# Irving v. Social Security Administration

> District Court, N.D. Oklahoma · August 16, 2023

URL: https://www.frixlaw.com/law-library/cases/10387277

## Case

- **Court:** District Court, N.D. Oklahoma
- **Decided:** August 16, 2023
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

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## Opinion text

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF OKLAHOMA

TERRIE I., )
)
Plaintiff, )
)
v. ) Case No. 22-CV-148-CDL
)
KILOLO KIJAKAZI, )
Acting Commissioner of the )
Social Security Administration, )
)
Defendant. )

OPINION AND ORDER

Plaintiff seeks judicial review of a decision of the Commissioner of the Social
Security Administration (Commissioner) denying Social Security disability benefits. The
parties have consented to proceed before a United States Magistrate Judge in accordance
with 28 U.S.C. § 636(c)(1), (2). For the reasons set forth below, the Court reverses the
Commissioner’s decision denying benefits and remands the case for further proceedings.
I. Standard of Review
The Social Security Act (the Act) provides disability insurance benefits to
qualifying individuals who have a physical or mental disability. See 42 U.S.C. § 423. The
Act defines “disability” as an “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
period of not less than 12 months.” See 42 U.S.C. § 423(d)(1)(A).
Judicial review of a Commissioner’s disability determination “‘is limited to
determining whether the Commissioner applied the correct legal standards and whether the
agency’s factual findings are supported by substantial evidence.’” Noreja v. Soc. Sec.

Comm’r, 952 F.3d 1172, 1177 (10th Cir. 2020) (citing Knight ex rel. P.K. v. Colvin, 756
F.3d 1171, 1175 (10th Cir. 2014)). “Substantial evidence is more than a mere scintilla and
is such relevant evidence as a reasonable mind might accept as adequate to support a
conclusion.” Id. at 1178 (quoting Grogan v. Barnhart, 399 F.3d 1257, 1261 (10th Cir.
2005)); see also Biestek v. Berryhill, --- U.S. ---, 139 S. Ct. 1148, 1154 (2019). “Evidence

is not substantial if it is overwhelmed by other evidence in the record or constitutes mere
conclusion.” Noreja, 952 F.3d at 1178 (quoting Grogan, 399 F.3d at 1261-62).
So long as supported by substantial evidence, the agency’s factual findings are
“conclusive.” Biestek, 139 S. Ct. at 1152 (quoting 42 U.S.C. § 405(g)). Thus, the court may
not reweigh the evidence or substitute its judgment for that of the agency. Noreja, 952 F.3d

at 1178.
II. Background and Procedural History
The plaintiff filed a Title II application and protectively filed a Title XVI application
for disability benefits on February 25, 2020, alleging a disability onset date of February 25,
2020. (R. 26, 92). The plaintiff alleged disability due to a combination of impairments,

which are identified in her application as “car accident, brain injury, microevolve, memory
issues, high blood pressure, irritable bowel syndrome, GERD, eczema, ulcer disease, lung
problems, goiter, diverticulitis, heart issues, asthma, anxiety, allergies, [and] depression.”
(R. 92-93).1 She was 55 years old on the alleged onset date. Id. The plaintiff completed
high school and vocational training. (R. 51). She lives with her disabled son, and she is
paid through a state program to take care of him, earning about $850 per month. (R. 49-

50). She has past relevant work as a home care provider and manager in a housing facility
for the disabled. (R. 53-54).
The plaintiff’s application was denied on initial review and on reconsideration. An
Administrative Law Judge (ALJ) held a hearing via telephone on September 29, 2021. (R.
43-87). The plaintiff and a vocational expert (VE) provided testimony. See id. The ALJ

denied benefits in a decision dated October 12, 2021. (R. 28-42). The Appeals Council
issued a decision on January 27, 2022 denying the plaintiff’s request for review of the
ALJ’s decision. (R. 1-6). Following the Appeals Council’s denial, the plaintiff timely filed
a Complaint in this Court. (See Doc. 2). Accordingly, the Court has jurisdiction to review
the ALJ’s October 12, 2021 decision under 42 U.S.C. § 405(g).

III. The ALJ’s Decision
The Commissioner uses a five-step, sequential process to determine whether a
claimant is disabled and, therefore, entitled to benefits. See 20 C.F.R. § 404.1520(a)(4)(i)-
(v). A finding that the claimant is disabled or is not disabled at any step ends the analysis.
See id.; see also Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007) (citing Williams v.

1 The administrative record repeatedly identifies one of the plaintiff’s alleged
conditions as “microevolve.” (See, e.g., R. 123, 145, 151, 153, 158). Neither party’s
briefing discussed or questioned this alleged impairment. (See R. 299). As such, although
this term is unclear, it does not appear to be relevant to the issues raised on appeal of the
ALJ’s decision.
Bowen, 844 F.2d 748, 751 (10th Cir. 1988)). The claimant bears the burden on steps one
through four. Lax, 489 F.3d at 1084.
At step one, the claimant must demonstrate that she is not engaged in any substantial

gainful activity. See Lax, 489 F.3d at 1084. Here, the ALJ determined the plaintiff’s work
caring for her son met the level of substantial gainful activity in the third quarter of 2020.
(R. 28). However, the ALJ found there has been a continuous 12-month period in which
she did not engage in substantial gainful activity; accordingly, the ALJ proceeded to step
two. (R. 29).

At step two, the claimant must establish an impairment or combination of
impairments that is severe. See Lax, 489 F.3d at 1084. Here, the ALJ determined that the
plaintiff has severe impairments of urinary tract disorder, migraines, anxiety, obsessive-
compulsive disorder (OCD), and spine disorder. (R. 29). The ALJ found the plaintiff’s
obesity does not significantly limit the plaintiff’s work-related functioning and is therefore

nonsevere. Id.
At step three, the ALJ determines whether the claimant’s severe impairment or
impairments is equivalent to one that is listed in Appendix 1 of the regulation, which the
Commissioner “acknowledges are so severe as to preclude substantial gainful activity.”
Williams, 844 F.2d at 751 (internal quotation and citation omitted); see 20 C.F.R. §§

404.1520(d); 20 C.F.R. Part 404, subpt. P, app’x 1 (Listings). Here, the ALJ found that the
plaintiff’s physical and mental impairments do not meet or equal the criteria for any
Listing, specifically noting Listings under Sections 1.00 (musculoskeletal system) and
12.00 (mental disorders). The ALJ also discussed the “paragraph B” criteria—four areas
of mental functioning used to determine whether a claimant’s mental impairments
functionally equal a Listing. See 20 C.F.R. § 404 Subpt. P App’x 1. The ALJ found that
the plaintiff has a moderate limitation in understanding, remembering, and applying

information; a mild limitation in interacting with others; a moderate limitation in
concentrating, persisting, or maintaining pace; and a mild limitation in adapting or
managing oneself. (R. 29-30). Because the plaintiff does not have at least one extreme or
two or more marked limitations, the ALJ found the paragraph B criteria are not satisfied.
(R. 30).

At step four, the claimant must show that her impairment or combination of
impairments prevents her from performing work she has performed in the past. The ALJ
first determines the claimant’s residual functional capacity (RFC) based on all the relevant
medical and other evidence. 20 C.F.R. § 404.1520(e); see also Winfrey v. Chater, 92 F.3d
1017, 1023 (10th Cir. 1996). The ALJ next determines the physical and mental demands

of the claimant’s past relevant work. Winfrey, 92 F.3d at 1023. Finally, the ALJ determines
whether the RFC from phase one allows the claimant to meet the job demands found in
phase two. Id.
Here, the ALJ determined that the plaintiff has the RFC to perform
medium work as defined in 20 CFR 404.1567(c) and 416.967(c)
except occasionally climbing ramps or stairs; never climbing
ladders, ropes, or scaffolds; frequently balancing; occasionally
stooping, kneeling, crouching, or crawling; must avoid frequent
exposure to loud noises, dust, odors, fumes, and pulmonary irritants
and unprotected heights and dangerous moving machinery; able to
understand, remember, and carry out simple tasks with routine
supervision; able to pace and persist for an eight-hour workday and
40-hour work week; able to interact appropriately with supervisors,
coworkers, and the general public on a superficial work basis; can
respond appropriately to changes in a routine work setting which are
gradually introduced.
(R. 30-31). The ALJ found that the plaintiff is unable to perform her past relevant work as
a resident care aide, teacher aide, and home attendant. (R. 34-35). However, citing the VE’s
testimony, the ALJ found that the plaintiff could perform alternative jobs existing in
significant numbers in the national economy, including (1) laundry worker, Dictionary of
Occupational Titles (DOT) # 361.687-018, medium exertion, unskilled work, specific
vocational preparation (SVP) Level 2, with approximately 68,000 such jobs available in

the national economy; (2) hand packager, DOT # 920.587-018, medium exertion,
unskilled work, SVP Level 2, with approximately 32,000 such jobs available in the national
economy; and (3) sandwich maker, DOT # 317.664-010, medium exertion, unskilled
work, SVP Level 2, with approximately 28,000 such jobs available in the national
economy. (R. 35-36). As such, the ALJ found the plaintiff not disabled at step five. (R. 36).

IV. Discussion
A. Issues
The plaintiff argues that the ALJ failed to properly consider various portions of the
record relating primarily to (1) the plaintiff’s ability to lift, carry, reach, and use her hands
as specified in the RFC determination, and (2) the effects of her migraine headaches and
dizziness on her ability to perform work-related activities. The plaintiff also argues that the

ALJ erred at step three in failing to consider whether her headache symptoms meet or equal
a Listing. The Commissioner contends that the ALJ properly evaluated the record evidence
and substantial evidence supports the ALJ’s decision.
The plaintiff’s brief focuses primarily on the ALJ’s alleged non-compliance with
the Commissioner’s regulations governing evaluation of medical opinion evidence. (See
Doc. 14 at 3-11 (citing, inter alia, 20 C.F.R. § 416.920c(c)). The plaintiff argues that the

ALJ failed to properly evaluate the medical opinions and other medical evidence in the
record concerning her exertional capacity, her alleged limitations in using her upper
extremities, and her neurocognitive disorder. The plaintiff specifically argues that the ALJ
failed to properly evaluate the findings of medical sources including Kenneth Trinidad,
D.O., River Smith, Ph.D., and state agency reviewing physicians and psychologists.

However, the Court finds that the plaintiff has not established any reversible error
with respect to these opinions under 20 C.F.R. §§ 404.1520c or 416.920c. The ALJ’s
decision addressed each of the medical source opinions in the record. (See R. 33-34).
Consistent with the regulations, the decision articulated how persuasive (or unpersuasive)
the ALJ found each source’s opinion, with discernible reasoning as to how the ALJ

weighed the supportability and consistency factors. 20 C.F.R. § 404.1520c(b); see Keyes-
Zachary v. Astrue, 695 F.3d 1156, 1166 (10th Cir. 2012) (“Where, as here, we can follow
the adjudicator’s reasoning in conducting our review, and can determine that correct legal
standards have been applied, merely technical omissions in the ALJ’s reasoning do not
dictate reversal. In conducting our review, we should, indeed must, exercise common

sense. The more comprehensive the ALJ’s explanation, the easier our task; but we cannot
insist on technical perfection.”).
Additionally, the plaintiff’s brief argues that the ALJ failed to properly assess the
consistency of her subjective statements with various medical source evidence and prior
administrative findings. Puzzlingly, the plaintiff argues that the ALJ failed to address how
her subjective complaints “corroborated” Dr. Trinidad’s findings—rather than whether the
ALJ properly assessed the plaintiff’s hearing testimony and other subjective statements

regarding her symptoms and limitations. (See Doc. 14 at 14-15). The Commissioner argues
that the plaintiff has therefore waived any argument that the ALJ failed to properly assess
the consistency of her statements under 20 C.F.R. §§ 404.1529(c) and 416.929(c).
The Court notes that the plaintiff’s brief is less than ideally clear in setting forth the
applicable standards the ALJ was bound to follow. However, the Court may not “abdicate

its traditional judicial function, nor escape its duty to scrutinize the record as a whole to
determine whether the conclusions reached are reasonable, and whether the hearing
examiner applied correct legal standards to the evidence.” Womack v. Astrue, No. CIV-07-
167-W, 2008 WL 2486524 (W.D. Okla. June 19, 2008) (citing Bridges v. Gardner, 368
F.2d 86, 90 (5th Cir. 1966), inter alia). Moreover, the Court finds that the Commissioner

had adequate notice and opportunity to brief this issue in light of the plaintiff’s brief, and
in fact did so in its response brief. (See Doc. 15 at 9-11). Accordingly, the analysis infra
addresses the ALJ’s decision insofar as it relates to the ALJ’s evaluation of the plaintiff’s
testimony and other subjective statements in the record.
B. Subjective Statements

In assessing a claimant’s complaints of pain and other symptoms, an ALJ must
consider: “(1) whether the claimant established a pain-producing impairment by objective
medical evidence; (2) if so, whether the impairment is reasonably expected to produce
some pain of the sort alleged (what we term a ‘loose nexus’); and (3) if so, whether
considering all the evidence, both objective and subjective, the claimant’s pain was in fact
disabling.” Keyes-Zachary, 695 F.3d at 1166-67 (citing Luna v. Bowen, 834 F.2d 161, 163-
64 (10th Cir. 1987)).2 In evaluating pain, the Commissioner considers factors including:

(i) [The claimant’s] daily activities;
(ii) The location, duration, frequency, and intensity of . . . pain or other
symptoms;
(iii) Precipitating and aggravating factors;
(iv) The type, dosage, effectiveness, and side effects of any
medication [the claimant] take[s] or ha[s] taken to alleviate . . . pain
or other symptoms;
(v) Treatment, other than medication, [the claimant] receive[s] or
ha[s] received for relief of . . . pain or other symptoms;
(vi) Any measures [the claimant] use[s] or ha[s] used to relieve . . .
pain or other symptoms (e.g., lying flat on your back, standing for 15
to 20 minutes every hour, sleeping on a board, etc.); and
(vii) Other factors concerning [the claimant’s] functional limitations
and restrictions due to pain or other symptoms.
20 C.F.R. §§ 404.1529(c), 416.929(c); see also Keyes-Zachary, 695 F.3d at 1167; Branum
v. Barnhart, 385 F.3d 1268, 1273-74 (10th Cir. 2004) (quoting Hargis v. Sullivan, 945 F.2d
1482, 1489 (10th Cir. 1991)) (describing several similar factors which should be analyzed).
The plaintiff testified that she has impairments including urinary tract disorder,
migraines, anxiety, OCD, and spine disorders. (R. 31). The ALJ acknowledged the
plaintiff’s testimony that, due her impairments, she has limitations in lifting, squatting,
bending, standing, reaching, kneeling, talking, stair climbing, seeing, remembering,

2 While the Commissioner now describes the analysis as involving a two-step
process, the current regulatory policy generally comports with the approach as outlined in
previous cases, including Luna and Keyes-Zachary. See Paulek v. Colvin, 662 F. App’x
588, 593-94 (10th Cir. 2016) (unpublished). (Under 10th Cir. R. 32.1(A), “[u]npublished
decisions are not precedential, but may be cited for their persuasive value.”).
completing tasks, concentrating, understanding, and following instructions. Id. She takes
ibuprofen for her pain. (R. 58). She uses an inhaler twice a day for asthma. (R. 58-59). She
has been hospitalized for breathing problems but has not visited the ER for breathing

difficulties. (R. 59-60). Certain fumes and odors can trigger her breathing problems. (R.
59-60).
The plaintiff testified that she can walk 10 to 15 minutes before becoming tired and
needing to rest. She stated that she can lift or carry less than five pounds. (R. 65). She
testified that she has worsening vision problems, and that she has been told the issue is

neurologic in origin. (R. 60, 65). She also experiences dizziness sometimes, and she has
had “numerous falls.” (R. 60, 65-66). The plaintiff testified that at times, she loses her
balance, and noted that she has “trouble with depth perception.” (R. 70). A few weeks
before the ALJ hearing, she had a “significant” fall, resulting in a head injury. (R. 71).
Consistency determinations “are peculiarly the province of the finder of fact.”

Kepler v. Chater, 68 F.3d 387, 391 (10th Cir. 1995); see also White v. Barnhart, 287 F.3d
903, 910 (10th Cir. 2001) (ALJ’s evaluation of symptom allegations “warrant particular
deference”). However, the ALJ must explain “the link between the evidence and”
consistency determination. Kepler, 68 F.3d at 391; see also 20 C.F.R. § 404.1529 (ALJ
must provide “specific reasons . . . supported by the evidence in the case record”). Although

an ALJ is not required to discuss every piece of evidence, he must consider the entire record
and “must discuss the uncontroverted evidence he chooses not to rely upon, as well as
significantly probative evidence he rejects.” Mays v. Colvin, 739 F.3d 569, 576 (10th Cir.
2014) (quoting Clifton v. Chater, 79 F.3d 1007, 1009-10 (10th Cir. 1996)).
Here, the ALJ’s decision recited rote language in concluding that the plaintiff’s
subjective complaints of functional limitations “are not entirely consistent with the medical
evidence and other evidence in the record.” (R. 31). In explaining this finding, the ALJ

noted that, despite her alleged limitations, the plaintiff testified that she
helps care for her son who has autism. She was able to help care for
her pets. She can handle her personal care. She needs reminders to
take her medications. She was able to prepare meals. She could do
housework. She was able to drive. She could shop in stores. She
could pay bills and manage funds. She was able to spend time with
others.
Id. The ALJ also summarized portions of the plaintiff’s medical records, medical opinions,
and prior administrative findings.
However, the ALJ’s decision provides no traceable explanation for why the ALJ
found the plaintiff could perform, inter alia, the standing, walking, lifting, and carrying
required to perform medium-exertion work. As set forth in the Commissioner’s guidelines,
Most medium jobs, like most light jobs, require the worker to stand
or walk most of the time. Also, as in light work, most unskilled
medium jobs require gross use of the hands to grasp, hold, and turn
objects rather than use of the fingers for fine movements of small
objects. Medium work is distinct from the less strenuous levels in
the activities needed to accomplish the considerable lifting and
carrying involved for the full range of medium work. A maximum
of 50 pounds may be lifted at a time, with frequent lifting or carrying
of objects weighing up to 25 pounds.
(SSR 83-14). The ALJ’s decision cites little, if any, evidence showing that the plaintiff
could perform work at this exertional range. The plaintiff’s self-reported daily activities,
as cited in the decision, hardly establish that she could lift or carry 50-pound objects,
frequently lift or carry 25-pound objects, or sustain the more “strenuous” standing and
walking requirements of medium work, in light of the medical evidence. Id.
For example, an MRI of the cervical spine on March 4, 2021, revealed C6-7 disc

osteophyte complex, greater on the right side, resulting in moderate bilateral foraminal
stenosis. (R. 33 (citing Ex. 22F)). The scan also showed mild central canal narrowing and
mild multilevel degenerative findings, without high-grade central or foraminal stenosis. Id.
While the ALJ’s decision referenced these findings, it provided no elucidation as to how
the ALJ weighed this evidence in formulating the plaintiff’s RFC. Although the ALJ’s

decision acknowledged this evidence, the decision never explained how the ALJ weighed
the MRI findings in light of the plaintiff’s alleged limitations in standing, walking, postural
activities, lifting, and other tasks using the upper extremities.
On November 14, 2018, Dr. Trinidad examined the plaintiff in connection with a
worker’s compensation claim. Dr. Trinidad noted that the plaintiff was injured in an

“almost head-on” vehicle collision in 2011, while in the course of her employment as a
program manager for a home care provider. (R. 401). Dr. Trinidad reported that the plaintiff
had “constant pain and spasm in her neck and upper back, worsened with stooping and
lifting.” (R. 402). The plaintiff described pain, weakness, and paresthesias in both arms, as
well as lower back pain exacerbated by bending, stooping, and lifting. Id. The plaintiff also

described memory problems and other mental limitations; daily vertigo; dizziness triggered
by bright lights; and moderate to severe headaches. (R. 401-402).
Dr. Trinidad reported that the plaintiff
sustained injuries and work-related trauma . . . when she was
transporting a patient and was involved in a head-on collision. She
injured her neck and back and also has been diagnosed with a
traumatic brain injury with postconcussive syndrome, posttraumatic
headaches and posttraumatic vertigo. She has been seen by
numerous physicians. At this time, it appears that she has achieved
maximal medical recovery[.] She will require ongoing follow-up
with Dr. Coggins, her primary care physician, and Dr. Cauthon, a
neurologist.
(R. 404). Dr. Trinidad stated that he considered the plaintiff under the American Medical
Association Guides to the Evaluation of Permanent Impairment, concluding that her
impairments resulted in “permanent anatomic abnormalities.” (R. 406). Dr. Trinidad set
forth the findings of his physical examination that he based this conclusion on, including
range of motion limitations in the cervical and lumbar spine, C6-7 disc derangement, loss
of strength in both arms, and “[a]dditive impairment to the upper extremities from
radiculopathy,” paraspinous muscle spasms in the thoracic and lumbar spine, and traumatic
brain injury with postconcussive symptoms. (R. 404-405). Dr. Trinidad noted that,
“[b]eyond this point, it appears that her condition is stable and maximum recovery has been
achieved.” (R. 405).
Dr. Trinidad concluded that, as a result of her impairments, the plaintiff “had [9]
percent impairment due to range of motion abnormalities of the cervical spine [and] . . . 12
percent impairment due to range of motion abnormalities of the lumbar spine.” (R. 33). As
such, Dr. Trinidad opined that the plaintiff “should be considered for vocational retraining
to place her in a sedentary light duty[sic] job.” (R. 406). Dr. Trinidad continued that, if the
plaintiff “is not a candidate for retraining, then she would be considered 100 percent
permanently and totally disabled on an economic basis . . . .” Id.
The ALJ noted certain objective findings in Dr. Trinidad’s examination, including
tenderness and muscle spasm bilaterally from C4-C7, T1-T4, and L5-S1, and decreased
range of motion in the cervical spine. (R. 33). However, the ALJ concluded that he was

“not persuaded by” Dr. Trinidad’s opinion, finding that more recent medical records
showed “mild tenderness, normal strength, tone, gait and range of motion.” (R. 33). The
ALJ also noted that “[t]he worker’s compensation evaluation is not binding on” the
Commissioner. (R. 33).
However, the ALJ was still required to perform a meaningful analysis of Dr.

Trinidad’s findings, as with any other significantly probative evidence, within the context
of the record as a whole. Although the ALJ’s decision did limit the plaintiff’s RFC to
“occasional” climbing, stooping, kneeling, crouching, or crawling, and only “frequent”
balancing, nothing in the ALJ’s discussion of the medical record contradicts the plaintiff’s
testimony that she has greater limitations in walking, lifting, carrying, and various postural

activities. Further, the RFC determination did not restrict the plaintiff from performing “the
considerable lifting and carrying” of objects up to 50 pounds, despite the plaintiff’s
testimony that she can only lift or carry up to five pounds. (SSR 83-14). Nor does the RFC
determination appear to address the plaintiff’s reported balance problems or the visual
limitations she testified to and reported to various medical providers.

In formulating the plaintiff’s RFC, the ALJ appears to have relied most heavily on
the prior administrative findings of Herbert Meites, M.D., dated July 17, 2020, and the
reconsideration findings of William McAfee, M.D., dated October 31, 2020. (See R. 34).
Drs. Meites and McAfee each opined that the plaintiff could perform medium-exertion
work. However, notably, both of the reviewing physicians lacked the benefit of the
plaintiff’s 2021 cervical spine MRI. The only evidence discussed in the ALJ’s decision
dated after the March 2021 MRI is a July 2, 2021 visit with her primary care provider,

Curtis Coggins, M.D., when the plaintiff reported that she had recently fallen after feeling
a “pop” in her back when she got up from a chair. (See R. 893). Moreover, the reviewing
consultants’ findings did not address the plaintiff’s subsequent testimony regarding pain
and problems with balancing, falling, lifting, and other functions, and the limiting effects
of her headaches.

SSR 16-3p states that in evaluating a claimant’s symptoms:
it is not sufficient for our adjudicators to make a single, conclusory
statement that “the individual’s statements about his or her
symptoms have been considered” or that “the statements about the
individual’s symptoms are (or are not) supported or consistent.”
2017 WL 5180304 at *10. The SSR further states:
The determination or 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 articulated so the
individual and any subsequent reviewer can assess how the
adjudicator evaluated the individual’s symptoms.
Id. Here, instead of giving “specific reasons” for rejecting the plaintiff’s statements, the
ALJ’s decision ignored testimony by the plaintiff about the limiting effects of her
headaches and what triggers headaches. At the ALJ hearing, the plaintiff testified as
follows:
Q: What triggers . . . a headache? What kind of triggers do you have?
A: Oh goodness gracious, lights, lights does, I’ve had them so long
and so many of them, stress, lights . . . . I think there’s so many
different triggers.
(R. 73). Oddly, the ALJ’s decision did not acknowledge the plaintiff’s testimony or other
statements in the record about her alleged sensitivity to light. (See, e.g., R. 403 (November
14, 2018 report of Dr. Trinidad noting that the plaintiff “state[d] that bright lights cause her
to be dizzy”); R. 801 (January 12, 2021 note that plaintiff “reports headaches mild to severe
every day with light/noise sensitivity, throbbing”)). The decision indicated that the ALJ
adopted “further limits” in the RFC determination in light of the plaintiff’s “complaints of

pain and headaches.” (R. 34). However, it is not clear why the ALJ adopted certain
limitations but not others.
As such, the ALJ’s decision did not adequately explain why he discounted the
plaintiff’s complaints regarding limitations and pain from her physical impairments.
Remand is therefore necessary for further consideration of the record as to the plaintiff’s

physical RFC and, as appropriate, an explanation sufficient to enable meaningful review
of the ALJ’s reasoning in light of the record as a whole.
Finally, the plaintiff contends the ALJ improperly failed to address whether her
headaches meet or medically equal Listing 11.02 (epilepsy), in accordance with the
Commissioner’s guidelines in SSR 19-4p regarding claimants with a primary headache
disorder. The Commissioner contends that the evidence in the record does not support a

finding that the plaintiff meets Listing 11.02, and cites agency guidance that “the
adjudicator is not required to articulate specific evidence supporting his or her finding that
the individual’s impairment(s) does not medically equal a listed impairment.” SSR 17-2p,
2017 WL 3928306, at *4. However, the Commissioner does not dispute that the ALJ’s
decision failed to identify, mention, or otherwise address Listing 11.02. As such, the Court
cannot determine whether the ALJ found the plaintiff's migraines do not meet or equal
Listing 11.02, or whether the ALJ failed to consider that Listing. On remand, to the extent
needed, the ALJ shall provide a sufficient articulation to enable judicial review of the ALJ’s
consideration of Listing 11.02 at step three.
V. Conclusion
For the reasons set forth above, the Court finds the ALJ’s conclusion is legally
erroneous and is not supported by substantial evidence. Therefore, the decision of the
Commissioner finding Plaintiff not disabled for the relevant period is reversed and
remanded for further proceedings consistent with this opinion.
ORDERED this 16th day of August, 2023.

Unietre □ Like
Christine D. Little
United States Magistrate Judge

17

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10387277. Public record. Not legal advice.