Opinion

Merriman

Court: District Court, N.D. Indiana
Filed: Feb 6, 2026
Cited by: 0 cases
Authority: More cited than 38.5%

remanding where an ALJ restricted “the plaintiff to simple work because of his sleep apnea, but did not explain why someone with hypersomnia should be able to stay awake at work just because it's simple work”

How later courts described this case

remanding where an ALJ restricted “the plaintiff to simple work because of his sleep apnea, but did not explain why someone with hypersomnia should be able to stay awake at work just because it's simple work”

Written by the judges who cited it.

The opinion

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF INDIANA

HAMMOND DIVISION

TRACEY A. M.1,

Plaintiff,

v. CASE NO. 2:24-CV-241-SJF

FRANK BISIGNANO, COMMISSIONER

OF SOCIAL SECURITY2,

Defendant.

OPINION and ORDER

Plaintiff Tracey M. (“Ms. M”) seeks judicial review of the Social Security

Commissioner’s decision denying Ms. M’s application for Disability Insurance Benefits

(“DIB”) under Title II of the Social Security Act (“Act”). This Court may enter a ruling

based on the parties’ consent pursuant to 28 U.S.C. § 636(b)(1)(B) and 42 U.S.C. § 405(g).

[DE 11]. For the reasons discussed below, the Court REMANDS the decision of the

Commissioner of the Social Security Administration (“SSA”).

I. OVERVIEW OF THE CASE

Ms. M filed an application for DIB on March 21, 2022, alleging disability

beginning January 1, 2020. (Administrative Record 27; hereinafter “AR”). She was

denied initially, on reconsideration, and after a hearing before an administrative law

judge (“ALJ”). (Id.). The ALJ issued an unfavorable decision on October 26, 2023. (AR

1 To protect privacy interests, and consistent with the recommendation of the Judicial Conference, the

Court refers to the plaintiff by first name, middle initial, and last initial only.

2 Frank Bisignano became the Commissioner of Social Security on May 6, 2025. Under Rule 25(d) of the

Federal Rules of Civil Procedure, Frank Bisignano is substituted as the defendant in this suit.

24). Ms. M then requested further review of the ALJ’s decision, and the Appeals Council

denied this request on May 15, 2024. (AR 1). Thus, the ALJ’s decision became the final

decision of the Commissioner. Fast v. Barnhart, 397 F.3d 468, 470 (7th Cir. 2005).

Ms. M filed suit in this court on July 12, 2024. This court has jurisdiction under 42

U.S.C. § 405(g).

II. APPLICABLE STANDARDS

A. Disability Standard

To qualify for DIB and SSI, a claimant must be “disabled” as defined under the

Act. A person is disabled under the Act if “he or she has an inability to engage in any

substantial gainful activity by reason of a medically determinable physical or mental

impairment which can be expected to last for a continuous period of not less than

twelve months.” 42 U.S.C. § 423(d)(1)(A). Substantial gainful activity is defined as work

activity that involves significant physical or mental activities done for pay or profit. 20

C.F.R § 404.1572.

The Commissioner’s five-step sequential inquiry in evaluating claims for DIB

under the Act includes determinations of: (1) whether the claimant is engaged in

substantial gainful activity; (2) whether the claimant’s impairments are severe; (3)

whether any of the claimant’s impairments alone or in combination, meet or equal one

of the Listings in Appendix 1 to Subpart P of Part 404; (4) whether the claimant can

perform his past relevant work based upon his Residual Functional Capacity (“RFC”);

and, if not, (5) whether the claimant is able to perform other work. 20 C.F.R. §§ 404.1520.

The claimant bears the burden of proof at every step except Step Five, where the burden

of proof shifts to the Commissioner. Clifford v. Apfel, 227 F.3d 863, 868 (7th Cir. 2000), as

amended (Dec. 13, 2000).

B. Standard of Review

The Court has authority to review a disability decision by the Commissioner

pursuant to 42 U.S.C. § 405(g). But this Court’s role in reviewing social security cases is

limited. Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008). The question on judicial review

is not whether the claimant is disabled; rather, the Court considers whether the ALJ

used “the correct legal standards and [whether] the decision is supported by substantial

evidence.” Roddy v. Astrue, 705 F.3d 631, 636 (7th Cir. 2014) (citing Simila v. Astrue, 573

F.3d 503, 513 (7th Cir. 2009)). Substantial evidence must be “more than a scintilla but

may be less than a preponderance.” Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir. 2007).

Substantial evidence has also been understood as “such relevant evidence as a

reasonable mind might accept as adequate to support a conclusion.” Richardson v.

Perales, 402 U.S. 389, 401 (1971); see Summers v. Berryhill, 864 F.3d 523, 526 (7th Cir.

2017). The Supreme Court has also noted that “substantial evidence” is a term of art in

administrative law, and that “whatever the meaning of ‘substantial’ in other contexts,

the threshold for such evidentiary sufficiency is not high” in social security appeals.

Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019). The Court reviews the entire

administrative record to determine whether substantial evidence exists, but it may not

reconsider facts, reweigh the evidence, resolve conflicts of evidence, decide questions of

credibility, or substitute its judgment for that of the ALJ. Young v. Barnhart, 362 F.3d 995,

1001 (7th Cir. 2004).

On the other hand, an ALJ’s decision cannot stand if it lacks evidentiary support

or inadequately discusses the issues. Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003).

At a minimum, the ALJ must articulate her analysis of the record to allow the reviewing

court to trace the path of her reasoning and to be assured the ALJ has considered the

important evidence in the record. Scott v. Barnhart, 297 F.3d 589, 595 (7th Cir. 2002). The

ALJ need not address every piece of evidence in the record so long as she provides a

glimpse into the reasoning behind her analysis to build the requisite “logical bridge”

from the evidence to her conclusions. Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008). If

there is evidence that contradicts a finding of no disability, however, the ALJ must

confront it and explain why it was rejected. Moore v. Colvin, 743 F.3d 1118, 1123 (7th Cir.

2014)(citing Indoranto v. Barnhart, 374 F.3d 470, 474 (7th Cir. 2004)).

If the ALJ’s decision is not supported by substantial evidence, remand is

typically the appropriate remedy. Briscoe ex rel. Taylor v. Barnhart, 425 F.3d 345, 355 (7th

Cir. 2005). On the other hand, “[a]n award of benefits is appropriate only where all

factual issues have been resolved and the record can yield but one supportable

conclusion.” Id. (quoting Campbell v. Shalala, 988 F.2d 741, 744 (7th Cir. 1993)).

III. DISCUSSION

A. Summary of the ALJ’s Decision Denying Benefits

Ms. M’s hearing before the ALJ took place on September 19, 2023. (AR 27). Ms. M

appeared in person and was represented by two attorneys. On October 26, 2023, the ALJ

issued a written decision finding that Ms. M was not disabled from January 1, 2020,

through June 30, 2022, the date last insured, conducting the requisite five-step analysis

for evaluating claims for disability benefits. 20 C.F.R. § 404.1520. (AR 41).

At Step One, an ALJ’s inquiry focuses on whether a claimant is engaging in

substantial gainful activity. Here, the ALJ determined that Ms. M had not engaged in

substantial gainful activity since her alleged onset date of January 1, 2020. (20 C.F.R. §

404.1571 et seq., and § 416.971 et seq.). (AR 29).

At Step Two, an ALJ’s inquiry focuses on whether the claimant’s impairments

are severe. For an impairment to be considered severe, an impairment or combination

of impairments must significantly limit the claimant’s ability to perform basic work-

related activities. 20 C.F.R. § 404.1521. The ALJ concluded that Ms. M suffered from the

following severe impairments: systemic lupus erythematous, asthma, Raynaud’s

disease, osteoarthritis, Sjorgen’s disorder, undifferentiated connective tissue disorder,

major depressive disorder, generalized anxiety disorder, migraines, and morbid obesity

(AR 29). The ALJ thus concluded that these medically determinable impairments

significantly limit Ms. M’s ability to perform basic work activities as required by SSR

85-28. On the other hand, an impairment is considered non-severe when the medical

evidence establishes only a slight abnormality or combination of slight abnormalities

that would have no more than a minimal effect on the claimant’s ability to perform

basic work functions. See, e.g., 20 C.F.R. § 404.1522; S.S.R. 85-28, 1985 WL 56856 (Jan. 1,

1985). The ALJ found that Ms. M had the following nonsevere impairments: pineal cyst

in brain, an eyelid neoplasm, celiac’s disease, degenerative joint disease of the right

knee, right ankle impingement syndrome, and sprain of the anterior talofibular

ligament of the left ankle. (AR 30).

The ALJ concluded at Step Three that Ms. M does not have an impairment or

combination of impairments that meets or medically equals the severity of one of the

listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. § 404.1520(d),

404.1525, 404.1526, 416.920(d), 416.925 and 416.926). The ALJ considered Listings 3.30,

14.02, 14.09, 11.02, 12.06, and SSRs 19-2p and 19-4p. Accordingly, before moving on to

Step Four, the ALJ proceeded to determine whether Ms. M can perform her past

relevant work based on her residual functional capacity (“RFC”).

A claimant’s RFC includes limitations for all medically determinable

impairments, including non-severe impairments. 20 C.F.R. § 404.1545(a)(2). The RFC is

the most that an individual can do despite her limitations. 20 C.F.R. § 404.1545(a). To

determine a claimant’s RFC, the ALJ must consider the claimant’s symptoms, their

intensity, persistence, and limiting effects, and the consistency of these symptoms with

the objective medical evidence and other evidence in the record. 20 C.F.R. §

404.1545(a)(1). Physical exertion levels in an RFC are classified as either sedentary, light,

medium, heavy, or very heavy. 20 C.F.R. § 404.1567. The ALJ concluded that Ms. M

retained the RFC to perform less than the full range of light work as defined in 20 C.F.R.

404.1567(b). The ALJ thus determined that Ms. M could:

perform light work as defined in 20 CFR 404.1567(b) except where the

claimant can occasionally climb ramps and stairs, balance, stoop,

kneel, crouch, and crawl; but never climb ladders, ropes, and scaffolds.

The claimant must avoid exposure to extreme heat/cold, wetness,

humidity, dust, fumes, gases, odors, and poor ventilation; and must

avoid exposure to hazards such as unprotected heights and moving

mechanical parts. The claimant can understand, remember, and carry

out simple instructions; and use judgment to make simple work

related decisions. The claimant can have occasional interactions with

coworkers, supervisors, and the general public.

Based on this RFC, at Step Four, the ALJ found that Ms. M was unable to

perform her past relevant work as a legal secretary, receptionist, and administrative

clerk. (AR 39). Accordingly, the ALJ moved on to last step in the five-step sequential

analysis to determine whether Ms. M could perform other work.

At Step Five, the burden of proof shifts to the Commissioner, who must “provid[e]

evidence that demonstrates that other work exists in significant number in the national

economy that [the claimant] can do, given his residual functional capacity and

vocational factors.” 20 C.F.R. § 404.1560(c)(2); see also Liskovitz v. Astrue, 559 F.3d 736,

742-43 (7th Cir. 2009). The ALJ found that, while Ms. M could not perform any past

relevant work, she retained the RFC to perform the representative jobs of

cleaner/housekeeping (177,876 jobs nationally); marker (136,785 jobs nationally); and

routing clerk (117,925 jobs nationally).

Finding that Ms. M could make an adjustment to other work that existed in

significant numbers in the national economy, the ALJ determined that Ms. M was not

under a disability, as defined in the Act, from her alleged onset date of January 1, 2020,

to her date last insured of June 30, 2022. (AR 41).

B. Issues for Review

Ms. M raises three overarching arguments in support of remand. First, Ms. M

contends that the ALJ failed to assess work limits associated with her fatigue. Next, Ms.

M maintains that the ALJ erred by not following the requirements of Social Security

Ruling (“SSR”) 96-8p, which requires that the RFC assessment “include[s] a narrative

discussion describing how the evidence supports each conclusion, citing specific

medical facts [] and nonmedical evidence.” [DE 14 at 6]. As part of this argument, Ms.

M specifically challenges the ALJ’s finding that she could perform light work despite

her treating specialist and primary provider opining that she was precluded from full-

time work. She also alleges that the ALJ failed to adequately account for her severe

migraines or her moderate limitation in concentration, persistence, or pace, or to

adequately explain the RFC findings that she could be on her feet for six hours in a

workday and had limitations regarding the use of her hands. Finally, Ms. M argues that

the ALJ did not set forth a legally sufficient symptoms assessment under SSR 16-3p and

other applicable regulations, specifically raising the ALJ’s discussion of Ms. M’s

migraine treatment, limited daily activities, and other specialized treatment. [Id. at 14].

In response, the Commissioner contends that the ALJ’s decision was detailed and

well-supported, addressing all of Plaintiff’s impairments and providing support for the

ALJ’s requisite RFC findings. The Commissioner also directly responds to Ms. M’s

specific challenges.

For the reasons explained below, Ms. M’s first argument—that the ALJ failed to

assess work limitations associated with her symptoms of fatigue—warrants remand for

further administrative proceedings. As this first argument provides a basis for remand,

the Court will not reach Ms. M’s other arguments in support of remand.

C. Discussion

1. RFC Assessment

An RFC is “an assessment of an individual’s ability to do sustained work-related

physical and mental activities in a work setting on a regular and continuing basis.” SSR

96-8p. “A ‘regular and continuing basis’ means 8 hours a day, for 5 days a week, or an

equivalent work schedule.” Id. The RFC is the most someone “can do despite their

mental and physical limitations.” 20 C.F.R. § 404.1545(a)(1) and § 416.945(a)(1); SSR 96-

8p(5) (emphasis added). The RFC is crafted based on “all the relevant evidence in the

case record, including information about the individual’s symptoms and any ‘medical

source statements’ – i.e., opinions about what the individual can still do despite his or

her impairment(s) – submitted by an individual’s treating source or other acceptable

medical sources.” SSR 96-8p.

“The RFC assessment must include a discussion of why reported symptom-

related functional limitations and restrictions can or cannot reasonably be accepted as

consistent with the medical and other evidence.” SSR 96-8p. Thus, when crafting a

claimant’s RFC, an ALJ must follow a two-step sequential process to determine whether

a claimant’s symptoms can be accepted as consistent with objective medical evidence

and other evidence. First, the ALJ must determine whether there are underlying

medically determinable mental or physical impairments that could reasonably be

expected to produce the claimant’s pain or symptoms. Second, if there are underlying

physical or mental impairment(s) that could reasonably be expected to produce the

claimant’s pain or other symptoms, the ALJ must then evaluate the intensity,

persistence, and limiting effects of the claimant’s symptoms to determine the extent to

which they limit the claimant’s work-related activities. See 20 C.F.R. § 416.929(a). The

ALJ evaluates the intensity, persistence, and limiting effects of symptoms by

considering a claimant’s subjective statements and complaints related to their

symptoms and pain, as well as any description medical sources and other nonmedical

sources provide about how these symptoms affect a claimant’s ability to work. See 20

C.F.R. § 404.1529(a).

The ALJ must also consider “whether there are any inconsistencies in the

evidence and the extent to which there are any conflicts between [a claimant’s]

statements and the rest of the evidence . . . “ 20 C.F.R. § 404.1529(c)(4). Accordingly, a

claimant’s alleged symptoms are determined to diminish their capacity to work “to

extent that [the claimant’s] alleged functional limitations and restrictions due to

symptoms, such as pain, can reasonably be accepted as consistent with the objective

medical and other evidence.” 20 C.F.R. § 404.1529(c)(4).

The “RFC assessment must include a narrative discussion describing how the

evidence supports each conclusion, citing specific medical facts.” SSR 96-8p. This

“analysis must say enough to enable a review of whether the ALJ considered the

totality of a claimant’s limitations.” Lothridge v. Saul, 984 F.3d 1227, 1233 (7th Cir. 2021).

2. The ALJ’s Assessment of Ms. M’s Fatigue

As stated, Ms. M’s first argument is that the ALJ failed to assess work limitations

related to her fatigue, which Ms. M explains is a common symptom of lupus, connective

tissue disease, Sjorgen’s disorder, and depression, all of which the ALJ found to be

severe impairments. Here, the ALJ acknowledged that fatigue was one of Ms. M’s

symptoms, noting that Ms. M

testified that she could not work due to her symptoms that included

migraines, pain, and exhaustion. . . . [S]he would sleep for up to four

hours at a time, and that she need to nap during the day. [She] testified

that her fatigue would affect her activities of daily living . . . .[S]he testified

that her “lupus flares” were very unpredictable, and that she would

experience a lot of pain, body aches, and no energy during a flare. These

“flares” would occur two to three times a month.

(AR 34). The ALJ also observed Ms. M’s statements that her fatigue affected her daily

living, but also noted that “she testified that she was able to get up, take her

medications, take a shower, feed and care for her cats, prepare meals, and check on her

parents with whom she lived. She could do dishes, vacuum, dust, clean the bathroom;

but the claimant testified that she had difficulty with other tasks like laundry and taking

the garbage out.” (Id.). The ALJ then found that Ms. M’s “medically determinable

impairments could reasonably be expected to cause the alleged symptoms; however,

[her] statements concerning the intensity, persistence and limiting effects of these

symptoms are not entirely consistent with the medical evidence and other evidence in

the record for the reasons explained in this decision.” (AR 34)

The ALJ proceeded to summarize the medical evidence in the record and to

discuss the persuasiveness of the medical opinions in the record. As stated, based on

this evidence, the ALJ determined that Ms. M could: