RIDDLE

IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF NORTH CAROLINA

SHAWN R., )

)

Plaintiff, )

v. ) 1:25CV118

)

FRANK BISIGNANO, )

Commissioner of Social Security, )

)

Defendant. )

ORDER AND MEMORANDUM OPINION

OF UNITED STATES MAGISTRATE JUDGE

The plaintiff, Shawn R. (“Shawn”),

has sought review of a final decision of Shawn filed an application for

the Commissioner of Social Security supplemental security income

denying his claim for supplemental alleging a disability onset date of

security income.1 The Court has September 7, 2021.2 (Tr. 202-08.)

considered the certified The application was denied initially

administrative record and dispositive and upon reconsideration. (Tr. 114-

briefs from each party. Because the 19, 122-28.) After a hearing, the ALJ

Administrative Law Judge’s (“ALJ”) determined on August 9, 2024 that

decision does not allow for Shawn was not disabled under the

meaningful judicial review, the Court Act. (Tr. 18-32.) The Appeals Council

grants Shawn’s request for remand, as denied a request for review, making

set forth below. the ALJ’s decision the final decision

for review. (Tr. 1-6.)

I. PROCEDURAL HISTORY

1 Transcript citations refer to the Civil Procedure 25(d), Frank Bisignano is

Administrative Transcript of Record filed automatically substituted as the

manually with the Commissioner’s defendant in this suit.

Answer. See Docket Entry 5. By Order of

Reference, this matter was referred to the 2 Shawn also filed an application for

Undersigned to conduct all proceedings disability insurance benefits, but that

in this case pursuant to 28 U.S.C. § claim was dismissed because he did not

636(c). See Docket Entry 8. Frank satisfy the insurance coverage

Bisignano became the Commissioner of requirements. (Tr. 18, 32, 202-08.)

the Social Security Administration on Shawn does not challenge this dismissal.

May 7, 2025. Pursuant to Federal Rule of

II. STANDARD OF REVIEW “The Commissioner uses a five-step

process to evaluate disability claims.”

While Section 405(g) of Title 42 of the Hancock v. Astrue, 667 F.3d 470,

United States Code “authorizes 472-73 (4th Cir. 2012) (citing 20

judicial review of the Social Security C.F.R. §§ 416.920(a)(4),

Commissioner’s denial of social 404.1520(a)(4)).

security benefits,” see Hines v.

Barnhart, 453 F.3d 559, 561 (4th Cir. Under this process, the

2006), the scope of that review is Commissioner asks, in

specific and narrow, see Smith v. sequence, whether the

Schweiker, 795 F.2d 343, 345 (4th claimant: (1) worked during the

Cir. 1986). Specifically, review is alleged period of disability; (2)

limited to determining if there is had a severe impairment; (3)

substantial evidence in the record to had an impairment that met or

support the Commissioner’s decision. equaled the requirements of a

42 U.S.C. § 405(g); Hunter v. listed impairment; (4) could

Sullivan, 993 F.2d 31, 34 (4th Cir. return to her [or his] past

1992); Hays v. Sullivan, 907 F.2d relevant work; and (5) if not,

1453, 1456 (4th Cir. 1990). In could perform any other work

reviewing for substantial evidence, in the national economy.

the Court does not re-weigh

conflicting evidence, make credibility Id. at 472. A finding adverse to the

determinations, or substitute its claimant at any of several points in

judgment for that of the this five-step sequence forecloses a

Commissioner. Craig v. Chater, 76 disability designation and ends the

F.3d 585, 589 (4th Cir. 1996). Put inquiry. Id. at 473. “Through the

simply: the issue before the Court is fourth step, the burden of production

not whether Shawn is disabled but and proof is on the claimant. If the

whether the finding that he is not claimant reaches step five, the burden

disabled is supported by substantial shifts to the Secretary to produce

evidence and based upon a correct evidence that other jobs exist in the

application of the relevant law. Id. national economy that the claimant

can perform considering his age,

III. THE ALJ’S DECISION education, and work experience.”

Hunter, 993 F.2d at 35 (internal

The ALJ followed the correct process, citations omitted).

set forth in 20 C.F.R. § 416.920, to

determine disability. See Albright v. The ALJ determined at step one that

Comm’r of Soc. Sec. Admin., 174 F.3d Shawn had not engaged in substantial

473, 475 n.2 (4th Cir. 1999). gainful activity since the alleged onset

date of September 7, 2021. (Tr. 20.)

2

The ALJ next found the following in the work setting, further

severe impairments at step two: defined to mean a maximum

“status-post motor vehicle accident noise setting of 3, which is

with intestinal injury/hernia, partial moderate according to the

bowel resection and irritable bowel Selected Characteristics of

syndrome (IBS); migraines; status- Occupations (SCO). He is

post sinus surgery with allergies; generally able to understand

chronic obstructive pulmonary simple instructions and

disease (COPD); hypertension; perform simple tasks; he can

degenerative disc disease; depressive maintain concentration,

disorder; post-traumatic stress persistence, and pace to stay on

disorder (PTSD); substance use task for 2-hour periods over

disorder.” (Tr. 21.) At step three, the [the] course of [a] typical 8-

ALJ found that Shawn did not have an hour workday with normal

impairment or combination of breaks in order to perform such

impairments listed in, or medically tasks; in a low stress work

equal to one listed in, Appendix 1. (Tr. setting, which is further

21.) defined, in addition to the type

of work being performed, to

The ALJ next set forth Shawn’s mean no production-pace or

Residual Functional Capacity (“RFC”) quota-based work; rather, he

and determined that he could perform requires a goal-oriented job

light work with the following primarily dealing with things

additional limitations: instead of people, with no more

than occasional changes in the

occasional climbing ladders, work setting, and no more than

ropes or scaffolds and stooping occasional social interaction

but frequent climbing ramps with supervisors, co-workers

and stairs, balancing, kneeling, and/or the public as part of the

crouching, and crawling. Avoid job.

concentrated exposure to

humidity and temperature (Tr. 25-26.)

extremes of cold and heat.

Avoid concentrated exposure to At the fourth step, the ALJ

pulmonary irritants, such as determined that Shawn was unable to

fumes, odors, dust, gases, poor perform his past relevant work. (Tr.

ventilation and the like, and 30.) Last, at step five, the ALJ

workplace hazards, such as concluded that there were other jobs

dangerous moving machinery in the national economy that Shawn

and unprotected heights. Avoid could perform. (Tr. 30.)

concentrated exposure to noise IV. DISCUSSION

3

impairments).” Hall v. Harris, 658

In pertinent part, Shawn contends F.2d 260, 265 (4th Cir. 1981).

that “[t]he ALJ failed to adequately

account for the vocationally limiting “Social Security Ruling 96-8p

effects of [his] chronic migraine explains that the RFC ‘assessment

headaches in the RFC.” See Docket must include a narrative discussion

Entry 10 at 5. Shawn further contends describing how the evidence supports

that “[t]he ALJ erred by failing to each conclusion, citing specific

evaluate [his] need for frequent medical facts (e.g., laboratory

bathroom usage when assessing the findings) and nonmedical evidence

RFC.” Id. at 15. As explained in (e.g., daily activities, observations).’”

greater detail below, the Court agrees Monroe v. Colvin, 826 F.3d 176, 189

on both grounds and remands for (4th Cir. 2016) (internal quotations

further administrative proceedings. omitted). An ALJ need not discuss

every piece of evidence in making an

A. Standard for the RFC RFC determination. See Reid v.

Determination. Comm. of Soc. Sec., 769 F.3d 861, 865

(4th Cir. 2014). Yet, the ALJ “must

The RFC measures the most a build an accurate and logical bridge

claimant can do in a work setting from the evidence to [the]

despite the physical and mental conclusion.” Brown v. Commissioner,

limitations of his or her impairments 873 F.3d 251, 269 (4th Cir. 2017).

and any related symptoms (e.g., pain). “The RFC assessment must first

See 20 C.F.R. § 416.945; see also identify the individual’s functional

Dunn v. Colvin, 607 Fed. App’x 264, limitations or restrictions and assess

272 (4th Cir. 2015) (claimant’s RFC is his or her work-related abilities on a

“[a] medical assessment of what an function-by-function basis . . . . Only

individual can do in a work setting in [then] may RFC be expressed in terms

spite of the functional limitations and of the exertional levels of work,

environmental restrictions imposed sedentary, light, medium, heavy, and

by all of his or her medically very heavy.” SSR 96-8p, 1996 WL

determinable impairment(s)”) 374184, at *1.

(internal citation omitted); Hines v.

Barnhart, 453 F.3d 559, 562 (4th Cir. The Fourth Circuit has held that

2006). The RFC includes both a “meaningful review is frustrated when

“physical exertional or strength an ALJ goes straight from listing the

limitation” that assesses the evidence to stating a conclusion.”

claimant’s “ability to do sedentary, Thomas v. Berryhill, 916 F.3d 307,

light, medium, heavy, or very heavy 311 (4th Cir. 2019) (explaining that “a

work,” as well as “nonexertional proper RFC analysis has three

limitations (mental, sensory or skin components: (1) evidence, (2) logical

4

explanation, and (3) conclusion”). As at 595-96. In so doing, the ALJ need

noted earlier, the ALJ “must both not credit them if they conflict with

identify evidence that supports his the objective medical evidence or if

conclusion and ‘build an accurate and the underlying impairment could not

logical bridge from [that] evidence to reasonably be expected to cause the

his conclusion.’” Woods v. Berryhill, symptoms alleged. Id. Where the ALJ

888 F.3d 686, 694 (4th Cir. 2018) has considered the relevant factors,

(alteration in original) (quoting see 20 C.F.R. § 416.929(c)(3), and

Monroe, 826 F.3d at 189). An ALJ’s heard the claimant’s testimony and

failure to do so constitutes reversible observed his or her demeanor, the

error. See Lewis v. Berryhill, 858 F.3d Court will defer to the ALJ’s

858, 868 (4th Cir. 2017). Where an determination regarding those

ALJ’s “analysis is incomplete and subjective complaints. Shively v.

precludes meaningful review,” Heckler, 739 F.2d 987, 989 (4th Cir.

remand is appropriate. Monroe, 826 1984).

F.3d at 191.

Those relevant factors include:

Moreover, “[a]n ALJ assesses the

credibility of a claimant’s subjective (i) [Plaintiff’s] daily

statements about his condition as part activities;

of the RFC assessment,” Ladda v.

Berryhill, 749 F. App’x 166, 170 (4th (ii) The location, duration,

Cir. 2018) (unpublished), using a two- frequency, and intensity

part test: “First, there must be of [Plaintiff’s] pain or

objective medical evidence showing other symptoms;

‘the existence of a medical

impairment(s) which results from (iii) Precipitating and

anatomical, physiological, or aggravating factors;

psychological abnormalities and

which could reasonably be expected to (iv) The type, dosage,

produce the pain or other symptoms effectiveness, and side

alleged,’” Craig, 76 F.3d at 594 (citing effects of any medication

20 C.F.R. §§ 416.929(b), [Plaintiff] take[s] or

404.1529(b)). [has] taken to alleviate

his pain or other

If such an impairment exists, the ALJ symptoms;

must then consider, as the second

prong of the test, all available (v) Treatment, other than

evidence, including the claimant’s medication, [Plaintiff]

statements about pain, to determine receive[s] or [has]

whether the claimant is disabled. Id. received for relief of his

5

pain or other symptoms; source. Id. at *5. The ruling also notes

that “the extent to which the person’s

(vi) Any measures [Plaintiff] impairment-related symptoms are

use[s] or [has] used to consistent with the evidence of

relieve his pain or other record” will be considered and that

symptoms (e.g., lying flat “[c]onsistency and supportability

on [her] back, standing between reported symptoms and

for 15 to 20 minutes objective medical evidence is key in

every hour, sleeping on a assessing the RFC.” Id. at *8.

board, etc.); and

B. The ALJ’s Assessment Omitted

(vii) Other factors concerning Certain Support for its RFC

[Plaintiff’s] functional Finding.

limitations and

restrictions due to pain Shawn contends that “[t]he ALJ failed

or other symptoms. to adequately account for the

vocationally limiting effects of [his]

Last, SSR 19-4p also provides chronic migraine headaches in the

guidance on how to evaluate primary RFC.” See Docket Entry 10 at 5. As

headache disorders, such as explained in greater detail below, this

migraines, in disability claims. See objection is persuasive.

SSR 19-4p, 2019 WL 4169635 at *2.

The ruling notes that regulations Here, at step two, the ALJ found

require medically determinable without elaboration that Shawn’s

impairments be established by migraines were a severe impairment.

objective medical evidence from an (Tr. 20.) At step three, the ALJ

acceptable medical source; “a referenced Listing 11.02 (regarding

person’s statement of symptoms, a epilepsy), Listing 11.00 (regarding

diagnosis, or a medical opinion” will various forms of seizures), and SSR

not be used to establish the existence 19-4p (regarding headaches) and

of a medically determinable concluded without elaboration that

impairment; and a finding of Shawn had not met or equaled a

disability will not be made “based on listing. (Tr. 23.) As part of his step

a person’s statement of symptoms three analysis, in pertinent part, the

alone.” Id. The ruling indicates that a ALJ noted that “in February 2023,

primary headache disorder is when he was evaluated for headaches,

established as a medically no cognitive issues were

determinable impairment “by demonstrated, and his memory was

considering objective medical intact.” (Tr. 24, 233-40, 819-52, 1511-

evidence (signs, laboratory findings, 15.)

or both)” from an acceptable medical Next, the ALJ determined Shawn’s

6

RFC. The ALJ noted that Shawn period of time, currently impacts

testified he stopped working after his quality of life. There are some features

car accident in 2021 and that of cluster like episodes as well.

thereafter he experienced migraines Normal elemental neurological

several times a week with both light examination. Having at least

and noise sensitivity. (Tr. 26.) The headache 15+ per month.”).) The ALJ

ALJ acknowledged that Shawn next noted that during a January

testified that his migraines could last 2024 consultative examination he

from between two to three hours to an complained of weekly migraine

entire day. (Tr. 26.) The ALJ then headaches though he did not appear

observed that on November 4, 2022, to be in acute distress. (Tr. 28, 1518,

Shawn complained of migraines that 1520.)

occurred one to two times a week and

did not respond to Excedrin. (Tr. 27 The ALJ then turned to evaluating the

referencing Tr. 765 (“Bothering him medical opinions of record and made

most right now are migraines. He one reference to

often wakes up with bad ones, lately 1- headaches/migraines. Specifically,

2 times weekly. Takes excedrin [sic] the ALJ noted that on reconsideration

without much improvement. Gets a non-examining state agency medical

N/V, avoids light, sound, then consultant (Dr. Joan Redd) found

eventually resolves.”).) The ALJ noted Shawn capable of light work with

that, despite his complaints, Shawn postural and environmental

did not appear to be in acute distress. restrictions. (Tr. 29, 92-95.) The ALJ

(Tr. 27, 765.) concluded that this opinion was

“generally persuasive” and noted in

The ALJ further noted that in pertinent part that the need for

February of 2023 Shawn was postural and environmental

evaluated for headaches and stated restrictions was consistent with,

that they occurred at least fifteen among other impairments, migraines.

times a month. (Tr. 27 (“The same (Tr. 29, 92-95.) The ALJ’s RFC

month, he was evaluated for limited Shawn’s exposure to noise but

headaches. He said they occurred at did not include off task, absentee, or

least 15 times per month.”) (internal light sensitive limitations. (Tr. 25-26.)

citation omitted) referencing Tr. 826

(“presents for evaluation of headaches C. The ALJ’s Assessment of Shawn’s

that meet . . . [the] criteria for Migraines and Headaches Does

Migraine, present since, but Not Allow for Meaningful Review.

significantly worse in both severity

and frequency since a car accident The Court cannot conduct a

with significant trauma including loss meaningful review of the ALJ’s

of consciousness for undisclosed decision based on the analysis in the

7

record. into the RFC determination.

Specifically, Dr. Redd indicated that

First, the ALJ acknowledges Shawn’s Shawn should avoid concentrated

testimony that he is sensitive to light exposure to extreme heat, cold,

and noise, but then—without humidity, noise, fumes (odors, dusts,

adequate explanation—only includes gases, and poor ventilation), and

a noise limitation in the RFC. (Tr. 26, hazards (machinery and heights). (Tr.

49 (“My migraines, I get several times 93-94.) However, she explained after

a week now. And they’re very extreme, this that Shawn should also avoid

too, to where very sensitive to light concentrated exposure to

and sound. I have to put myself in the “intense/flashing lights.” (Tr. 93.)

bedroom and cut off all the lights and

don’t let nobody in because it hurts so While the ALJ’s RFC determination

bad, just the sound and light and it includes the other limitations set

makes me sick.”).) forth above, it omits any limitation

regarding light. (Tr. 26.) Given

This disconnect alone would require Shawn’s testimony regarding light

remand for additional administrative sensitivity, it is unclear from the

proceedings. See Myers v. Saul, No. record whether this was an

1:20CV420, Docket Entry 16 at 8 intentional or accidental omission.

(M.D.N.C. July 2, Regardless, it prevents substantial

2021), recommendation adopted, slip evidence review. See Harvey J. L. v.

op. (M.D.N.C. July 20, 2021) (remand O’Malley, No. 1:23CV162, 2024 WL

warranted for further findings related 6968939, at *5 (M.D.N.C. Jan. 23,

to light sensitivity); Southard v. Saul, 2024) (remand warranted where ALJ

No. CIV-19-307-STE, 2019 WL omitted restrictions in medical

7285554, at *4 (W.D. Okla. Dec. 27, opinions otherwise credited); Green

2019) (finding reversible error where v. Saul, No. 1:19CV1175, 2020 WL

the ALJ failed to accommodate or 5633287, at *4 (M.D.N.C. Sept. 21,

properly discount claimant’s well- 2020) (same), recommendation

supported allegations of adopted by Slip Op. (Oct. 8, 2020);

photophobia). Martin v. Berryhill, No. 1:16CV171,

2017 WL 728234, at *5 (M.D.N.C.

Second, the ALJ further explained Feb. 23, 2017) (same)

that he found the medical opinion of recommendation adopted by Slip Op.

the non-examining state agency (March 24, 2017).

physician (Dr. Joan Redd) who

evaluated the record on Third, and most importantly, the ALJ

reconsideration to be “generally made no findings about the frequency

persuasive” (Tr. 29), and yet did not and severity of Shawn’s headache-

incorporate one of its key findings related symptoms, which are critical

8

to the overall disability analysis has three components: (1)

determination. See, e.g., Woody v. evidence, (2) logical explanation, and

Kijakazi, No. 22-1437, 2023 WL (3) conclusion”).3 A remand is

5745359, at *1 (4th Cir. Sept. 6, 2023) therefore in order.

(ALJ’s failure to reach an express

conclusion on the “potentially The Commissioner’s arguments to the

dispositive issue of whether the contrary are unavailing. The

frequency and severity” of claimant’s Commissioner spends much of his

headaches affected the RFC finding brief setting forth reasons for

“is an error of law that necessitates affirming the ALJ’s decision that the

remand”); see also generally Young v. ALJ never specifically set forth.

Barnhart, 362 F.3d 995, 1002 (7th (Docket Entry 11 at 8-13.) These are

Cir. 2004) (remanding where “[t]he impermissible post hoc agency

ALJ [did] not sufficiently connect[] justifications. See Anderson v. Colvin,

the dots between [the plaintiff’s] No. 1:10CV671, 2014 WL 1224726, at

impairments, supported by *1 (M.D.N.C. Mar. 25, 2014)

substantial evidence in the record, (concluding that the Court may not

and the RFC finding”). consider post-hoc rationalizations

and may only consider reasons first

These omissions preclude judicial set forth by the administrative

review. Shawn was assessed for agency) (citing Securities & Exch.

several severe impairments including Comm'n v. Chenery Corp., 332 U.S.

migraines. (Tr. 21.) The ALJ’s 194 (1947)). By way of non-exhaustive

decision does not adequately address example, the Commissioner contends

Shawn’s migraines and instead that Shawn had little treatment for

merely partially summarizes the migraines and points out that he did

record and then renders a conclusion, not identify migraines when

skipping the formation of a logical completing disability paperwork.

bridge between the RFC (Docket Entry 11 at 8-9.) But the ALJ

determination and the medical never made such findings in his

record. See Thomas, 916 F.3d at 311 decision.4

(explaining that “a proper RFC Beyond this, Shawn testified at his

3 See Myers v. Saul, No. 1:20CV420, (same), recommendation adopted, slip

Docket Entry 16 at 12 (M.D.N.C. July 2, op. (M.D.N.C. Aug. 23, 2019).

2021) (remand warranted where it was

impossible to trace the logical path of the 4 Despite the Commissioner’s objections

ALJ’s reasoning), recommendation to the contrary (Docket Entry 11 at 8-13),

adopted, slip op. (M.D.N.C. July 20, the ALJ also fails to address evidence that

2021); Porterfield v. Berryhill, No. would be logically related to the analysis

1:18CV319, Docket Entry 18 at 7 of Shawn’s migraine headaches, such as

(M.D.N.C. Aug. 6, 2019) certain treatment modalities (like

9

hearing that he gets migraines suggests that these [diagnostic] tests

“several times a week now,” that they can confirm either the existence of

are “very sensitive to light and sound,” migraines or their likely severity.”)

that some last a “whole day” and (citation omitted) (brackets omitted);

others last “only two or three hours,” Harrington v. Colvin, No. 7:15-cv-20-

that he puts himself in his “bedroom FL, 2016 WL 320144, at *4 (Jan. 4,

and cut[s] off all the lights . . . because 2016 E.D.N.C.) (ALJ reliance on the

it hurts so bad,” and that he has “to unremarkable result of CT scan

stay in bed.” (Tr. 49.) The vocational “merely suggests that the cause of her

expert testified that an individual off headaches cannot be identified

task more than 15% of the work day or through such testing, not that she

absent two or more days a month does not suffer from headaches.”);

would be unable to work. (Tr. 59.) The Strickland v. Barnhart, 107 F. App’x

dispositive question of migraines was 685, 689 (7th Cir. 2004)

thus before the ALJ. (unpublished) (“The ALJ . . . appears

to have thought, incorrectly, that the

The Commissioner also points to [normal] neurological test results

instances of Shawn’s normal mental somehow undercut [plaintiff’s] claims

status findings upon examination as that her migraines are severely

support for the ALJ’s RFC painful.”).

determination, some of which the ALJ

noted and some of which he did not. As noted, the larger problem here is

(Docket Entry 11 at 9.) However, the that the ALJ goes straight from listing

absence of objective findings of an this evidence to setting forth Shawn’s

intermittent impairment during a RFC, which accommodates some of

given medical examination is not his alleged limitations (phonophobia)

necessarily dispositive of the issue of but omits others (photophobia,

migraine pain. See, e.g., Patricia M. v. absenteeism, time off task) making it

Bisignano, No. 1:24CV691, 2025 WL impossible to trace the ALJ’s

2697242, at *10 (M.D.N.C. Sept. 22, reasoning. (Tr. 25-30.)

2025) (“findings of normal attention,

concentration, orientation, and fund The Commissioner also points to

of knowledge had little probative Shawn’s activities of daily living

force to detract from Plaintiff’s (Docket Entry 11 at 10) but again fails

reports of disabling headaches”); to acknowledge that the intermittent

Taylor v. Astrue, No. 7:10-cv-149-FL, nature of migraine headaches would

2011 WL 2669290 *3 (E.D.N.C. Jul. 7, only periodically impact daily

2011) (“[N]othing in the record activities. See Patricia M., 2025 WL

injections of Emgality for migraines (Tr. limitation described above).

844-45, 944, 1519, 48)) and opinion

evidence (like Dr. Redd’s photophobia

10

2697242, at *9 (“[T]he ALJ failed to when assessing the RFC.” (Docket

acknowledge the possibility that Entry 10 at 15.) As with its assessment

Plaintiff engaged in the activities cited of Shawn’s migraine-related

by the ALJ on days when Plaintiff did limitations, the ALJ’s summation of

not experience a severe migraine that the evidence related to Shawn’s IBS

required her to lie down in a dark lacks a logical bridge to his RFC

room[.]”) (collecting cases). determination omitting extra

bathroom breaks or time off-task.

Finally, the Commissioner also points

to the medical opinion evidence. More specifically, in his decision, at

(Docket Entry 11 at 9.) However, as step two and without elaboration, the

explained, Dr. Redd’s opinion actually ALJ noted that Shawn’s IBS was a

sets forth a migraine-related severe impairment. (Tr. 21 (“The

limitation to account for Shawn’s claimant has the following severe

alleged light sensitivity, which the impairments: status-post motor

ALJ failed to address. For all of these vehicle accident with intestinal

reasons, and consistent with the injury/hernia, partial bowel resection

practice of other judges in this district and irritable bowel syndrome (IBS) . .

in similar circumstances,5 a remand . .”).)

for further administrative

proceedings is proper. Next, at step three, the ALJ noted that

Shawn’s “gastrointestinal diseases

D. The ALJ’s Assessment of Shawn’s have been considered under listings

Bathroom Usage Does Not Allow 5.06 and 5.08.” (Tr. 24.) In support,

for Meaningful Review. the ALJ set forth the pertinent criteria

for each listing and stated without

Shawn further contends that “[t]he elaboration or reference to the record

ALJ erred by failing to evaluate [his] that it had not been met. (Tr. 24.)

need for frequent bathroom usage Next, the ALJ assessed Shawn’s RFC.

5 See, e.g., Patricia M., 2025 WL WL 307347 (M.D.N.C. Jan. 27, 2025);

2697242, at *8-12; Myers, No. 1:20-cv- Darlene A. v. Colvin, No. 1:23CV976,

00420, Docket Entry 16 at 4- 2024 WL 5262869, at *4-7 (M.D.N.C.

13, recommendation adopted, slip op. Dec. 31, 2024); Thomas H. v. O’Malley,

(M.D.N.C. July 20, 2021); Porterfield, No. 1:22CV876, 2024 WL 1350070, at

No. 1:18-cv-00319, Docket Entry 18 at 3- *4-5 (M.D.N.C. Mar. 29, 2024); Stephen

10, recommendation adopted, slip op. B. v. O’Malley, No. 1:22CV1026, 2024

(M.D.N.C. Aug. 23, 2019); Victor R. v. WL 945065, at *6 (M.D.N.C. Mar. 5,

Colvin, No. 1:24CV205, 2025 WL 33699, 2024); Jennifer V.T. v. Kijakazi, No.

at *4-9 (M.D.N.C. Jan. 6, 2025), 1:22CV417, 2023 WL 6388203, at *8

recommendation adopted sub nom. (M.D.N.C. Sept. 29, 2023).

Rivera v. Colvin, No. 1:24-CV-205, 2025

11

In pertinent part, the ALJ that in February of 2024, Shawn

summarized Shawn’s testimony as presented to the emergency room for

follows: “[t]he claimant testified he abdominal pain over his hernia site

stopped working after his accident in and also complained of diarrhea. (Tr.

2021. He had bowel resection and had 28, 1543-72, 1546 (“Patient with

a hernia. He experiences pain in his history of abdominal hernia presents

stomach and has IBS.” (Tr. 26.) The with progressively worsening

ALJ then correctly observed that abdominal pain, nausea, vomiting

Shawn was involved in a motor and bowel incontinence that has been

vehicle accident on his alleged onset going on since Monday but has gotten

date. (Tr. 27, 310.) An “exploratory worse today.”).) The ALJ pointed out

laparotomy was performed [which] that Shawn’s partner reported a

revealed ileal mesentery with active possible overdose in that his

oozing; the bowel was deemed non- symptoms began after taking an

viable[;] and 15cm of the ileum was excessive amount of medication and

resected.” (Tr. 27, 312-13.) Shawn was drinking heavily. (Tr. 28, 1549-50.)

subsequently seen with complaints of Shawn denied this and left the

rectal bleeding and diarrhea and was emergency room against medical

found to have a ventral hernia and advice. (Tr. 28-29, 1543, 1548.)

internal hemorrhoids that would

eventually require repair. (Tr. 27, 759, The ALJ then considered the medical

772-74.) opinions. In pertinent part, the ALJ

noted that the light work

The ALJ then noted that on recommended by the non-examining

November 4, 2022, Shawn state agency consultant was

complained of “diarrhea (improved consistent with his “abdominal pain.”

with cholestyramine).” (Tr. 27, 764.) (Tr. 29, 80-82, 92-95.) However, the

In February of 2023, the ALJ pointed ALJ’s RFC did not accommodate any

out, Shawn’s provider noted a need for additional bathroom breaks

“concern for fecal incontinence and or time off task. (Tr. 25-26.)

passing bowel movements without

realizing it” though on examination In sum, the ALJ summarized evidence

Shawn had mild tenderness related to and concluded that the RFC

his hernia but an otherwise normal accommodates Shawn’s IBS.

exam. (Tr. 27, 832-33.) The ALJ next However, Fourth Circuit precedent is

noted that Shawn complained of clear that meaningful review is

diarrhea and abdominal pain at a frustrated where an ALJ goes straight

January 2024 consultation, where he from listing evidence to stating a

could not toe walk due to abdominal conclusion. See Woods v. Berryhill,

pain. (Tr. 28, 1518-20.) 888 F.3d 686, 694 (4th Cir. 2018).

The ALJ also accurately pointed out And beyond this, the Fourth Circuit

12

has pointed out that “[o]bviously, the the day goes on, but his “extreme

need to visit the bathroom many diarrhea all through the day does not

times throughout the day impacts subside. I mean it keeps me going to

one’s ability to work.” Dowling v. the bathroom.” (Tr. 51.) The

Comm’r of Soc. Sec. Admin., 986 F.3d vocational expert testified that if an

377, 389 (4th Cir. 2021) (“[T]he ALJ individual were off task 15% of the

should evaluate the frequency at workday, including bathroom breaks

which Appellant needed to use the beyond customary breaks, he could

bathroom and analyze how that not hold a job. (Tr. 58-59.) The

restriction impacted her ability to vocational expert also testified that if

work.”), superseded by regulation on an individual required between five to

other grounds recognized by six unscheduled bathroom breaks

Drumgold v. Comm’r of Soc. Sec., 144 lasting more than approximately 10

F.4th 596, 604 (4th Cir. 2025). minutes each time, he would not be

able to perform competitive

Thus, while the ALJ here did not employment. (Tr. 61.)

necessarily have to include

accommodations for bathroom However, despite its materiality to the

breaks in the RFC, he did have an outcome of the case, the ALJ did not

obligation to explain (and support analyze whether Shawn needed

with substantial evidence) his implicit additional bathroom breaks when

finding that bathroom breaks beyond assessing the RFC. (Tr. 25-30.) Nor

normal breaks in a workday were did he make an allowance for time off

unnecessary. See SSR, 1996 WL task or explain why an allowance was

374185, at *6 (characterizing eight- unnecessary (Tr. 25-30), even though

hour workday as having “a morning he found that Shawn’s intestinal

break, a lunch period, and an damage with bowel resection, hernia,

afternoon break at approximately 2- and IBS constituted severe

hour intervals”). impairments at step two and

discussed evidence (summarized

This error is not harmless. Shawn above) related to that impairment in

testified that his intestinal damage the decision (Tr. 21). The ALJ’s

since his car accident (including medical summary contains an

removal of parts of his intestines) insufficient logical bridge to the RFC

“keeps me sick and hurting on a daily which does not account for these

basis where I use the bathroom five, issues. (Tr. 27-30.)

six times a day. I have to run back and

forth. I stay sick. Nauseated.” (Tr. 43.) Remand for further administrative

Sometimes it is more frequent. (Tr. proceedings is therefore warranted.

48.) He alleged waking up nauseous See, e.g., Sharee B. v. Bisignano, No.

and vomiting, which might subside as 5:25-CV-00045, 2025 WL 4065846,

13

at *16 (S.D.W. Va. Dec. 17, 2025) why Shawn did not require additional

(remanding where ALJ “provided breaks or time off task beyond normal

absolutely zero analysis regarding the breaks to account for his bathroom

effect on Claimant’s RFC of the usage. (Docket Entry 11 at 18-19.) In

ongoing Crohn’s-related symptoms” support, he points to medical

or “any analysis as to whether or not evidence the ALJ relied upon,

the ‘ongoing symptoms of Crohn’s indicating that Shawn reported

disease’ post-bowel resection would improvement with his bowel

cause her to be off-task a significant medication. (Id. at 19, Tr. 764-65.)

portion of the workday”); Joanne P. v. Nevertheless, even if the ALJ

Dudek, No. 5:24-CV-00384, 2025 WL accurately found that Shawn’s IBS

1510664, at *18 (S.D. W.Va. Apr. 22, related symptoms improved, the ALJ

2025) (remand appropriate where did not find that they ceased entirely.

ALJ determination lacked basis for no The lack of explanation makes it

RFC limitations regarding bathroom impossible for the Court to determine

breaks); Laura J v. O’Malley, No. whether the ALJ’s determination is

7:22-CV-00402, 2024 WL 1954157, at supported by substantial evidence.

*5 (W.D. Va. Feb. 14, 2024) (same) See Sharee B., 2025 WL 4065846, at

(citation omitted); Sharp v. Comm’r *16 (relying on similar reasoning).

of Soc. Sec., No. 1:21-CV-00015-FDW,

2022 WL 949873, at *4 (W.D.N.C. The Commissioner also points to

Mar. 29, 2022) (same). roughly seven hundred pages of

record evidence and contends that it

And the Commissioner’s objections as demonstrates that Shawn “did not

to this issue are not persuasive. While require ongoing or extensive

the Commissioner asserts that treatment for bowel complaints or

Shawn’s objection is no more than a urinary frequency during the relevant

“disagreement with the conclusions period.” (Docket Entry 11 at 19

the ALJ drew from the evidence, referencing 743-852, 868-1510, 1527-

which is not a valid basis for remand,” 42.) But the ALJ never made such a

(Docket Entry 11 at 18), this is not finding in his decision and post hoc

what Shawn is contending. Rather, explanations like this by the

Shawn contends (and the Court Commissioner are not permitted. See

agrees) that the ALJ’s analysis here Anderson, 2014 WL 1224726, at *1.

lacks a logical bridge between the RFC

and the omission or exclusion of time The Commissioner also points out

off task or extra breaks to use the that no medical opinion in the record

bathroom. (Docket Entry 10 at 15.) indicates that Shawn required

additional breaks or off task time to

Next, the Commissioner contends use the bathroom. (Docket Entry 11 at

that the ALJ adequately explained 19.) However, it was the ALJ who

14

concluded that Shawn’s IBS was a decision has no preclusive effect, as it

severe impairment at step two and is vacated and the new hearing is

who therefore had an obligation to conducted de novo).°®

provide a logical bridge between his

RFC determination and the evidence V. CONCLUSION

related to Shawn’s IBS. That did not

occur here. IT IS THEREFORE ORDERED

that the Commissioner’s decision

In the end, the point here as to both finding no disability be REVERSED

Shawn’s migraines and IBS is not that and that the matter be REMANDED

the record necessarily compels to the Commissioner under sentence

accommodation for light sensitivity, four of 42 U.S.C. § 405(g). The

time off task, absenteeism, or extra Commissioner should be directed to

breaks in the RFC, but that the remand the matter to the ALJ for

evidence here triggers the ALJ’s duty proceedings consistent with this

to explain their omission. Because the Order. To the extent that Shawn seeks

ALJ did not adequately do so, remand an immediate award of benefits, the

is required. Finally, the undersigned request is DENIED.

declines consideration of the

additional issue(s) raised by Shawn at A Judgment remanding this action

this time. Hancock v. Barnhart, 206 will be entered contemporaneously

F. Supp. 2d 757, 763-64 n.3 (W.D. Va. with this Order.

2002) (on remand, the ALJ’s prior

J aGi McFadden

United States Magistrate Judge

March 8, 2026

6 Shawn’s final objection is that “[t]he correctly points out, the ALJ never

ALJ erred by failing to perform a addressed a restriction imposed by one of

function-by-function evaluation of [his] his physicians limiting him to lifting no

contested and relevant abilities to lift, more than ten pounds. (/d. at 11-12, Tr.

carry, push and pull weight.” See Docket 476.) Nevertheless, in limiting Shawn to

Entry 10 at 10. Because remand is proper light work, the ALJ concluded that he

for other reasons discussed above, there could lift up to twenty pounds. 20 CFR §

is no need to address that final objection. 416.967(b). The Commissioner may, if he

Nevertheless, the Court will note that, at so chooses, evaluate this apparent

least on its face, Shawn’s argument discrepancy further on remand.

seems to carry some force. As Shawn

15