# Gonzales v. Commissioner, Social Security Administration

> District Court, N.D. Texas · June 30, 2025

URL: https://www.frixlaw.com/law-library/cases/11086940

## Case

- **Court:** District Court, N.D. Texas
- **Decided:** June 30, 2025
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

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## Opinion text

IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
ABILENE DIVISION

LUCIA G., §
Plaintiff, §
§
v. § No. 1:24-CV-083-BW
§
COMMISSIONER OF THE SOCIAL §
SECURITY ADMINISTRATION, §
Defendant. §
MEMORANDUM OPINION AND ORDER
Plaintiff Lucia G. (“Plaintiff”) brings this action pursuant to the Social
Security Act (the “Act”), seeking review of the final decision of the Commissioner of
Social Security (the “Commissioner”), that denied her application for Disability
Insurance Benefits (“DIB”) under Title II of the Act, and her application for
Supplemental Security Income (“SSI”) under Title XVI of the Act. (See Dkt. No. 1.)
The Court has jurisdiction over this action under 42 U.S.C. §§ 405(g), 1383(c), and
the parties consented to proceed before the undersigned in accordance with 28
U.S.C. § 636(c) and Special Order Nos. 3-350 and 3-354. (See Dkt. No. 12.)
Plaintiff filed a brief on appeal (Dkt. No. 15 (“P. Br.”)), to which the
Commissioner filed a brief in response (Dkt. No. 16 (“D. Br.”)), and Plaintiff filed a
brief in reply (Dkt. No. 17 (“Reply”)). After considering the pleadings, briefs, and
administrative record, the Commissioner's decision is REVERSED and
REMANDED for administrative further proceedings as set forth below.
I. BACKGROUND
On May 24, 2021, Plaintiff protectively filed applications for DIB and SSI,

alleging disability beginning May 24, 2021, due to hypertension, diabetes,
neuropathy in both feet, hernia, and migraines. (See Transcript (“Tr.”) 16, 211, 261.)
The claims were denied initially on April 20, 2022, and again upon reconsideration
on February 27, 2023, after which Plaintiff timely requested an administrative
hearing. (Tr. 16, 105, 115, 127, 135.)

On October 6, 2022, Administrative Law Judge Sherrill Carvalho (“the ALJ”)
held a telephonic hearing, at which Plaintiff appeared and testified. (Tr. 16.)
Plaintiff was represented at the hearing by Matthew Lord, an attorney. Id. Barbara
Dunlap, an impartial vocational expert, also appeared and testified at the hearing.
Id. The ALJ issued an unfavorable decision on January 25, 2024, finding Plaintiff

not disabled. (Tr. 16-27.) On April 23, 2024, the Appeals Council denied Plaintiff’s
request for further review. (Tr. 1-7.) The ALJ’s January 25, 2024 decision thus
became the “final decision” of the Commissioner subject to judicial review under 42
U.S.C. § 405(g).
II. LEGAL STANDARDS

A. District Court Review
Judicial review of the Commissioner’s denial of benefits is limited to whether
the Commissioner’s position is supported by substantial evidence and whether the
Commissioner applied the proper legal standards in evaluating the evidence. See 42
U.S.C. § 405(g); Copeland v. Colvin, 771 F.3d 920, 923 (5th Cir. 2014); Ripley v. Chater,
67 F.3d 552, 555 (5th Cir. 1995). Substantial evidence is “more than a mere scintilla.
It means such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971); accord

Copeland, 771 F.3d at 923. To determine whether substantial evidence of disability
exists, four elements of proof must be weighed: (1) objective medical facts;
(2) diagnoses and opinions of treating and examining physicians; (3) claimant’s
subjective evidence of pain and disability; and (4) claimant’s age, education, and
work history. See Wren v. Sullivan, 925 F.2d 123, 126 (5th Cir. 1991) (citing DePaepe

v. Richardson, 464 F.2d 92, 94 (5th Cir.1972)).
The Commissioner, rather than the courts, must resolve conflicts in the
evidence, including weighing conflicting testimony and determining witnesses’
credibility, and the Court does not try the issues de novo. See Martinez v. Chater, 64

F.3d 172, 174 (5th Cir. 1995); Greenspan v. Shalala, 38 F.3d 232, 237 (5th Cir. 1994).
Thus, the court may not reweigh the evidence or substitute its judgment for the
Commissioner’s but must scrutinize the entire record to ascertain whether substantial
evidence supports the hearing decision. See Copeland, 771 F.3d at 923; Hollis v.
Bowen, 837 F.2d 1378, 1383 (5th Cir. 1988). The Court “may affirm only on the

grounds that the Commissioner stated for [the] decision.” Copeland, 771 F.3d at 923.
“Absent an error that affects the substantial rights of a party, administrative
proceedings do not require ‘procedural perfection.’” Wilder v. Colvin, No. 13-CV-
3014-P, 2014 WL 2931884, at *5 (N.D. Tex. June 30, 2014) (quoting Taylor v. Astrue,
706 F.3d 600, 603 (5th Cir. 2012)). “The ALJ is not required to discuss every piece
of evidence in the record nor must the ALJ follow formalistic rules of articulation.”
Hunt v. Astrue, No. 4:12-CV-244-Y, 2013 WL 2392880, at *7 (N.D. Tex. June 3,

2013) (citing Castillo v. Barnhart, 151 F. App’x 334, 335 (5th Cir. 2005)). “Procedural
errors affect the substantial rights of a claimant only when they ‘cast into doubt the
existence of substantial evidence to support the ALJ’s decision.’” Wilder, 2014 WL
2931884, at *5 (quoting Morris v. Bowen, 864 F.2d 333, 335 (5th Cir. 1988)).

“Remand is required only when there is a realistic possibility that the ALJ would
have reached a different conclusion absent the procedural error.” Id. (citing January
v. Astrue, 400 F. App’x 929, 933 (5th Cir. 2010)).
B. The Sequential Evaluation Process
“In order to qualify for disability insurance benefits or [supplemental security
income], a claimant must suffer from a disability.” Copeland. 771 F.3d at 923 (citing

42 U.S.C. § 423(d)(1)(A)). The Act defines “disability” as the inability to engage in
substantial gainful activity by reason of any medically determinable physical or
mental impairment that can be expected to result in death or last for a continued
period of 12 months. See id. § 423(d)(1)(A); see also Copeland, 771 F.3d at 923; Cook v.
Heckler, 750 F.2d 391, 393 (5th Cir. 1985).

An ALJ must follow a five-step sequential evaluation to determine whether a
claimant is disabled within the meaning of the Act. See Wren, 925 F.2d at 125
(summarizing 20 C.F.R. § 404.1520(b)-(f)). On the first four steps of the analysis, the
claimant has the initial burden of proving that he is disabled. Bowen v. Yuckert, 482
U.S. 137, 146 n. 5 (1987). The burden shifts to the Secretary on the fifth step to show
that the claimant is capable of performing work in the national economy and is
therefore not disabled. Id. “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).
At step one, the ALJ must determine whether the claimant is engaged in
substantial gainful work activity. See 20 C.F.R. § 404.1520(b). If so, the claimant is

not disabled. If the claimant is not engaged in substantial gainful work activity, the
ALJ proceeds to step two and determines whether the claimant has an impairment,
or combination of impairments, that is “severe” within the meaning of the Act,
meaning that it imposes significant restrictions on the claimant’s ability to perform
basic work activities. Id. § 404.1520(c). If the claimant does not have a severe

impairment or combination of impairments, the analysis concludes with a finding of
“not disabled.” If the claimant does, the ALJ continues to step three.
At step three, the ALJ examines whether a claimant’s impairment meets or
medically equals the criteria of a listed impairment in Appendix 1 of Subpart P of
Regulation No. 4 (the “Listings”). Id. § 404.1520(d). If the impairment meets or

medically equals the criteria of a Listing and meets the durational requirement, the
claimant is disabled. Id. § 404.1509. If not, the ALJ determines the claimant’s
residual functional capacity (“RFC”), which is the ability to perform physical or
mental work activities on a sustained basis notwithstanding limitations for the
collective impairments. See id. § 404.1520(e)-(f).
The ALJ then proceeds to step four and determines whether the claimant’s
RFC permits him or her to perform the requirements of his or her past relevant work.
20 C.F.R. § 404.1520(f). If the claimant can perform such requirements, then he or

she is not disabled. Id. If an individual's impairment precludes him or her from
performing past work, the analysis proceeds to the fifth and final step, wherein the
burden shifts to the Commissioner to show that there is other gainful employment
available in the national economy that the claimant is capable of performing.
Greenspan, 38 F.3d at 236. This burden may be satisfied either by reference to the

Medical-Vocational Guidelines of the regulations or by expert vocational testimony
or other similar evidence. Fraga v. Bowen, 810 F.2d 1296, 1304 (5th Cir. 1987).
III. ALJ’s FINDINGS
The ALJ analyzed Plaintiff’s claim for benefits under the process described

above and made the following findings in her January 25, 2025 decision:
1. The claimant meets the insured status requirements of the Social Security
Act through December 31, 2021.
2. The claimant has not engaged in substantial gainful activity since May 24,
2021, the alleged onset date (20 CFR 404.1571 et seq., and 416.971 et seq.).
3. The claimant has the following severe impairments: Hypertension,
diabetes, neuropathy in both feet, hernia, obesity, and migraines (20 CFR
404.1520(c) and 416.920(c)).
4. The claimant does not have an impairment or combination of impairments
that meets or medically equals the severity of one of the listed impairments
in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d),
404.1525, 404.1526, 416.920(d), 416.925 and 416.926).
5. The claimant has the residual functional capacity to perform light work as
defined in 20 CFR 404.1567(b) and 416.967(b)1 except light work with the
following abilities and restrictions: Lift and carry 20 pounds occasionally
and 10 pounds frequently; sit 6 hours in an 8-hour workday; stand and
walk 6 hours in an 8-hour workday; occasionally climb ramps and stairs;
never climb ladders, scaffolds, or ropes; occasionally balance (as defined in
the SCO), stoop, kneel, crouch, and crawl; and should avoid direct sunlight
and very loud, level 5 noise.
6. The claimant is unable to perform any past relevant work (20 CFR
404.1565 and 416.965).
7. The claimant was born on May 26, 1965, and was 55 years old, which is
defined as an individual of advanced age, on the alleged disability onset
date (20 CFR 404.1563 and 416.963).
8. The claimant has a limited education (20 CFR 404.1564 and 416.964).
9. The claimant has acquired work skills from past relevant work (20 CFR
404.1568 and 416.968).).
10. Considering the claimant’s age, education, work experience, and residual
functional capacity, the claimant has acquired work skills from past
relevant work that are transferable to other occupations with jobs existing
in significant numbers in the national economy (20 CFR 404.1569,
404.1569a, 404.1568(d), 416.969, 416.969a, and 416.968(d)).
11. The claimant has not been under a disability, as defined in the Social
Security Act, from May 24, 2021, through the date of this decision (20
CFR 404.1520(g) and 416.920(g)).).
(Tr. 16-27.)

1 “Light work involves lifting no more than 20 pounds at a time with frequent lifting or
carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job
is in this category when it requires a good deal of walking or standing, or when it involves sitting
most of the time with some pushing and pulling of arm or leg controls. To be considered capable of
performing a full or wide range of light work, [the claimant] must have the ability to do substantially
all of these activities. If someone can do light work, [the SSA] determine[s] that he or she can also
do sedentary work, unless there are additional limiting factors such as loss of fine dexterity or
inability to sit for long periods of time.” 20 C.F.R. § 404.1567(b).
Accordingly, the ALJ determined that, for the application for a period of
disability and disability insurance benefits, protectively filed on May 24, 2021, the
claimant is not disabled under sections 216(i) and 223(d) of the Act. (Tr. 27.) The

ALJ also determined that, for the application for supplemental security income filed
on May 24, 2021, the claimant is not disabled under section 1614(a)(3)(A) of the Act.
Id.
IV. ANALYSIS

Plaintiff asserts a single point of error—that “the ALJ’s RFC determination is
unsupported by substantial evidence because she constructed the RFC out of whole
cloth.” (See P. Br. at 1, 7-12.) Plaintiff argues that the RFC is not supported by
substantial evidence because the ALJ did not rely on a medical opinion and instead
relied on her own lay interpretation of the raw medical data to assess Plaintiff’s RFC.

(See id. at 8-12.) In particular, Plaintiff complains that the ALJ had no basis, other
than her own unsupported opinion, to determine that Plaintiff could perform the
standing and walking requirements of light work despite her “diabetic neuropathy
and well-documented foot and leg problems.” (See id.)
The Commissioner argues in response that the record contained sufficient

evidence for the ALJ to properly assess Plaintiff’s RFC, and neither the regulations
nor controlling case law mandate that a claimant’s RFC be derived directly from a
medical opinion, as RFC is an administrative assessment rather than a medical
assessment, and Congress “tasked the ALJs with exclusive jurisdiction over the
determination of a claimant’s ability to engage in exertional and non-exertional
work-related task[s].” (See D. Br. at 5-7.) According to the Commissioner, the ALJ
discussed evidence showing that Plaintiff was able to perform work at the light level
of exertion, including Plaintiff’s reports that she was doing well and her normal

musculoskeletal examinations findings, and the ALJ’s RFC finding was supported by
substantial evidence. (See id. at 7-10.)
A. Relevant Medical Evidence
On August 25, 2020, Plaintiff established care as a new patient with Rebecca
Perkins, NP (“Ms. Perkins”), at Texas Tech Physicians of Lubbock. (Tr. 379.)

Plaintiff’s past medical history was significant for diabetes mellitus. Plaintiff stated
that she had not checked her blood sugar in a while, but she took her Metformin
daily, and she was not concerned about her diabetes at that time. (Id.) She reported
having an area of the left great toe that was swollen and discolored, and which
sometimes drained. (Id.) She also reported having a partial colectomy two years ago

and a colostomy for about one year, which was reversed; after the reversal, she
developed a “knot” in her right lower quadrant that sometimes “popped out” when
she tried to lift anything. (Id.) She reported having stomach pain and heartburn after
eating, but she had regular bowel movements and no constipation. (Tr. 379-80.)
Her examination indicated BMI of 31.47, which is defined as obese. (Tr. 382,

384.) Her lungs were clear; her heart had a regular rate and rhythm with no
murmurs, rubs, or gallops; and there was right lower quadrant abdominal tenderness
and an inguinal hernia. (Tr. 382.) Her musculoskeletal range of motion was
normal; strength was normal; and sensation and motor function were normal (Tr.
382-83). She was assessed with diabetes, cellulitis, and inguinal hernia. (Tr. 388.)
On September 8, 2020, Plaintiff presented to Ms. Perkins for follow-up

regarding lab results, which showed her A1C at 10.6 and her lipid panel elevated.
(Tr. 366.) Plaintiff stated she had been compliant with medications, and she had no
acute concerns. (Id.) She denied shortness of breath, chest pain, headache, nausea,
or swelling of extremities. (Id.) Her examination indicated her lungs were clear; her
heart had a regular rate and rhythm with no murmurs, rubs, or gallops; and she had

no abdominal abnormalities. (Tr. 368.) Musculoskeletal range of motion and gait
were normal. (Id.) Her diabetic foot examination was abnormal, showing no
sensation of the toes (left 1st, 3rd, 5th, big, and right 1st, 3rd, 5th, big). (Tr. 369.)
Plaintiff was assessed with Type 2 diabetes and dyslipidemia; she was referred for

diabetic education and was to “[c]ontinue all current medications” and “[b]egin
Bydureon BCise and farxiga.” (Tr. 371-72.)
On September 22, 2020, Plaintiff presented to Ms. Perkins for a well woman
exam. (Tr. 449.) Plaintiff reported she was doing well. (Id.) Her physical
examination was unchanged with normal musculoskeletal range of motion and

strength and no abnormal cardiopulmonary or abdominal findings. (Tr. 452-53.)
On November 8, 2022, Plaintiff presented to the emergency room complaining
of right flank pain, headache, and fever. (Tr. 485.) Her symptoms had started three
days prior. (Id.) She had had decreased appetite and energy for one week and had
not taken her diabetic medications during that time. (Id.) She was admitted for
evaluation and treatment. (Tr. 487) and discharged on November 16, 2022 (Tr. 476).
According to the discharge summary, Plaintiff was diagnosed with dilated CBD
(common bile duct), dyslipidemia, bacterial infection, headache, hyperglycemia,

hyponatremia, leukocytosis, diabetes, urinary tract infection, and abdominal pain.
(Tr. 478.) She was noted to have “very uncontrolled type 2 diabetes” and
“significant diabetic neuropathy” with “old dry wounds to toes bilaterally.” (Id.) An
abdominal CT scan showed evidence of prior cholecystectomy and was otherwise
unremarkable. (Tr. 476.)

Plaintiff’s physical examination on discharge indicated her BMI was 35.34;
her lungs were clear; her heart had a regular rate and rhythm with no murmurs, rubs,
or gallops; and she had no abdominal abnormalities. (Tr. 481.) She had no edema
or other abnormalities of her extremities, and her motor strength and sensation were
normal. (Id.) Physical examinations during Plaintiff’s hospitalization indicated she

had no cardiopulmonary abnormalities; no musculoskeletal abnormalities, except for
right flank pain; and her musculoskeletal range of motion was normal (Tr. 487, 492.)
On September 24, 2023, imaging of the left foot showed osseous destructive
changes of the first proximal phalanges concerning for osteomyelitis. (Tr. 572.)

Plaintiff was hospitalized from October 3, 2023, through October 11, 2023, for
wound of the great left toe with worsening swelling and erythema, which eventually
required amputation of the toe. (Tr. 573-74.) According to the discharge summary
indicated, Plaintiff was diagnosed with osteomyelitis of left great toe, status-post
amputation of left great toe, diabetes with hyperglycemia, diabetic neuropathy,
hypertension, dyslipidemia, peripheral vascular disease, and anxiety
hyperventilation. (Id.) Her examination upon discharge indicated that her lungs
were clear with unlabored breathing; her heart had a regular rate and rhythm with no

murmurs, rubs, or gallops; she had no abdominal abnormalities; and her
musculoskeletal range of motion was normal. (Id.) Plaintiff’s examinations during
the hospitalization indicated similar findings, and she was alert, fully oriented, and
cooperative with appropriate mood and affect, normal judgment, and normal
psychiatric thoughts. (See Tr. 581, 587, 598, 600.)

B. The ALJ’s disability decision was not supported by substantial evidence.
As noted above, Plaintiff contends that the ALJ improperly relied on her own
lay opinion to determine that Plaintiff could perform the standing and walking
requirements of light work despite significant diabetic neuropathy, amputation of her
left great toe, and no sensation in her feet. (See P. Br. 7-8.) Plaintiff notes that if the

ALJ had limited Plaintiff to sedentary work, given her advanced age, limited
education, and work experience she would have been found disabled under the
Medical-Vocational Guidelines. (See id. (citing 20 C.F.R. §§ 404.1569, 416.969,
App’x. 2 to Subpt. P of Pt. 404, 201.02).)
The Commissioner argues in response that because ALJs have “exclusive

jurisdiction” over the RFC and the record contained sufficient evidence for the ALJ
to properly assess Plaintiff’s RFC, the ALJ was not required to rely on a medical
source opinion. (See D. Br. 5.) While the Commissioner is correct that the ALJ is
responsible for devising the RFC, that RFC must still have substantial evidentiary
support. See Ripley, 67 F.3d at 557. An ALJ cannot rely on her own unsupported
opinion as to a claimant’s limitations resulting from medical conditions. Raper v.
Colvin, 262 F. Supp. 3d 415, 422 (N.D. Tex. 2017) (citing Williams v. Astrue, 355 F.

App’x. 828, 832 n.6 (5th Cir. 2009)).
RFC is what an individual can still do despite her limitations. SSR 96-8p,
1996 WL 374184, at *2 (July 2, 1996). It reflects the individual’s maximum
remaining ability to do sustained work activity in an ordinary work setting on a

regular and continuing basis. Id.; 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. SSR 96-8p, 1996 WL 374184, at *2. RFC is not the least an
individual can do but the most. Id. The RFC is a function-by-function assessment,
with both exertional and nonexertional factors to be considered, and it is based on all

the relevant evidence in the case record. Id. at 3–6. The responsibility for
determining a claimant’s RFC lies with the ALJ. See Villa v. Sullivan, 895 F.2d 1019,
1023–24 (5th Cir. 1990). The ALJ must discuss the claimant’s ability to perform
sustained work activity on a regular and continuing basis and resolve any
inconsistencies in the evidence. SSR 96-8p, 1996 WL 374184, at *7.

In making the RFC assessment, the ALJ must consider all symptoms,
including pain, and the extent to which these symptoms can be reasonably accepted
as consistent with objective medical evidence and other evidence. See 20 C.F.R.
§ 404.1529; SSR 16-3p, 2017 WL 5180304, at *1 (Oct. 25, 2017); SSR 96-8p, 1996
WL 374184, at *5. The ALJ must also consider limitations and restrictions imposed
by all of an individual's impairments, even impairments that are not severe. See SSR
96-8p, 1996 WL 374184, at *5. The ALJ may draw reasonable inferences from the
evidence in making his decision, but the social security ruling also cautions that

presumptions, speculation, and supposition do not constitute evidence. See, e.g., SSR
86-8, 1986 WL 68636, at *8 (1986), superseded by SSR 91-7c, 1991 WL 231791, at *1
(Aug. 1, 1991) (changing the ruling only to the extent the SSR discusses the former
procedures used to determine disability in children).

The ALJ is not required to incorporate limitations in the RFC that she did not
find the record supported. See Muse v. Sullivan, 925 F.2d 785, 790 (5th Cir. 1991)
(“The ALJ as factfinder has the sole responsibility for weighing the evidence and
may choose whichever physician’s diagnosis is most supported by the record.”). In
reviewing the ALJ’s decision, a finding of no substantial evidence is appropriate only

if no credible evidentiary choices or medical findings support the decision. Boyd v.
Apfel, 239 F.3d 698, 704 (5th Cir. 2001).
With respect to the ALJ’s consideration of medical opinion evidence, the
Social Security Agency comprehensively revised its regulations governing medical
opinion evidence creating a new regulatory framework effective for claims filed on or

after March 27, 2017. See Revisions to Rules Regarding the Evaluation of Medical
Evidence, 82 Fed. Reg. 5844 (Jan. 18, 2017) (technical errors corrected by 82 Fed.
Reg. 15, 132-01 (March 27, 2017). Here, Plaintiff filed her claims on May 24, 2021,
and therefore, the 2017 regulations are applicable to her claims.
Under these revised regulations, the ALJ must determine the persuasiveness of
a physician’s medical opinion. 20 C.F.R. § 416.920c. To determine the
persuasiveness of each medical opinion, the ALJ considers supportability,

consistency, relationship with the plaintiff, specialization, and other factors that tend
to support or contradict a medical opinion. Id. §§ 404.1520c(c)(1)-(5), 416.920c(c)(1)-
(5). The most important factors are supportability and consistency. Id.
§§ 404.1520c(b)(2), 416.920c(b)(2). An ALJ must also discuss how she considered
the supportability and consistency factors in her determination or decision. Id. “At a

minimum, the ALJ's discussion [of these factors] must give enough reasons to permit
meaningful judicial review.” Hubbard v. Comm’r of Soc. Sec., No. 4:20-CV-588-BP,
2022 WL 196297, at *4 (N.D. Tex. Jan. 21, 2022) (citations omitted).
In this case, the ALJ found, as stated above, that Plaintiff had the RFC to

perform light work except that she could lift and carry 20 pounds occasionally and 10
pounds frequently; sit 6 hours in an 8-hour workday; stand and walk 6 hours in an 8-
hour workday; occasionally climb ramps and stairs; never climb ladders, scaffolds, or
ropes; occasionally balance (as defined in the SCO), stoop, kneel, crouch, and crawl;
and should avoid sunlight and very loud, level 5 noise. (Tr. 21.)

Citing Ripley and other similar cases, Plaintiff argues that the ALJ erred when
she found that Plaintiff could stand and walk for six hours in an 8-hour workday as
there was no medical opinion in the record regarding the effects of Plaintiff’s
impairments on her RFC. (See P. Br. 9-10.) In Ripley, the ALJ found that the
claimant could perform sedentary work even though there was no medical evidence
or testimony to support that conclusion. 67 F.3d at 557. The Fifth Circuit noted that
the record contained a vast amount of evidence establishing that the claimant had a
back problem, but it did not clearly establish the effect that condition had on the

claimant’s ability to work, remanded the case with instructions for the ALJ to obtain
a report from a treating physician regarding the effects of the claimant's back
condition on his ability to work. Id. at 557–58. The Fifth Circuit rejected the
Commissioner’s argument that the evidence substantially supported the ALJ’s
conclusion because the court was unable to determine the effects of the claimant’s

condition, “no matter how ‘small,’” on his ability to work, absent a report from a
qualified medical expert. Id. at 557 n.27.
The Commissioner counters that the absence of a medical source statement,
“does not, in itself, make the record incomplete.” (D. Br. at 5 (citing Ripley, 67 F.3d

at 557).) The Commissioner also cites Joseph-Jack v. Barnhart, 80 F. App’x. 317, 318
(5th Cir. 2003), for the proposition that “the Fifth Circuit rejected the claimant’s
argument that because the record was devoid of an RFC assessment by a medical
source, the ALJ was not competent to assess RFC.” (D. Br. at 5.) The Court finds
the Commissioner's citation to Joseph-Jack unpersuasive. In Moore v. Saul, the court

rejected the Commissioner's identical argument, finding that “[i]n Joseph-Jack, the
ALJ relied on state medical consultants who had reviewed the claimant’s medical
evidence and determined that the claimant was not disabled. The ALJ created the
RFC but did so relying heavily on the opinions of medical experts.” Moore v. Saul,
No. 320cv161, 2022 WL 987735, at *3 (N.D. Miss. Mar. 31, 2022) (citing Joseph-
Jack, 80 F. App’x at 318); see also Harris v. Comm’r, Soc. Sec. Admin., No. 4:22-CV-487-
P, 2023 WL 5826869, at *5 (N.D. Tex. Aug. 22, 2023), adopted, WL 5826975 (N.D.
Tex. Sept. 8, 2023). “Accordingly, Joseph-Jack does not stand for the proposition that

the ALJ may interpret medical data [her]self but rather affirms the ALJ’s role in
crafting the RFC in reliance on medical expert opinion.” Harris, 2023 WL 5826869,
at *5-6 (collecting cases remanded based on ALJ’s reliance on lay opinion to
formulate the RFC).

In contrast, the Court finds persuasive the analysis from a number of district
courts throughout the Circuit that have considered whether the ALJ impermissibly
substituted his or her lay opinion. See Barbara H. v. Kijakazi, No. 3:20-CV-01890,
2022 WL 300541, at *4 (N.D. Tex. Jan. 12, 2022) (“Here, the ALJ rejected all the
medical expert evidence concerning the effects of [the plaintiff's] impairments and

determined [the plaintiff's] RFC based on his own evaluation of findings from [the
plaintiff's] various physical exams, tests, and readings. This RFC determination is
not supported by substantial evidence.”) (collecting cases), adopted, 2022 WL 296050
(N.D. Tex. Feb. 1, 2022); Lopez v. Saul, No. SA-19-CV-01088, 2020 WL 4934462, at
*4 (W.D. Tex. Aug. 22, 2020) (“Where ‘the ALJ rejects the only medical opinions of

record, interprets the raw medical data, and imposes a different RFC, the ALJ has
committed reversible error.’” (quoting Garcia v. Berryhill, No. EP-17-CV-00263, 2018
WL 1513688, at *2 (W.D. Tex. Mar. 27, 2018))); Deborah S. v. Comm’r of Soc. Sec.
Admin., No. 4:20-CV-1580, 2021 WL 4442514, at *6 (S.D. Tex. Sept. 28, 2021)
(“Here, there were no other medical opinions the ALJ considered. In an opinion
short on discussion of the medical records, the ALJ improperly substituted his
opinion without reasoning and analysis for all four medical opinions to formulate an
RFC.”) (collecting cases).

Furthermore, the 2017 regulatory change does not allow the ALJ to overstep
the bounds of a lay person’s competence and render a medical judgment. See Moore,
2022 WL 987735, at *2 (“And by ‘raw medical evidence,’ this court is referring to
evidence that does not permit ‘common-sense judgments about functional capacity’
and instead requires the ALJ to ‘overstep the bounds of a lay person's competence

and render a medical judgment.’ . . . A lay person would not readily understand how
medical notations about disc bulging and ‘moderate facet degenerative changes’
impact one's ability to work.”) (citing Minor v. Astrue, No. 1:13cv17, 2014 WL
936438, at *6 (S.D. Miss. March 10, 2014) (citing Gordils v. Sec’y of Health and Hum.

Servs., 921 F.2d 327, 329 (1st Cir. 1990))).
“If the ALJ finds no medical opinion of record to be even partially persuasive,
there is typically an evidentiary gap in the record between the claimant’s raw medical
data, impairments, and remaining ability to work.” Harris, 2023 WL 5826869, at *6.
Accordingly, the Court considers whether the ALJ, by finding no medical opinion in

the record at least partially persuasive, impermissibly substituted her lay opinion as
there was no medical opinion in the record that stated the effects of Plaintiff’s
limitations on her ability to work or if she was disabled.
In this case, there were no medical opinions in the file. The ALJ noted that
“[t]he State agency medical consultants who evaluated Plaintiff’s case at the initial
and reconsideration administrative levels, found insufficient evidence because
Plaintiff did not cooperate.” (Tr. 25 (citing Tr. 78-81, 82-85, 89-92, 94-98).)
Specifically, on April 19, 2022, the State agency medical consultant noted that

Plaintiff failed to return ADLs (activities of daily living), failed to respond to calls or
letters, and refused to give ADLs via phone. (Tr. 84.) Furthermore, the consultant
noted that Plaintiff’s last exam was a well woman exam in September 2020, which
documented no acute symptoms and normal physical examination findings. (Id.)
Similarly, in February 2023, the State agency medical consultant noted Plaintiff’s

failure to return ADLs, failure to respond to calls or letters, and refusal to give ADLs
via phone. (Tr. 91.) In both instances, the State agency medical consultant found
“the evidence is insufficient for determination.” (Tr. 84, 91.)
The ALJ considered these State agency medical consultant opinions and
found them “not persuasive because there was, and is, sufficient evidence to evaluate

the case.” (Tr. 25.) The ALJ noted that neither the objective medical evidence nor
any other non-medical evidence established that Plaintiff’s ability to function was so
severely impaired as to preclude the performance of light work with the limitations
noted. (Tr. 25.) Here, unlike Joseph-Jack, the ALJ did not rely on any medical

opinion that stated the effects of Plaintiff’s limitations on her ability to work or
whether she was disabled. The ALJ did not rely on such an opinion because none
exists in the record. Thus, while the ALJ cited raw medical reports showing
“normal” physical examination findings,2 the ALJ did not find any medical opinion
persuasive. (See Tr. 25.) Despite these normal examination findings, the record also
showed significant diabetic neuropathy, amputation of the left great toe, and

“abnormal/no sensation in her toes.” (Tr. 369, 515-17, 529, 572, 577, 597, 625.)
Plaintiff also testified that she uses a walker since her surgery; she can only be on her
feet for 30 minutes and needs to sit for a couple of hours before standing again; she
goes shopping in a wheelchair; and she has issues standing in the shower because of
balance problems. (Tr. 45-44.)

Absent a report from a qualified medical expert, the Court is unable to
determine the effects of Plaintiff’s conditions and symptoms on her ability to work.
Therefore, the Court can only conclude that the ALJ substituted her own lay opinion
for that of the medical expert opinions of record and there is an evidentiary gap in
the record. See Miller v. Comm’r of Soc. Sec., No. 1:20-CV-194, 2021 WL 7541415, at

*9 (S.D. Miss. Dec. 17, 2021), adopted, 2022 WL 566175 (S.D. Miss. Feb. 24, 2022)
(“If the ALJ finds no medical opinion of record to be even partially persuasive, there
is typically an evidentiary gap in the record between the claimant’s raw medical data,
impairments, and remaining ability to work.”) (internal citations omitted); see also

Ripley, 67 F.3d at 557 n.27 (the court must be able to determine the effects of the
claimant's condition on his ability to work, “no matter how ‘small”).

2 Specifically, the ALJ noted that Plaintiff had good, full, or normal strength in her
bilateral upper and lower extremities, intact or normal sensation and motor function except
for neuropathy in the lower extremities, and normal gait and station. (Tr. 25.)
Because there is not substantial evidence to support the ALJ’s RFC
assessment, the Court must determine whether such error caused harm.
“‘Procedural 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) (quoting Mays v. Bowen, 837 F.2d 1362, 1364 (5th Cir. 1988)).
Accordingly, the Court may not vacate the judgment unless Plaintiff shows she was
prejudiced by the ALJ’s error. See Mays, 837 F.2d at 1364. Prejudice occurs when

procedural errors cast doubt on the existence of substantial evidence in support of the
ALJ’s decision. See Morris v. Bowen, 864 F.2d 333, 335 (5th Cir. 1988).
In this case, the Court finds that the ALJ’s substitution of her lay opinion for
that of a medical opinion was not harmless error. The record contained no medical
opinion evidence which could be used to reasonably conclude that Plaintiff’s RFC

was appropriate. Without medical opinion evidence, it is at best unclear whether the
ALJ’s conclusion that Plaintiff retained the RFC to perform light work was
supported by substantial evidence and whether an RFC with greater limitations may
have directed a finding of not disabled. Remand is necessary when, as here, the ALJ
rejected all available medical opinions, cited raw medical data, and made judgments

regarding the claimant’s RFC. Beachum v. Berryhill, No. 1:17-cv-0009, 2018 WL
4560214, at *4 (W.D. Tex. Sept. 21, 2018) (internal citation omitted)). Accordingly,
the ALJ's substitution of his lay opinion is not harmless, and remand is required on
this basis.
V. CONCLUSION
For the reasons set forth above, the Commissioner’s decision is REVERSED
and REMANDED for further administrative proceedings.
SO ORDERED on June 30, 2025.

On

BRIA cKAY
UNITED STATES MAGISTRATE JUDGE

22

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/11086940. Public record. Not legal advice.