Opinion

McCasland

Court: District Court, M.D. Tennessee
Filed: Jun 17, 2026
Cited by: 0 cases
Authority: More cited than 41.0%

The opinion

IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF TENNESSEE

NASHVILLE DIVISION

RANDALL McCASLAND, )

Plaintiff )

) Civil Action No. 3:25-cv-00385

v. ) Judge Crenshaw/Frensley

)

FRANK BISIGNANO, )

COMMISSIONER OF SOCIAL SECURITY, )

Defendant. )

REPORT AND RECOMMENDATION

This is a civil action filed pursuant to 42 U.S.C. § 405(g), to obtain judicial review of the

final decision of the Commissioner of Social Security denying Plaintiff Disability Insurance

Benefits (“DIB”), as provided under Title II of the Social Security Act (“the Act”). The case is

currently pending on Plaintiff’s Motion for Judgment Based on the Administrative Record. Docket

No. 10. Plaintiff has filed an accompanying Memorandum. Docket No. 10-1. Defendant has filed

a Response, arguing that the decision of the Commissioner was supported by substantial evidence

and should be affirmed. Docket No. 12.

For the reasons stated below, the undersigned recommends that Plaintiff’s Motion for

Judgment Based on the Administrative Record (Docket No. 10) be GRANTED and that this action

be REMANDED.

I. INTRODUCTION

Plaintiff filed her application for Disability Insurance Benefits (“DIB”) on October 13,

2021, alleging that she had been disabled since April 1, 2020, due to short-term memory loss,

dementia, bipolar disorder, doctor’s orders not to drive, and hypothyroidism. See, e.g., Docket No.

9 (“TR”), p. 49. Plaintiff died on November 27, 2021, and her spouse, Randall McCasland,

submitted a substitution of party. TR 75-77. Plaintiff’s application was denied both initially (TR

54) and upon reconsideration (TR 67). Plaintiff subsequently requested (TR 83-84) and received

(TR 27-48) a hearing. Plaintiff’s hearing was conducted on August 17, 2023, by Administrative

Law Judge (“ALJ”) William Taylor. TR 27. Mr. McCasland—current Plaintiff—and vocational

expert (“VE”), Chelsea Brown, appeared by phone and testified. Id.

On April 2, 2024, the ALJ issued a decision unfavorable to Plaintiff, finding that Plaintiff

was not disabled within the meaning of the Social Security Act and Regulations. TR 12-25.

Specifically, the ALJ made the following findings of fact:

1. The claimant met the insured status requirements of the Social Security Act through

June 30, 2025.

2. The claimant did not engage in substantial gainful activity from April 1, 2020, the

alleged onset date through her date of death of November 27, 2021 (20 CFR 404.1571

et seq.).

3. The claimant had the following severe impairments: bipolar disorder with memory

deficits; anxiety (20 CFR 404.1520(c)).

4. The claimant did not have an impairment or combination of impairments that met or

medically equaled the severity of one of the listed impairments in 20 CFR Part 404,

Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525 and 404.1526).

5. After careful consideration of the entire record, the undersigned finds that the claimant

has [sic] the residual functional capacity to perform a full range of work at all exertional

levels but with the following non-exertional limitations: could have understood,

remembered, and carried out job instructions regarding simple, routine, repetitive job

duties and could have performed simple, routine, repetitive work tasks; could have

tolerated occasional interaction with supervisors and co-workers and work with objects

and not with the general public; could have maintained attention, concentration, and

pace; could have been punctual and worked within a set schedule; could have used

judgement [sic] to make work decisions; occasionally adjusted to changes in a work

setting and job duties.

6. The claimant was unable to perform any past relevant work (20 CFR 404.1565).

7. The claimant was born on October 20, 1967 and was 52 years old, which is defined as

an individual closely approaching advanced age, on the alleged disability onset date

(20 CFR 404.1563).

8. The claimant had at least a high school education (20 CFR 404.1564).

9. Transferability of job skills is not material to the determination of disability because

using the Medical-Vocational Rules as a framework supports a finding that the claimant

was “not disabled,” whether or not the claimant has transferable job skills (See SSR

82-41 and 20 CFR Part 404, Subpart P, Appendix 2).

10. Considering the claimant’s age, education, work experience, and residual functional

capacity, there were jobs that existed in significant numbers in the national economy

that the claimant could have performed (20 CFR 404.1569 and 404.1569a).

11. The claimant has not been under a disability, as defined in the Social Security Act, from

April 1, 2020, through the date of death of November 27, 2021 (20 CFR 404.1520(g)).

TR 17-19, 21-23.

On April 9, 2024, Plaintiff timely filed a request for review of the hearing decision. TR

145. On February 25, 2025, the Appeals Council issued a letter declining to review the case (TR

1-6), thereby rendering the decision of the ALJ the final decision of the Commissioner. This civil

action was thereafter timely filed, and the Court has jurisdiction. 42 U.S.C. § 405(g). If the

Commissioner’s findings are supported by substantial evidence, based upon the record as a whole,

then these findings are conclusive. Id.

II. REVIEW OF THE RECORD

The parties and the ALJ have thoroughly summarized and discussed the medical and

testimonial evidence of record. Ms. McCasland’s medical records from January 1, 2016, to

November 26, 2021, were requested from Centerstone but were not received. TR 205-11. The ALJ

issued a subpoena for records from Centerstone on November 30, 2023, and the records were again

not released. TR 141-43, 345-51. The ALJ requested assistance from the Office of Hearings

Operations regional office, which advised him to issue a decision with the medical evidence in the

record. TR 15. Without Ms. McCasland’s medical records from Centerstone, the record is

incomplete.

III. CONCLUSIONS OF LAW

A. Standard of Review

This Court’s review of the Commissioner’s decision is limited to the record made in the

administrative hearing process. See 42 U.S.C. § 405(g); Miller v. Comm’r of Soc. Sec., 811 F.3d

825, 833 (6th Cir. 2016). The purpose of this review is to determine: (1) whether substantial

evidence exists in the record to support the Commissioner’s decision, and (2) whether any legal

errors were committed in the process of reaching that decision. 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) (alteration in original), quoting Consol. Edison Co. v. NLRB, 305 U.S. 197,

229 (1938). Nevertheless, it is the ALJ's duty to develop the record so that this Court can determine

whether the residual functional capacity was supported by substantial evidence. Brazile v. Sec’y of

Health & Hum. Servs., No. 92-4275, 1993 U.S. App. LEXIS 18082, 1993 WL 262466, at *3 (6th

Cir. July 8, 1993), citing Born v. Secretary of Health and Human Servs., 923 F.2d 1168, 1173 (6th

Cir. 1990); see also Cook v. Chater, No. 95-2254, 1996 U.S. App. LEXIS 19082, 1996 WL 338525,

at *2 (6th Cir. June 18, 1996).

“Substantial evidence” means “such relevant evidence as a reasonable mind might accept

as adequate to support the conclusion.” Her v. Comm’r of Soc. Sec., 203 F. 3d 388, 389 (6th Cir.

1999), citing Richardson v. Perales, 402 U.S. 389, 401 (1971). “Substantial evidence” has been

further quantified as “more than a mere scintilla of evidence, but less than a preponderance.” Bell

v. Comm’r of Soc. Sec., 105 F. 3d 244, 245 (6th Cir. 1996), citing Consol. Edison Co., 305 U.S. at

229; see also Gentry v. Comm’r of Soc. Sec., 741 F.3d 708, 722 (6th Cir. 2014).

The reviewing court does not substitute its findings of fact for those of the Commissioner

if substantial evidence supports the Commissioner’s findings and inferences. Garner v. Heckler,

745 F. 2d 383, 387 (6th Cir. 1984). In fact, even if the evidence could also support a different

conclusion, the decision of the ALJ must stand if substantial evidence supports the conclusion

reached. Her, 203 F. 3d at 389, citing Key v. Callahan, 109 F. 3d 270, 273 (6th Cir. 1997).

If the Commissioner did not consider the record as a whole; however, the Commissioner’s

conclusion is undermined. Hurst v. Sec’y of Health & Human Servs., 753 F. 2d 517, 519 (6th Cir.

1985), citing Allen v. Califano, 613 F. 2d 139, 145 (6th Cir. 1980). Moreover, an ALJ’s decision

lacks the support of substantial evidence if the ALJ fails to follow agency rules and regulations,

“even where the conclusion of the ALJ may be justified based upon the record.” Miller v. Comm’r

of Soc. Sec., 811 F. 3d 825, 833 (6th Cir. 2016), citing Gentry v. Comm’r of Soc. Sec., 741 F. 3d

708, 722 (6th Cir. 2014) (internal citations omitted); Cole v. Astrue, 661 F. 3d 931, 937 (6th Cir.

2011); Wilson v. Comm’r of Soc. Sec., 378 F. 3d 541, 544 (6th Cir. 2004); accord Goppert v.

Berryhill, No. 3:16-cv-02739, 2018 WL 513435, at *4 (M.D. Tenn. Jan. 23, 2018) (Report and

Recommendation adopted Mar. 1, 2018, 2018 WL 138533).

In reviewing the decisions of the Commissioner, courts look to four types of evidence: (1)

objective medical findings regarding Plaintiff’s condition; (2) diagnoses and opinions of medical

experts; (3) subjective evidence of Plaintiff’s condition; and (4) Plaintiff’s age, education, and

work experience. Miracle v. Celebrezze, 351 F. 2d 361, 374 (6th Cir. 1965).

B. Proceedings At The Administrative Level

The claimant carries the ultimate burden to establish an entitlement to benefits by proving

his or her “inability to engage in any substantial gainful activity by reason of any medically

determinable physical or mental impairment which can be expected to last for a continuous period

of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). “Substantial gainful activity” not only

includes previous work performed by Plaintiff, but also, considering Plaintiff’s age, education, and

work experience, any other relevant work that exists in the national economy in significant

numbers regardless of whether such work exists in the immediate area in which Plaintiff lives, or

whether a specific job vacancy exists, or whether Plaintiff would be hired if he or she applied. 42

U.S.C. § 423(d)(2)(A).

At the administrative level of review, the claimant’s case is considered under a five-step

sequential evaluation process summarized as follows:

(1) If the claimant is working and the work constitutes substantial gainful activity,

benefits are automatically denied.

(2) If the claimant is not found to have an impairment which significantly limits his

or her ability to work (a “severe” impairment), then he or she is not disabled.

(3) If the claimant is not working and has a severe impairment, it must be

determined whether he or she suffers from one of the “listed” impairments or its

equivalent.1 If a listing is met or equaled, benefits are owing without further

inquiry.

(4) If the claimant does not suffer from any listing-level impairments, it must be

determined whether the claimant can return to the job he or she previously held in

light of his or her residual functional capacity (e.g., what the claimant can still do

despite his or her limitations). By showing a medical condition that prevents him

or her from returning to such past relevant work, the claimant establishes a prima

facie case of disability.

(5) The burden then shifts to the Commissioner to establish the claimant’s ability

to work by proving the existence of a significant number of jobs in the national

economy which the claimant could perform, given his or her age, experience,

education, and residual functional capacity.

See, e.g. 20 CFR §§ 404.1520, 416.920. See also Moon v. Sullivan, 923 F.2d 1175, 1181 (6th Cir.

1990).

The Commissioner’s burden at the fifth step of the evaluation process can be satisfied by

relying on the medical-vocational guidelines, otherwise known as the grid, but only if the claimant

1 The Listing of Impairments is found at 20 CFR § 404, Subpt. P, App. 1.

is not significantly limited by a non-exertional impairment, and then only when the claimant’s

characteristics identically match the characteristics of the applicable grid rule. Moon, 923 F. 2d at

1181; 20 CFR § 404, Subpt. P, App. 2, Rule 200.00(e)(1), (2). See also Damron v. Sec’y of Health

& Human Servs., 778 F. 2d 279, 281-82 (6th Cir. 1985). Otherwise, the grid cannot be used to

direct a conclusion, but only as a guide to the disability determination. Id. In such cases where the

grid does not direct a conclusion as to the claimant’s disability, the Commissioner must rebut the

claimant’s prima facie case by coming forward with particularized proof of the claimant’s

individual vocational qualifications to perform specific jobs, which is typically obtained through

vocational expert testimony. See Varley v. Sec’y of Health & Human Servs., 820 F. 2d 777, 779

(6th Cir. 1987).

In determining residual functional capacity for purposes of the analysis required at stages

four and five above, the Commissioner is required to consider the combined effect of all the

claimant’s impairments: mental and physical, exertional and non-exertional, severe and nonsevere.

See 42 U.S.C.§ 423(d)(2)(B).

C. Plaintiff’s Statement Of Errors

Plaintiff contends that the ALJ committed reversible error when he: (1) failed to properly

consider the evidence in assessing Ms. McCasland’s residual functional capacity; (2) failed to

properly weigh the evidence related to her disabling symptoms, and (3) relied on the testimony of

a vocational expert that may not accurately reflect Ms. McCasland’s limitations. Docket No. 10-1,

p. 7. Accordingly, Plaintiff maintains that, pursuant to 42 U.S.C. § 405(g), the Commissioner’s

decision should be reversed, or in the alternative, remanded. Id.

Sentence four of § 405(g) states as follows:

The court shall have power to enter, upon the pleadings and transcript of the record,

a judgment affirming, modifying, or reversing the decision of the Commissioner of

Social Security, with or without remanding the cause for a rehearing.

42 U.S.C. §§ 405(g), 1383(c)(3).

“In cases where there is an adequate record, the Secretary’s decision denying benefits can

be reversed and benefits awarded if the decision is clearly erroneous, proof of disability is

overwhelming, or proof of disability is strong and evidence to the contrary is lacking.” Mowery v.

Heckler, 771 F. 2d 966, 973 (6th Cir. 1985). Furthermore, a court can reverse the decision and

immediately award benefits if all essential factual issues have been resolved and the record

adequately establishes a plaintiff's entitlement to benefits. Earley v. Comm’r of Soc. Sec., 893 F.3d

929, 934-35 (6th Cir. 2018), citing Faucher v. Sec’y of Health & Human Servs., 17 F. 3d 171, 176

(6th Cir. 1994). See also Newkirk v. Shalala, 25 F. 3d 316, 318 (6th Cir. 1994).

1. Determining Residual Functional Capacity (“RFC”)

Plaintiff maintains that the ALJ improperly declined to incorporate all the limitations

provided by Dr. Tramontana in determining Ms. McCasland’s RFC. Docket No. 10-1, p. 9. Plaintiff

contends that the ALJ’s finding that Ms. McCasland could perform simple, routine, repetitive work

tasks does not account for the limitations in verbal recall that Dr. Tramontana assessed. Id. Plaintiff

also argues that Dr. Tramontana assessed significant deficits and problems with Ms. McCasland’s

concentration, which is inconsistent with the ALJ’s finding that she could maintain attention,

concentration, and pace. Id. Plaintiff highlights further mental limitations supported by the limited

evidence in the record. Id. at 10. Finally, Plaintiff contends that the ALJ substituted his opinion for

that of a medical professional and that no medical opinion in the record corresponds with the ALJ’s

finding. Id. at 11.

Defendant responds that the ALJ properly found that Ms. McCasland retained the RFC to

perform a reduced range of simple, routine, and repetitive work with occasional interaction with

co-workers and supervisors, but no work with the general public. Docket No. 12, p. 4. Defendant

contends that the ALJ articulated appropriate bases for the weight given to the evidence of record

to determine Ms. McCasland’s RFC. Id. Defendant argues that the ALJ considered the disability

claim, but it was not supported by the record based on opinion evidence, Ms. McCasland’s medical

treatment, and the other medical evidence in the record. Id. at 3. Defendant contends that after

considering the entire record, the ALJ found that Ms. McCasland had severe impairments of

bipolar disorder with memory deficits and anxiety. Id. Specifically, Defendant contends that the

ALJ did not find an impairment or combination of impairments listed in or medically equal to one

contained in 20 C.F.R. Part 404, Subpart P, Appendix 1 (“the Listings”). Id.

“Residual Functional Capacity” is defined as the “maximum degree to which the individual

retains the capacity for sustained performance of the physical-mental requirements of jobs.” 20

CFR §404, Subpt. P, App. 2 ' 200.00(c). With regard to the evaluation of physical abilities in

determining a claimant’s RFC, the Regulations state:

When we assess your physical abilities, we first assess the nature and extent of your

physical limitations and then determine your residual functional capacity for work

activity on a regular and continuing basis. A limited ability to perform certain

physical demands of work activity, such as sitting, standing, walking, lifting,

carrying, pushing, pulling, or other physical functions (including manipulative or

postural functions, such as reaching, handling, stooping or crouching), may reduce

your ability to do past work and other work.

20 CFR§ 404.1545(b).

The ALJ in the case at bar ultimately determined that Plaintiff retained the RFC for a full

range of work at all exertional levels but with the following non-exertional limitations: could have

understood, remembered, and carried out job instructions regarding simple, routine, repetitive job

duties and could have performed simple, routine, repetitive work tasks; could have tolerated

occasional interaction with supervisors and co-workers and work with objects and not with the

general public; could have maintained attention, concentration, and pace; could have been punctual

and worked within a set schedule; could have used judgment to make work decisions; occasionally

adjusted to changes in a work setting and job duties. TR 19. The ALJ explained:

In making this finding, the undersigned considered all symptoms and the extent to

which these symptoms can reasonably be accepted as consistent with the objective

medical evidence and other evidence, based on the requirements of 20 CFR

404.1529 and SSR 16-3p. The undersigned also considered the medical opinion(s)

and prior administrative medical finding(s) in accordance with the requirements of

20 CFR 404.1520c. In considering the claimant’s symptoms, the undersigned must

follow a two-step process in which it must first be determined whether there is an

underlying medically determinable physical or mental impairment(s)--i.e., an

impairment(s) that can be shown by medically acceptable clinical or laboratory

diagnostic techniques—that could reasonably be expected to produce the claimant’s

pain or other symptoms.

Second, once an underlying physical or mental impairment(s) that could reasonably

be expected to produce the claimant’s pain or other symptoms has been shown, the

undersigned must 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. For this purpose, whenever statements about the intensity,

persistence, or functionally limiting effects of pain or other symptoms are not

substantiated by objective medical evidence, the undersigned must consider other

evidence in the record to determine if the claimant’s symptoms limit the ability to

do work-related activities.

In September 2018, VUMC treatment notes indicated the claimant reported

cognitive difficulties, memory decline, trouble expressing her thoughts, mixing up

her words, pacing, and being easily distracted. It was noted she was taking

psychiatric medication from Centerstone (1F). In April 2021, DMA indicated the

claimant was doing well on Lithium for bipolar disorder. It was noted her bipolar

disorder had associated urinary frequency. However, the next month, she reported

to DMA with concerns about the side effects of Lithium. She reported itchy skin all

over her body along with muscle weakness in her legs/ arms, which she felt were

caused by Lithium (2F).

On November 21, 2021, the claimant presented to the emergency room (ER) at

Centennial Medical Center with mania and increased anxiety over the past few

weeks. She stated she been [sic] recently admitted to the Parthenon about 2 months

prior for similar symptoms. She stated that during her stay, she was taken off Xanax.

She stated she was off of it for several weeks before recently restarting it via her

psychiatrist at Centerstone. She stated that she had not been on it long enough to

see any benefit and reported she was anxious. She denied suicidal ideations. She

was told she could increase her Xanax for the next few days but would need to

follow-up with Centerstone, as she had just been restarted on Xanax on November

6 (4F). The claimant passed away November 27, 2021. It was indicated on her death

certificate that she was found in her home wedged between the mattress and foot

board of the bed and that positional asphyxia was the immediate cause of death

(3F).

As for medical opinion(s) and prior administrative medical finding(s), the

undersigned cannot defer or give any specific evidentiary weight, including

controlling weight, to any prior administrative medical finding(s) or medical

opinion(s), including those from medical sources. The undersigned has fully

considered the medical opinions and prior administrative medical findings as

follows: The prior administrative medical findings indicated there was insufficient

evidence to offer a medical opinion. Thus, since no medical opinion was offered,

this was not afforded any degree of persuasiveness (1A,4A).

In September 2018, the claimant underwent a neuropsychological evaluation with

Dr. Michael Tramontana who indicated she sometimes became frustrated and

needed encouragement to not give up. He described her as tense, restless, and

somewhat scattered in providing her history. Dr. Tramontana indicated her

performance on some of the testing items was slow and inconsistent with her

reaction times, indicative of mildly slow processing speed. She struggled with

memory performance and had poor to extremely poor recall and memory

performance. Dr. Tramontana found she exhibited significant deficits in various

aspects of memory. He indicated she also had emotional factors present, as she

reported diminished enjoyment, nervousness, and difficulty relaxing. He reported

that her psychological insight was likely limited. Dr. Tramontana indicated she had

problems concentrating. He found significant memory decline involving verbal

recall. Dr. Tramontana’s evaluation was supported by his objective testing results

and his own face-to-face observations of the claimant. Thus, his evaluation findings

were persuasive (1F).

The claimant’s husband, Randall McCasland testified that he was married to the

claimant for 6 [sic] years and 8 months and they lived together. He indicated that

she was on several psychiatric medications, including Xanax. He testified that the

day after Thanksgiving 2021, they both went to be[d] in separate rooms. He stated

that when he got up the next morning around 8 a.m., she did not get up like she

normally did. He stated he thought she was just sleeping in. He said around 10 a.m.

[sic], he went into her room and found her in between the mattress and footboard

of the bed. He stated she was cold and had started to change color. He testified that

he was unsure if her medications had anything to do with her death.

While the claimant had residual limitation that precluded a full range of activities

and tasks, the medical evidence available demonstrated that she remained capable

of performing work within the above residual functional capacity on a regular

sustained basis prior to her death. The medical evidence failed to show symptoms

of the frequency and/ or severity to preclude all work. After careful consideration

of the evidence, the undersigned finds that the claimant’s medically determinable

impairments could reasonably be expected to cause the alleged symptoms;

however, the claimant’s 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.

Based on the foregoing, the undersigned finds the claimant has the above residual

functional capacity assessment, which is supported by the medical opinions and

evidence discussed above.

TR 19-21.

In so finding, the ALJ considered Ms. McCasland’s Neuropsychological Evaluation

Report. TR 231-34. Specifically, the ALJ stated:

In September 2018, VUMC treatment notes indicated the claimant reported

cognitive difficulties, memory decline, trouble expressing her thoughts, mixing up

her words, pacing, and being easily distracted. It was noted she was taking

psychiatric medication from Centerstone (1F).

…