ALISA B. v. COMMISSIONER OF SOCIAL SECURITY
Case No. 2:24-cv-3194
UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF OHIO WESTERN DIVISION
08/29/25
Bowman, M.J.
PAGEID #: 1791
Plaintiff Alisa B. filed this Social Security appeal to challenge the Defendant‘s finding that she is not disabled. See
I. Summary of Administrative Record
On April 15, 2021, Plaintiff filed an application for Disability Insurance Benefits (“DIB”), as well as an application for supplemental security income (“SSI”), alleging that she became disabled beginning July 1, 2017 based on a combination of mental and physical impairments. During the alleged disability period, she engaged in substantial gainful activity at times, including a period of time in 2022 when she worked fulltime as a dishwasher at a local restaurant. (R. 25-26.) In April 2023 at the time of the ALJ‘s decision, Plaintiff continued to be employed in the same position, but only part-time. (Id.)1
Plaintiff has a high school education and no past relevant work involving transferable skills. She was 23 years old on the date of her alleged onset of disability, which is considered a “younger individual,” and remained in the same age category through the date of the ALJ‘s decision. She lives with her fiancé and three minor children. Based on her work history, she met insured status requirements for DIB only through September 30, 2019.2 (R. 25.)
The ALJ determined that Plaintiff has the following severe impairments: “disorders of the spine, right ankle disorder, asthma, disorders of the female genital organs, anemia and thrombosis with factor V disorder, depressive disorder, anxiety disorder, attention deficit hyperactivity disorder (ADHD), and trauma- and stressor-related disorder.” (R. 26.) The ALJ also found the following non-severe physical impairments: hypersomnia, appendicitis, right hand and finger lacerations, lung nodules, right shoulder tendonitis,
The ALJ further determined that Plaintiff retains the residual functional capacity (“RFC”) to perform a range of light work, subject to additional non-exertional limitations:
[S]he can occasionally balance, stoop, kneel, crouch, and climb ramps and stairs; can never crawl or climb ladders, ropes, or scaffolds; must avoid concentrated exposure to extreme cold, extreme heat, wetness, humidity, vibration, and fumes, odors, dust, gases, and poor ventilation; must avoid all exposure to hazards including moving machinery and unprotected heights; can understand, remember, and carry out routine tasks requiring no more than normal breaks; can occasionally interact with the public, coworkers, and supervisors; can have no frequent changes in the work setting; and can have no fast-paced production demands.
(R. 31.)
Based on the RFC as determined and in reliance on vocational expert testimony, the ALJ found that Plaintiff could still perform a substantial number of unskilled jobs existing in the national economy, including the representative positions of office helper, router, and mail clerk. (R. 39.) Therefore, the ALJ concluded that Plaintiff was not under a disability at any point in time through the date of her decision. (R. 40.)
II. Judicial Standard of Review
To be eligible for benefits, a claimant must be under a “disability.” See
When a court is asked to review the Commissioner‘s denial of benefits, the court‘s first inquiry is to determine whether the ALJ‘s non-disability finding is supported by substantial evidence.
The Secretary‘s findings are not subject to reversal merely because substantial evidence exists in the record to support a different conclusion.... The substantial evidence standard presupposes that there is a ‘zone of choice’ within which the Secretary may proceed without interference from the courts. If the Secretary‘s decision is supported by substantial evidence, a reviewing court must affirm.
Id. (citations omitted); see also Biestek v. Berryhill, 587 U.S. 97, 103 (2019) (holding that substantial evidence is evidence a reasonable mind might accept as adequate to support a conclusion and that the threshold “is not high“).
In considering an application for supplemental security income or for disability benefits, the Social Security Agency is guided by the following sequential benefits analysis: at Step 1, the Commissioner asks if the claimant is still performing substantial gainful activity; at Step 2, the Commissioner determines if one or more of the claimant‘s impairments are “severe”; at Step 3, the Commissioner analyzes whether the claimant‘s impairments, singly or in combination, meet or equal a Listing in the Listing of
A plaintiff bears the ultimate burden to prove by sufficient evidence that she is entitled to disability benefits.
III. Analysis
In this judicial appeal, Plaintiff asserts that the ALJ‘s decision is not supported by substantial evidence based on alleged errors in the ALJ‘s evaluation of the opinion evidence. Plaintiff generally argues that the ALJ‘s analysis is flawed due to internal inconsistencies, and that it did not support the mental RFC limitations as determined. Plaintiff criticizes the ALJ‘s analysis of two mental health opinions as well as the analysis of a consulting physician‘s opinion. The Court finds no error.
A. The ALJ‘s Assessment of Mental Health Opinion Evidence
Plaintiff attacks the ALJ‘s articulated assessment of mental health opinions provided by reviewing psychologist Dr. Swain and consulting examiner Dr. Tanley.3
1. Dr. Swain
Psychologist Jennifer Swain completed a Psychiatric Review Technique assessment at the initial consideration level on December 14, 2021. As stated, she found only mild impairment in two functional domains, but moderate limitations in the domains of concentrate, persist, or maintain pace, and in Plaintiff‘s ability to adapt or manage oneself. (R. 74.) Based on the two moderate limitations, Dr. Swain opined that Plaintiff should be “[l]imited to a simple learned work routine which does not have fast-paced production demands” and in “a structured and predictable work setting with infrequent changes in responsibilities and expectations” (R. 78.)
The ALJ articulated her evaluation of the consistency and supportability factors of Dr. Swain‘s opinion before evaluating the “persuasiveness” of that opinion as follows:
This opinion was not well supported by Dr. Swain, as she did not provide much explanation for her opinion. This opinion is somewhat consistent with the other evidence of record, but other evidence shows the claimant is more limited in regard to understanding, remembering, or applying information and interacting with others. Based on the evidence discussed above, I find that the claimant has moderate limitation in understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace; and adapting or managing oneself with the mental residual functional capacity defined above. Therefore, Dr. Swain‘s opinion is found to be somewhat persuasive.
Contrary to Plaintiff‘s argument, the ALJ‘s analysis closely adheres to controlling regulations that require an ALJ to consider multiple factors when evaluating the “persuasiveness” of each administrative finding or medical source opinion, while articulating how the ALJ considered the “supportability” and “consistency” factors. See
The discussion of supportability focuses on the provider‘s explanations for his or her opinions, including whether the opinions are supported by relevant objective medical evidence (such as lab results or imaging studies) or other supporting explanations such as clinical observations.
Generally... we review decisions of administrative agencies for harmless error. Heston v. Comm‘r of Soc. Sec., 245 F.3d 528, 535 (6th Cir.2001); NLRB v. Wyman–Gordon Co., 394 U.S. 759, 766 n. 6 (1969) (noting that courts are not required to “convert judicial review of agency action into a ping-pong game” where “remand would be an idle and useless formality“).
Rabbers v. Comm’r v. Soc. Sec. Admin., 582 F.3d 647, 654 (6th Cir. 2009).
In any event, it is true that the ALJ found “moderate” limitations in all four functional domains even though all three psychologists, including Dr. Swain, found only mild limitations in two domains. (R. 37.) And it is also true that most evidence summarized by the ALJ does not support more than mild limitations in the domains of understanding, remembering or applying information or in social interactions. But Plaintiff‘s criticism that the ALJ offered no explanation at all for finding greater limitations than endorsed by Dr. Swain is not accurate. The ALJ explicitly discussed some evidence to support her finding of moderate limitations in those two domains, including Plaintiff‘s report that she had been enrolled in special education in high school and Dr. Tanley‘s assessment that she functioned in the low average range of verbal intelligence. (R. 29, 35--36.) With respect to finding that Plaintiff has moderate rather than mild limitation in interacting with others, the ALJ also cited to clinical examination records that included one record of a “hostile mood.” (R. 29-30.) This Court must affirm so long as substantial evidence exists to uphold the ALJ‘s finding of “moderate” rather than merely “mild” limitations in the referenced functional domains, as exists in this case.
On June 7, 2022, Plaintiff attended a telehealth consultative psychological examination performed by James C. Tanley, Ph.D. (R. 1663-1568.) Dr. Tanley noted that Plaintiff self-reported a diagnosis of PTSD based on childhood trauma, but has never been psychiatrically hospitalized. (R. 1565.) Plaintiff also told Dr. Tanley that she has never filed for mental disability leave nor has she ever been referred by an employer for mental health treatment. (Id.) She takes no psychiatric medication for her PTSD, (R. 1567), but has treated with a therapist for the past two years. (R. 1565.) During the clinical interview, she stated that she gets along “very well with people.” (Id.)
Like Dr. Swain, Dr. Tanley assessed Plaintiff‘s abilities in the four functional domains. On the date of assessment, he found Plaintiff to be “unimpaired” in her abilities in maintaining attention and concentration, and in maintaining persistence and pace to perform both simple and multistep tasks. (R. 1568.) He opined that “she would be expected to show little or no difficulty with tasks of increasing complexity and multistep tasks.” (Id.) In other words, his opinion was consistent with Dr. Swain‘s opinion of no more than mild limitation in the domain of understanding, remembering and applying information. But Dr. Tanley also noted the possibility of some undefined amount of worsening in the future: “Were her PTSD symptoms to worsen, they could negatively impact this domain by interfering with her ability to focus and to concentrate.” (Id., emphasis added.)
Dr. Tanley similarly noted that Plaintiff‘s social presentation was “unremarkable” with no apparent limitations in the domain of interacting with others at the time of his clinical interview – again consistent with Dr. Swain. He noted that Plaintiff reported she does “very well with people,” and did not report any problems with people in her work
In this appeal, Plaintiff criticizes the ALJ for failing to discuss or incorporate into RFC limitations Dr. Tanley‘s hypothesis that Plaintiff‘s PTSD symptoms “could potentially worsen and cause difficulties with concentration and social interaction in the future.” (Doc. 10, PageID 1765-1766.) Plaintiff complains that the mental RFC as assessed “did not fully account for the possibility of worsening PTSD symptoms affecting [Plaintiff‘s] ability to maintain focus and complete tasks,” (Doc. 10, PageID 1770), or “how periodic worsening could affect her work capacity,” or her “potential for heightened difficulty in social situations due to PTSD.” (Id., PageID 1771.)
The Court finds no error. A claimant‘s RFC is the most that a claimant can do despite his or her impairments.
An ALJ is not required to specifically discuss hypothetical or speculative comments of possible limitations that are based on the mere possibility that a medical condition might worsen on an unknown future date. See Griffith v. Comm’r of Soc. Sec., 582 F. App‘x 555, 564 (6th Cir. 2014) (no error in omitting equivocal restrictions; doctor had described only possible restrictions using “may” and “seems”); see also Benson v. Comm’r of Soc. Sec., No. 3:19-cv-2804, 2021 WL 804150, at *3 (N.D. Ohio Mar. 2, 2021) (“Other judges have found no error in the failure to include limitations phrased in non-definitive language.“) (citing Golden v. Berryhill, No. 3:18-cv-227, 2019 WL 2109322, at *7 (N.D. Ohio Feb. 28, 2019), rep. & rec. adopted sub nom. Golden v. Comm’r of Soc. Sec., 2019 WL 2106566 (N.D. Ohio May 14, 2019) (finding substantial evidence supports the ALJ‘s determination not to include certain limitations “as Dr. Hill indicated these limitations not as requirements, but rather as possibilities, as she wrote that Plaintiff ‘may need’ these additional [limitations].“)).
B. The ALJ‘s Assessment of Dr. Chang‘s Opinion
Plaintiff levels similar criticisms at the ALJ‘s analysis of the opinion of a consulting physician. Douglas Chang, MD, reviewed Plaintiff‘s medical records on November 2, 2021 on initial consideration. (R. 76.) The ALJ accurately summarized Dr. Chang‘s opinions before articulating the “supportability” and “consistency” factors.
[Dr. Chang] found that the claimant could perform light work with no climbing of ladders, ropes, or scaffolds or crawling, occasional climbing of
ramps and stairs and stooping, frequent balancing, kneeling, and crouching, avoidance of concentrated exposure to extreme cold and heat, wetness, humidity, and vibration, and avoidance of even moderate exposure to hazards (machinery, heights, etc.) and fumes, odors, dusts, gases, poor ventilation, etc.... This opinion is not well supported by Dr. Chang‘s explanation for his opinion, as he only stated that more recent medical evidence of record did not change the residual functional capacity that was completed on September 3, 2021 .... This opinion is generally consistent with the other evidence of record except environmental limitations are not supported or consistent and other evidence shows the claimant is more limited in regard to postural limitations and hazards. May 3, 2021, x-ray views of the lumbar spine showed mild, chronic anterior wedging of the L1 vertebral body and no dynamic instability (Exhibit 1F, at 45), supporting a finding that the claimant requires additional postural limitations. Nurse practitioner Ms. Owens reported on February 2, 2022, that the claimant had asthma (Exhibit 9F, at 43), but limitations from asthma were not mentioned in the medical treatment evidence. Therefore, I find that the claimant must avoid concentrated exposure as opposed to even moderate exposure to fumes, odors, dusts, gases, poor ventilation, etc. Therefore, Dr. Chang‘s opinion is found to be generally persuasive.
(R. 36-37.)
As with the ALJ‘s evaluation of the psychological opinion evidence, Plaintiff argues that the ALJ “contradicts herself by stating that Dr. Chang‘s opinion was not well-supported by his explanation” but nevertheless goes on to credit his opinion as generally persuasive. (Doc. 10, PageID 1768.) The Court finds no inconsistency or contradiction. Once again, the ALJ‘s analysis merely reflects the mandatory articulation that is required under the regulations. The “supportability” factor has a specific regulatory meaning in this context. The statement that Dr. Chang‘s opinion was not particularly well-supported reflects the reality that Dr. Change did not expound upon the basis for his opinions. The ALJ also appropriately explained why she still found Dr. Chang‘s opinions to be “generally persuasive” in part based on the “consistency” factor since the opinions were “generally consistent with the other evidence of record” except for her postural and environmental limitations.
The Court concludes that the ALJ adequately explained her reasons for choosing an RFC that limits Plaintiff only from “concentrated” exposure. At the hearing, Plaintiff testified that she uses an albuterol inhaler “as needed.” The ALJ discussed that testimony as well as a single reference in a February 2022 medical record that recorded Plaintiff‘s asthma diagnosis. The ALJ then pointed out that, apart from Dr. Chang‘s consulting opinion based on his review of records, there are no medical records by any treatment provider that refer to any limitations at all from asthma. (R. 37.) In other words, not only did Dr. Chang fail to explain why he believed that Plaintiff should be limited to “moderate” irritant exposure, but that particular opinion was inconsistent with the record, which supports a limitation to avoid “concentrated” exposure. The ALJ‘s explanation substantially supports her RFC finding. In addition, Plaintiff does not argue that any of the representative positions that the ALJ determined she could perform would in any way be
Notably, the only other changes made by the ALJ to Dr. Chang‘s opinions resulted in an increase in Plaintiff‘s physical restrictions. For example, the ALJ found that she must avoid all exposure (as opposed to avoiding moderate exposure as endorsed by Dr. Chang) to hazards including moving machinery and unprotected heights. (Compare R. 31 and 37 with R. 90.) And in contrast to Dr. Chang‘s opinion that Plaintiff could “frequently” balance, kneel and crouch, the ALJ determined that she could perform those postural activities only occasionally. (Compare R. 31 with R. 76, 89.) Apart from the serious question as to how the ALJ‘s determination of more restrictive physical RFC findings than those endorsed by Dr. Chang could have been prejudicial or altered the outcome of this case, the Court finds no error. As with the alteration of the asthma-related limitations, the ALJ referred to specific medical evidence that substantially supported her increase to Plaintiff‘s limitations.
III. Conclusion and Order
Because the Defendant‘s decision is well supported by substantial evidence in the record as a whole, IT IS ORDERED THAT the Defendant‘s decision be AFFIRMED and that the above-captioned case be CLOSED.
s/Stephanie K. Bowman
Stephanie K. Bowman
United States Chief Magistrate Judge