# Crispens

> District Court, S.D. Ohio · March 13, 2026

URL: https://www.frixlaw.com/law-library/cases/11338767

## Case

- **Full name:** Helen C. v. Commissioner of Social Security
- **Court:** District Court, S.D. Ohio
- **Decided:** March 13, 2026
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

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## Opinion text

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION

HELEN C.,1 : Case No. 2:25-cv-00166
:
Plaintiff, : Magistrate Judge Caroline H. Gentry
: (by full consent of the parties)
vs.
:
:
COMMISSIONER OF SOCIAL
:
SECURITY,
:
Defendant. :

DECISION AND ORDER

Plaintiff filed an application for Disability Insurance Benefits in August 2022.
Plaintiff’s claim was denied initially and upon reconsideration. After a hearing at
Plaintiff’s request, the Administrative Law Judge (ALJ) concluded that Plaintiff was not
eligible for benefits because she was not under a “disability” as defined in the Social
Security Act. The Appeals Council denied Plaintiff’s request for review. Plaintiff
subsequently filed this action.
Plaintiff seeks an order remanding this matter to the Commissioner for the award
of benefits or, in the alternative, for further proceedings. The Commissioner asks the
Court to affirm the non-disability decision. For the reasons set forth below, this Court
REVERSES the Commissioner’s decision and REMANDS for further proceedings.

1 See S.D. Ohio General Order 22-01 (“The Committee on Court Administration and Case Management
of the Judicial Conference of the United States has recommended that due to significant privacy concerns
in social security cases federal courts should refer to claimants only by their first names and last
initials.”).
I. BACKGROUND
Plaintiff asserts that she has been under a disability since March 10, 2022. At that

time, she was fifty-two years old and was considered a “person closely approaching
advanced age.” 20 C.F.R. § 404.1563(d). Plaintiff has a “high school education and
above.” 20 C.F.R. § 404.1564(b)(4).
The evidence in the Administrative Record (“AR,” Doc. No. 6) is summarized in
the ALJ’s decision (“Decision,” Doc. No. 6-2 at PageID 36-54), Plaintiff’s Statement of
Errors (“SE,” Doc. No. 8), the Commissioner’s Memorandum in Opposition (“Mem. In

Opp.,” Doc. No. 10), and Plaintiff’s Reply Memorandum (“Reply,” Doc. No. 11). Rather
than repeat these summaries, the Court will discuss the pertinent evidence in its analysis
below.
II. STANDARD OF REVIEW
The Social Security Administration provides Disability Insurance Benefits to

individuals who are under a “disability,” among other eligibility requirements. Bowen v.
City of New York, 476 U.S. 467, 470 (1986); see 42 U.S.C. §§ 402, 423(a)(1), 1382(a).
The term “disability” means “the inability to do any substantial gainful activity by reason
of any medically determinable physical or mental impairment which . . . has lasted or can
be expected to last for a continuous period of not less than 12 months.” 20 C.F.R.

§ 404.1505(a).
This Court’s review of an ALJ’s unfavorable decision is limited to two inquiries:
“[W]hether the ALJ applied the correct legal standards and whether the findings of the
ALJ are supported by substantial evidence.” Blakley v. Comm’r of Soc. Sec., 581 F.3d
399, 406 (6th Cir. 2009); see 42 U.S.C. § 405(g) (“The findings of the Commissioner of
Social Security as to any fact, if supported by substantial evidence, shall be conclusive.”).

“Unless the ALJ has failed to apply the correct legal standards or has made findings of
fact unsupported by substantial evidence,” this Court must affirm the ALJ’s decision.
Emard v. Comm’r of Soc. Sec., 953 F.3d 844, 849 (6th Cir. 2020). Thus, the Court “may
not try the case de novo, nor resolve conflicts in evidence, nor decide questions of
credibility.” Id.
“Under the substantial-evidence standard, a court looks to an existing

administrative record and asks whether it contains ‘sufficien[t] evidence’ to support the
agency’s factual determinations.” Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019)
(citation omitted). This limited standard of review does not permit the Court to weigh the
evidence and decide whether the preponderance of the evidence supports a different
conclusion. Instead, the Court is confined to determining whether the ALJ’s decision is

supported by substantial evidence, which “means—and means only—‘such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.’” Id.
(citation omitted). This standard “presupposes that there is a zone of choice within which
the decisionmakers can go either way, without interference by the courts.” Mullen v.
Bowen, 800 F.2d 535, 545 (6th Cir. 1986). Thus, the Court may be required to affirm the

ALJ’s decision even if substantial evidence in the record supports the opposite
conclusion. Key v. Callahan, 109 F.3d 270, 273 (6th Cir. 1997).
The other line of judicial inquiry—reviewing the correctness of the ALJ’s legal
criteria—may result in reversal even when the record contains substantial evidence
supporting the ALJ’s factual findings. Rabbers v. Comm’r of Soc. Sec., 582 F.3d 647, 651
(6th Cir. 2009). “[E]ven if supported by substantial evidence, ‘a decision of the

Commissioner will not be upheld where the SSA fails to follow its own regulations and
where that error prejudices a claimant on the merits or deprives the claimant of a
substantial right.’” Id. (citations omitted). Such an error of law will require reversal even
if “the outcome on remand is unlikely to be different.” Cardew v. Comm’r of Soc. Sec.,
896 F.3d 742, 746 (6th Cir. 2018) (internal quotations and citations omitted).

III. FACTS
A. The ALJ’s Factual Findings
The ALJ was tasked with evaluating the evidence related to Plaintiff’s application
for benefits. In doing so, the ALJ considered each of the five sequential steps set forth in
the Social Security regulations. See 20 C.F.R. § 404.1520. The ALJ made the following
findings of fact:

Step 1: Plaintiff has not engaged in substantial gainful activity since March
10, 2022, the alleged onset date.

Step 2: She has the severe impairments of osteoarthritis, degenerative disc
disease of the lumbar spine, gastritis, irritable bowel syndrome,
gastroesophageal reflux disease, type II diabetes mellitus,
tendinosis/tendinitis, and insomnia.

She has the nonsevere impairments of hyperlipidemia, hypertension,
squamous cell carcinoma, and residuals of a remote left knee
surgery.

Her alleged impairments of dementia and Alzheimer’s disease are
not medically determinable impairments because they are not
validated by objective evidence.
Step 3: She does not have an impairment or combination of impairments
that meets or equals the severity of one in the Commissioner’s
Listing of Impairments, 20 C.F.R. Part 404, Subpart P, Appendix 1.

Step 4: Her residual functional capacity (RFC), or the most she can do
despite her impairments, see Howard v. Comm’r of Soc. Sec., 276
F.3d 235, 239 (6th Cir. 2002), consists of light work as defined in 20
C.F.R. § 404.1567(b), subject to the following limitations:
“[Plaintiff] can never climb ladders, ropes, or scaffolds; can
occasionally climb ramps and stairs; can occasionally stoop, kneel,
crouch, and crawl; and can frequently balance as that term is defined
in the Dictionary of Occupational Titles (DOT).”

She is able to perform past relevant work as a contract bid
administrator, a procurement manager, and composite work
consisting of elements of a contract manager and supervisor.

Step 5: In addition to her past relevant work, considering Plaintiff’s age,
education, work experience, and RFC, there are jobs that exist in
significant numbers in the national economy that she can perform.

(Decision, Doc. No. 6-2 at PageID 41-49.) These findings led the ALJ to conclude that
Plaintiff does not meet the definition of disability. (Id. at PageID 49.)
B. Plaintiff’s Cognitive Complaints
1. Plaintiff’s self-reported symptoms
Plaintiff complained of memory loss, anxiety, depression, and difficulty with
understanding, remembering, concentrating, paying attention, following written and
spoken instructions, and handling changes in routine. (AR, Doc. No. 6-6 at PageID 208-
09.) She found it difficult to remember “what [she] did day to day at times” and to
remember people she did not see often. (Id. at PageID 202.) She did not need reminders
to care for her personal needs but did need to set alarms to remind her to take
medications. (Id. at PageID 205.)
During the November 2023 hearing, Plaintiff testified that she had been diagnosed
with the onset of Alzheimer’s and dementia and that her memory issues had worsened in

the past six months. (AR, Doc. No. 6-2 at PageID 69.) She experienced difficulty with
recall and recognizing people. (Id.) She could focus for approximately twenty minutes
when reading. (Id. at PageID 70-71.) She still needed to set alarms to remind herself to
take her medications. (Id.)
2. Objective medical evidence
Plaintiff underwent a neurological evaluation in August 2021. (AR, Doc. No. 6-7

at PageID 392-97.) She reported a family history of Alzheimer’s dementia and a one-year
history of progressive memory loss. (Id. at PageID 393.) She experienced daily memory
loss for short- and long-term events. (Id.) Plaintiff reported being “increasingly
forgetful,” repeating herself in conversations, and having difficulty with word-finding
and following conversations. (Id.) Sumaiya Salim, M.D. noted that Plaintiff’s scores on

the Montreal Cognitive Assessment (MOCA) were “quite good” but noted that Plaintiff
“disproportionately missed recall,” which was “consistent with [Plaintiff’s] complaints of
primarily memory loss.” (Id. at PageID 392.) Dr. Salim recommended that Plaintiff
undergo a neuropsychological examination, brain MRI, and laboratory testing. (Id.)
A September 2021 MRI of the brain was normal (AR, Doc. No. 6-7 at PageID

399.) During a neuropsychological evaluation in February 2022, Plaintiff stated that her
memory difficulties with recent and remote events had “gradually worsened” over the
past year. (AR, Doc. No. 6-7 at PageID 343.) Plaintiff also reported difficulty with
forgetting conversations, repeating herself, word-finding, maintaining attention, and
losing her train of thought. (Id. at PageID 344.) Plaintiff stated that she was independent
in her basic activities of daily living but benefitted from following a routine and

“sometimes forg[ot] whether she completed a task” if she deviated from her routine. (Id.)
Plaintiff also used calendars and reminders to manage appointments and medications. She
occasionally forgot to pay bills. (Id.)
Dr. Salim reported that the neuropsychological testing showed a “broadly average
cognitive profile” with “some evidence of variable task engagement.” (AR, Doc. No. 6-7
at PageID 343, 346.) Dr. Salim noted that the testing showed below average functioning

in the domains of fund of knowledge and semantic fluency, and exceptionally low scores
in constructional drawing. (Id. at PageID 343, 345.) The testing also indicated mild
depression and elevated anxiety. (Id. at PageID 343, 346.) Dr. Salim concluded that
Plaintiff did “not meet criteria for a neurocognitive disorder” and found “no evidence to
suggest that [Plaintiff was] experiencing the early stages of a neurodegenerative process.”

(Id. at PageID 343.) Dr. Salim further stated: “Rather, the etiology of her mild cognitive
inefficiencies is likely multifactorial. Potential contributing factors include worry and
recent stressors, chronic pain, and poor sleep, although she stated that her sleep has
improved with medication.” (Id. at PageID 343.)
C. Osteoarthritis, Degenerative Disc Disease, and Tendinosis/Tendinitis

1. Plaintiff’s self-reported symptoms
Plaintiff stated that the combination of her physical conditions caused difficulty
with lifting, walking, sitting, standing, squatting, bending, kneeling, and climbing stairs.
(AR, Doc. No. 6-6 at PageID 208.) She reported that she needed to change positions
often and had difficulty sleeping at night because of the discomfort caused by these
conditions. (Id. at PageID 204, 207.) She could prepare simple meals and do light

housework, although her husband did the cooking and helped with activities such as
carrying loads of laundry. (Id. at PageID 205.)
During the November 2023 hearing, Plaintiff testified that she experienced pain in
her hip and lower back when sitting, standing and lying down, and also had numbness
and tingling in her legs and back. (AR, Doc. No. 6-6 at PageID 67-68, 72-73.) She also
testified that she took Gabapentin and Morphine to manage the pain, as Oxycodone had

not alleviated it. (Id. at PageID 69.)
2. Objective medical evidence
Orthopedic records show that Plaintiff received treatment and took medication for
knee pain at least as early as January 2021. (AR, Doc. No. 6-7 at PageID 356.) In
December 2021, she continued to complain of chronic pain and difficulty climbing stairs,

although she reported that her use of a cream and patches decreased the severity of her
symptoms. (Id. at PageID 370.) A physical examination showed no effusion and full
range of motion, although Joseph Ruane, D.O. also documented inferior peripatellar pain
and minimal crepitus. (AR, Doc. 6-7 at PageID 370.)
March 2022 right hip x-rays showed a “calcific structure suspicious for an intra-

articular body” but were otherwise normal and showed no femoroacetabular
osteoarthritis. (AR, Doc. No. 6-7 at PageID 378.) During an orthopedic follow-up visit in
March 2022, Plaintiff complained that her knee and right hip pain had increased over the
past two months. (Id. at PageID 374.) She also complained of some weakness, numbness,
and paresthesias in the right leg. (Id.) Dr. Ruane reported that the physical examination
showed “some pain at end range” upon right hip range of motion testing, modest

tenderness of the lateral soft tissues, increased pain with seated bench testing, altered
sensation of the leg, positive Trendelenburg testing of the right hip, and decreased (4/5)
abduction. (Id.) Dr. Ruane increased Plaintiff’s gabapentin dosage and recommended
EMG testing. (Id. at PageID 375.) EMG testing and a nerve conduction study in April
2022 were normal. (Id. at PageID 405.) Plaintiff began physical therapy for her pain
complaints later in April 2022. (Id. at PageID 606.)

In June 2022, Plaintiff told Dr. Ruane that she continued to experience left knee
pain, as well as right hip pain and discomfort. (AR, Doc. No. 6-7 at PageID 382.)
According to Dr. Ruane, Plaintiff’s gait was “not noticeably antalgic,” but he otherwise
documented “strongly positive” Trendelenburg signs, diffuse and nonspecific discomfort
to palpation, hip flexor pain and weakness, and diffuse pain and crepitus of the left knee.

(Id.) A right hip MRI taken later that month showed tendinosis and partial tearing of the
right gluteus minimus insertion on the greater trochanter, tendinosis and partial tearing of
the right hamstring origin, and a tear of the right anterior superior labrum. (AR, Doc. No.
6-8 at PageID 775.) After reviewing the MRI report, Dr. Ruane performed a right hip
diagnostic ultrasound and injection in July 2022. (AR, Doc. No. 6-7 at PageID 381, 434.)

At an orthopedic follow-up visit in August 2022, Plaintiff reported that she
received no relief from the diagnostic injection. (AR, Doc. No. 6-7 at PageID 436.) Dr.
Ruane again documented examination abnormalities that included right hip tenderness,
positive Trendelenburg testing, and decreased (4/5) strength during right hip abduction.
(Id.) Dr. Ruane reported that the June 2022 right hip ultrasound showed gluteus minimus
tendinopathy with a low-grade partial-thickness tear of the gluteus minimus, as well as

severe gluteus medius tendinopathy with a low-grade partial-thickness tear of the gluteus
medius. (Id. at PageID 437.) Dr. Ruane thereafter administered a right ischial tuberosity
and hamstring injection. (Id. at PageID 438.)
Plaintiff nevertheless continued to complain of pain at the next orthopedic visit in
September 2022. (Id. at PageID 440.) Dr. Ruane again documented several abnormal
examination findings, including limited range of motion, a short stride length, and

difficulty with toe and heel walking, although Plaintiff’s tandem gait was intact. (Id.) Dr.
Ruane also noted that lumbar spine x-rays showed mild to moderate multilevel
degenerative changes, including disc degeneration and facet arthropathy, that were most
notable at the L4-5 and L5-S1 levels. (Id. at PageID 441.) Dr. Ruane noted: “[Plaintiff]
presents with right L5 radiculopathy secondary to disc degeneration and facet arthropathy

likely contributing to foraminal stenosis. I do think that she has some element of opioid-
induced hyperalgesia as well.” (Id.) Later that month, Plaintiff told Dr. Ruane that the
injections and physical therapy were of “no help.” (AR, Doc. No. 6-8 at PageID 803.) In
October 2022, Plaintiff told Dr. Ruane that her hip pain remained “intense.” (AR, Doc.
No. 6-7 at PageID 595.) Dr. Ruane noted that although Plaintiff rated her pain at a level

of nine out of ten (with ten being the highest pain), she “fortunately appear[ed] to be
rather comfortable.” (Id.) Dr. Ruane further noted that Plaintiff may have developed a
tolerance to her pain medication, and so he recommended pain management treatment.
(Id. at PageID 596.)
Plaintiff began treatment with pain management physician Andrew McNicol,
M.D. in November 2022. (AR, Doc. No. 6-7 at PageID 726.) She complained of left

knee, right hip, and low back pain. (Id.) The physical examination showed mild joint
effusion, tenderness to palpation, and crepitus of the left knee. (Id. at PageID 728.) A
lumbar spine MRI in December 2022 showed multilevel discogenic changes, facet
arthropathy, and broad-based disc protrusions at the L2-3 and L4-5 levels. (Id. at PageID
708.) Dr. McNicol administered a left leg genicular nerve block in December 2022. (Id.
at PageID 730.) At a follow-up visit in January 2023, Plaintiff reported “moderate relief”

from the injection, but she nevertheless rated her pain at a level of nine out of ten. (Id. at
PageID 735.) Dr. McNicol prescribed Valium. (Id. at PageID 736.) Orthopedist Dr.
Ruane prescribed Morphine in February 2023. (Id. at PageID 721.) Later that month, Dr.
McNicol performed a left-sided genicular radiofrequency ablation procedure. (Id. at
PageID 740-742.)

D. Gastritis and Gastroesophageal Reflux Disease (GERD)
1. Plaintiff’s self-reported symptoms
Plaintiff stated that the combination of her physical conditions caused difficulty
with lifting, walking, sitting, standing, squatting, bending, kneeling, and climbing stairs.
(AR, Doc. No. 6-6 at PageID 208.) She reported that she needed to change positions

often and had difficulty sleeping at night because of the discomfort caused by these
conditions. (Id. at PageID 204, 207.) She could prepare simple meals and do light
housework, although her husband did the cooking and helped with activities such as
carrying loads of laundry. (Id. at PageID 205.) During the November 2023 hearing,
Plaintiff testified that she experienced nausea and vomiting because of her ulcer when she
ate “anything that [she] shouldn’t” or was anxious. (Id. at PageID 70-71.)

2. Objective medical evidence
Primary care records show that Plaintiff’s physician prescribed Pantoprazole for
chronic gastritis in November 2021. (AR, Doc. No. 6-7 at PageID 311.) Plaintiff was
hospitalized for complaints of upper abdominal pain and nausea in July 2022. (Id. at
PageID 451, 665.) A CT scan of the abdomen and pelvis was suggestive of an enhancing
mass involving the wall of the stomach. (Id. at PageID 451.) An upper gastrointestinal

endoscopy (EGD) showed gastritis with grade 3 reflux esophagitis, albeit with no
bleeding, as well as a hiatal hernia. (Id.) At a follow-up gastroenterology visit in August
2022, Paul Bonner, D.O. reported that the July 2022 endoscopy showed a “giant gastric
ulcer” that extended across the pylorus and into the duodenum. (Id. at PageID 544.) A
repeat EGD in August 2022 showed significant healing of the ulcer but “a large linear

scar extending across the pylorus caus[ed] a gastric outlet obstruction.” (Id.) A physical
examination showed moderate tenderness in the epigastric region. (Id. at PageID 546.)
An endoscopy in September 2022 showed a “nearly completely obstructing non-
bleeding linear gastric ulcer of moderate severity” at the pylorus. (AR, Doc. No. 6-7 at
PageID 563.) Plaintiff was hospitalized later that month for a diagnosis of “gastric outlet

obstruction secondary to a giant prepyloric gastric ulcer,” and Dr. Bonner performed a
laparoscopic truncal vagotomy with gastrojejunostomy. (Id. at PageID 446, 571.) After a
post-operative visit in October 2022, Dr. Bonner reported that upper gastrointestinal
imaging was negative for any complications or leaking. (Id. at PageID 585.) Plaintiff said
she was tolerating a diet without difficulty and her bowels were functioning normally.
(Id.) However Dr. Bonner advised Plaintiff that she was at a high risk for experiencing

delayed gastric emptying from the vagotomy procedure. (Id.)
E. Insomnia
1. Plaintiff’s self-reported symptoms
Plaintiff stated that she had difficulty sleeping at night because of the discomfort
caused by her physical conditions. (AR, Doc. No. 6-6 at PageID 208.) During the
November 2023 hearing, Plaintiff testified that she had difficulty sleeping if she was

anxious and that she slept only five to six hours per night. (Id. at PageID 73.)
2. Objective medical evidence
Primary care records show that Jennifer Briones, M.D. was prescribing Ambien
and Trazodone for primary insomnia in November 2021. (AR, Doc. No. 6-8 at PageID
836.) Dr. Briones was still prescribing those medications in November 2022, and she

noted: “Chronic[,] stable condition on current therapy.” (AR, Doc. No. 6-8 at PageID
846.) Dr. Briones made identical notations in subsequent progress notes that were dated
in February and August 2023. (Id. at PageID 857, 865.)
F. The ALJ’s Decision
1. Plaintiff’s cognitive complaints

Addressing Plaintiff’s claimed impairments of dementia and Alzheimer’s disease,
the ALJ noted that the January 2022 neuropsychological evaluation had “broadly normal
findings, no evidence to support early stages of neurodegenerative process, and mild
cognitive inefficiencies likely associated with stressors, chronic pain, and poor sleep.”
(Decision, Doc. No. 6-2 at PageID 42 (emphasis added).) Nevertheless, the ALJ found
that “the evidence of record does not identify any etiology for [Plaintiff’s] subjective

reports of memory loss or confirmation of either alleged impairment.” (Id. (emphasis
added).) The ALJ reasoned that “in the absence of laboratory or clinical findings or
medical observations validating the existence of a medically determinable impairment
that could reasonably be expected to produce [Plaintiff’s] alleged memory loss, an
impairment in this regard cannot be medically determined.” (Id.) Thus, because the
record contained “no objective evidence to validate the existence of a medically

determinable impairment related to [Plaintiff’s] memory,” the ALJ summarily concluded
her analysis of Plaintiff’s cognitive complaints:
Social Security Ruling 16-3p states, “[a]n individual’s symptoms . . . will
not be found to affect the ability to perform work-related activities for an
adult … unless medical signs or laboratory findings show medically
determinable impairment is present … We must have objective medical
evidence from an acceptable medical source to establish the existence of a
medically determinable impairment that could reasonably be expected to
produce an individual’s alleged symptoms” (See 20 CFR 404.1521).

(Id.)
2. Plaintiff’s physical impairments
The ALJ concluded that although Plaintiff’s medically determinable impairments
could reasonably be expected to cause her symptoms, the “intensity, persistence and
limiting effects of these symptoms are not entirely consistent with the medical evidence
and other evidence in the record ….” (Decision, Doc. No. 6-2 at PageID 46.)
With respect to the medically determinable impairments of osteoarthritis,
degenerative disc disease, and tendinosis/ tendinitis, the ALJ explained her analysis of

Plaintiff’s symptoms as follows:
Principally, the record reflects complaints of musculoskeletal pain in the
context of degenerative disc disease of the lumbar spine, osteoarthritis in
the knees with a remote history of surgical intervention on the left, and
tendinosis/tendinitis. [Plaintiff’s] interventions for these impairments
included a period of physical therapy and high dosages of opioids, which
one treatment provider described as unsafe and for which [Plaintiff] seemed
disinclined to engage in weaning despite medical advice. Despite both
subjective reports during testimony and notations in the record of 10/10
pain, physical examinations throughout the period at issue were largely
unremarkable, with only moderate findings as reflected above. At no time
did [Plaintiff] require an assistive device for ambulation despite [Plaintiff’s]
pain and indeed remained able to drive, seek out treatment, and
meaningfully participate in her own care.

(Decision, Doc. No. 6-2 at PageID 46.)
With respect to Plaintiff’s gastritis and gastroesophageal reflux disease, the ALJ
noted that she “was treated both with chronic medications as well as a gastrointestinal
surgical intervention.” (Decision, Doc. No. 6-2 at PageID 46.) The ALJ found that
although Plaintiff was “provided an unspecified lifting limitation after gastrointestinal
surgery,” there was “no indication that this limitation was permanent.” (Id.) The ALJ did
not address Plaintiff’s complaints about nausea and vomiting related to her ulcer. (Id.)
With respect to Plaintiff’s insomnia, the ALJ stated only that “treatment was
conservative and complaints sporadic during the period at issue.” (Decision, Doc. No. 6-2
at PageID 46.)
The ALJ concluded her evaluation of Plaintiff’s symptoms by explaining that
“having considered [Plaintiff’s] subjective reports as well as the totality of the record as a

whole, the undersigned finds [Plaintiff] capable of light work” with the restrictions of
never climbing ladders, ropes, or scaffolds; occasionally climbing ramps and stairs;
occasionally stooping, kneeling, crouching, and crawling; and frequently balancing.
(Decision, Doc. No. 6-2 at PageID 46.) The ALJ summarily concluded that the RFC
adequately accounted for Plaintiff’s alleged symptoms:

In summary, the location, duration, frequency, and intensity of [Plaintiff’s]
alleged symptoms, as well as precipitating and aggravating factors, are
adequately addressed and accommodated in the above residual functional
capacity. The objective evidence fails to document the presence of any
impairment or combination of impairments that could reasonably be
expected to result in pain or other symptoms of such a severity or frequency
as to preclude the range of work described above.

(Id. at PageID 47.)
IV. LAW AND ANALYSIS
A. Plaintiff’s Assignments Of Error

Plaintiff asserts that the ALJ’s RFC is unsupported by substantial evidence for two
reasons: 1) the ALJ “improperly evaluated Plaintiff’s subjective complaints pursuant to
SSR 16-3p and mischaracterized the record while ignoring a probative line of evidence
that was consistent with Plaintiff’s subjective complaints;” and 2) the ALJ “failed to
account for each severe impairment and to consider the combination of Plaintiff’s
impairments, both severe and non-severe, when formulating the RFC ….” (SE, Doc. No.
8 at PageID 891.) Finding error in the ALJ’s analysis of Plaintiff’s symptoms, the Court
does not address Plaintiff’s other alleged error and instead instructs the ALJ to address
both of them on remand.

B. The ALJ Did Not Comply with SSR 16-3p When She Evaluated
Plaintiff’s Symptoms.

1. Applicable legal framework
The ALJ’s evaluation of Plaintiff’s symptoms was governed by a detailed Social
Security regulation (20 C.F.R. § 404.1529) and SSR 16-3p, which mandates a two-step
process for evaluating an individual’s symptoms. SSR 16-3p, 2017 WL 5180304, *3
(S.S.A. revised and republished Oct. 25, 2017).2
At the first step, the ALJ must “determine whether the individual has a medically
determinable impairment that could reasonably be expected to produce the individual’s
alleged symptoms.” 2017 WL 5180304, at *3. The ALJ must base this determination
upon objective medical evidence in the form of medical signs or laboratory findings. Id.
Medical signs are “anatomical, physiological, or psychological abnormalities established
by medically acceptable clinical diagnostic techniques that can be observed apart from an
individual’s symptoms.” Id. The ALJ will not, however, consider whether the objective

medical evidence supports the alleged severity of the individual’s symptoms. Id.
At the second step, the ALJ must “evaluate the intensity and persistence of an
individual’s symptoms . . . and determine the extent to which an individual’s symptoms
limit his or her ability to perform work-related activities.” 2017 WL 5180304, at *9.

2 Although SSRs do not have the same force and effect as statutes or regulations, they are binding on all
components of the Social Security Administration. 20 C.F.R. § 402.35(b)(1).
Among other things, the ALJ must decide whether the alleged symptoms and
accompanying limitations are consistent with the evidence in the record. Id. at *8. The

Social Security Administration “recognize[s] that some individuals may experience
symptoms differently and may be limited by symptoms to a greater or lesser extent than
other individuals with the same medical impairments, the same objective medical
evidence, and the same non-medical evidence.” Id. The ALJ must therefore examine “the
entire case record, including the objective medical evidence; an individual’s statements
about the intensity, persistence, and limiting effects of symptoms; statements and other

information provided by medical sources and other persons; and any other relevant
evidence in the individual’s case record.” Id. at *9. Further, when determining whether an
individual’s statements are consistent with her symptoms, the ALJ will keep in mind that
the individual’s statements may themselves be inconsistent because “[s]ymptoms may
vary in their intensity, persistence, and functional effects, or may worsen or improve with

time.” Id. at *8-9.
When evaluating the intensity, persistence and limiting effects of the claimant’s
alleged symptoms, the ALJ must consider the following factors:
1. Daily activities;
2. The location, duration, frequency, and intensity of pain or other
symptoms;
3. Factors that precipitate and aggravate the symptoms;
4. The type, dosage, effectiveness, and side effects of any medication
an individual takes or has taken to alleviate pain or other symptoms;
5. Treatment, other than medication, an individual receives or has
received for relief of pain or other symptoms;
6. Any measures other than treatment an individual uses or has used to
relieve pain or other symptoms (e.g., lying flat on his or her back,
standing for 15 to 20 minutes every hour, or sleeping on a board);
and
7. Any other factors concerning an individual’s functional limitations
and restrictions due to pain or other symptoms.
2017 WL 5180304, at *7-8. The ALJ need only discuss those factors that are pertinent
based upon the evidence in the record. Id. However, the ALJ’s discussion of the
applicable factors “must contain specific reasons for the weight given to the individual’s
symptoms, be consistent with and supported by the evidence, and be clearly articulated so
the individual and any subsequent reviewer can assess how the adjudicator evaluated the
individual’s symptoms.” Id. at *10; see also Felisky v. Bowen, 35 F.3d 1027, 1036 (6th
Cir. 1994) (if an ALJ discounts or rejects a claimant’s subjective complaints, “he must
clearly state his reasons for doing so”).
The ALJ will also consider whether the individual sought medical treatment and

followed the treatment that was prescribed. 2017 WL 5180304, at *9. Attempts to obtain
treatment may show that symptoms are intense and persistent; conversely, a lack of such
efforts may show that an individual’s symptoms are not intense or persistent. Id.
Similarly, “if the individual fails to follow prescribed treatment that might improve
symptoms, [the ALJ] may find the alleged intensity and persistence of an individual’s

symptoms are inconsistent with the overall evidence of record.” Id.
However, the ALJ “will not find an individual’s symptoms inconsistent . . . on this
basis without considering possible reasons he or she may not comply with treatment or
seek treatment consistent with the degree of his or her complaints.” 2017 WL 5180304, at
*9. The SSR explains, for example, that individuals may not seek or follow treatment due
to side effects from medications, an inability to afford treatment, or an inability to

understand the need for treatment due to a mental impairment. Id. at *9-10. The ALJ may
need to contact the claimant—or to question the claimant at the administrative hearing—
to ascertain the reason(s) for the lack of treatment. Id. at *9. The ALJ “will explain how
[he or she] considered the individual’s reasons” in the evaluation of the individual’s
symptoms. Id. at *10 (emphasis added); cf. Dooley v. Comm’r of Soc. Sec., 656 F. App’x
113, 119 (6th Cir. 2016) (the ALJ must consider the reasons for not obtaining treatment

“before drawing an adverse inference from the claimant’s lack of medical treatment.”).
2. The ALJ erred when evaluating Plaintiff’s symptoms
The ALJ declined to evaluate Plaintiff’s cognitive symptoms solely because there
was no objective medical evidence of Alzheimer’s disease or dementia. (Decision, Doc.
No. 6-2 at PageID 42.) But the absence of a mental medically determinable impairment

such as dementia or Alzheimer’s disease does not justify summarily dismissing cognitive
complaints when there are physical medically determinable impairments that could
“reasonably be expected to produce” the same symptoms. See 20 C.F.R. § 404.1521; SSR
16-3p, 2017 WL 5180304, at *3.
Here, the ALJ found that “the evidence of record does not identify any etiology

for [Plaintiff’s] subjective reports of memory loss.” (Decision, Doc. No. 6-2 at PageID 42
(emphasis added).) This statement is belied by Dr. Salim’s opinion (which the ALJ cited)
that the etiology of Plaintiff’s mild cognitive deficits was “likely multifactorial” and that
“[p]otential contributing factors include worry and recent stressors, chronic pain, and
poor sleep.” (AR, Doc. No. 6-7 at PageID 343, 356; see also Decision, Doc. No. 6-2 at
PageID 42). It is further belied by the ALJ’s determination that Plaintiff had severe,

medically determinable impairments of osteoarthritis, lumbar spine degenerative disc
disease, tendinosis/tendinitis, and insomnia. (Decision, Doc. No. 6-2 at PageID 41.)
Because these impairments and their symptoms (such as pain) could reasonably be
expected to produce Plaintiff’s cognitive symptoms, the ALJ was required to evaluate
those symptoms under SSR 16-3p. Since the ALJ did not do so, reversal is required.
The ALJ further erred when analyzing Plaintiff’s pain complaints. The ALJ

explained that Plaintiff’s pain was extreme (10/10); Plaintiff did not want to stop taking a
high (and indeed unsafe) dosage of opioids; physical examinations were “largely
unremarkable, with only moderate findings”; Plaintiff did not require an assistive device,
such as a cane, to ambulate; and Plaintiff “remained able to drive, seek out treatment and
meaningfully participate in her own care.” (Decision, Doc. No. 6-2 at PageID 46.)

Although the ALJ did not explicitly dismiss Plaintiff’s pain complaints, she also did not
explain whether, and to what extent, she accounted for them in the RFC. Absent such an
explanation, it is reasonable to conclude that the ALJ completely discounted Plaintiff’s
pain complaints because she did not find them to be credible.
However, SSR 16-3p does not permit ALJs to assess a claimant’s credibility when

evaluating their symptoms. Instead, ALJs shall “consider all of the evidence … when
they evaluate the intensity and persistence of symptoms” and “determine how symptoms
limit ability to perform work-related activities.” SSR 16-3p, 2017 WL 5180304, at *1.
The ALJ’s explanation does not comply with this requirement. The ALJ did not explain,
for example, whether she considered Plaintiff’s testimony that she alternates standing and
sitting positions to alleviate pain. Nor did the ALJ explain why she did not include

postural limitations in the RFC.
The ALJ similarly erred by failing to adequately explain why she discounted
Plaintiff’s complaints about her gastrointestinal condition. The ALJ described Plaintiff’s
treatment history for this condition in her summary of the medical evidence. (Decision,
Doc. No. 6-2 at PageID 44-45.) The ALJ acknowledged that Plaintiff was hospitalized for
several days in July 2022 for gastritis and grade 3 reflux esophagitis. (Id. at PageID 44

(citing AR, Doc. No. 6-7 at PageID 451).) The ALJ also acknowledged that Plaintiff
underwent a truncal vagotomy with gastrojejunostomy in September 2022. (Id. at PageID
45 (citing AR, Doc. No. 6-7 at PageID 446).) The ALJ then summarized an October 2022
post-operative follow-up visit and stated that the report showed that Plaintiff was
“tolerating a diet without difficulty, with normally functioning bowels, and plans to

follow up in 6-12 months to evaluate her gastrojejunostomy (Exhibit 7F, page 97).” (Id.
(citing AR, Doc. No. 6-7 at PageID 585).)
But in her evaluation of Plaintiff’s subjective complaints, the ALJ merely
acknowledged Plaintiff’s treatment history and stated: “The record also shows a history
of gastroesophageal reflux disease and irritable bowel syndrome for which [Plaintiff] was

treated both with chronic medications as well as a gastrointestinal surgical intervention.”
(Decision, Doc. No. 6-2 at PageID 46.) The ALJ did not cite any evidence or provide any
reasoning to discount Plaintiff’s subjective complaints about this condition. Indeed, the
ALJ did not even acknowledge Plaintiff’s testimony that she continued to experience
issues with nausea and vomiting (AR, Doc. No. 6-2 at PageID 70-71), much less explain
whether or how the RFC accommodates Plaintiff’s gastrointestinal impairments.

(Decision, Doc. No. 6-2 at PageID 46-47.) The ALJ therefore also failed to evaluate
Plaintiff’s gastrointestinal complaints pursuant to SSR 16-3p.
Defendant argues that the ALJ’s decision is supported by substantial evidence and
“[t]he Court should decline Plaintiff’s invitation to reweigh the evidence.” (Mem. In
Opp., Doc. No. 10 at PageID 914 (citing Wright v. Massanari, 321 F.3d 611, 614 (6th
Cir. 2003).) This assertion misses the mark. The law does “presuppose[] that there is a

zone of choice within which the decisionmakers can go either way, without interference
by the courts.” Mullen, 800 F.2d at 545; see also White, 572 F.3d at 282. And the ALJ’s
decision “need not be so comprehensive as to account with meticulous specificity for
each finding and limitation, nor is the ALJ required to discuss every piece of evidence in
the record.” Correa v. Comm’r of Soc. Sec., No. 1:23-cv-685, 2023 U.S. Dist. LEXIS

231766, at *31 (N.D. Ohio Dec. 14, 2023) (citing Renstrom v. Astrue, 680 F.3d 1057,
1067 (8th Cir. 2012); Simons v. Barnhart, 114 F. App’x 727, 733 (6th Cir. 2004)).
Nevertheless, the ALJ must “build an accurate and logical bridge between the
evidence and his conclusion.” Amber S., 2023 U.S. Dist. LEXIS 171553, at *12. See also
Julie P. v. Comm’r of Soc. Sec., No. 2:21-cv-4170, 2022 U.S. Dist. LEXIS 116490, at

*13 (S.D. Ohio June 30, 2022) (Jolson, M.J.) (citation omitted), report and
recommendation adopted, No. 2:21-cv-4170, 2022 U.S. Dist. LEXIS 138572 (S.D. Ohio
Aug. 3, 2022) (Morrison, D.J.), aff’d, Pettit v. Comm’r of Soc. Sec., No. 22-3826, 2023
U.S. App. LEXIS 10964 (6th Cir. 2023); Alevras v. Colvin, No. 13 C 8409, 2015 U.S.
Dist. LEXIS 59394, *12 (N.D. Ill. May 6, 2015) (“merely summarizing medical evidence
is not the same as analyzing it and explaining how the evidence supports the conclusion

that the claimant is not disabled”) (citation omitted). Here, the ALJ’s failure to build a
logical bridge between the cited evidence and her conclusions prevents the Court from
engaging in meaningful judicial review, which necessitates a remand. See Blakley, 581
F.3d at 409 (citing Wilson v. Comm’r of Soc. Sec, 378 F.3d 541, 544 (6th Cir. 2004)).
C. The ALJ’s Errors Are Not Harmless.
The ALJ’s errors can only be excused as harmless if they do not prejudice the

claimant on the merits or deprive her of substantial rights. Rabbers, 582 F.3d at 654. The
Court finds that the ALJ’s errors were not harmless because they prejudiced Plaintiff on
the merits. Therefore, reversal is required.
V. REMAND
Under Sentence Four of 42 U.S.C. § 405(g), the Court has authority to affirm,

modify, or reverse the Commissioner’s decision “with or without remanding the cause for
rehearing.” Melkonyan v. Sullivan, 501 U.S. 89, 99 (1991). Consequently, a remand
under Sentence Four may result in the need for further proceedings or an immediate
award of benefits. E.g., Blakley, 581 F.3d at 410; Felisky, 35 F.3d at 1041. The latter is
warranted where the evidence of disability is overwhelming or where the evidence of

disability is strong while contrary evidence is lacking. Faucher v. Sec’y of Health &
Human Servs., 17 F.3d 171, 176 (6th Cir. 1994).
A judicial award of benefits is unwarranted in the present case because the
evidence of disability is neither overwhelming nor strong while contrary evidence is
lacking. Faucher, 17 F.3d at 176. However, Plaintiff is entitled to an Order remanding
this case to the Social Security Administration pursuant to Sentence Four of Section

405(g) for the reasons stated above. On remand, the ALJ should further develop the
record as necessary, particularly as to Plaintiff’s subjective complaints, and evaluate the
evidence of record under the applicable legal criteria mandated by the Commissioner’s
regulations and rulings and governing case law. The ALJ should evaluate Plaintiff’s
disability claim under the required five-step sequential analysis to determine anew
whether Plaintiff was under a disability and whether her application for Disability

Insurance Benefits should be granted.

IT IS THEREFORE ORDERED THAT:

1. Plaintiff’s Statement of Errors (Doc. No. 8) is GRANTED;

2. The Court REVERSES the Commissioner’s non-disability determination;

3. No finding is made as to whether Plaintiff was under a “disability” within
the meaning of the Social Security Act;

4. This matter is REMANDED to the Social Security Administration under
Sentence Four of 42 U.S.C. § 405(g) for further consideration consistent
with this Decision and Order; and

5. This case is terminated on the Court’s docket.
s/ Caroline H. Gentry
Caroline H. Gentry
United States Magistrate Judge

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/11338767. Public record. Not legal advice.