Hernandez v. Commissioner, Social Security Administration

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF TEXAS

ABILENE DIVISION

DIANE HERNANDEZ, §

§

Plaintiff, §

§

v. § Civil Action No. 1:24-cv-00143-BP

§

COMMISSIONER OF §

SOCIAL SECURITY, §

§

Defendant. §

MEMORANDUM OPINION AND ORDER

Diane L. Hernandez (“Hernandez”) applied for Title II Disability Insurance Benefits

(“DIB”) and Supplemental Security Income (“SSI”) under the Social Security Act (“SSA”). The

Commissioner denied her application initially and upon reconsideration, deciding that she was not

disabled. Hernandez appealed. There is no reversible error in the residual functional capacity

(“RFC”) that the Administrative Law Judge (“ALJ”) formulated, and there is substantial evidence

to support the ALJ’s findings that Hernandez was not disabled and that there were a significant

number of jobs exist in the national economy that she could perform. Accordingly, the Court

AFFIRMS the Commissioner’s decision and DISMISSES the case with prejudice.

I. BACKGROUND

Hernandez was born on January 5, 1967. Soc. Sec. Admin. R. (hereinafter “Tr.”) 32. She

applied for DIB and SSI on November 4, 2021, alleging disability since April 1, 2018. ECF No. 1

at 1, Tr. 19. On the alleged disability onset date, she was closely approaching advanced age. Tr.

32. After a telephonic hearing on November 9, 2023, the ALJ denied her application for benefits

in a decision dated February 21, 2024. Tr. 16-55. The Appeals Council (“AC”) denied her request

for review, making the ALJ’s decision the final decision of the Commissioner. Tr. 7-11. Hernandez

filed this civil action seeking judicial review under 42 U.S.C. §§ 405(g) and 1383(c). See ECF

No. 1; Higginbotham v. Barnhart, 405 F.3d 332, 334 (5th Cir. 2005) (citing 20 C.F.R.

§ 416.1400(a)(5)) (“[T]he Commissioner’s decision does not become final until after the [AC]

makes its decision denying the claimant’s request for review.”).

II. STANDARD OF REVIEW

Titles II and XVI of the SSA govern the DIB program and SSI programs, respectively. See

42 U.S.C. §§ 401-434; §§1381-1383f. Claimants seeking benefits under either program must prove

that they are “disabled” within the meaning of the SSA. See Hollis v. Bowen, 837 F.2d 1378, 1382

n.3 (5th Cir. 1988) (stating the “relevant law and regulations governing the determination of

disability under a claim for [DIB] are identical to those governing the determination under a claim

for [SSI]”). A person is disabled if he is unable “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.” 42 U.S.C. § 423(d)(1)(A), § 1382c(a)(3)(A). To determine whether a claimant is

disabled and thus entitled to benefits, the Commissioner employs a sequential five-step evaluation

process. 20 C.F.R. §§ 404.1520(a), 416.920(a).

First, the claimant must not be presently doing any substantial gainful activity. Id.

§ 404.1520(a)(4)(i). “Substantial gainful activity” is work that “involves doing significant physical

or mental activities” for pay or profit. Id. § 404.1572. Second, the claimant must have a severe

impairment or combination of impairments. Id. § 404.1520(a)(4)(ii). Third, disability exists if the

impairment or combination of impairments meets or equals an impairment in the federal regulatory

list. See 20 C.F.R. § 404.1520(a)(4)(iii) (referencing 20 C.F.R. pt. 404, subpt. P, app. 1). Before

proceeding to steps four and five, the Commissioner assesses the claimant’s RFC and considers

her past relevant work (“PRW”). See id. § 404.1520(a)(4), (e)-(f). RFC means “the most [a

claimant] can still do despite [her] limitations.” Id. § 404.1545(a)(1).

Previously, PRW meant work the claimant performed “within the past 15 years, that was

substantial gainful activity, and that lasted long enough for [the claimant] to learn to do it.” Id. §

404.1560(b)(1). The definition has since changed, and as of June 22, 2024, PRW means the “work

that you have done within the past five years that was substantial gainful activity and that lasted

long enough for you to learn to do it.” 20 C.F.R. § 404.1560(b)(2). The Commissioner made his

decision regarding Hernandez’s application prior to June 22, 2024, so the previous definition is

proper in this case. See Tr. 28.

Fourth, if the claimant’s medical status alone does not constitute a disability, the

impairment or impairments must prevent the claimant from returning to his PRW considering his

or her RFC. Id. § 404.1520(a)(4)(iv). Fifth, the impairment must prevent the claimant from doing

any other relevant work, considering the claimant’s RFC, age, work experience, and education. Id.

§ 404.1520(a)(4)(v); Crowley v. Apfel, 197 F.3d 194, 197-98 (5th Cir. 1999).

“A finding that a claimant is disabled or is not disabled at any point in the five-step review

is conclusive and terminates the analysis.” Lovelace v. Bowen, 813 F.2d 55, 58 (5th Cir. 1987).

“The claimant bears the burden of showing he is disabled through the first four steps of the

analysis; on the fifth, the Commissioner must show that there is other substantial work in the

national economy that the claimant can perform.” Audler v. Astrue, 501 F.3d 446, 448 (5th Cir.

2007).

Judicial review is limited to determining whether the Commissioner applied correct legal

standards and whether substantial evidence in the record supports the Commissioner’s decision.

Leggett v. Chater, 67 F.3d 558, 564 (5th Cir. 1995); Hollis v. Bowen, 837 F.2d 1378, 1382 (5th

Cir. 1988). “Substantial evidence is such relevant evidence as a reasonable mind might accept to

support a conclusion.” Ripley v. Chater, 67 F.3d 552, 555 (5th Cir. 1995) (quoting Greenspan v.

Shalala, 38 F.3d 232, 236 (5th Cir. 1994)). “It is more than a mere scintilla and less than a

preponderance.” Boyd v. Apfel, 239 F.3d 698, 704 (5th Cir. 2001) (quoting Harris v. Apfel, 209

F.3d 413, 417 (5th Cir. 2000)). “A finding of no substantial evidence is appropriate only if no

credible evidentiary choices or medical findings support the decision.” Id. (quoting same). The

Court may neither reweigh evidence in the record nor substitute its judgment for the

Commissioner’s, but it will carefully scrutinize the record to determine if substantial evidence is

present. Harris v. Apfel, 209 F.3d 413, 417 (5th Cir. 2000); Hollis, 837 F.2d at 1383. “Conflicts in

the evidence are for the [Commissioner] and not the courts to resolve.” Brown v. Apfel, 192 F.3d

492, 496 (5th Cir. 1999) (alteration in original) (quoting Selders v. Sullivan, 914 F.2d 614, 617

(5th Cir. 1990)).

III. ANALYSIS

The Commissioner, acting through the ALJ, completed the five-step evaluation process

here. See Tr. 19-28. First, the ALJ found Hernandez had not engaged in substantial gainful activity

since April 1, 2018. Id. at 21. Second, he found the following medically severe impairments: status-

post bilateral carpal tunnel syndrome (“CTS”) repair; status-post trigger finger releases, left knee

meniscus tear, degenerative disc disease of the lumbar spine, and tarsal tunnel syndrome. Id. at 22.

Third, he identified no impairment or combination of impairments that qualify under the federal

regulatory list. Id. He then assessed Hernandez’s RFC and found “[a]fter careful consideration of

the entire record” that Hernandez could “perform light work as defined in 20 CFR 404.1567(b)

and 416.967(b) with the following limitations: frequent handling, fingering, and feeling with the

bilateral upper extremities.” Id. At step four, the ALJ determined that Hernandez was unable to

perform any past relevant work because “[her] past relevant work would be precluded by the light

[RFC].” Id. at 26.

At step-five, the ALJ found that there were jobs that existed in significant numbers in the

national economy that Hernandez could perform, specifically as a marker, electronics worker, and

locker room attendant. Id. at 27. Moreover, the ALJ found that because of her advanced age, she

still could perform the work of a companion, and that 60,000 positions available positions as a

companion “constitutes a significant number of jobs in the national economy.” Id. The step-five

finding meant that Hernandez was ineligible for DIB or SSI because she was not disabled, a finding

that terminated the ALJ’s evaluation. Id.; see Lovelace, 813 F.2d at 58.

Hernandez seeks reversal of the ALJ’s decision because the “ALJ’s [RFC] assessment [was

not] supported by substantial evidence when there were no medical opinions in Hernandez’s file

that assessed how her severe impairments affected her ability to work.” ECF No. 12 at 2. She

further alleges that the ALJ impermissibly “relied on his own interpretation of the raw medical

data to determine the RFC.” Id.

A. Substantial evidence supports the ALJ’s RFC determination.

The RFC is an ALJ’s assessment, based on all relevant medical and other evidence in the

record, of the most that a claimant can still do despite her limitations. See 20 C.F.R. § 404.1545

(emphasis added). It reflects the individual’s maximum remaining ability to do sustained work

activity in an ordinary work setting on a regular and continuing basis. See Social Security

Regulation (“SSR”) 96-8P, 1996 WL 374184, at *2 (S.S.A. July 2, 1996); see Myers v. Apfel, 238

F.3d 617, 620 (5th Cir. 2001). A regular and continuing basis is an eight-hour day, five days a

week, or an equivalent schedule. See SSR 96-8P, 1996 WL 374184 at *2. “The RFC determination

is a combined medical assessment of an applicant’s impairments with descriptions by physicians,

the applicant, or others of any limitations on the applicant’s ability to work.” Mary L. v. Comm’r

of Soc. Sec., No. 3:23-cv-1430-BK, 2024 WL 3939571, at *3 (N.D. Tex. Aug. 26, 2024). The RFC

determination is the sole responsibility of the ALJ. See Taylor v. Astrue, 706 F.3d 600, 602 (5th

Cir. 2012) (citing Ripley, 67 F.3d at 557); 20 C.F.R. § 404.1546. Substantial evidence must support

an RFC determination, and the ALJ, not the court, resolves any conflicts in the evidence. See S.K.

v. O’Malley, No. 3:24-cv-092-BR, 2024 WL 2162777, at *2 (N.D. Tex. May 14, 2024).

“Because a determination [of] whether an impairment[ ] is severe requires an assessment

of the functionally limiting effects of an impairment[ ], [all] symptom-related limitations and

restrictions must be considered at this step.” Martinez v. Kijakazi, No. 3:20-cv-3282-BH, 2022

WL 4590577, at *11 (N.D. Tex. Sept. 29, 2022) (quoting SSR 96-3P, 1996 WL 374181, at *2

(S.S.A. July 2, 1996)). Ultimately, a severity determination may not be “made without regard to

the individual's ability to perform substantial gainful activity.” Stone v. Heckler, 752 F.2d 1099,

1104 (5th Cir. 1985).

In making an RFC determination, the ALJ considers evidence of a claimant’s symptoms,

including pain, and the extent to which these symptoms can reasonably be accepted as consistent

with the objective medical evidence and other evidence in the record. See 20 C.F.R. § 404.1529(a).

The ALJ also examines a claimant’s medical history which often documents “such matters as test

results, physicians’ interpretations of those tests, diagnoses, treatments and procedures, and

information regarding [a claimant’s] recovery from those procedures.” Wills v. Kijakazi, No. 22-

20609, 2023 WL 4015174, at *4 (5th Cir. 2023) (per curiam).

“Under the current regulations, ALJs do not ‘defer or give any specific evidentiary weight,

including controlling weight, to any medical opinion(s) or prior administrative medical findings.’”

Mary L., 2024 WL 3939571, at *4 (quoting 20 C.F.R. §§ 404.1520c(a), 416.920c(a)). In reviewing

all evidence in the record, “an ALJ is free to reject any medical opinion when the evidence supports

a contrary conclusion.” Ward v. Comm’r of Soc. Sec., No. 5:24-cv-00153-BP, 2025 WL 531783,

at *5 (N.D. Tex. Feb. 18, 2025) (internal citations omitted). Additionally, an ALJ’s RFC finding

does not need to “mirror or match a medical opinion.” Mary L., 2024 WL 3939571, at *4 (internal

citations omitted). Nor is there a requirement that an ALJ is required to incorporate limitations in

the RFC that she did not find the record supported. Muse v. Sullivan, 925 F.2d 785, 790 (5th Cir.

1991).

While an ALJ generally should “request a medical source statement describing the type of

work that the applicant is still capable of performing[, t]he absence of such a statement . . . does

not, in itself, make the record incomplete.” Gonzales v. Colvin, No. 3:15-cv-0685-D, 2016 WL

107843, at *9 (N.D. Tex. Jan. 11, 2016) (quoting Ripley, 67 F.3d at 577); see also Vasquez v.

O’Malley, No. 24-50233, 2024 WL 4381269, at *2 (5th Cir. 2024) (finding “[a]n administrative

record is not per se incomplete without a medical opinion about a claimant’s limitations, so long

as it otherwise contains substantial evidence to make the RFC assessment”). Medical opinions are

just one category of evidence that ALJs consider when making an RFC determination. See 20

C.F.R. § 1513.

The pertinent SSRs explain that an RFC assessment takes into consideration many factors,

not just medical evidence. See SSR 96-8p, 1996 WL 374184 at *3 (July 2, 1996) (RFC is based

on all the relevant evidence of an individual’s abilities to do work-related activities); see Johnny

M. v. Saul, No. 5:20-cv-173-BR, 2022 WL 9597736, at *4 (N.D. Tex. Jan. 21, 2022) (affirming

the ALJ’s decision based on substantial evidence because the ALJ had considered the medical and

other evidence in the record, even absent a medical source statement describing the types of work

Plaintiff could do). Thus, when there is no medical statement in the record, the inquiry shifts and

“focuses upon whether the decision of the ALJ is supported by substantial evidence in the existing

record.” Ripley, 67 F.3d at 557; see S.K., 2024 WL 2162777, at *3 (finding that “[a]n ALJ may

properly make a disability determination that does not expressly adopt any medical opinion when

it is based on substantial evidence”).

Although a claimant's step-two burden is quite low, it remains exceedingly difficult to show

that substantial evidence does not support an ALJ's opinion, in whole or in part. Evidence is

substantial if it “is more than a mere scintilla,” but it need not be greater than a preponderance.

Boyd, 239 F.3d at 704. It is the bare minimum needed for “a reasonable mind [to] accept to support

a conclusion.” Ripley, 67 F.3d at 555 (quoting Greenspan, 38 F.3d at 236). A finding of no

substantial evidence is only appropriate where a reasonable mind could not support the ALJ's

conclusion based on the evidence under consideration. See id.

Substantial evidence did not support the ALJ’s RFC determination in Ripley, thus

warranting remand, because the record “d[id] not clearly establish…the effect [the claimant’s]

condition had on his ability to work.” Id. at 557. The ALJ found Ripley not disabled because he

could perform sedentary work. Id. Even though the record included “a vast amount of medical

evidence,” including “reports discussing the extent of Ripley’s injuries,” no reports from “qualified

medical experts” showed how Ripley’s condition affected his ability to perform sedentary work.

Id. at 557 & n.27.

After Ripley, the Court found that reversible error lies where the “record does not clearly

establish” how an applicant’s condition affects her ability to work. Bowles v. Comm'r of Soc. Sec.,

No. 7:20-cv-00112-O-BP, 2021 WL 7451148, at *3 (N.D. Tex. Oct. 19, 2021), rec. adopted, 2022

WL 768546 (N.D. Tex. Mar. 14, 2022); Fitzpatrick v. Colvin, No. 3:15-cv-3202-D, 2016 WL

1258477, at *7-8 (N.D. Tex. Mar. 31, 2016); Thornhill v. Colvin, No. 3:14-cv-335-M, 2015 WL

232844, at *10 (N.D. Tex. Dec. 15, 2014), rec. adopted, 2015 WL 232844 (N.D. Tex. Jan. 16,

2015).

Hernandez argues that substantial evidence did not support the ALJ’s RFC determination.

ECF No. 12 at 2. She asserts that the ALJ found that she had been diagnosed with numerous severe

physical impairments, but that the medical consultants did not assess how her severe impairments

affected her ability to work. ECF No. 12 at 7-8. Hernandez continues that the ALJ relied on his

own interpretation of raw medical data and non-medical evidence to assess her RFC. Id.

However, the record reflects that in determining the RFC, the ALJ incorporated medical

evidence and reviewed the entire record. For instance, the ALJ indicates that he “considered all

symptoms and the extent to which these symptoms can reasonably be accepted as consistent with

the objective medical evidence and other evidence.” Tr. 22. He considered Hernandez’s subjective

complaints, objective medical evidence including records from surgeries, therapy, x-ray, and

Hernandez’s testimony. Tr. 22.

The ALJ found that “the objective medical evidence does not provide strong support for

the claimant’s allegations of disabling impairments.” Tr. 23. He then summarized portions of the

objective medical evidence and observed that “[Hernandez] is generally noted to have normal

ambulation.” Tr. 23. He also considered this evidence and the non-medical evidence including that

offered at the hearing in which Hernandez confirmed that she had worked part-time for much of

the period after the alleged onset date of disability and served as the “ primary caregiver for her

nearly dependent mother.” Id. The ALJ states that “[t]he combination of medical and non-medical

evidence suggests that [Hernandez] is not as limited as alleged.” Id.

The ALJ also reviewed physical therapy records showing that Hernandez was able to stand

to cook and clean with minimal problems and was able to do her basic activities of daily living.

Id. He also noted the results of Hernandez’s MRI in 2019, that showed no significant disc disease

and only “mild multilevel degenerative changes.” Tr. 24 (referencing Tr. 472, 475). He also

compared her complaints of pain with records that indicated that Hernandez’s “gait and station

were normal, straight leg raises were negative, and sensory and motor function were intact.” Tr.

24 (referencing Tr. 391, 405, 408, 410, 412, 424, 432, 436, 439, 443, 447). He observed that

“[i]maging of the pelvis and bilateral hips was unremarkable.” Id. (referencing Tr. 468). Finally,

he noted that x-rays of the bilateral knees were grossly unremarkable, and that “[Hernandez]

maintained adequate range of motion in all extremities…” Id. (referencing Tr. 466-467).

In reaching his decision, the ALJ carefully considered medical records, medical opinions,

Hernandez’s hearing testimony, and other evidence in the record. Tr. 22-25. Addressing the

hearing testimony, the ALJ found that Hernandez’s medically determinable impairments could be

expected to cause some of her alleged symptoms. Tr. 23. Nonetheless, he found determined that

Hernandez’s statements regarding the intensity, persistence, and limiting effects of the symptoms

were not entirely consistent with the medical evidence or other evidence in the record. Id. In

support of this finding, the ALJ noted some of Hernandez’s work history after the alleged onset

disability date, medical records, and results of her unremarkable tests. Id.

After reviewing the entire record, the ALJ states that although the “medical consultants

who reviewed the record….concluded there was insufficient evidence to evaluate the claims,” the

evidence received at the hearing, including the claimant’s testimony and the updated orthopedic

records “support the light [RFC].” Tr. 25. The ALJ’s opinion references many factors that led to

his conclusion that Hernandez is not disabled. The ALJ dedicated five pages of his opinion to an

analysis of the entire record, including Hernandez’s testimony at the hearing, previous treatment

and examinations from health care professionals, reported daily activities, medical opinions, and

prior administrative medical findings. Tr. 21-25.

ALJs may assign more or less persuasive value to certain evidentiary sources and reach an

RFC based on some, but not all, of the evidentiary record. Vasquez v. Comm'r of Soc. Sec., No.

7:21-cv-00028-O-BP, 2022 WL 2975471, at *5 (N.D. Tex. June 30, 2022), rec. adopted, No. 7:21-

cv-00028-O-BP, 2022 WL 2972240 (N.D. Tex. July 26, 2022). Thus, even though the ALJ noted

that some of the medical consultants concluded there was insufficient evidence to evaluate the

claim, the ALJ’s decision is not devoid of any medical opinions, and the record as a whole supports

his conclusion. The ALJ did not wholly reject the medical consultant’s assessments, and he

explained the reasoning for his decision. Accordingly, the ALJ properly evaluated the medical

opinion evidence of record in reaching his conclusion.

B. The ALJ did not rely solely on his own judgment in determining the RFC.

Hernandez also claims that because there are no opinions from medical consultants in the

record that assessed how her complaints affected her ability to work, the ALJ impermissibly

substituted his own judgment for a competent medical opinion in forming Hernandez’s RFC. See

ECF No. 12 at 4-5. However, an ALJ’s RFC determination need not mirror a medical

professional’s assessment.

In a similar case where the ALJ’s RFC assessment did not restate any medical opinion, the

Fifth Circuit noted that “[alt]hough the ALJ neither adopted the state agency report verbatim nor

accepted the testimony of [a medical expert], it cannot be said that his decision was not based on

substantial evidence or that he improperly applied the relevant legal standards.” Webster v.

Kijakazi, 19 F.4th 715, 719 (5th Cir. 2021). Moreover, the pertinent SSRs explain that an RFC

assessment takes into consideration many factors, not just medical evidence. See SSR 96-8p, 1996

WL 374184 at *3 (July 2, 1996) (RFC is based on all the relevant evidence of an individual’s

abilities to do work-related activities). Further, under agency policy, even though the ALJ’s RFC

assessment may adopt a medical source statement, or elements of it, they are not the same. See id.

Accordingly, an ALJ is permitted to consider the totality of the evidence in assessing a claimant’s

RFC.

There is no requirement that the ALJ consider or find at least one medical opinion

persuasive for substantial evidence to support his RFC assessment. Nor is an ALJ required to adopt

a specific physician’s assessment. Instead, the ALJ is responsible for weighing all the evidence

and determining a claimant’s capacity for work. See Miller v. Kijakazi, No. 22-60541, 2023 WL

234773 at *4 (5th Cir. Jan. 18, 2023). The Fifth Circuit also indicated that even in situations where

no medical statement or opinion is present, the Court’s “inquiry focuses upon whether the decision

of the ALJ is supported by substantial evidence in the existing record.” Ripley, 67 F.3d at 557;

accord Gutierrez v. Barnhart, No. 04-11025, 2005 WL 1994289, at *7 (5th Cir. Aug. 19, 2005)

(“This Court has held that the absence of a medical source statement about a plaintiff’s ability to

work does not, by itself, make the record incomplete.”). The Fifth Circuit has commented that

“experienced ALJs can draw their own conclusions based on accurate medical information.”

Barrett, 906 F.3d at 343.

Here, the ALJ heard Hernandez’s testimony and description of her work activities after the

alleged onset date of disability, assessed her subjective complaints and symptoms, and considered

the objective medical evidence. He then determined that her symptoms were not as serious as she

claimed, and he provided a reasoned basis for the RFC finding and conclusion that Hernandez was

not disabled. See Tr. 22-25. Contrary to Hernandez’s claim, under Fifth Circuit authority, the mere

absence of a medical opinion does not render the record insufficient, underdeveloped, or erroneous

so long as substantial evidence supports the ALJ’s decision. See Gutierrez, 2005 WL 1994289, at

*7,

The Fifth Circuit has held that “ALJs are no longer required to give controlling weight to

a treating physician’s opinion...” Webster, 19 F.4th at 719-20. To that end, the ALJ here properly

exercised his responsibility as fact finder to weigh the evidence and incorporate limitations in

Hernandez’s RFC assessment that the record supported. Audler, 501 F.3d at 447. This evidence

included expert medical opinion and non-expert evidence in the record as a whole. The ALJ relied

on that evidence is arriving at his RFC determination as the regulations and case law require.

Accordingly, he did not commit reversible error on this point.

IV. CONCLUSION

Because the ALJ applied the proper legal standards and substantial evidence supports the

ALJ’s decision, the Court AFFIRMS the Commissioner’s decision and DISMISSES this case

with prejudice.

It is so ORDERED on March 24, 2025.

Lf 0 enn Ma.

Hal R. Ray, Jr.

UNITED STATES MAGISTRATE JUDGE

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