The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF NORTH CAROLINA
KIMBERLY M., )
)
Plaintiff, )
)
v. ) 1:22CV859
)
MARTIN J. O’MALLEY;! )
Commissioner of Social Security, )
)
Defendant. )
MEMORANDUM OPINION AND ORDER
OF UNITED STATES MAGISTRATE JUDGE
Plaintiff Kimberly M. (“Plaintiff”) brought this action pursuant to Section 205(g) of
the Social Secutity Act (the “Act”), as amended (42 U.S.C. § 405(g)), to obtain judicial review
of a final decision of the Commissioner of Social Secutity denying her claim for Disability
Insutance Benefits (“DIB”) undet Title II of the Act. The parties have filed cross-motions
for judgment, and the administrative record has been certified to the Coutt for review.
I, PROCEDURAL HISTORY
Plaintiff protectively filed an application for DIB on April 13, 2020, alleging a disability
onset date of Februaty 18, 2020. (Tr. at 16, 247-51, 255-56.)? Plaintiff's application was denied
initially (Tr. at 118-36, 155-63) and upon teconsidetation (It. at 137-52, 165-69). Thereafter,
1. On Decembet 20, 2023, Martin J. O’Malley was sworn in as Commissioner of Social Security, replacing Acting
Commissioner Kilolo Kijakazi. Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure, Martin J.
O’Malley should be substituted for Kilolo Kijakazi as Defendant in this suit. No further action need be taken
to continue this suit by teason of the last sentence of section 405(g) of the Social Security Act, 42 USC. §
405(¢).
2 Transcript citations refer to the Sealed Administrative Record [Doc. #9].
Plaintiff requested an administrative heating de novo before an Administrative Law Judge
(“ALJ”). (Le. at 171-72.) On November 17, 2021, Plaintiff, along with her attorney, attended
the subsequent telephonic heating, at which Plaintiff and an impattial vocational expert
testified. (Ir. at 16.) Following the hearing, the AL] concluded that Plaintiff was not disabled
within the meaning of the Act (T'r. at 36), and on August 16, 2022, the Appeals Counsel denied
PlaintifPs request for review of that decision, thereby making the ALJ’s conclusion the
Commissionet’s final decision for purposes of judicial review (T'r. at 1-7).
Il LEGAL STANDARD
Federal law “authorizes judicial review of the Social Security Commissionet’s denial of
social security benefits.” Hines v. Batnhatt, 453 F.3d 559, 561 (4th Cir. 2006). However, the
scope of review of such a decision is “extremely limited.” Frady v. Harris, 646 F.2d 143, 144
(4th Cir. 1981). “The courts are not to try the case de novo.” Oppenheim y. Finch, 495 F.2d
396, 397 (4th Cir. 1974). Instead, “a reviewing court must uphold the factual findings of the
AL) if they are supported by substantial evidence and were reached through application of the
cottect legal standard.” Hancock v. Asttue, 667 F.3d 470, 472 (4th Cir. 2012) (@nternal
quotation omitted).
“Substantial evidence means ‘such relevant evidence as a reasonable mind tight accept
as adequate to support a conclusion.” Hunter v. Sullivan, 993 F.2d 31, 34 (4th Cir. 1993)
(quoting Richardson v. Perales, 402 U.S. 389, 390 (1971)). “It consists of more than a mete
scintilla of evidence but may be somewhat less than a preponderance.” Mastto v. Apfel, 270
F.3d 171, 176 (4th Cir. 2001) (internal citations and quotation marks omitted). “If there is
evidence to justify a refusal to direct a verdict wete the case befote a juty, then there is
substantial evidence.” Hunter, 993 F.2d at 34 (internal quotation marks omitted).
“In reviewing for substantial evidence, the court should not undertake to re-weigh
conflicting evidence, make credibility determinations, or substitute its judgment for that of the
[AL]].” Mastro, 270 F.3d at 176 (internal brackets and quotation marks omitted). “Where
conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the
responsibility for that decision falls on the ALJ.” Hancock, 667 F.3d at 472. “The issue before
[the reviewing court], therefore, is not whether [the claimant] is disabled, but whether the
AL)’s finding that [the claimant] is not disabled is supported by substantial evidence and was
teached based upon a cottect application of the relevant law.” Craig v. Chater, 76 F.3d 585,
589 (4th Cit. 1996).
In undertaking this limited review, the Court notes that “[a] claimant for disability
benefits beats the burden of proving a disability.” Hall v. Harris, 658 F.2d 260, 264 (4th Cir.
1981). In this context, “disability” means the “inability to engage in any substantial gainful
activity by reason of any medically determinable physical or mental impairment which can be
expected to result in death or which has lasted or can be expected to last for a continuous
petiod of not less than 12 months.” Id. (quoting 42 U.S.C. § 423(d)(1)(A)).3
“The Social Security Act comprises two disability benefits programs. The Social Security Disability Insurance
Program (SSDI), established by ‘Title II of the Act as amended, 42 U.S.C. § 401 et seq., provides benefits to
disabled persons who have contributed to the program while employed. ‘The Supplemental Security Income
Program (SSI), established by ‘Title XVI of the Act as amended, 42, US.C. § 1381 et seq,, ptovides benefits to
indigent disabled petsons. ‘The statutory definitions and the regulations promulgated by the Secretary for
determining disability, see 20 C.F.R. pt. 404 (SSDI); 20 CER. pt. 416 (SSI), governing these two programs ate,
in all aspects relevant here, substantively identical.” Craig, 76 F.3d at 589 n.1.
“The Commissioner uses a five-step process to evaluate disability claims.” Hancock, □
667 F.3d at 472 (citing 20 C.F.R. §§ 404.1520(a)(4); 416.920(a)(4)). “Under this process, the
Commissioner asks, in sequence, whether the claimant: (1) worked during the alleged period
of disability; (2) had a severe impairment; (3) had an impairment that met ot equaled the
tequitements of a listed impairment; (4) could return to her past relevant work; and (5) if not,
could perform any other work in the national economy.” Id,
A finding adverse to the claimant at any of several points in this five-step sequence
forecloses a disability designation and ends the inquity. For example, “[t]he first step
determines whether the claimant is engaged in ‘substantial gainful activity.’ If the claimant is
working, benefits are denied. ‘I'he second step determines if the claimant is ‘severely’ disabled.
If not, benefits are denied.” Bennett v. Sullivan, 917 F.2d 157, 159 (4th Cir. 1990).
On the other hand, if a claimant carties his or her burden at the fitst two steps, and if
the claimant’s impaitment meets or equals a “listed impaitment” at step thtee, “the claimant
is disabled.” Mastro, 270 F.3d at 177. Alternatively, if a claimant cleats steps one and two,
but falters at step three, i.e., “[i]f a claimant’s impaitment is not sufficiently severe to equal or
exceed a listed impairment,” then “the AL] must assess the claimant’s residual functional
capacity (“RFC’).” Id. at 179.4 Step four then requires the AL] to assess whether, based on
4 “RFC is a measurement of the most a claimant can do despite [the claimant’s] limitations.” Hines, 453 F.3d
at 562 (noting that administrative regulations require RFC to teflect claimant's “ability to do sustained work-
related physical and mental activities in a work setting on a regular and continuing basis . . . [which] means 8
hours a day, for 5 days a week, or an equivalent work schedule” (internal emphasis and quotation marks
omitted)), ‘The RFC includes both a “physical exertional or strength limitation” that assesses the claimant’s
“ability to do sedentary, light, medium, heavy, or very heavy work,” as well as “nonexertional limitations
(mental, sensory, or skin impaitments).” Hall, 658 F.2d at 265. “REC is to be determined by the AL] only after
[the ALJ] considers all relevant evidence of a claimant’s impairments and any related symptoms (¢,¢., pain).”
Hines, 453 F.3d at 562-63.
that RFC, the claimant can “perform past relevant work”; if so, the claimant does not qualify
as disabled. Id. at 179-80. However, if the claimant establishes an inability to return to prior
wotk, the analysis proceeds to the fifth step, which “requires the [Government] to prove that !
a significant number of jobs exist which the claimant could perform, despite the claimant’s
impairments.” Hines, 453 F.3d at 563. In making this determination, the AL] must decide
“whether the claimant is able to perform other work considering both [the claimant’s RFC]
and [the claimant’s] vocational capabilities (age, education, and past work experience) to adjust
to a new job.” Hall, 658 F.2d at 264-65. If, at this step, the Government cannot catty its
“evidentiaty burden of proving that [the claimant] remains able to work other jobs available
in the community,” the claimant qualifies as disabled. Hines, 453 F.3d at 567.
Ill. DISCUSSION
In the present case, the ALJ found that Plaintiff had not engaged in “substantial gainful
activity” since her alleged onset date. The ALJ therefore concluded that Plaintiff met her
burden at step one of the sequential evaluation process. (I'r. at 18.) At step two, the AL]
further determined that Plaintiff suffered from the following severe impaitments:
cetvical degenerative disc disease (DDD) with status post fusion; Crohn’s
disease; gastroesophageal reflux disease (GERD); migtaine headaches; major
depressive disorder (MDD) with anxious distress; posttraumatic stress disorder
(PTSD); and unspecified cognitive disorder[.]
(Ir. at 18-19.) The ALJ found at step three that none of these impaitments, individually or
in combination, met or equaled a disability listing. (Ir. at 19-22.) Therefore, the ALJ assessed
Plaintiffs RFC and determined that she could perform light work with the following,
additional limitations:
[Plaintiff] can no more than frequently stoop, kneel, crouch, crawl, or climb
staits and ramps but could only occasionally balance or climb ladders, ropes, or
scaffolds; must avoid concentrated or frequent exposute to extreme cold,
extreme heat, pulmonaty ittitants, ot hazards. Also, [Plaintiff] was limited to
undetstanding, temembering and cattying out simple and some detailed
instructions, defined to mean work activity consistent with reasoning level 4 or
SVP 2 occupations as defined by the DOT as leatned within 30 days or less; can
sustain concentration, attention, and pace sufficient enough to catty out those
instructions for two hout intervals over the course of [a] typical eight-hour
workday; can work in occupations requiting only occasional interactions with
cowotkets, supetvisors, and the public; involving low stress work defined as
having few changes in work setting or work processes with only simple work
telated decisions.
(Tr. at 22.) At step four of the analysis, the ALJ determined, based on the above RFC and the
vocational expert’s testimony, that Plaintiff was unable to perform any of her past relevant
work. (I'r. at 34.) However, the AL] found at step five that, given Plaintiffs age, education,
work experience, and RFC, along with the testimony of the vocational expert tegatding those
factors, Plaintiff could perform other jobs available in the national economy and therefore
was not disabled under the Act. (T'r. at 35-36.)
Plaintiff now challenges the AL]’s decision in three respects. First, she contends that
“[t]he ALJ’s decision does not contain a summaty or evaluation of Plaintiffs testimony,” and
that this omission violated Social Security Regulation 16-3p. (Pl.’s Br. [Doc. #17] at 1.)
Second, Plaintiff argues that the AL] “failed to adequately account for the vocationally limiting
effects of Plaintiffs migraine headaches in the [RFC assessment].” (Id.) ‘Third, Plaintiff claims
that the Appeals Council “erred by refusing to consider new evidence.” (Id.) After a thorough
teview of the tecord, the Court agrees that the ALJ’s failute to address Plaintiff's testimony
requires remand. Accordingly, the Court need not address Plaintiff's additional arguments at
this time.
Under the applicable regulations, the ALJ’s decision must “contain specific reasons for
the weight given to the individual’s symptoms, be consistent with and supported by the
evidence, and be clearly atticulated so the individual and any subsequent teviewer can assess
how the adjudicator evaluated the individual’s symptoms.” Social Security Ruling 16-3p, Titles
Il and XVI: Evaluation of Symptoms in Disability Claims, 2017 WL 5180304 (Oct. 25, 2017);
see also 20 C.F.R. § 404.1529. Moreover, in Arakas v. Comm’r of Soc, Sec., 983 F.3d 83 (4th
Cir. 2020), the Fourth Circuit clarified the procedure an ALJ must follow when assessing a
claimant’s statements:
When evaluating a claimant’s symptoms, ALJs must use the two-step
framework set forth in 20 C.F.R. § 404.1529 and SSR 16-3p, 2016 WL 1119029
(Mar. 16, 2016). First, the ALJ must determine whether objective medical
evidence presents a “medically determinable impairment” that could reasonably
be expected to produce the claimant’s alleged symptoms. 20 CFR. §
404.1529(b); SSR 16-3p, 2016 WL 1119029, at *3.
Second, after finding a medically determinable impairment, the AL] must assess
the intensity and persistence of the alleged symptoms to determine how they
affect the claimant’s ability to work and whether the claimant is disabled. See 20
C.F.R. § 404.1529(c); SSR 16-3p, 2016 WL 1119029, at *4. At this step,
objective evidence is wot required to find the claimant disabled. SSR 16-3p, 2016
WL 1119029, at *4—-5. SSR 16-3p recognizes that “[s]ymptoms cannot always
be measured objectively through clinical or laboratory diagnostic
techniques.” Id. at *4. Thus, the ALJ must consider the entire case record and
may “not distegatd an individual’s statements about the intensity, persistence, _
and limiting effects of symptoms solely because the objective medical evidence
does not substantiate” them. Id. at *5.
983 F.3d at 95-96. Under SSR 16-3p, in evaluating a claimant’s symptoms in light of the entire
case tecotd at the second step of this framework, the ALJ must consider the claimant’s
testimony tegarding the limiting effects of the symptoms, along with information from other
medical and non-medical sources. SSR 16-3p at *6-*7. Ultimately, “it is not sufficient for [an
ALJ] to make a single, conclusory statement that ‘the individual’s statements about his or her
symptoms have been considered’ ot that ‘the statements about the individual’s symptoms are
(or ate not) supported of consistent.’ It is also not enough for [an ALJ] simply to recite the
factors described in the regulations for evaluating symptoms. The determination ot decision
must contain specific reasons for the weight given to the individual's symptoms, be consistent
with and supported by the evidence, and be cleatly articulated so the individual and any
subsequent teviewer can assess how the [AL]] evaluated the individual's symptoms.” SSR16-
3p at *9-*10.
In the present case, the ALJ failed to discuss—or even acknowledge—Plaintiffs
testimony at the administrative heating, Instead, the ALJ only addressed statements made by
Plaintiff and her father in Function Reports completed in April 2020 and March 2021,
respectively. In het decision, the AL] described these reports as follows:
The claimant alleged on a disability report that was completed on April 21, 2020,
that she suffers from Crohn’s disease, PISD, depression, anxiety, fecal
incontinence, migtaines, inflammatory arthritis, cataracts, perianal abscess, and
cognitive dysfunction, which limits her ability to work (Exh. 3E/2). Andrew
Meyet, the claimant’s father, assisted in completing a function report on the
claimant on Match 17, 2021 (Exh. 18E). Mr. Meyer indicated that the claimant’s
conditions affected her ability for lifting, squatting, bending, standing, teaching,
walking, sitting, kneeling, talking, climbing stairs, remembering, completing
tasks, concentrating, understanding, following instructions, using her hands,
and getting along with othets (Exh. 18E/14). He further stated that her
symptoms of her Crohn’s disease caused het to have nausea and vomiting (Exh.
18E/17). He further stated that her GERD caused her to have a lot of
hoatseness, sore throat, belching, nausea and vomiting and she was sometimes
unable to talk without coughing constantly and cleating her throat which did
not seem to work vety well to help with clearer speech (Exh. 18E/17). He also
stated that due to her cognitive dysfunction, she was unable to remember where
she put things, and she had to have mall security help her find her cat in the lot
many times (Exh. 18E,/18). He further stated that she had difficulty with word
finding and following directions (Exh. 18E/19).
Despite those allegations, Mr. Meyer indicated on the same function report that
the claimant took cate of a pet cat, putting food and water out for the cat (Exh.
18E/21), It was also noted that the claimant could bathe herself (Exh. 18E/23).
It was further noted that the claimant was able to do vety light cleaning, dtive a
cat, go out alone and she could go shopping in stotes (Exh. 18E/24, 25). Mr.
Meyer further indicated that the claimant spent time with others in person and
on the phone, email and texting (Exh. 18E/27).
(I'r. at 22-23.) The AL] found that “[alll the activities that Mr. Meyer reported that the
claimant could petform ate inconsistent with his previous statements. Mr. Meyer has
described daily activities that are not limited to the extent one would expect, given the
complaints of disabling symptoms and limitations.” (I'r. at 23.)
In the next patagraph of the AL]’s decision, without acknowledging or describing any
of Plaintiff's subjective complaints beyond the bate list of alleged impairments from het April
2020 Function Report, the ALJ concluded that “claimant’s statements concerning the
intensity, persistence and limiting effects of [her] symptoms ate not entirely consistent with
the medical evidence and other evidence in the record,” but without any discussion of the
Plaintiffs statements in the Function Repott or in her testimony. (I't. at 23) (emphasis added).
Significantly, at the hearing on November 17, 2021—approximately one yeat and two
yeats after the Function Reports cited by the ALJ— Plaintiff testified at length regarding her
physical and mental abilities, At the close of the heating, Plaintiffs counsel summarized het
televant testimony and related limitations:
[Plaintiff has] had Crohn’s disease for many years, [and] she still has significant
problems with abdominal pain, nausea and fecal incontinence. And especially
due to the fecal incontinence, we believe that she would require additional
breaks during the workday to either change her Depends or just to use the
facilities.
In addition to that, with [her] migraine headaches, she suffers headaches several
times pet week, which would also interfere with her ability to attend and
complete work tasks in two hour increments as required ... to do even unskilled
work.
(Tr. at 79.) In terms of incontinence, Plaintiff testified that she had to change her prior work
and could not see patients anymore because her “incontinence had gotten so bad.” (Tr. at 54.)
She further testified that she could not work due to PTSD and her incontinence, explaining
as follows:
A ... 50 ]—it’s just alot. Its constant bowel movement issue that I have
no conttol over because my sphincter is destroyed from disease and sutgery and
there’s nothing that they can do. I ttied everything, even a device that they
implanted in me... . It’s just a very terrible situation, embarrassing.
Q [Y]ou mentioned the fecal incontinence. How many bowel movements
do you typically have a day?
A I guess that it’s very hatd for me [to] give an estimate. So it could be
three. It could be ten. Sometimes it could be more than ten if I eat something,
I guess, that doesn’t get absorbed properly because I’ve had multiple bowel
tesections. So I don’t absorb normally. It’s very unpredictable. And I write it
down. I don’t know what I can and can’t eat.
Q With the Depends, do you wear them every single day?
A Yes, I wear [whatever] is cheapest. It’s not necessarily Depends, but I
also weat like a big Maxi pad that is almost—tt looks like an open diaper inside
thete so that I could change that and not have to pull the Depends because it’s
like four or five times a day that something comes out and ] don’t want to smell.
So I take out the pad if it’s not a blow out, and that way I can preserve
the Depends and put another pad in, if that makes sense.
Q And do you still have the same number of bowel movements, even
though you started taking Humita earlier this year?
A Oh, yeah. Yeah, I think it’s worse because my rheumatologist said
maybe you have more Lupus and Humita’s going to make the lupus symptoms
wotse. So I don’t know what’s going on.
Q And this fecal incontinence, do you have problems with nausea ot
abdominal pain?
10
A So my biggest problem is nausea. And I don’t know, like my—I have a
lot of, I guess, reflux and probably gastric involvement of my Crohn’s. So I get
a lot of nausea and I have to take a drug called Zoftan.... I have to take it
every day and now my insurance isn’t giving me enough. It’s vety tough and
I’m still nauseous with that.... And I get nauseous before a bowel movement.
I don’t know if ’'m going to throw up, if I’m going to have a bowel
movement because I don’t have a lot of feeling down there. It’s when it—you
know, I could feel the nausea and then I could feel the stool hit my skin. But
in my rectum I can’t really feel what’s going on.
(Tt. at 64-66.) Significantly, PlaintifPs reports of up to ten bowel movements a day are
consistent with her reports to her providers throughout the time period at issue. The AL]
recounted two of these tepotts in the administrative decision (see Tr. at 26, 27, 1206, 2866),
along with Plaintiffs statement at an April 2020 gastroenterology appointment that “[w]hen
she went out for a walk, she would weat a Depends and a pad” (Tr. at 26, 1206).5 However,
the AL] never addressed if, let alone how, these problems might affect Plaintiffs RFC.
When faced with a substantially similar issue in Dowling y. Comm’r of Soc. Sec.
Admin., 986 F.3d 377, 389 (4th Cir. 2021), the Fourth Circuit required remand. Specifically,
the Court found that
[t]here [was] considerable evidence in the record demonstrating that Appellant
regulatly experienced diarrhea and incontinence, as well as drainage from her
anal fissure. Appellant argues that these problems caused her to requite
bathroom breaks at a frequent, and often unpredictable, rate. Obviously, the
need to visit the bathroom many times throughout the day impacts one’s ability
to work. And yet, the ALJ did not analyze Appellant’s need for regular
bathroom breaks. Instead, the AL] simply noted that Appellant
“accommodate[d] her drainage and accidents by using pads.” J.A. 16. That
finding misses the point. Pads may keep Appellant’s clothes clean and help
reduce the potential for embattassing accidents. However, they do not save
5 The transcript of the hearing also reflects that Plaintiff had to leave the hearing to go to the bathroom partway
through the proceeding. (Tr. at 67.) In addition, Plaintiffs later medical records submitted to the Appeals
Council reflect that she underwent an Anorectal Manometty procedure shortly after the hearing, which
confitmed findings “consistent with weak anal sphincters and pelvic floor dyssenergia’” with a diagnosis of “Full
incontinence of feces.” (T'r. at 86-87).
11
Appellant any trips to the bathroom, since the pads need to be changed once
they ate soiled. On remand, the ALJ should evaluate the frequency at which
Appellant needed to use the bathroom and analyze how that testtiction
impacted her ability to work.
Dowling, 986 F.3d at 389. Notably, in the present case, Plaintiffs attorney specifically
questioned the vocational expert regarding breaks during the workday:
Q [B]ased on your education, training and experience, what would be the
typical breaks that are allowed . . . during an eight-hour workday?
A On morning 15-minute, half-hour lunch and 15-minute afternoon.
Q Okay. Ifa claimant requited two additional 10-minute breaks duting the
workday to use the bathtoom, for example, would that have an effect on the
claimant’s ability to work in the national economy?
A [YJes, [the need for additional breaks] would eliminate all work.
(Tr. at 77-78.) In light of this testimony, along with Plaintif? s consistent, but unaddressed,
reports that she experienced fecal incontinence throughout the relevant time period, temand
is required so that the AL] may addtess this issue in the fitst instance. See also Moore v.
Kijakazi, 2022 WL 834295 (E.D.N.C. Match 21, 2022) (“Moreover, notably absent from the
AL]’s RFC assessment is any discussion of Claimant’s testimony from the administrative
heating, and the AL] is requited to consider a claimant's statements about het symptoms, 20
C.F.R. § 416.929(a); S.S.R. 16-3p.” (emphasis in original, internal citations omitted)).
Plaintiff further testified that she experienced pain when sitting for an extended period
of time due to both spinal pain radiating to het left leg and recurrent rectal abscesses and sores
from her frequent stools. (Tr. at 68.) Plaintiff testified that with respect to her ability to sit,
“sitting with my rectal abscess has been, you know, the sores from the stool getting on me is
difficult too.” (Tr. at 68.) Plaintiff further testified that when she has “an active dtaining
12
abscess down there” she cannot sit and instead has to lay down to rest that area. (T'r. at 68.)
Again, the ALJ failed to acknowledge ot addtess this testimony, nor did she explain the
absence of sitting restrictions in the RFC aseusemedtt. See Dowling, 986 F.3d at 388-89; see
also Denise R. v. Kijakazi, 2023 WL 4898288 (D. Md. July 31, 2023) (finding that “the ALJ
does not appeat to have evaluated Plaintiffs testimony regarding her ability to sit” in light of
het impaitments including incontinence, and “[w]hile it is not necessary that an AL] addtess
evety piece of a claimant’s testimony, the AL} erroneously ignored Plaintiffs testimony about
her difficulty sitting, which is the central component of sedentary work and material to the
disability determination in this case.”); Gravely v. Kijakazi, 2023 WL 2349600 (M.D.N.C.
Match 3, 2023) (noting that “[t]he ALJ did not mention or discuss Plaintiffs testimony that
she could not sit more than five minutes at a time, nor did the ALJ otherwise address or
mention any limitations on sitting” and “i]t is unclear whether the AL] considered the related
incontinence at all, since it is not mentioned in the decision even though it was a significant
part of Plaintiffs testimony and was teflected repeatedly in the medical records” and
remanding in light of Dowling). Notably, in the present case, Plaintiffs attorney questioned
the vocational expert regarding sitting restrictions, and, as with the need for additional breaks,
the expert testified that the addition of a sit/stand option to the jobs relied upon by the ALJ
would eliminate those positions. (Tr. at 76.) Because the ALJ did not addtess Plaintiffs
sitting restrictions at all, or even mention the effect of her rectal abscesses on her ability to sit,
the Court cannot follow the AL]’s reasoning, and the sitting limitations would potentially
affect the determination in light of the vocational expert’s testimony.
13 !
Similar problems ate teflected in the AL]’s failure to address Plaintiffs testimony
tegatding her ongoing migraine headaches. Plaintiff testified that, at the time of the
administrative heating, her migraines occutted “almost daily.” (Tr. at 66.) She farther
indicated that, if she takes her abortive medication early enough, the headaches may “go away
in a couple of hours,” but that “sometimes they last for days.” (Tt. at 66.) She reported the
same frequency of migraines despite taking all of het medications as directed, and stated that
her doctors “have not found something that works.” (T't. at 66-67.) Significantly, Plaintiff
testified that, when her headaches last for days, she has needed to contact her doctot or go to
the emetgency room “because [she doesn’t] know what to do.” (I'r. at 66.)
When recounting the medical evidence, the ALJ noted Plaintiffs reports to her
neurologist that she experienced migraines “[a]t least weekly, lasting several days” and that her
rescue medication, Sumatriptan, worked well “at times.” (I't. at 27.) ‘The AL] also noted that
Topitamate, which Plaintiff took as a daily prophylactic for migraines, caused memory and
cognitive problems. (I't. at 27-28.) ‘The ALJ found that as of August 2021, Plaintiffs
migraines were “considered chronic and stable.” (Tr. at 28.) Nothing in this discussion
explains what, if any, parts of Plaintiffs testimony and reports to her doctors the AL) found
inconsistent with the evidence. Moreover, the Function Report completed by Plaintiff's
father—the only subjective evidence discussed by the ALJ—does not address Plaintiff's
headache impaitment at all. (See Tr. at 22-23.) Accordingly, as with Plaintiffs gastrointestinal
impairments, the administrative decision lacks any meaningful—or reviewable—explanation
of how the RFC accounts for the symptoms of Plaintiffs headache disorder. In particular,
when asked to define “the tolerance for absenteeism in the national economy,” the vocational
14
expert answeted that “no mote than once a month” would be allowed. (Tr. at 78.) While it
is entitely possible that the ALJ could identify reasons for rejecting Plaintiff's testimony that
she expetienced at least one debilitating headache a week, and therefore would not miss more
than one day of work per month due to het symptoms, the ALJ did not make any such findings
in het decision.
Ultimately, the AL]’s failute to acknowledge or address Plaintiffs hearing testimony at
all in her decision, let alone provide teasons for distegarding the limitations identified by
Plaintiff duting the heating, leaves the Court unable to determine the ALJ’s reasoning and
renders the ALJ’s decision unsupported by substantial evidence. ‘These are issues that should
be addressed and considered by the AL] in the first instance.
IT IS THEREFORE ORDERED that the Commissionet’s decision finding no
disability is REVERSED, and that the matter is REMANDED to the Commissioner under
sentence four of 42 U.S.C. § 405(g). The Commissioner is directed to remand the matter to
the ALJ for further consideration of Plaintiffs claim. Defendant’s Dispositive Brief [Doc.
#18] is DENIED, and Plaintiffs Motion for Judgment on the Pleadings [Doc. #16] is
GRANTTED to the extent set out herein. However, to the extent Plaintiff seeks an immediate
awatd of benefits, her Motion is DENIED.
This, the 11% day of March, 2024.
__/s/ Joi Elizabeth Peake __
United States Magistrate Judge
15