Edwards v. Commissioner of Social Security

IN THE UNITED STATES DISTRICT COURT February 19, 2025

FOR THE SOUTHERN DISTRICT OF TEXAS Nathan Ochsner, Clerk

HOUSTON DIVISION

VIOLA E.,1 §

§

Plaintiff, §

§

v. § No. 4:24-cv-1107

§

MARTIN O’MALLEY,

§

Commissioner of Social Security,

§

§

Defendant.

§

MEMORANDUM AND ORDER

Plaintiff Viola E. (“Plaintiff”) filed this suit seeking judicial review of an

administrative decision. ECF No. 1. Jurisdiction is predicated upon 42 U.S.C.

§ 405(g). Plaintiff appeals from the decision of the Commissioner of the Social

Security Administration (“Commissioner”) denying Plaintiff’s claim for disability

insurance benefits under Title II of the Social Security Act (“the Act”) and

supplemental security income benefits under Title XVI of the Act.2 Plaintiff filed a

motion for summary judgment. Pl.’s MSJ, ECF No. 8. Commissioner filed a

response, requesting the decision be affirmed. Def.’s Response, ECF No. 11.

1 Pursuant to the May 1, 2018 “Memorandum Re: Privacy Concern Regarding Social Security and

Immigration Opinions” issued by the Committee on Court Administration and Case Management

of the Judicial Conference of the United States, the Court uses only Plaintiff’s first name and last

initial.

2 On April 29, 2024, based on the parties’ consent, the case was transferred to this Court to conduct

all proceedings pursuant to 28 U.S.C. § 636(c). Order Transferring, ECF No. 3.

Accordingly, the Court construes the Commissioner’s response as a cross-motion

for summary judgment. Bacot v. O’Malley, No. 4:23-cv-3233, 2024 WL 4329144,

at *1 (S.D. Tex. Aug. 12, 2024). Plaintiff filed a reply. Pl.’s Reply, ECF No. 14.

Plaintiff seeks an order rendering benefits or remand for further consideration,

arguing that the ALJ’s RFC determination is unsupported by substantial evidence

and is the product of legal error because she failed to properly evaluate the opinion

evidence. ECF No. 1 at 2. Commissioner counters that the ALJ properly evaluated

the medical source opinions. ECF No. 11. Based on the briefing, the record, and the

applicable law, the Court finds that the ALJ failed to properly evaluate the opinion

evidence in making her RFC determination. Because this is the second time the ALJ

failed to properly evaluate the opinion evidence, and the record is fully developed,

the Court reverses and renders judgment for Plaintiff.3

I. BACKGROUND

Plaintiff is 59 years old, R. 87, 95, 111, 127,4 and completed high school.

R. 1470. Plaintiff worked as a nurse’s aide, chef, and salad preparer. R. 71–75.

3 “The court shall have power to enter, upon the pleadings and transcript of the record, a

judgment…reversing the decision of the Commissioner of Social Security, with or without

remanding the cause for a rehearing.” 42 U.S.C. § 405(g). A court may also issue a final judgment

that a claimant is “entitled to any payment or payments under this subchapter.” Giles R. v. Kijakazi,

No. 4:20-cv-1220, 2021 WL 4502842, at *10 n.43 (S.D. Tex. Sept. 30, 2021) (first citing 42 U.S.C.

§ 405(i); then citing Garrison v. Colvin, 759 F.3d 995, 1023 (9th Cir. 2014) (finding the district

court erred by remanding for a new hearing when nothing further in the record needed to be

developed and giving instructions to remand for the calculation and award of benefits)).

4 “R.” citations refer to the electronically filed Administrative Record, ECF No. 5.

Plaintiff alleges a disability onset date of December 31, 2016. R. 96, 112. Plaintiff

claims she suffers from physical and mental impairments. R. 112.

On March 4, 2019, Plaintiff filed her application for disability insurance

benefits and supplemental security income under Titles II and XVI of the Act,

respectively. R. 95, 354. Plaintiff based5 her application on bipolar disorder,

depressive disorder, high blood pressure, diabetes, cysts (both feet), rheumatoid

arthritis (both hands), high cholesterol, and plantar formatosis. R. 96. The

Commissioner denied Plaintiff’s claim initially, R. 96–110, and on reconsideration.

R. 131–45.

A hearing was held before an Administrative Law Judge (“ALJ”). An attorney

represented Plaintiff at the hearing. R. 49–94. Plaintiff and a vocational expert

(“VE”) testified at the hearing. R. 49–94. The ALJ issued a decision denying

Plaintiff’s request for benefits. R. 29–31. The Appeals Council denied Plaintiff’s

request for review, making the ALJ’s decision final. R. 4. Plaintiff sought judicial

review, and the case was remanded for further administrative proceedings. R. 1666–

83. Following remand from the Appeals Council, the ALJ held another hearing, and

5 For Plaintiff’s disability insurance claim, the relevant time period is December 31, 2016—

Plaintiff’s alleged onset date—through March 31, 2020—Plaintiff’s last insured date. R. 95. The

Court will consider medical evidence outside this period to the extent it demonstrates whether

Plaintiff was under a disability during the relevant time frame. See Williams v. Colvin, 575 F.

App’x 350, 354 (5th Cir. 2014); Loza v. Apfel, 219 F.3d 378, 396 (5th Cir. 2000). For Plaintiff’s

supplemental security income claim, the relevant time period is December 31, 2016 through

January 18, 2024—the date of the ALJ’s decision. R. 1607.

again issued a decision denying benefits.6 R. 1641–65; 1610–38. The Appeals

Council denied Plaintiff’s request for review, upholding the ALJ’s decision. R. 4–7.

Plaintiff appealed the Commissioner’s ruling to this Court. ECF No. 1.

II. STANDARD OF REVIEW OF COMMISSIONER’S DECISION.

The Social Security Act provides for district court review of any final decision

of the Commissioner that was made after a hearing in which the claimant was a

party. 42 U.S.C. § 405(g). In performing that review:

6 An ALJ must follow five steps in determining whether a claimant is disabled. 20 C.F.R.

§ 416.920(a)(4). The ALJ here determined Plaintiff was not disabled at step five. R. 1629. At step

one, the ALJ found that Plaintiff did not engage in substantial gainful activity during the period

from her alleged onset date through her date last insured. R. 1613 (citing 20 C.F.R. §§ 404.1571

et seq. and 416.971 et seq.). At step two, the ALJ found that Plaintiff has the following severe

impairments: anxiety/depressive disorder, degenerative disc disease of the cervical spine,

angioedema, degenerative joint disease of the right knee, diabetes mellitus, peripheral neuropathy,

and cataracts. Id. (citing 20 C.F.R. §§ 404.1520(c) and 416.920(c)). At step three, the ALJ

determined that Plaintiff did not have an impairment or combination of impairments that met or

medically equaled the severity of one of the listed impairments in the regulations that would lead

to a disability finding. R. 1613–16 (referencing 20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526,

416.920(d), 416.925, and 416.926). The ALJ found that Plaintiff has the RFC to perform medium

work as defined in 20 CFR §§ 404.1567(c) and 416.967(c), with the following limitations:

occasionally climb ramps and stairs, but should never climb ladders, ropes, or scaffolds;

occasionally, balance, stoop, kneel, crouch and crawl; avoid concentrated exposure (which means

the exposure can occur at the frequent level or below) to extreme heat, extreme cold, dangerous

moving machinery (this would exclude motor vehicles), unprotected heights, wet, slippery, or

uneven surfaces, vibration, and noise at the DOT level 4 (loud); occasionally push, pull, and

operate foot controls bilaterally; frequently handle and finger bilaterally; exercise frequent near,

far accommodations, field of vision, color vision, and depth perception; remember and follow

simple instructions; and perform the tasks assigned, but not at a production rate pace—however

she can meet the end of day work goals; have occasional contact with co-workers, supervisors, and

the general public; occasionally adapt to changes in the workplace. R. 1617–27. At step four, the

ALJ determined that through the date last insured, Plaintiff was unable to perform her past relevant

work as a nurse aide and salad counter attendant. R. 1627 (citing 20 C.F.R. §§ 404.1565 and

416.965). At step five, the ALJ determined that there are jobs that exist in significant numbers in

the national economy that Plaintiff can perform (citing 20 C.F.R. §§ 404.1569, 404.1569a,

416.969, and 416.969a). Therefore, the ALJ concluded that Plaintiff was not disabled. R. 1629.

The court shall have power to enter, upon the pleadings and transcript of the

record, a judgment affirming, modifying, or reversing the decision of the

Commissioner . . ., with or without remanding the cause for a rehearing. The

findings of the Commissioner . . . as to any fact, if supported by substantial

evidence, shall be conclusive[.]

Id. Judicial review of the Commissioner’s decision denying benefits is limited to

determining whether that decision is supported by substantial evidence on the record

as a whole and whether the proper legal standards were applied. Id.; Boyd v. Apfel,

239 F.3d 698, 704 (5th Cir. 2001); Loza v. Apfel, 219 F.3d 378, 393 (5th Cir. 2000).

“Substantial evidence” means “such relevant evidence as a reasonable mind might

accept as adequate to support a conclusion.” Biestek v. Berryhill, 139 S. Ct. 1148,

1154 (2019) (quotations omitted). It is “more than a scintilla but less than a

preponderance.” Carey v. Apfel, 230 F.3d 131, 135 (5th Cir. 2000). The “threshold

for such evidentiary sufficiency is not high.” Biestek, 139 S. Ct. at 1154.

The Court weighs four factors to determine “whether there is substantial

evidence of disability: (1) objective medical facts; (2) diagnoses and opinions of

treating and examining physicians; (3) subjective evidence of pain and disability;

and (4) the claimant’s age, education, and work history.” Conley-Clinton v. Saul,

787 F. App’x 214, 216 (5th Cir. 2019) (citing Martinez v. Chater, 64 F.3d 172, 174

(5th Cir. 1995)).

A reviewing court may not reweigh the evidence in the record, try the issues de

novo, or substitute its judgment for that of Commissioner, even if the evidence

preponderates against Commissioner’s decision. Brown v. Apfel, 192 F.3d 492, 496

(5th Cir. 1999). Even so, judicial review must not be “so obsequious as to be

meaningless.” Id. (quotations omitted). The “substantial evidence” standard is not a

rubber stamp for Commissioner’s decision and involves more than a search for

evidence supporting Commissioner’s findings. Singletary v. Brown, 798 F.2d 818,

822–23 (5th Cir. 1986); Cook v. Heckler, 750 F.2d 391, 393 (5th Cir. 1985). Rather,

a reviewing court must scrutinize the record as a whole, taking into account whatever

fairly detracts from the substantiality of evidence supporting Commissioner’s

findings. Singletary, 798 F.2d at 823. “Only where there is a ‘conspicuous absence

of credible choices or no contrary medical evidence’ will we find that the substantial

evidence standard has not been met.” Qualls v. Astrue, 339 F. App’x 461, 464 (5th

Cir. 2009) (internal quotation omitted).

III. THE SHIFTING BURDEN OF PROOF.

An individual claiming entitlement to disability insurance benefits and

supplement security income under the Act has the burden of proving his disability.

Johnson v. Bowen, 864 F.2d 340, 343–44 (5th Cir. 1988) (citing Neal v. Bowen, 829

F.2d 528, 530 (5th Cir. 1987)). The Act defines disability as 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 period of not less than twelve months.”

42 U.S.C. § 423(d)(1)(A). The impairment must be proven through medically

accepted clinical and laboratory diagnostic techniques. 42 U.S.C. § 423(d)(3). The

impairment must be so severe that the claimant is “incapable of engaging in any

substantial gainful activity.” Foster v. Astrue, No. H-08-2843, 2011 WL 5509475,

at *6 (S.D. Tex. Nov. 10, 2011) (citing Anthony v. Sullivan, 954 F.2d 289, 293 (5th

Cir. 1992)). A claimant is eligible for benefits only if the onset of the impairment

started by the date the claimant was last insured. Id. (citing Ivy v. Sullivan, 898 F.2d

1045, 1048 (5th Cir. 1990)).

Commissioner applies a five-step sequential process to determine disability

status. Id. The claimant bears the burden of proof at the first four steps to establish

that a disability exists. Farr v. Astrue, No. G-10-205, 2012 WL 6020061, at *2 (S.D.

Tex. Nov. 30, 2012). The burden shifts to Commissioner at step five to show that

the claimant can perform other work. Id. The burden then shifts back to the claimant

to rebut this finding. Id. If at any step in the process Commissioner determines that

the claimant is or is not disabled, the evaluation ends. Id.

IV. PLAINTIFF IS ENTITLED TO SUMMARY JUDGMENT.

Plaintiff raises one issue: that substantial evidence does not support the ALJ’s

RFC determination because the ALJ failed to properly evaluate the medical opinions

of Dr. Sahi, Dr. Herman, Dr. Spoor, Dr. Hardaway, and Dr. Campa. ECF No. 8 at 8-

15. Plaintiff contends that the ALJ failed to comply with the requirements of

20 C.F.R. §§ 404.1520c, 416.920c by not evaluating each opinion’s persuasiveness.

Id. at 8.

Plaintiff asserts that although the ALJ found Dr. Sahi’s opinion “slightly

persuasive,” the ALJ’s RFC determination that Plaintiff can perform medium

exertion work, which entails “considerable lifting,” contradicts Dr. Sahi’s opinion

that Plaintiff is capable of, at most, “moderate lifting.” Id. at 9. Further, Plaintiff

argues that although the ALJ found Dr. Herman and Dr. Spoor’s opinions that

Plaintiff could lift up to twenty-five pounds frequently and fifty pounds occasionally,

sit for six hours, stand/walk for six hours, occasionally engage in

climbing/kneeling/crouching/crawling, and use the bilateral fingers on an occasional

but not frequent basis “somewhat persuasive,” the ALJ asserted that the opinion was

“consistent with the determination that [P]laintiff’s conditions are not disabling.” Id.

Plaintiff also asserts that, regarding Dr. Hardaway’s opinion that Plaintiff is

unlikely to have the ability to sustain concentration and persist in work-related

activity at a reasonable pace, and maintain effective social interaction on a consistent

and independent basis with supervisors, co-workers and the public, or cope with

normal pressures in a competitive work setting, the ALJ did not explain why she

determined these limitations were inconsistent with his findings7 or why his

7 Maintained eye contact, absence of confusion, independent early arrival at the appointment,

grammatically correct speech, and easily established rapport. R. 973, 975–76.

examination findings8 would serve to undermine rather than support his opinion. Id.

at 12–13. Further, Plaintiff asserts that although the ALJ found Dr. Campa’s opinion

that Plaintiff has moderate limitations for several9 cognitive/psychological functions

“somewhat persuasive,” the ALJ stated that the opinion was merely persuasive to

the extent it can be viewed as “generally consistent with” her determination that

Plaintiff’s conditions “while severe, are not disabling” and further stated that the

opinion was “internally inconsistent.” Id. at 13–14.

Commissioner responds that the ALJ properly evaluated both opinions. ECF

No. 11 at 16.

A. The ALJ Must Analyze Each Medical Opinion’s Supportability and

Consistency.

Between the third and fourth steps of the sequential analysis, the ALJ must

decide the claimant’s RFC, which is defined as “the most the claimant can still do

despite his [or her] physical and mental limitations . . . based on all relevant evidence

8 Below average abstract thinking, poor interpretation of common idioms, depressed mood, below

average fund of information, below average intelligence, impaired delayed memory, inability to

subtract serial 7s from 100, and below average judgment. R. 975–76.

9 Maintain attention and concentration for extended periods, perform activities within a schedule,

maintain regular attendance, be punctual within customary tolerances; complete a normal workday

and workweek without interruptions from psychologically-based symptoms, perform at a

consistent pace without an unreasonable number and length of rest periods, interact appropriately

with the general public, accept instructions and respond appropriately to criticism from

supervisors, get along with coworkers or peers without distracting them or exhibiting behavioral

extremes, respond appropriately to changes in the work setting, and be aware of normal hazards

and take appropriate precautions. R. 107–08, 123–24.

in the claimant’s record.” Winston v. Berryhill, 755 F. App’x 395, 399 (5th Cir.

2018) (citation omitted). The RFC determination is the “sole responsibility of the

ALJ.” Taylor v. Astrue, 706 F.3d 600, 602–03 (5th Cir. 2012) (quoting Ripley v.

Chater, 67 F.3d 552, 557 (5th Cir. 1999)). When making the RFC determination, the

ALJ must consider all medical opinions contained in the record. 42 U.S.C.

§ 405(b)(1). The ALJ must “incorporate limitations into the RFC assessment that

were most supported by the record.” Conner v. Saul, No. 4:18-CV-657, 2020

WL4734995, at *8 (S.D. Tex. Aug 15, 2020) (citing Muse v. Sullivan, 925 F.2d 785,

790 (5th Cir. 1991)). As an administrative factfinder, the ALJ is entitled to

significant deference in deciding the appropriate weight to accord the various pieces

of evidence in the record, including the credibility of medical experts and the weight

to be accorded their opinions. See Scott v. Heckler, 770 F.2d 482, 485 (5th Cir.

1985).

For claims filed on or after March 27, 2017, like the instant case, the Social

Security Administration requires ALJs to explain how they evaluate a medical

opinion’s persuasiveness. See Johnson v. Kijakazi, No. 4:20-CV-04271, 2022 WL

3588042, at *3 (S.D. Tex. Aug. 22, 2022) (citing Shugart v. Kijakazi, 2022 WL

912777, at *3 (S.D. Tex. Mar. 29, 2022) (citing 20 C.F.R. §§ 404.1520c, 416.920c)).

The ALJ must “consider prior administrative medical findings and medical evidence

from . . . Federal or State agency medical or psychological consultants,” but is not

required to adopt those findings. Howen v. Saul, No. Civ. Action H-19-4358, 2021

WL 1169331, at *6 (S.D. Tex. Mar. 25, 2021) (citing 20 C.F.R. § 404.1513a(b),

(b)(1)). “As with medical opinions, the ALJ must articulate how persuasive he finds

each based on the consideration of the factors enumerated in 20 C.F.R.

§ 404.1520c(c).” Id. (citing 20 C.F.R. § 404.1520c(a), (b)). “In evaluating

persuasiveness, the ALJ considers five factors: (i) supportability; (ii) consistency;

(iii) the source’s relationship with the patient; (iv) the source’s specialty; and (v)

‘other factors that tend to support or contradict’ the opinion.” Id. (citing Shugart,

2022 WL 912777, at *3 (citing and quoting 20 C.F.R. § 404.1520c(c))). “Among

those factors, the most important are supportability and consistency.” Johnson, 2022

WL 3588042, at *3 (citing Shugart, 2022 WL 912777, at *3 (citing § 404.1520(c)(b)

(2))). The ALJ “must articulate how supportability and consistency were

considered.” Id.

“The supportability and consistency factors involve different analyses and

require the ALJ to explain his reasoning for his persuasiveness finding with respect

to each factor.” Rai R. v. Kijakazi, No. 4:21-CV-2270, 2022 WL 4450487, at *4

(S.D. Tex. Sept. 23, 2022) (citing Kilby v. Kijakazi, No. 4:20-cv-03035, 2022 WL

1797043, at *3 (S.D. Tex. Mar. 15, 2022)). “With respect to ‘supportability,’ ‘the

strength of a medical opinion increases as the relevance of the objective medical

evidence and explanations presented by the medical source increase,’ and

consistency is ‘an all-encompassing inquiry focused on how well a medical source

is supported, or not supported, by the entire record.’” Id. (emphasis in original)

(quoting Luckett v. Kijakazi, No. 4:20-CV-04002, 2021 WL 5545233, at *4 (S.D.

Tex. Nov. 26, 2021) (citing 20 C.F.R. §§ 404.1520c(c)(1), 404.920c(c)(1)) (quoting

Vellone v. Saul, 1:20-cv-00261, 2021 WL 319354, at *6 (S.D.N.Y. Jan. 29, 2021))).

B. Dr. Sahi, Dr. Herman, and Dr. Spoor Provided Medical Opinions on

Plaintiff’s physical capabilities.

On October 28, 2019, Department of Assistive and Rehabilitative Services

referred Plaintiff to Dr. Sahi, M.D., for an evaluation10 of Plaintiff’s ability to

sit/stand, walk, and lift.11 Dr. Sahi gathered a history from Plaintiff, reviewed

Plaintiff’s records, and conducted her own physical examination on Plaintiff.12 At

the conclusion of her report, Dr. Sahi stated:13

Based on current evidence, the patient is able to sit and stand for long

period of time, walk for moderate distances and able to do moderate

lifting.

As relevant to Plaintiff’s RFC argument, ECF No. 8 at 8, Dr. Sahi noted in her

examination that Plaintiff appears to have difficulty walking on her heels or toes and

10 “It was explained to the examinee prior to evaluation the purpose of the examination…” R. 930.

11 R. 933 (Dr. Sahi’s exam notes).

12 R. 930–33 (Dr. Sahi’s exam notes).

13 R. 933 (Dr. Sahi’s exam notes).

had tenderness and reduced range of motion in the knees.14

On January 24, 2020, Dr. Herman, M.D., evaluated Plaintiff and stated that

Plaintiff could lift up to twenty-five pounds frequently and fifty pounds occasionally,

sit for at least six hours, stand/walk for six hours, occasionally engage in

climbing/kneeling/crouching/crawling, and use the bilateral fingers on an occasional

but not frequent basis.15 Dr. Spoor, M.D., made the same determination.16

C. Dr. Hardaway and Dr. Campa Provided Medical Opinions on

Plaintiff’s Mental Capabilities.

On January 24, 2020, Dr. Hardaway, PhD, HSP, a licensed psychologist,17

evaluated Plaintiff’s concentration and abilities to persist in work-related activity,

maintain effective social interaction, and cope with normal pressures in a

competitive work setting.18 Dr. Hardaway found Plaintiff to be “friendly and

cooperative.”19 Dr. Hardaway noted Plaintiff’s symptoms of “depressed mood”20

and that “[h]er medical and physical conditions appear to be contributing negatively

14 R. 932, 936 (Dr. Sahi’s exam notes).

15 R. 104–06, 120–22 (Dr. Herman’s findings during Physical RFC Assessment).

16 R. 141–43, 157–59 (Dr. Spoor’s findings during Physical RFC Assessment).

17 R. 977.

18 R. 976–77 (Dr. Hardaway’s exam notes).

19 R. 975 (Dr. Hardaway’s exam notes).

20 R. 975 (Dr. Hardaway’s exam notes).

to her state of mental health.”21 After putting Plaintiff through various examinations

related to Plaintiff’s presentation,22 memory,23 fund of knowledge and intelligence,24

concentration and attention,25 thought content and process,26 and judgment,27

Dr. Hardaway made the following observations about Plaintiff:28

It appears that [Plaintiff] is unlikely to have the ability to sustain

concentration and persist in work-related activity at a reasonable pace

due to depression and anxiety secondary to cocaine abuse withdrawal.

It appears unlikely that she could maintain effective social interaction

on a consistent and independent basis with supervisors, co-workers, and

the public, or cope with normal pressures in a competitive work setting.

With further stabilization of symptoms, she may benefit from

21 R. 977 (Dr. Hardaway’s exam notes).

22 Dr. Hardaway observed that Plaintiff sustained eye contact. Dr. Hardaway further observed that

Plaintiff spoke in full, grammatically correct sentences with below average vocabulary, a normal

rate of speech and normal verbal intonation, and that Plaintiff engaged in reciprocal conversation.

R. 975 (Dr. Hardaway’s exam notes).

23 Dr. Hardaway noted that although Plaintiff was immediately able to repeat three words, after

delay, she was able to repeat only one word. R. 976 (Dr. Hardaway’s exam notes).

24 Dr. Hardaway noted below average fund of information and intelligence, based on informal

assessment. R. 976 (Dr. Hardaway’s exam notes).

25 Dr. Hardaway noted that Plaintiff could complete four digits forward and backward and count

down from 20 to 1. However, Plaintiff was unable to subtract serial 7s from 100. She was able to

correctly spell “world” forward and backward. R. 976 (Dr. Hardaway’s exam notes).

26 Dr. Hardaway noted that Plaintiff’s thinking was goal-directed but that her abstract thinking

appeared to be below average. Dr. Hardaway observed that Plaintiff struggled to interpret common

idioms, but that she had greater capacity to identify similarities in word pairs. Plaintiff denied

delusional thinking, thought broadcasting, obsessive thoughts, excessive fears, and current suicidal

and homicidal ideations. R. 975 (Dr. Hardaway’s exam notes).

27 Dr. Hardaway noted that Plaintiff’s judgment was below average. R. 976 (Dr. Hardaway’s exam

notes).

28 R. 977 (Dr. Hardaway’s exam notes).

vocational services for job placement assistance and/or to explore

vocational options.

On February 2, 2020, Dr. Campa, Ph.D., a psychologist and state agency medical

consultant,29 evaluated Plaintiff.30 Dr. Campa found Plaintiff markedly limited in

her ability to understand and remember detailed instructions, as well as her ability

to carry out such instructions.31, 32

D. The ALJ’s Evaluations of Each Opinion.

The ALJ determined Plaintiff’s RFC as follows:33

After careful consideration of the entire record, I find that [Plaintiff]

has the residual functional capacity to perform medium work as defined

in 20 CFR 404.1567(c) and 416.967(c) except that she can occasionally

climb ramps and stairs, but should never climb ladders, ropes, or

scaffolds. [Plaintiff] can occasionally, balance, stoop, kneel, crouch and

crawl. She should avoid concentrated exposure to extreme heat,

extreme cold, dangerous moving machinery, unprotected heights, wet,

slippery, or uneven surfaces, vibration, and noise at the DOT level 4

(loud). [Plaintiff] can occasionally push, pull, and operate foot controls

29 R. 1626.

30 R. 107–09, 123–25 (Dr. Campa’s findings during Mental RFC Assessment).

31 R. 107–09, 123–25 (Dr. Campa’s findings during Mental RFC Assessment).

32 Dr. Campa also found that Plaintiff has moderate limitations in her abilities to: maintain attention

and concentration for extended periods; perform activities within a schedule, maintain regular

attendance, and be punctual within customary tolerances; complete a normal workday and

workweek without interruption from psychologically based symptoms, and perform at a consistent

pace without an unreasonable number and length of rest periods; interact appropriately with the

general public; accept instructions and respond appropriately to criticism from supervisors; get

along with coworkers or peers without distracting them or exhibiting behavioral extremes; respond

appropriately to changes in the work setting; and be aware of normal hazards and take appropriate

precautions. R. 107–09, 123–25 (Dr. Campa’s findings during Mental RFC Assessment).

33 R. 1617.

bilaterally. She can frequently handle and finger bilaterally. [Plaintiff]

can exercise frequent near, far, accommodations, field of vision, color

vision, and depth perception. She can remember and follow simple

instructions. [Plaintiff] can perform the tasks assigned, but not at a

production rate pace; however she can meet the end of the day work

goals. [Plaintiff] can have occasional contact with co-workers,

supervisors, and the general public. She can occasionally adapt to

changes in the workplace.

In reaching this determination, the ALJ considered Plaintiff’s symptoms, hearing

testimony, medical history, and various medical opinions, including those of

Dr. Sahi, Dr. Herman, Dr. Spoor, Dr. Hardaway, and Dr. Campa.

The ALJ summarized Dr. Sahi’s opinion and found it “only slightly

persuasive” and explained this reasoning:34

The opinion does not provide a specific function by function

assessment of [Plaintiff’s] abilities related to work activities as required

by the Social Security Administration’s regulatory provisions. Further

the rather generalized and vague degree of limitation given to

[Plaintiff’s] ability to sit and stand as well as walk and lift is not

inconsistent with the other information of record which generally is

consistent with limiting [Plaintiff] to medium exertion with postural

and climbing restrictions. For example, [Plaintiff] stated she is not able

to lift anything to[o] heavy and exams generally show [Plaintiff] with a

normal range of motion and normal strength with no tenderness or

swelling regarding her musculoskeletal area and displaying a[ ] normal

range of motion with normal alignment and no tenderness regarding her

back. Further, x-rays found no active pathology in [Plaintiff’s] knees.

In finding Dr. Sahi’s opinion “slightly persuasive,” the ALJ failed to explain how

Dr. Sahi’s findings supported her opinion, as required by § 404.1520c(b)(2) and

34 R. 1625.

(c)(1). First, the ALJ’s determination that the “opinion does not provide a specific

function by function assessment” is of the kind that this district has found wanting.

See Cox v. Comm’r of Soc. Sec., No. 3:23-cv-00143, 2024 WL 3627773, at *5 (S.D.

Tex. Aug. 1, 2024) (“Saying that ‘there is not a great degree or specific function by

function assessment’…is the same as saying that ‘there is not much

quantification.’”). Additionally, the ALJ deemed the degree of limitation assigned

to Plaintiff’s ability to sit, stand, walk, and lift “generalized and vague,” which

likewise does not constitute an adequate articulation of the supportability factor. See

Erlandsen v. O’Malley, No. 4:23-cv-83-ALM-KPJ, 2024 WL 898915, at *5 (E.D.

Tex. Feb. 14, 2024) (internal citations omitted) (ALJ determination that the medical

opinion is “too vague” is a “boilerplate evaluation” for which the court has “serious

reservations”).

Notwithstanding the ALJ’s erroneous supportability analysis, “[p]rocedural

perfection in administrative proceedings is not required as long as the substantial

rights of a party have not been affected.” Audler v. Astrue, 501 F.3d 446, 448 (5th

Cir. 2007) (internal quotation and quotation marks omitted). For procedural error to

serve as a basis for relief, Plaintiff must “show that prejudice resulted from [the]

error.” Jones v. Astrue, 691 F.3d 730, 734-35 (5th Cir. 2012). In other words,

Plaintiff must show that it is conceivable that a different administrative conclusion

would have been reached, had the ALJ conducted a proper evaluation of the doctors’

opinions. Nancy S. v. Comm’r of Soc. Sec. Admin., No. 3:22-cv-429-D-BK, 2023

WL 6299864, at *7 (N.D. Tex. Sept. 7, 2023) (quoting Keel v. Saul, 986 F.3d 551,

555 (5th Cir. 2021)). Because Plaintiff did not do so, she did not show prejudice.

The ALJ assessed the consistency of Dr. Sahi’s opinion with other sources,

namely Plaintiff’s statement, exams, and x-rays. In characterizing Dr. Sahi’s degree

of limitation as ultimately being in line with “medium exertion with postural and

climbing restrictions” and therefore being consistent with the record (based on

specific examples, i.e., the statement, exams, and x-rays), this consistency analysis

provides more explanation than the analyses held insufficient in other cases. E.g.,

Howen, 2021 WL 1169331, at *6 (ALJ’s explanation was error because it “wholly

failed to articulate…how consistent [the doctor’s] opinion was with other sources”);

Nunley v. Kijakazi, No. 4:22-cv-625, 2023 WL 2386747, at *6 (S.D. Tex. Mar. 6,

2023) (“the ALJ does not explain why the evidence he cited…is inconsistent

with…[the doctor’s] standing/walking limitation”).

Plaintiff asserts that the ALJ’s RFC determination that Plaintiff is capable of

medium exertion work is inconsistent with Dr. Sahi’s assessment that Plaintiff is

capable of “moderate lifting.” Plaintiff correctly notes that medium exertion work,

by definition, involves “considerable lifting.” Titles II & XVI: Determining

Capability to Do Other Work—the Med.-Vocational Rules of Appendix 2, SSR 83-

10 (S.S.A. 1983). Further, “[t]he considerable lifting required for the full range of

medium work usually requires frequent bending-stooping.” Id. However, the ALJ

accounts for the apparent discrepancy by qualifying her language: “[Plaintiff] has

the residual functional capacity to perform medium exertion work

except…[Plaintiff] can occasionally…stoop…” R. 1617 (emphases added).

Therefore, the Court disagrees that the ALJ failed to draw the requisite “logical

bridge” between Dr. Sahi’s opinion and the RFC determination. ECF No. 8 at 9.

The ALJ also summarized Dr. Herman and Dr. Spoor’s opinions and found

them to be “somewhat persuasive,” and explained:35

Although the opinion is consistent with the determination that

[Plaintiff’s] conditions are not disabling, the opinion indicated

[Plaintiff] can occasionally feel bilaterally appears not to be supported

by any direct information contained in the opinion and is not wholly

consistent with or supported by the evidence available at the hearing.

More specifically, the evidence available to hearing level indicated

normal sensory responses to pinprick and vibration and while

limitations were noted in the knee joints by the examiner[]s there was

no indication of the decreased sense of feel. In fact, on exams the

Tinel’s and Romberg tests were negative bilaterally and sensation was

generally noted as normal.

Out of an abundance of caution, the undersigned found the evidence as

a whole to support limiting [Plaintiff] to frequent handling and

fingering due to the [Plaintiff’s] symptoms of chronic pain and

difficulty in picking things up. Moreover, the evidence supports a

finding of degeneration in [Plaintiff’s] cervical spine and neuropathy

which is not inconsistent with limiting [Plaintiff] to frequent handling

and fingering.

35 R. 1626.

R. 21. As noted above, the ALJ must explain how the doctors’ findings supported

their opinions, as required by § 404.1520c(b)(2) and (c)(1). To the extent the ALJ

noted the absence of in-opinion support for the doctors’ opinions that Plaintiff can

occasionally feel bilaterally, she properly addressed supportability. Nonetheless, she

erred when she looked “to the evidence in the medical record [as a whole] as opposed

to the evidence” Drs. Herman and Spoor presented to support their opinions;

consideration of the overall record goes to consistency and not supportability. Kilby,

2022 WL 1797043, at *3. However, Plaintiff did not show prejudice from the error.

Plaintiff asserts that the ALJ failed to analyze the consistency of the medical

opinions with evidence from other medical and nonmedical sources in stating that

“the opinion is consistent with the determination that [Plaintiff’s] conditions are not

disabling” and that the ALJ mischaracterized the record when she stated that the

limitation to occasional bilateral feeling was not wholly consistent with or supported

by the evidence available at the hearing. Plaintiff correctly notes that the first

statement does not provide the requisite consistency analysis. See Kilby, 2022 WL

1797043, at *4 (“[T]he ‘logic bridge’ between the cited medical evidence and the

ALJ’s finding that the opinion is unpersuasive is completely absent”). However, the

ALJ does not appear to have mischaracterized the record.

While “[t]he law requires the ALJ to make affirmative findings regarding a

claimant’s subjective complaints,” and “the subjective complaints…must be

considered along with medical evidence in determining the individual’s work

capacity,” “[i]t is well settled that an ALJ’s credibility findings on claimant’s

subjective complaints are entitled to deference.” Collins v. Astrue, 493 F. Supp. 2d

858, 875–76 (S.D. Tex. 2007) (internal citations omitted). Given the ALJ’s reference

to Drs. Spoor and Herman’s findings (which include Plaintiff’s subject complaints

of numbness (i.e., lack of bilateral feeling)) alongside Plaintiff’s “normal sensory

responses to pinprick and vibration” and mostly negative results from the Tinel’s

and Romberg tests36 for bilateral feeling and sensation, “[t]he ALJ’s decision clearly

demonstrates that [s]he considered the medical records, along with [Plaintiff’s]

subjective complaints…and found that the evidence of record does not fully support

the claimant’s allegations about the severity of these symptoms.” Brumley v. Saul,

No. 4:20-cv-585, 2021 WL 1111045, at *2 (S.D. Tex. Mar. 23, 2021).

Plaintiff also argues that the ALJ’s assessment that the limitation to occasional

bilateral feeling is not wholly consistent with or supported by the evidence available

at the hearing is contradicted by the ALJ’s determination that the evidence supports

a finding of peripheral neuropathy. However, although peripheral neuropathy is

sometimes associated with a limitation of occasional feeling, it may also be

36 Plaintiff takes issue with the ALJ’s characterization of the Tinel’s test results as “negative,”

pointing to a single instance of a positive test result. The Court disagrees that the ALJ

mischaracterized the record evidence. Dennis H. v. Kijakazi, No. 4:22-cv-3501, 2024 WL 816630,

at *6 n.13 (holding that the ALJ did not mischaracterize the record evidence where only one of the

cited medical records favored Plaintiff’s position).

associated with a limitation of frequent feeling. Compare Halterman ex rel.

Halterman v. Astrue, Civ. Action No. 11-0630, 2012 WL 3764051, at *6 n.9 (W.D.

La. July 20, 2012) (“Due to his peripheral neuropathy, [Plaintiff’s] fine manipulation

skills and ability to feel were limited to occasional.”) with Thompson v. Kijakazi,

Civ. Action No. 22-2149, 2023 WL 5028943, at *5 (E.D. La. July 21, 2023)

(“[Plaintiff] can…feel on a frequent basis especially from a seated position; and she

should not be working at heights due to peripheral neuropathy”).

Plaintiff also asserts that the ALJ’s statement that the evidence supports and

is consistent with her RFC determination is an impermissible substitution of her own

“lay opinion for the medical opinion of experts.” The Court disagrees; this is not a

case where “the ALJ rejected the medical opinions of treating and examining doctors

alike, without contradictory evidence from a medical expert of any kind,” Salmond

v. Berryhill, 892 F.3d 812, 819 (5th Cir. 2018); rather, the ALJ evaluated

contradictory evidence from various tests, including the several negative Tinel’s, in

coming to her conclusion.

The ALJ summarized Dr. Hardaway’s opinion and found it to be “only

slightly persuasive,” and explained:37

Although the general diagnostic impression identifying the general

impairments appears to be overall consistent with the evidence of

record, the degree of limitation, offered, albeit somewhat vague in

37 R. 1624.

degree, appears not to be wholly supported by or consistent with the

direct observations or with the other evidence of record. (See Exhibits

1F19F). For example, during the exam the consultant examiner

indicated the claimant was cooperative and maintained good eye

contact. In addition, the examiner noted the claimant had good

concentration and did not appear to be confused. Further, she was able

to independently arrive at the scheduled appointment and in fact arrived

early and was able to communicate in full grammatically correct

sentences. In addition to sustained eye contact rapport was also noted

to be easily established. These direct observations are inconsistent with

the opinion that the claimant would be unlikely to sustain concentration

and persist in work-related activities as well as inconsistent with the

opinion the claimant would be unlikely to maintain effective social

interaction with coworkers supervisors and the general public or cope

with pressures in a competitive work setting.

Moreover, the evidence available at the hearing level frequently shows

on mental status examinations that the claimant is alert with a normal

affect and is oriented to time, place, and person with good judgment

and good insight. Additionally, the evidence available to hearing level

also indicates the claimant’s behavior during most exams was normal

and cooperative with an average fund of knowledge. (See Exhibits 13F,

15F,17F, and 19F).

In consideration of the entire record, the claimant’s limitations are most

consistent with being able to follow simple instructions, perform the

tasks assigned but not at a production rate pace; however, being able to

meet the end of day work goals, and being able to have occasional

contact with coworkers supervisors and the general public as well as

being able to occasionally adapt to changes in the workplace. In

summary, while the undersigned agrees with the examiner that some

degree of limitation exists in each of the paragraph B criteria, the

evidence available to hearing level is not consistent with a finding of

disabled. (See Exhibits 1F-19F, hearing testimony).

The ALJ did not provide an adequate supportability analysis because she failed to

explain how the medical evidence Dr. Hardaway presented supported38 his opinion.

The ALJ’s blanket assessment that Plaintiff’s sustained eye contact, absence of

confusion, independent early arrival to the exam by bus, and easily established

rapport fail to support Dr. Hardaway’s opinion that Plaintiff is unlikely to maintain

effective social interaction with coworkers, supervisors, and the general public, or

cope with pressures in a competitive setting, and shows that the ALJ made no attempt

to draw the requisite logical bridge between the evidence and the persuasiveness

finding. Kilby, 2022 WL 1797043, at *4 (internal citation omitted) (“An ALJ’s

persuasiveness discussion is critical to his analysis and…must provide the Court

with an adequate discussion of his reasons for finding a particular medical opinion

to be persuasive or unpersuasive…the Court [should not be required] to merely

speculate about the reasons behind the ALJ’s persuasiveness finding or lack thereof”

(internal quotation and quotation marks omitted)).

The ALJ also failed to provide an adequate consistency analysis. Although

the ALJ identifies certain exam results, e.g., “alert with a normal affect and is

oriented to time, place, and person with good judgment and good insight” as being

“not consistent with a finding of disabled,” she did not further illuminate the

38 Although in her analysis the ALJ primarily used “inconsistent” rather than “does not support”

or “unsupported,” the ALJ nonetheless conducted a supportability analysis because she analyzed

the relationship between the medical evidence relied on by the doctor and the doctor’s opinion. A

“case will not be remanded simply because the ALJ did not use ‘magic words.’” Keel v. Saul, 986

F.3d 551, 556 (5th Cir. 2021) (internal quotation omitted).

inconsistency. See Nunley, 2023 WL 2386747, at *6 (“the ALJ does not explain why

the evidence he cited—the consultative exam showing no muscle weakness or

atrophy, normal sensation in extremities, no edema, and negative Homa’s sign—is

inconsistent with…Dr. Ligon’s standing/walking limitation”). Therefore, “the ALJ

did not articulate [her]…consistency findings adequately to allow for meaningful

review of [her] decision that [Dr. Hardaway’s] opinion is [somewhat persuasive].”

Id.

“Absent sufficient articulation, the [C]ourt cannot discern whether the ALJ’s

assessment[ ] of the persuasiveness of [this] medical opinion…[is] supported by

substantial evidence and, in turn, whether the RFC assessment is supported by

substantial evidence.” Howen, 2021 WL 1169331, at *7.

The ALJ also summarized Dr. Campa’s opinion and found it to be “only

somewhat persuasive,” and explained:39

While [the opinion] is generally consistent with the determination that

the claimant’s conditions while severe, are not disabling, [the opinion]

is internally inconsistent. At the initial level, the opinion assigns both

limitations and no limitations in the claimant’s ability to concentrate,

persist, or maintain pace, interact with coworkers, supervisors, and the

general public, as well as the ability to adapt or manage oneself. Further

the reconsideration opinion indicates severe mental impairments exist,

which by definition result in some degree of limitation in the claimant’s

abilities to perform work-related activities; however, the

reconsideration consultant examiner[] assessed no degree of limitation

in any of the paragraph B criteria.

39 R. 1626–27.

Moreover, the evidence available to hearing level, is consistent with a

finding the claimant has severe mental impairments that allow her to

remember and follow instructions, while being able to perform the tasks

assigned but not at a production rate pace; however she can meet the

end of day work goals, and being able to have occasional contact with

coworkers, supervisors and the general public as well as being able to

occasionally adapt to changes in the workplace. (See Exhibits 1F-19F,

hearing testimony). For example, during other consulted examinations

and many mental status exams, the evidence available at hearing level

shows the claimant’s delayed memory to be impaired while remote

memory was intact, but concentration, attention, insight, ability to

interact and established rapport, and verbalize thoughts, needs, and

ability to travel independently, as being within normal limits. (See

Exhibits 6F, 4F, 19F, 17F, and 15F).

In sum, the above residual functional capacity assessment is supported

by the evidence of record.

Here, the ALJ provided no supportability analysis because she failed to assess how

Dr. Campa’s findings supported his opinion. Additionally, she failed to provide the

requisite consistency analysis, because she did not articulate how Dr. Campa’s

opinion is consistent with the overall record; the internal consistency of an opinion

is irrelevant. Again, therefore, “the [C]ourt cannot discern whether the ALJ’s

assessment[ ] of the persuasiveness of this medical opinion…[is] supported by

substantial evidence and, in turn, whether the RFC assessment is supported by

substantial evidence.” Howen, 2021 WL 1169331, at *7.

E. The ALJ Committed Harmful Error Regarding Plaintiff’s Mental

Limitations.

“Errors alone do not justify relief from an ALJ’s decision.” See id. (citing

Kneeland v. Berryhill, 850 F.3d 749, 761 (5th Cir. 2017) (quoting Audler, 501 F.3d

at 448)). The Fifth Circuit “requires . . . a showing that the claimant was prejudiced

by the agency’s failure to follow a particular rule before such a failure will be

permitted to serve as the basis for relief from an ALJ’s decision.” Id. (quoting Shave

v. Apfel, 238 F.3d 592, 597 (5th Cir. 2001)). “Prejudice can be established by

showing that the additional considerations might have led to a different decision.”

Id. (quoting Mettlen v. Barnhart, 88 F. App’x 793 (5th Cir. 2004) (internal quotation

and quotation marks omitted)).

Here, the ALJ denied Plaintiff benefits at step five of the sequential analysis,40

determining that work exists in significant numbers in the national economy that

Plaintiff could perform. R. 1629. The ALJ found Plaintiff could perform these jobs

based on the VE’s testimony. Id. Based on the current record, it is unclear whether

a more limited RFC that included limitations like those Dr. Hardaway and

Dr. Campa contemplated would have resulted in the VE testifying that Plaintiff

could not perform her past relevant work. “The principle that an ALJ should not

substitute his lay opinion for the medical opinion of experts is especially profound

in a case involving a mental disability.” Salmond v. Berryhill, 892 F.3d 812, 818 (5th

Cir. 2018) (quoting Morales v. Apfel, 225 F.3d 310, 319 (3d Cir. 2000)). See also

40 At step five, the ALJ must determine whether there are jobs that exist in significant numbers in

the national economy that Plaintiff can perform. 20 CFR 404.1560. If such jobs exist, then Plaintiff

is not disabled.

Brian K. L. v. Comm’r of Soc. Sec., No. 4:20-cv-2810, 2022 WL 902641, at *7 (S.D.

Tex. Mar. 28, 2022) (The ALJ is not permitted to “substitute her opinion for that of

the mental health professional, causing Plaintiff prejudice”). Therefore, the ALJ

committed harmful error. Because the ALJ has failed to properly evaluate the

opinion evidence a second time, and the record is fully developed, her decision

should be reversed and rendered. Giles R., 2021 WL 4502842, at *10 n.43 (internal

citations omitted).

CONCLUSION

Therefore, it is ORDERED that Plaintiff's motion for summary judgment,

ECF No. 8, is GRANTED, and Defendant’s cross-motion for summary judgment,

ECF No. 11, is DENIED. The Court instructs Commissioner to calculate disability

and Social Security Income benefits due Plaintiff consistent with this opinion.

Signed at Houston, Texas, on February 19, 2025.

Dena Rlermur

Dena Hanovice Palermo

United States Magistrate Judge

28