. 647, 650.)
As the ALJ noted, Boisvert was discharged with a diagnosis of “acute right
shoulder sprain strain fall possible rotator cuff tear,” and prescribed Ibuprofen.
(Tr. 642, 644, 656.)
Continuing chronologically, Boisvert was then examined by Dr.
Alexander Serbanescu, M.D. (Tr. 739-46.) His examination was consistent with
rotator cuff pathology. (Tr. 740.) In late 2019, Boisvert returned to Dr.
Serbanescu for a follow-up visit. (Tr. 731.) His right shoulder examination
showed no deformity, no erythema or swelling. (Tr. 733.) He also had full
shoulder forward flexion and external rotation, and 5/5 rotator cuff strength
testing in all planes. (Tr. 733.) An X-ray of the right shoulder confirmed no
fracture or dislocation, no significant arthritis, and no acute bony changes. (Tr.
733. Dr. Serbanescu diagnosed right shoulder rotator cuff tendinitis. (Tr. 733.)
Based on these records, the ALJ’s RFC determination that Boisvert was
capable of sedentary work with some limitations is supported by substantial
evidence. The ALJ appropriately addressed the evidence, including Boisvert’s
shoulder impairment, both before and after the September 2019 fall, and
explained the reasoning for the RFC determination. While the record indeed
reveals Boisvert suffered from shoulder pain and reduced range of motion at
times, the RFC included limitations on his use of his arms and shoulders,
including the limitation that he can lift no more than ten pounds at a time and
occasionally lift or carry articles like docket files, ledgers, and small tools.
Boisvert argues the evidence supports a different conclusion, but the ALJs
decision is not subject to reversal where substantial evidence supports the
conclusion he reached. See Stout v. Comm’r of Soc. Sec., No. 2:21-CV-164-MRM,
2022 WL 2115484, at *3 (M.D. Fla. June 13, 2022). Accordingly, the ALJ’s RFC
determination is supported by substantial evidence, and the Court finds no
error.
B. Duty to Develop the Record
Boisvert next argues the ALJ failed to develop the record. (Doc. 26 at 23.)
Specifically, Boisvert claims the ALJ should have requested an additional
consultative examination after his September 2019 fall, as well as a shoulder
MRI that had been ordered by Dr. Serbanescu and that Boisvert did not
undergo. (Doc. 26 at 23.) The Commissioner argues Boisvert bears the burden
of showing his limitations, and that the ALJ had sufficient evidence in the
record to enable him to make an informed decision. (Doc. 26 at 25-28.) The
Court agrees with the Commissioner.
The ALJ has a basic duty to develop a full and fair record. Ellison v.
Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003). “Nevertheless, the claimant
bears the burden of proving that he is disabled, and consequently, he is
responsible for producing evidence in support of his claim.” Id. The ALJ “is not
required to order a consultative examination as long as the record contains
sufficient evidence for the administrative law judge to make an informed
decision.” Ingram v. Comm’r of Soc. Sec. Admin., 496 F.3d 1253, 1269 (11th
Cir. 2007). “The duty is triggered, for example, when there is an ambiguity in
the record or when the record is inadequate to allow for proper evaluation of
the evidence.” Mishoe v. Astrue, No. 5:08-CV-371-OC-GRJ, 2009 WL 2499073,
at *7 (M.D. Fla. Aug. 14, 2009).
Further, “there must be a showing of prejudice before [the court] will find
that the claimant’s right to due process has been violated to such a degree that
the case must be remanded to the [Commissioner] for further development of
the record.” Brown v. Shalala, 44 F.3d 931, 935 (11th Cir. 1995). In evaluating
the necessity for a remand, courts are “guided by whether the record reveals
evidentiary gaps which result in unfairness or clear prejudice.” Id. To establish
an evidentiary gap in the record, a claimant must “identify what facts could
have been submitted that would have changed the outcome.” Correa v. Colvin,
No. 8:15-CV-461-T-TGW, 2016 WL 7334642, at *4 (M.D. Fla. Mar. 18, 2016).
Here, the record contained ample evidence for the ALJ to evaluate
Boisvert’s shoulder impairment, including physical examinations and X-ray
imaging, both before and after the September 2019 fall that Boisvert alleges
exacerbated his symptoms. As discussed above, after his fall, Boisvert was
examined in the emergency room. (Tr. 642-56.) Radiology revealed no acute
fracture or dislocation, and he was diagnosed with acute right shoulder sprain
from the fall, with possible rotator cuff tear. (Tr. 645, 650.) Days later, Boisvert
was examined by Dr. Serbanescu, who noted the examination was consistent
with rotator cuff pathology and ordered an MRI. (Tr. 740.) Boisvert had a
follow-up visit with Dr. Serbanescu. (Tr. 731.) While the record does not include
MRI results, Dr. Serbanescu noted that X-ray imaging revealed no fractions or
dislocations, no arthritis, and no acute bony changes. (Tr. 733.) Boisvert also
underwent a Hawkins test at that time, which confirmed the diagnosis of right
shoulder rotator cuff tendinitis. (Tr. 733.) And physical examinations showed
no deformity, no erythema, and no swelling, full shoulder forward flexion and
external rotation equal bilaterally, and 5/5 rotator cuff strength testing in all
planes. (Tr. 733.) The medical record after Boisvert’s September 2019 fall is
consistent as to the extent of his injury and limitations, and there is no
indication that an MRI was necessary to enable the ALJ to make an informed
decision.
For the same reasons, Boisvert’s assertion that the ALJ had a duty to
order a second consultative examination and “update the record” after his
September 2019 fall is also without merit. (See Doc. 26 at 23.) The record was
fully and fairly developed, including treatment notes, objective medical testing,
and Boisvert’s own testimony at the hearing, to enable the ALJ to make an
informed decision.
Boisvert has also not demonstrated any prejudice by identifying facts
that could have changed the outcome. As the Commissioner notes, Boisvert
cannot rely on “hope or speculation” that “a consultative examination might
produce evidence to support his claim.” (Doc. 26 at 26.) Mere speculation that
an additional examination might have changed the results is not sufficient to
show prejudice. See Slocumb v. Comm’r of Soc. Sec., No. 5:16-CV-617-OC-
10PRL, 2017 WL 2889804, at *4 (M.D. Fla. May 15, 2017) (“[T]he only
purported prejudice that Plaintiff points to in her brief is the lack of a
consultative psychological examination . . . but it is Plaintiff’s duty to show how
the ALJ’s failure to obtain a psychological examination prejudiced her, the
mere lack of a consultative examination is inadequate to meet Plaintiff’s
burden when the record contains sufficient evidence to determine whether she
is disabled.”).
In sum, there are no evidentiary gaps in the record which resulted in
unfairness or clear prejudice to Boisvert. The ALJ had sufficient evidence to
make an informed decision regarding Boisvert’s limitations. Accordingly, the
ALJ did not breach his duty to fully and fairly develop the record by failing to
order an MRI or an additional consultative examination.
C. Consideration of Boisvert’s Mental Impairments
Finally, Boisvert claims the ALJ erred by failing to account for his non-
exertional limitations in the RFC determination. (Doc. 26 at 29.) Boisvert
argues the mental limitations, which the ALJ included at steps two and three
of the sequential evaluation process, “in particular the limitation in
concentrating, persisting or maintaining pace, erode his ability to perform
sedentary work such as the assembler-type of jobs that the vocational expert
identified.” (Doc. 26 at 30.) The Commissioner argues “[t]he ALJ was not
required to include his ‘mild’ ratings in his RFC finding or in a hypothetical to
the VE because they were not an assessment of Plaintiff’s RFC[,]” and the
ALJ’s RFC actually did include mental limitations. (Doc. 26 at 31-32.) The
Court again agrees with the Commissioner.
At step two of the sequential evaluation process, the ALJ found that
Boisvert’s severe impairments included anxiety disorder, panic disorder, and
ADHD. (Tr. 18.) At step three, the ALJ considered the severity of Boisvert’s
mental impairments, singly and in combination, and concluded that they did
not meet or medically equal the criteria of listing 12.06. (Tr. 18.) Specifically,
the ALJ found “[i]n understanding, remembering or applying information, the
claimant had a mild limitation. In interacting with others, the claimant had a
moderate limitation. With regard to concentrating, persisting or maintaining
pace, the claimant had a mild limitation. As for adapting or managing oneself,
the claimant had experienced a mild limitation.” (Tr. 19.) In support, the ALJ
stated that Boisvert is the primary care giver for his 13-year-old son, he cooks,
does light cleaning and laundry, goes grocery shopping, is able to shower and
dress himself, cares for his dogs, tends his orchids, and socializes with friends.
(Tr. 19.)
Based on the mild limitation in the area of concentrating, persisting, or
maintaining pace, the ALJ was not required to include it the RFC assessment.
See Faircloth v. Comm’r of Soc. Sec., No. 6:21-CV-782-EJK, 2022 WL 2901218,
at *2 (M.D. Fla. July 22, 2022) (“[A]n ALJ is not required to include mental
limitations in the RFC finding merely because he identified mild mental
limitations in the PRT criteria.”); see also Sprague v. Colvin, No. 8:13-CV-576-
T-TGW, 2014 WL 2579629, at *6-7 (M.D. Fla. June 9, 2014) (concluding that
the ALJ did not err in the RFC finding by omitting mild functional limitations
relating to a mental impairment). As such, even if the ALJ did omit this
limitation from the RFC assessment, he committed no error because he
assessed it as mild at an earlier step.
However, the ALJ did consider Boisvert’s mental impairments in the
RFC assessment and also in his hypothetical to the VE. (Tr. 19-20.) The ALJ
specifically noted that the RFC “reflects the degree of limitation I have found
in the paragraph B mental function analysis.” (Tr. 19.) And in formulating the
RFC, the ALJ considered treatment notes and opinion evidence regarding
Boisvert’s symptoms. The ALJ stated:
Regarding the claimant’s anxiety disorder, panic
disorder, and ADHD, the claimant was diagnosed and
treated at Psychiatric Associates prior to the amended
onset date (Exhibits B3F and B7F). The claimant
continued treatment, returning on July 11, 2018, the
claimant returned for treatment and reported “I’m
fine” and continued treatment for opioid dependence,
panic disorder, ADHD, generalized anxiety disorder,
and panic disorder. The claimant’s mental status
exam was normal except for anxious mood. The
claimant was continued on Xanax. The claimant
returned on August 1, 2018, October 8, 2018,
December 20, 2018, April 3, 2019, September 5, 2019,
and February 27, 2020. (Exhibits B7F, B9F, and
B13F).
On September 30, 2019, while being treated at Family
Health center, the claimant was diagnosed with
anxiety and started on Xanax. The claimant continued
treatment and do [sic] to reporting continued
symptoms, the claimant’s medication as [sic] adjusted
on December 20, 2019. The claimant’s psychiatric
exams noted normal appearance and affect with
euthymic mood (Exhibit B12F).
(Tr. 22.)
The ALJ relied on psychiatric findings, and noted that they were
consistently normal, except for anxious mood which was being treated with
Xanax. (Tr. 22.) Indeed, treatment notes from the relevant period indicate that
Boisvert appeared his stated age, was cooperative, friendly, alert, oriented to
person, place, time, and situation, had normal attention and concentration,
good memory and insight, congruent affect with mood, organized thought
process, and normal thought content. (Tr. 527-28, 533-34, 610-11, 613-14, 748-
51.) His diagnoses of generalized anxiety disorder, ADHD, opioid dependence,
and panic disorder remained consistent, and he continued with a Xanax
prescription. (Tr. 527-34, 537-38, 610-14, 630-31, 748-51.)
Contrary to Boisvert’s contention that the ALJ did not account for
mental limitations in the hypothetical to the VE, he did by restricting Boisvert
to performing simple tasks and only occasional interaction with supervisors,
coworkers, and the public. (Tr. 71-72.) Based in part on these limitations, the
VE testified that Boisvert could not return to his past work as a chef because
“TcJontact with people would be more than occasional.” (Tr. 72.) Thus, the ALJ
properly considered Boisvert’s mental limitations in the RFC assessment and
the hypothetical question posed to the VE. Because the AlLJ’s RFC
determination is supported by substantial evidence, the Court finds no error
on this issue.
Accordingly, it is ORDERED:
(1) the Commissionevr’s final decision is AFFIRMED;
(2) The Clerk shall enter judgment for the Commissioner and against
Joseph William Boisvert and close the file.
ENTERED in Fort Myers, Florida, on September 7, 2022.
Ley
Lyte 6 A adlel™
“ Kefle C. Dudek
United States Magistrate Judge
20