Hlubek v. Social Security Administration

Filing 14

REPORT AND RECOMMENDATION recommending to Affirm the decision of the ALJ re 1 Social Security Complaint. Objections to R&R due by 3/21/2025. Signed by Magistrate Judge Mark A Roberts on 3/7/2025. (kms)

IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF IOWA
EASTERN DIVISION
ROBERT J. H.,

No. 24-cv-15-LTS

Plaintiff,

REPORT AND
RECOMMENDATION

vs.
COMMISSIONER OF SOCIAL
SECURITY1,
Defendant.
____________________
Robert J. H. (“Claimant”) seeks judicial review of a final decision of the
Commissioner of Social Security (“the Commissioner”) in denying his applications for
child’s insurance benefits2 (“CIB”) under Title II of the Social Security Act, 42 U.S.C.
Sections 401-34 and for Supplemental Security Income benefits (“SSI”) under Title XVI
of the Social Security Act, 42 U.S.C. Sections 1381-85. For the reasons that follow, I
recommend that the Commissioner’s decision be affirmed.
I.

BACKGROUND

Claimant was born in 1998. (AR3 at 62.) He is a high school graduate. (Id. at
225.) Claimant allegedly became disabled due to Marfan Syndrome, social anxiety,

1

On February 19, 2025, Leland Dudek was named the Acting Commissioner of Social Security.

2

A claimant is entitled to CIB if he or she is 18 years old and has a disability that began before
attaining age 22 and which exists at the time of the application. See 20 C.F.R. § 404.350(a)(5).
3

“AR” cites refer to pages in the Administrative Record.

1

scoliosis, and long term affects from spinal fusion. (Id. at 224.) Claimant’s alleged onset
of disability date is January 1, 2012. (Id. at 62.) On September 24, 2021, Claimant filed
his applications for CIB and SSI. (Id. at 60-61). His claims were denied originally on
April 20, 2022 (id. at 60-79) and were denied on reconsideration on June 9, 2022. (Id.
at 79-99.) A hearing was held on January 26, 2023, with Claimant and his attorney
David Potter4 appearing by online video before Administrative Law Judge (“ALJ”)
Matthew Bring. (Id. at 31-59.) Vocational Expert (“VE”) Deborah Determan also
appeared at the hearing telephonically. (Id.) Claimant and the VE both testified at the
hearing. The ALJ issued an unfavorable decision on March 8, 2023. (Id. at 10-23.)
Claimant requested review and the Appeals Council denied review on December
8, 2023. (Id. at 1-3.) Accordingly, the ALJ’s decision stands as the final administrative
ruling in the matter and became the final decision of the Commissioner. See 20 C.F.R.
§§ 404.981, 416.1481.
On February 5, 2024, Claimant timely filed his Complaint in this Court. (Doc.
1.) On July 15, 2024, all briefing was completed, and the Honorable Leonard T. Strand,
United States District Court Judge, referred the case to me for a Report and
Recommendation.
II.

DISABILITY DETERMINATIONS AND THE BURDEN OF PROOF

A disability is the “inability to engage in any substantial gainful activity by reason
of any medically determinable physical or mental impairment which can be expected to
result in death or which has lasted or can be expected to last for a continuous period of
not less than 12 months.” 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). A claimant has
a disability when, due to physical or mental impairments, the claimant:
is not only unable to do [the claimant’s] previous work but cannot,
considering [the claimant’s] age, education, and work experience, engage
4

Claimant is represented by attorney Anthony J. Olson on the instant Social Security appeal in
this Court.

2

in any other kind of substantial gainful work which exists . . . in significant
numbers either in the region where such individual lives or in several
regions of the country.
42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(A). A claimant is not disabled if the claimant
is able to do work that exists in the national economy but is unemployed due to an inability
to find work, lack of options in the local area, technological changes in a particular
industry, economic downturns, employer hiring practices, or other factors. 20 C.F.R.
§§ 404.1566(c), 416.966(c).
To determine whether a claimant has a disability, the Commissioner follows a fivestep sequential evaluation process.5 Swink v. Saul, 931 F.3d 765, 769 (8th Cir. 2019).
At steps one through four, the claimant has the burden to prove he or she is disabled; at
step five, the burden shifts to the Commissioner to prove there are jobs available in the
national economy. Moore v. Astrue, 572 F.3d 520, 523 (8th Cir. 2009). “If a claimant
fails to meet the criteria at any step in the evaluation of disability, the process ends and
the claimant is determined to be not disabled.” Pelkey v. Barnhart, 433 F.3d 575, 577
(8th Cir. 2006) (quotation omitted).
At step one, the ALJ will consider whether a claimant is engaged in “substantial
gainful activity.” Id. If so, the claimant is not disabled. 20 C.F.R. §§ 404.1520(a)(4)(i),
416.920(a)(4)(i). “Substantial activity is significant physical or mental work that is done
on a full- or part-time basis.

Gainful activity is simply work that is done for

compensation.” Dukes v. Barnhart, 436 F.3d 923, 927 (8th Cir. 2006) (citing Comstock
v. Chater, 91 F.3d 1143, 1145 (8th Cir. 1996); 20 C.F.R. §§ 404.1572(a)-(b),
416.972(a)-(b)).

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The five-step sequential evaluation applies to claimants “for child’s insurance benefits based
on disability.” 20 C.F.R. § 404.1520(a)(2).

3

If the claimant is not engaged in substantial gainful activity, at step two, the ALJ
decides if the claimant’s impairments are severe. 20 C.F.R. §§ 404.1520(a)(4)(ii),
416.920(a)(4)(ii). If the impairments are not severe, then the claimant is not disabled.
Id. An impairment is not severe if it does not significantly limit a claimant’s “physical
or mental ability to do basic work activities.” Id. §§ 404.1520(c), 416.920(c). The
ability to do basic work activities means the ability and aptitude necessary to perform
most jobs.

Bowen v. Yuckert, 482 U.S. 137, 141 (1987); see also 20 C.F.R.

§§ 404.1521(b), 416.921(b). These include:
(1) physical functions such as walking, standing, sitting, lifting, pushing,
pulling, reaching, carrying, or handling; (2) capacities for seeing, hearing,
and speaking; (3) understanding, carrying out, and remembering simple
instructions; (4) use of judgment; (5) responding appropriately to
supervision, co-workers, and usual work situations; and (6) dealing with
changes in a routine work setting.
Id. (quotation omitted) (numbers added; internal brackets omitted).
If the claimant has a severe impairment, at step three, the ALJ will determine the
medical severity of the impairment. 20 C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii).
If the impairment meets or equals one of the impairments listed in the regulations (“the
listings”), then “the claimant is presumptively disabled without regard to age, education,
and work experience.” Tate v. Apfel, 167 F.3d 1191, 1196 (8th Cir. 1999) (quotation
omitted).
If the claimant’s impairment is severe, but it does not meet or equal an impairment
in the listings, at step four, the ALJ will assess the claimant’s residual functional capacity
(“RFC”) and the demands of the claimant’s past relevant work.

20 C.F.R.

§§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). An individual’s RFC is the most that the
individual can do despite the combined effect of all his or her credible limitations. Id.
§§ 404.1545(a), 416.945(a); Toland v. Colvin, 761 F.3d 931, 935 (8th Cir. 2014). A

4

claimant’s RFC is based on all relevant evidence and the claimant is responsible for
providing the evidence the Commissioner will use to determine his or her RFC.
Eichelberger v. Barnhart, 390 F.3d 584, 591 (8th Cir. 2004). “Past relevant work” is
any work a claimant performed within the fifteen years prior to his or her application for
disability benefits that was substantial gainful activity and lasted long enough for the
claimant to learn how to do it. 20 C.F.R. §§ 404.1560(b)(1), 416.960(b)(1). If a
claimant retains the RFC to perform past relevant work, then the claimant is not disabled.
Id. §§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv).
At step five, if the claimant’s RFC will not allow the claimant to perform past
relevant work, then the burden shifts to the Commissioner to show that there is other
work the claimant can do, given the claimant’s RFC, age, education, and work
experience. Id. §§ 404.1520(a)(4)(v), 404.1560(c)(2), 416.920(a)(4)(v), 416.960(c)(2).
The ALJ must show not only that the claimant’s RFC will allow the claimant to do other
work, but also that other work exists in significant numbers in the national economy.
Eichelberger, 390 F.3d at 591 (citation omitted).
A.

The ALJ’s Findings
The ALJ made the following findings regarding Claimant’s disability status at each

step of the five-step process. Initially, the ALJ determined that Claimant had not attained
age 22 as of February 17, 2016. (AR at 13.) The ALJ then applied the first step of the
analysis and determined that Claimant had not engaged in substantial gainful activity since
February 17, 2016, the date he attained age 18. (Id.) At the second step, the ALJ
concluded from the medical evidence that Claimant suffered from the following severe
impairments: Marfan Syndrome status post aortic root repair and valve replacement,
scoliosis status post spinal fusion, and anxiety disorder. (Id.) At the third step, the ALJ
found that Claimant did not have an impairment or combination of impairments listed in
20 C.F.R. Pt. 404, Subpt. P, App. 1. (Id.) The ALJ evaluated Claimant’s claims under

5

listing 1.15 (disorders of the spine), 1.16 (lumbar spinal stenosis), 4.10 (aneurysm of
aorta or major branches), and 12.06 (anxiety disorders). (Id. at 13-15.) The ALJ also
determined that Claimant did not satisfy either the “paragraph B” or “paragraph C”
criteria. (Id. at 14-15.) At the fourth step, the ALJ determined that Claimant had the
following RFC:
[C]laimant has the residual functional capacity to perform sedentary work
as defined in 20 C.F.R. [§§] 404.1567(a) and 416.967(a) except that he can
only frequently, as opposed to constantly, perform handling and fingering.
He can never climb ladders, ropes or scaffolds. He can occasionally climb
stairs or ramps, balance, stoop, kneel, crouch, and crawl. He can never
work around hazards (such as unprotected heights and moving mechanical
parts). Mentally, the claimant can perform simple and routine tasks. He
can interact with coworkers on an occasional basis. He can interact with
the public on a brief and superficial basis.
(Id. at 15.) Also at the fourth step, the ALJ determined that Claimant had no past relevant
work. (Id. at 22.) At step five, the ALJ found that there were jobs that existed in
significant numbers in the national economy Claimant could perform, including polisher
of eye glass frames, weight tester, and press operator. (Id.) Thus, the ALJ concluded
that Claimant was not disabled. (Id. at 23.)
B.

The Substantial Evidence Standard
The ALJ’s decision must be affirmed “if it is supported by substantial evidence in

the record as a whole.” Grindley v. Kijakazi, 9 F.4th 622, 627 (8th Cir. 2021) (quoting
Pickney v. Chater, 96 F.3d 294, 296 (8th Cir. 1996)). “The phrase ‘substantial evidence’
is a ‘term of art’ used throughout administrative law. . . . [T]he threshold for such
evidentiary sufficiency is not high. . . . It means—and means only—such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.” Biestek
v. Berryhill, 139 S. Ct. 1148, 1154 (2019) (internal citations and quotations omitted); see
also Kraus v. Saul, 988 F.3d 1019, 1024 (8th Cir. 2021) (“Substantial evidence is less

6

than a preponderance, but enough that a reasonable mind might accept it as adequate to
support a conclusion.”) (Quoting Phillips v. Astrue, 671 F.3d 699, 702 (8th Cir. 2012)).
Thus, a court cannot disturb an ALJ’s decision unless it falls outside this available “zone
of choice” within which the ALJ can decide the case. Hacker v. Barnhart, 459 F.3d
934, 936 (8th Cir. 2006) (citation omitted). “An ALJ’s decision is ‘not outside the zone
of choice’ simply because [the c]ourt ‘might have reached a different conclusion had [it]
been the initial finder of fact.’” Kraus, 988 F.3d at 1024 (quoting Bradley v. Astrue,
528 F.3d 1113, 1115 (8th Cir. 2008)).
In determining whether the Commissioner’s decision meets this standard, the court
considers all the evidence in the record, but does not reweigh the evidence. Vester
v. Barnhart, 416 F.3d 886, 889 (8th Cir. 2005). A court considers “both evidence that
detracts from the Commissioner’s decision, as well as evidence that supports it.”
Fentress v. Berryhill, 854 F.3d 1016, 1020 (8th Cir. 2017). The court must “search the
record for evidence contradicting the [ALJ’s] decision and give that evidence appropriate
weight when determining whether the overall evidence in support is substantial.”
Baldwin v. Barnhart, 349 F.3d 549, 555 (8th Cir. 2003) (citing Cline v. Sullivan, 939
F.2d 560, 564 (8th Cir. 1991)). However, “even if inconsistent conclusions may be
drawn from the evidence, the [Commissioner’s] decision will be upheld if it is supported
by substantial evidence on the record as a whole.” Guilliams v. Barnhart, 393 F.3d 798,
801 (8th Cir. 2005); see also Igo v. Colvin, 839 F.3d 724, 728 (8th Cir. 2016) (providing
that a court “may not reverse simply because [it] would have reached a different
conclusion than the [Commissioner] or because substantial evidence supports a contrary
conclusion”).
III.

DISCUSSION

Claimant alleges that the ALJ committed reversible error by: (1) “failing to
consider all of the Claimant’s impairments in combination” and failing to properly

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consider Claimant’s subjective allegations of pain; (2) determining that Claimant “retains
the residual functional capacity to perform a limited range of sedentary work”; and (3)
failing to fully and fairly develop the medical record. (Doc. 7)
A.

Consideration of Claimant’s Impairments in Combination
1.

Parties’ Arguments

Claimant argues that,“[w]hile the ALJ acknowledged that he has severe
impairments, he disregarded [Claimant’s] allegations of chest pain, back pain, foot pain,
the need to alternate between sitting and standing frequently, and the need to lie down
frequently.” (Doc. 7 at 21.) Claimant maintains that there “are reports from numerous
treating and evaluating physicians, including the state agency consultants, corroborating
his subjective complaints.” (Id.) Claimant also argues that the ALJ disregarded his
subjective complaints of pain. (Id.) Claimant contends that his “complaints of pain are
well documented and supported by the medical evidence of record.”

(Id. at 22.)

Claimant asserts that the ALJ “offered little explanation for why he found [Claimant’s]
testimony not to be credible.” (Id.)
The Commissioner argues that the ALJ properly explained that the “overall record
including the objective medical evidence, [Claimant’s] routine and conservative
treatment, and his admitted activities, did not fully support his subjective complaints.”
(Doc. 11 at 19.) The Commissioner also points out that Claimant “does not identify any
particular functional limitation the ALJ failed to address, or otherwise explain how the
ALJ’s decision was not supported by substantial evidence.” (Id.) The Commissioner
concludes that “[b]ecause [Claimant] has not made an argument grounded in the record
that the ALJ’s conclusion is outside the ‘zone of choice,’ . . . the Court should affirm.”
(Id. at 20.)

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2.

Relevant Law

When assessing a claimant’s credibility, “the ALJ must consider all of the
evidence, including objective medical evidence, the claimant’s work history, and
evidence relating to the factors set forth in Polaski v. Heckler, 739 F.2d 1320, 1322 (8th
Cir. 1984).” Vance v. Berryhill, 860 F.3d 1114, 1120 (8th Cir. 2017). In Polaski, the
Eighth Circuit stated that:
The [ALJ] must give full consideration to all the evidence presented relating
to subjective complaints, including the claimant’s prior work record, and
observations by third parties and treating and examining physicians relating
to such matters as: (1) the claimant’s daily activities; (2) the duration,
frequency, and intensity of pain; (3) precipitating and aggravating factors;
(4) dosage, effectiveness, and side effects of medication; [and]
(5) functional restrictions.
739 F.2d at 1322. An ALJ is not required to methodically discuss each Polaski factor as
long as the ALJ “acknowledge[es] and examin[es] those considerations before
discounting [a claimant’s] subjective complaints.” Lowe v. Apfel, 226 F.3d 969, 972
(8th Cir. 2000) (citing Brown v. Chater, 87 F.3d 963, 966 (8th Cir. 1996)). The ALJ,
however, may not disregard “a claimant’s subjective complaints solely because the
objective medical evidence does not fully support them.” Renstrom v. Astrue, 680 F.3d
1057, 1066 (8th Cir. 2012) (quoting Wiese v. Astrue, 552 F.3d 728, 733 (8th Cir. 2009)).
Instead, an ALJ may discount a claimant’s subjective complaints “if there are
inconsistencies in the record as a whole.” Wildman v. Astrue, 596 F.3d 959, 968 (8th
Cir. 2010). Where an ALJ seriously considers, but for good reason explicitly discredits
a claimant’s subjective complaints, the court will not disturb the ALJ’s credibility
determination. Johnson v. Apfel, 240 F.3d 1145, 1148 (8th Cir. 2001); see also Schultz
v. Astrue, 479 F.3d 979, 983 (8th Cir. 2007) (providing that deference is given to an
ALJ when the ALJ explicitly discredits a claimant’s testimony and gives good reasons

9

for doing so). “The credibility of a claimant’s subjective testimony is primarily for the
ALJ to decide, not the courts.” Igo, 839 F.3d at 731 (quoting Pearsall v. Massanari,
274 F.3d 1211, 1218 (8th Cir. 2001)).
3.

Analysis

The record does not support Claimant’s argument that the ALJ failed to provide
good reasons for discounting Claimant’s subjective complaints. The ALJ articulated his
reasons for discounting Claimant’s allegations at length considering the hearing
testimony, Claimant’s medical records, and doctors’ medical opinions. (AR at 16-21.)
The ALJ provided a thorough summary of Claimant’s subjective allegations. See
id. at 16. The ALJ found that 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[.]”
(Id.) The ALJ thoroughly considered the intensity and severity of Claimant’s symptoms
in his discussion of Claimant’s RFC. (Id. at 20-21.) The ALJ also addressed the relevant
Polaski factors and considered: (1) the Claimant’s daily activities (Id. at 17-20); (2) the
duration, frequency, and intensity of the condition (id. at 17-21); (3) the use of medication
(id. at 17); (4) precipitating and aggravating factors (id. at 17-21); and (5) functional
restrictions (id.). See Wildman, 596 F.3d at 968.
Specifically, the ALJ determined that:
As an initial matter, the undersigned notes that the allegation of disability
is inconsistent with the claimant’s ability to complete nearly all of a college
program in software development. Although the claimant has been unable
to finish the final classes due to his social limitations, he has completed all
other coursework with acceptable grades and without any reported
difficulties (hearing testimony; 12E; 2F/14; 4F; 9F/15, 25). This does not,
in and of itself, indicate an ability to perform full-time work, but it
definitely suggests that the claimant retains sufficient mental abilities for
the performance of simple work. In particular, it shows that the claimant

10

is able to understand, remember, and apply information and complete
simple tasks. Given that he has nearly finished a software development
degree, it is likely that he is capable of detailed and complex tasks as well
as simple ones. However, to accommodate his anxiety and the difficulty
focusing due to pain (hearing testimony), the above residual functional
capacity limits the claimant to simple work.
As noted above, the claimant has not finished his degree, because his final
classes would require working in groups. The undersigned has accounted
for this difficulty in the residual functional capacity in the form of
limitations to only occasional interaction with coworkers and only brief and
superficial interactions with the public. Because the claimant reports that
he gets along “well” with authority figures (5E), no limitations on
interactions with supervisors are imposed.
The record as a whole does not establish that the claimant’s mental
impairments impose limitations beyond those mentioned above. Despite
claiming to be unable to leave his house alone and having to quit school due
to social anxiety, the claimant has sought only limited treatment for his
mental health impairments. The “potential for anxiety and/or depression
related to having a genetic illness” was noted as early as 2014 (7F/10-22),
but the claimant was not formally diagnosed with a social anxiety disorder
until September 2019 (2F/15). He has only taken anxiety medications
sporadically and has not pursued therapy despite it being offered and
recommended (2F/11-15; 4F; 10F; 17F). There is no evidence that he
stopped his medications or declined therapy due to financial limitations.
The results of mental status examination are not indicative of debilitating
mental symptoms. Prior to September 2020, examination generally failed
to reveal any mental abnormalities, let alone disabling ones (see, generally,
2F/17-43; 9F/20-29). Since September 2020, examination has consistently
revealed anxiousness, a depressed and blunted affect, and poor eye contact
(4F; 10F; 16F; 17F). However, even with these symptoms, the claimant
has been able to attend medical appointments outside of his home and
engage in limited interactions with medical providers (see, generally, 2F/413; 4F; 5F; 14F; 17F; 18F). He has repeatedly been described as
cooperative, albeit not particularly talkative (2F/12, 18, 26; 4F; 5F; 9F/16,
21, 26, 30; 10F; 14F). He had difficulty answering questions during the
consultative examination in December 2021 but was able to do so without

11

as much difficulty at the consultative examination in April 2022 (10F; 16F).
In both situations, the examiner was not previously known to the claimant.
In other regards, the results of mental status examination have been
unremarkable. In treatment notes from 2016 to present, there are no
findings of impaired memory, poor concentration, comprehension
difficulties, or distractibility (see, generally, 2F/1-45; 4F; 5F; 9F/1-29;
10F; 14F; 16F; 17F; 18F). His judgment has been at least “fair” and at
times normal (2F/15, 22; 4F; 17F). He exhibits normal thought content
and behavior, and he has not expressed suicidal ideation (2F/15, 22, 29,
34, 43; 10F; 18F). In short, the record is devoid of the type of significant
mental abnormalities that would indicate an inability to perform simple
work within the continues of the above residual functional capacity.
With respect to the claimant’s mental impairments, the undersigned finally
notes that his activities of daily living demonstrate that his concentration
and focus is sufficient for at least simple work. He reports playing video
games for large portions of the day, preparing his own meals, following
instructions, and managing his money (5E; 2F/14; 4F; 10F; 17F). He is
able to drive a vehicle and go grocery shopping when forced to do so (5E).
He completed many college classes during the period under review, as
noted previously. Moreover, despite some obvious discomfort about the
situation, the claimant was able to provide cogent and relevant responses to
the questions asked of him at the hearing (hearing proceedings). His
activities of daily living, in combination with his limited treatment and the
results of mental status examination, suggest that the claimant would be
mentally capable of simple work with minimal social demands.
(AR at 17-18.)
The ALJ also addressed Claimant’s physical impairments as they relate to his
subjective allegations of pain and disability. The ALJ reviewed Claimant’s scoliosis and
Marfan Syndrome. (Id. at 18.) The ALJ noted that treatment of these impairments was
successful and occurred prior to Claimant turning 18 years old.

(Id.)

The ALJ

acknowledged that “[t]here is residual aortic insufficiency, but no dilatation, stenosis, or
residual aneurysms are present (2F/8, 45; 5F; 8F; 9F/26; 14F). Likewise, there is some

12

‘mild’ or ‘minimal’ residual scoliosis (7F/448-449, 464, 481).” (Id.) Further, the ALJ
stated:
Since the claimant attained age 18 in February 2016, there has been only
limited, conservative treatment for any physical issues. For Marfan
Syndrome and the associated cardiac issues, the claimant takes
anticoagulant medication and atenolol, has his INR checked as needed, and
has yearly follow-ups with a cardiologist (2F/1-43; 9F/1-29; 5F; 13F; 14F).
He also attends annual physicals with a primary care provider (2F/11, 17,
25).
(Id.) The ALJ noted that at cardiac follow-up appointments in 2016 and 2017, Claimant
reported doing “quite well” and the cardiologists agreed that he was doing well and was
win stable condition. (Id.) The ALJ also explained that:
At the annual cardiac follow-up visit in 2018, the claimant complained of
chest discomfort but describe it as “occasional” and “brief” (9F/20). He
still reported “doing quite well” overall, and only a few months later, the
claimant again reported “occasional” chest discomfort and specifically
noted that it occurred when “standing too long” (2F/17). At that time,
neither his primary care doctor nor cardiologist prescribed any treatment or
work-up in response to these complaints of occasional chest pain (2F/17;
9F/20-23).
(Id.) The ALJ addressed cardiology follow-ups in 2019, 2020, and 2022, and noted that
at each appointment Claimant complained of chest discomfort when standing for long
periods of time which was relieved with sitting down. (Id. at 19.) The ALJ noted that
at each appointment the cardiologist ordered Holter monitor work-up and/or a chest CT,
and all three work-ups were “unremarkable.” (Id.)
The ALJ also addressed Claimant’s complaints of back and joint pain. (Id.) The
ALJ noted that:
[T]he only treatment documented [for back and joint pain] is over-thecounter Excedrin or Ibuprofen (2F/12, 18, 39; 9F/25, 29). This
conservative treatment is consistent with the fact that treatment notes
document only sporadic complaints of back pain interspersed between

13

denials of musculoskeletal concerns (2F/5, 11, 14, 17, 21, 25; 9F/15, 20,
25,29; 14F; 16F). Although the claimant has been offered a referral to pain
management for his back and joint pain, he has not pursued that referral
due to a lack of interest (7F/5). This failure is difficult to reconcile with
the allegation that the claimant’s pain would require additional breaks and
frequent absences from work (18E).
(Id.) The ALJ also found that, after reviewing the medical evidence, Claimant’s physical
examinations were also “inconsistent with the extreme pain and limitation alleged.” (Id.)
The ALJ acknowledged Claimant’s mild physical impairments but noted that “physical
examination has not shown the claimant to have any persistent limitations in strength, to
have difficulty with transfers or mobility, or to need an assistive device (see, generally,
2F/1-43; 5F; 7F; 8F; 9F/1-27; 10F; 14F; 16F; 18F).” (Id.)
The ALJ also noted that:
Despite allegations of need to take breaks while seated (hearing testimony;
12E), the claimant has not limited sitting in the residual functional capacity
or provided for position changes or extra breaks. At the consultative
examination, the claimant leaned forward while sitting and in so doing was
able to remain seated without exhibiting pain behaviors or changing
positions (16F). The claimant testified at the hearing that he could sit for
“a couple hours” without getting up. In the typical full-time work schedule,
a break is provided after each 2 hour block of the workday. Thus, the
claimant’s self-reported physical abilities are compatible with the sitting
required of sedentary work.
(Id. at 20.) Contrary to Claimant’s argument that in making this finding, the ALJ
improperly employed a “sit and squirm” test, see Doc. 7 at 23-24, the ALJ did not such
thing. The ALJ noted that Claimant was able to remain seated during a consultative
examination and testified at the hearing that he could sit for 2 hours without changing
positions.

14

The ALJ concluded that:
In summary, since 2016, there has been no significant change to the
claimant’s cardiac treatment regimen or recommendations except for
occasional work-up ordered in response to complaints of chest discomfort
when standing too long. There has been no treatment for back or joint pain
aside from over-the counter medications. The claimant’s complaints have
been of relatively benign symptoms, if any, and he has not reported any
significant limitations in functioning aside from pain with extended
standing. As such, the record is devoid of the type of significant complaints
or treatments that would be consistent with the claimant’s alleged
symptoms. . . .
For these reasons, the undersigned finds that the claimant’s statements
concerning the intensity, persistence, and limiting effects of his physical
symptoms are not entirely consistent with the medical evidence and other
evidence in the record. There is no dispute he should avoid extended
periods of standing and walking due to his history of spinal fusion and the
need to avoid cardiac stress. It is also reasonable to limit heavy lifting,
postural activities, environmental exposures, handling, and fingering for
the claimant’s safety, given his surgical history, and due to his pain
complaints. However, the evidence of record, taken as a whole, simply
does not indicate that the claimant would have been unable to perform work
within those parameters at any time since he attained age 18. The
undersigned therefore finds that a limitation to sedentary work with
additional postural and environmental limitations adequately accommodates
the claimant’s physical impairments since age 18.
(Id. at 19-20.)
In sum, I find that the ALJ appropriately discounted Claimant’s subjective
allegations of disability because the ALJ found inconsistencies in the evidence as a whole
and considered the Polaski factors. See Wildman, 596 F.3d at 968-69. Moreover,
contrary to Claimant’s arguments, the ALJ thoroughly explained his reasoning for
discounting Claimant’s subjective allegations of disability, in particular addressing the
inconsistencies in the medical evidence. Significantly, Claimant in is brief fails to point
out any deficiencies in the ALJ’s reasoning and fails to offer any specifics or identify any

15

medical evidence calling the ALJ’s thorough analysis into question. As such, I find the
ALJ did not err in discounting Claimant’s testimony or his allegations because substantial
evidence as a whole supported the ALJ’s credibility determination. It is not for this Court
to reweigh evidence. Thus, I recommend the District Court affirm this part of the ALJ’s
decision.
B.

RFC and Record Development
1.

Parties’ Arguments

Claimant argues that the “testimony regarding his pain, discomfort, and social
anxiety, as well as the opinions and findings of the treating and evaluating physicians
clearly illustrate that [Claimant] is unable to perform even a limited range of sedentary
work.” (Doc. 7 at 24.) Claimant maintains that the ALJ “offered no . . . supportive
medical evidence, and the medical evidence of record clearly does not support a
conclusion that he would be capable of performing a limited range of sedentary work.”
(Id. at 25.) Claimant focuses on the opinions of two consultative examining sources, Dr.
Taylor and Dr. Freeman, and asserts that the opinions of these doctors “explicitly address
the nature and severity of [Claimant’s] impairments, are supported with detailed
explanations for their opinions, are well supported by the medical evidence of record,
are in no way inconsistent with the other substantial evidence in the case record and are
not contradicted by any other medical source.” (Id.) According to Claimant, the opinions
of Dr. Taylor and Dr. Freeman “are consistent with, and are supported by the medical
evidence or record, and they are not contradicted by any other medical source” and as a
result, their opinions and findings “should have been accorded more weight than the ALJ
chose to assign.” (Id. at 25-26.) Claimant concludes that the ALJ’s “findings and
conclusions are not supported by substantial evidence and this case should be reversed
and remanded[.]” (Id. at 26.)

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Additionally, Claimant argues that the ALJ “neglected to fully and fairly develop
the medical record.” (Id.) Claimant contends that “[b]ased on the corroborative medical
evidence of record, if the ALJ had any doubts regarding [Claimant’s] condition, he could
have ordered additional consultative examinations to either corroborate or dispute the
opinions and findings of Dr. Taylor and/or Dr. Freeman.” (Id.) Claimant suggests that
the ALJ “failed to procure any medical evidence to support his conclusions” and this
matter should be remanded for further development of the record. (Id. at 27.)
The Commissioner argues that the “ALJ’s decision adequately evaluated all of
[Claimant’s] impairments.” (Doc. 11 at 11.) The Commissioner points out the lengthy
and thorough medical evidence that the ALJ considered in his decision. (Id. at 12-14.)
The Commissioner contends that “[a]lthough [Claimant] claims that the consultative
opinions are consistent with and supported by the medical evidence of record . . .
[Claimant] points to no such supporting evidence.”

(Id. at 17.)

Similarly, the

Commissioner argues that “while [Claimant] also claims that the consultative examiners’
opinions were corroborated by the opinions of his treating physicians, he does not identify
any such opinion.” (Id.) The Commissioner also argues that Claimant “does not attempt
to explain how the limitations already included in the RFC did not account for his
impairments, nor did he offer any purported limitation that was established in the record
that was not included in the RFC, or point to any examination finding establishing
additional functional limitations.”

(Id. at 17-18.)

The Commissioner asserts that

Claimant “has not met his burden to point to evidence in the record establishing
limitations greater than those already accounted for by the ALJ in the RFC.” (Id. at 18.)
The Commissioner concludes that the “ALJ cited extensively to the record and included
supported limitations in the RFC” and “[b]ecause the evidence substantially supports the
ALJ’s decision, the Court should affirm.” (Id. at 22.)

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2.

Pertinent Medical Evidence

On December 17, 2021, Claimant was referred by Disability Determination
Services (“DDS”) to Dr. Ashley H. Freeman, Ph.D., for a psychological report. At the
examination, which was performed online due to the COVID-19 pandemic, Claimant’s
primary complaint was “‘I don’t like talking to people and it’s hard for me to do physical
things.’” (AR at 1712.) Dr. Freeman’s general observations were as follows:
[Claimant] was cooperative. No involuntary movements were observed.
He appeared to be dressed casually. Level of effort was good.
Volume and rate of speech were within normal limits. Thought process
was normal. Thought content appeared consistent with reality. No
perceptual abnormalities were observed. Affect was appropriate to the
situation. Mood appeared dysphoric and anxious. He was tearful at the
beginning of the exam after being asked his reason for claiming disability.
He took a brief pause and left the video screen to grab a tissue. His mother
stated, “His nerves take over.” When asked about suicidal ideation, he
became tearful and took another break from the video to grab a drink of
water at his mother’s encouragement. He looked at his mother before
responding to most questions and frequently responded with “I don’t
know.” He was a very poor historian regarding dates and details of his
history.
(Id. at 1715.) Dr. Freeman diagnosed Claimant with social anxiety disorder and noted
that he was “visibly anxious throughout the exam and had difficulty responding and
answering questions.” (Id. at 1716.) Dr. Freeman opined that Claimant’s prognosis was
guarded and found that his “psychological problems are longstanding, pervasive, and
chronic.” (Id.) Dr. Freeman noted that Claimant “does not see a therapist and is not
taking any psychiatric medications.

A medical evaluation with a psychiatrist is

recommended. Treatment compliance is recommended.” (Id.) Dr. Freeman concluded
that Claimant: (1) “possesses the mental capacity to perform simple and repetitive tasks
as well as complex and detailed tasks”; (2) “should not experience impairment in

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consistent job performance due to psychosis or a thought disorder”; (3) “should not
require additional or special supervision for performance of most tasks”; (4) “was able
to carry out instructions, maintain attention, concentration, and pace”; (5) “will have
impairment interacting appropriately with supervisors, co-workers, and the public due to
his social anxiety”; (6) “will likely experience interruptions in his ability to complete a
normal workday or workweek due to his social anxiety”; and (7) “will very likely
experience impairment dealing with the usual stresses encountered in competitive work
due to his social anxiety.” (Id. at 1717.) Dr. Freeman also opined that “it is suspected
[Claimant’s] anxiety would be significant enough when in a work setting or when around
people that his functioning in these areas would be impaired.” (Id.)
On April 18, 2022, Claimant was referred by DDS to Dr. Dr. Mark C. Taylor,
M.D., for a consultative examination. In reviewing Claimant’s complaints, Dr. Taylor
noted that:
Since the spinal fusion, he has difficulties standing or walking for too far.
When he sits, he finds it beneficial to lean forward, which was noted when
I entered the room and he remained in that position until we had him move
to the examination table. He also described chronic chest pain and he has
followed with a cardiologist, Dr. Zittergruen. He also notices neck pain if
he looks down, such as when rinsing dishes. His feet hurt if he stands for
very long. The records also mentioned severe anxiety. His affect was quite
flat and he did not talk a lot, but he answered questions appropriately. . . .
As far as the chest and back pain, when the pain increases up to 3 or 4/10,
he then sits down, or even opts to lie down in the bed or on the couch. At
times, the pain can worsen but it is fairly random.
(AR at 1849.) Upon examination, Dr. Taylor opined that Claimant could sit frequently
but “must be able to lean forward and to change positions when needed.” (Id. at 1852.)
Due being on blood thinners for the aortic root repair, Dr. Taylor also opined that
Claimant must “avoid activities that would place him at risk for head trauma or significant

19

injuries or bleeding due to the blood thinner.” (Id. at 1853.) Further, Dr. Taylor opined
that due to surgery related to scoliosis, Claimant is limited in bending, lifting (20 pounds
occasionally), carrying, and climbing. (Id.) Based on foot problems, Dr. Taylor opined
that it would be difficult for Claimant to “perform a job that requires standing or walking
for significant periods of time.” (Id.)
3.

Relevant Law

The ALJ is responsible for assessing a claimant’s RFC, and his or her assessment
must be based on all of the relevant evidence. Guilliams, 393 F.3d at 803. Relevant
evidence for determining a claimant’s RFC includes “medical records, observations of
treating physicians and others, and an individual’s own description of his [or her]
limitations.” Lacroix v. Barnhart, 465 F.3d 881, 887 (8th Cir. 2006) (quoting Strongson
v. Barnhart, 361 F.3d 1066, 1070 (8th Cir. 2004)). While an ALJ must consider all of
the relevant evidence when determining a claimant’s RFC, “the RFC is ultimately a
medical question that must find at least some support in the medical evidence of record.”
Casey v. Astrue, 503 F.3d 687, 697 (8th Cir. 2007).
The ALJ also has a duty to develop the record fully and fairly. Cox v. Astrue,
495 F.3d 614, 618 (8th Cir. 2007). “There is no bright line rule indicating when the
[ALJ] has or has not adequately developed the record; rather, such an assessment is made
on a case-by-case basis.” Mouser v. Astrue, 545 F.3d 634, 639 (8th Cir. 2008).
To the extant that Claimant raises concerns with the ALJ’s consideration of Dr.
Taylor’s and Dr. Freeman’s opinions, under the rules, no medical opinion is
automatically given controlling weight. 20 C.F.R. § 404.1520c(a). Opinions from
medical sources are evaluated using the following factors: (1) supportability, (2)
consistency, (3) provider’s relationship with the claimant, (4) specialization, and (5) other
factors. Id. § 404.1520c(c). Supportability and consistency are the most important
factors when determining “how persuasive the ALJ find[s] a medical source’s medical

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opinions . . . to be.” Id. § 404.1520c(b)(2). The ALJ “may, but [is] not required to,
explain how [he or she] considered the factors in paragraphs (c)(3) through (c)(5). . . .”
Id.
Supportability concerns the internal consistency that a source’s opinion has with
the source’s own findings and notes. “The more relevant the objective medical evidence
and supporting explanations presented by a medical source are to support his or her
medical opinion(s) . . ., the more persuasive the medical opinions . . . will be.” 20
C.F.R. § 404.1520c(c)(1).

Consistency concerns the external consistency that the

source’s opinion has with the findings and opinions of other sources.

“The more

consistent a medical opinion[] . . . is with the evidence from other medical sources and
nonmedical sources in the claim, the more persuasive the medical opinion[] . . . will be.”
20 C.F.R. § 404.1520c(c)(2).
4.

Analysis

First, Claimant’s statement that the ALJ “offered no . . . supportive medical
evidence, and the medical evidence of record clearly does not support a conclusion that
he would be capable of performing a limited range of sedentary work,” see Doc. 7 at 25,
makes me question whether Claimant carefully read the ALJ’s decision. As discussed
extensively above, the ALJ thoroughly and exhaustively reviewed the medical evidence
in the record and cited to the record where appropriate in determining Claimant’s RFC
and ultimately whether Claimant met the requirements for disability under the five-step
sequential evaluation. See AR at 16-21. Second, Claimant’s statement that “testimony
regarding his pain, discomfort, and social anxiety, as well as the opinions and findings
of the treating and evaluating physicians clearly illustrate that [Claimant] is unable to
perform even a limited range of sedentary work,” see Doc. 7 at 24, is merely conclusory
and the Commissioner correctly points out that Claimant does not identify any such
opinions, even those of Dr. Taylor and Dr. Freeman, any such medical records, or any

21

such findings which support greater limitations than those already included in the ALJ’s
RFC determination.
As for Dr. Taylor’s and Dr. Freeman’s opinions, the ALJ considered and
addressed their opinions as follows:
Consultative examiner Dr. Mark Taylor concluded that the claimant could
lift up to 20 pounds occasionally, sit on a frequent basis, and stand/walk on
rare-to-occasional basis (16F). He also opined, among other things, that
the claimant would need to alternate sitting, standing, and walking as
needed for comfort (16F). These opinions were supported by Dr. Taylor’s
clinical findings, specifically his observation that the claimant leaned
forward while sitting. However, there are not other similar findings by
other medical personnel. Moreover, Dr. Taylor’s assertion that the
claimant may be capable of only “rare” standing and walking is inconsistent
with the unremarkable findings upon examination. Therefore, because the
opinions of Dr. Taylor are not entirely consistent with the record as a
whole, they have somewhat limited persuasive value. . . .
Consultative examiner Ashley Freeman, Ph.D., opined that the claimant
could perform simple, complex, and detailed tasks but that he would have
limitations on concentration, pace, and social interaction in the work setting
(10F). In addition, the social limitations Dr. Freeman imposed are
consistent with the abnormalities observed by other medical personnel (4F;
16F; 17F). However, to the extent Dr. Freeman concluded that the
claimant could not sustain competitive, full-time work, her opinions are
inconsistent with the claimant’s activities of daily living, his limited mental
health treatment, and the fact that no medical personnel have observed
significant limitations in memory, concentration, or focus (see, generally,
2F/1-45; 4F; 5F; 9F/1-29; 10F; 14F; 16F; 17F; 18F; hearing testimony;
5E). The opinions of Dr. Freeman have somewhat limited persuasive
value.
(AR at 20-21.) In support of these conclusions, the ALJ thoroughly reviewed Claimant’s
medical history and pointed to evidence throughout the record where Dr. Taylor’s and
Dr. Freeman’s opinions were inconsistent with the record as a whole. (Id. at 16-21.)
Therefore, based on the foregoing, I find that the ALJ both properly considered Dr.

22

Taylor’s opinions and Dr. Freeman’s opinions and properly addressed the consistency
and supportability of Dr. Taylors’s and Dr. Freeman’s opinions. The ALJ also properly
supported his conclusions that both Dr. Taylor’s and Dr. Freeman’s opinions were not
consistent with the record as a whole and were not adequately supported by objective
medical findings in the record. Even if different conclusions could be drawn on this
issue, the conclusions of the ALJ should be upheld because they are supported by
substantial evidence on the record as a whole. See Guilliams, 393 F.3d at 801. It is not
for this Court to reweigh evidence. Thus, I conclude that the ALJ properly evaluated
both Dr. Taylor’s and Dr. Freeman’s opinions.
Furthermore, in determining Claimant’s RFC, the ALJ thoroughly addressed and
considered Claimant’s medical history and treatment for his complaints. (AR at 16-21.)
The ALJ also properly considered and discussed Claimant’s subjective allegations of
disability in making his overall disability determination, including determining
Claimant’s RFC, finding that “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[.]” (Id. at 16.)
Therefore, having reviewed the entire record, I find that the ALJ properly
considered Claimant’s medical records, observations of treating physicians, and
Claimant’s own description of his limitations in making the ALJ’s RFC assessment for
Claimant. See Lacroix, 465 F.3d at 887. Further, I find that the ALJ’s decision is based
on a fully and fairly developed record. See Cox, 495 F.3d at 618. Because the ALJ
considered the medical evidence as a whole, I conclude that the ALJ made a proper RFC
determination based on a fully and fairly developed record. See Guilliams, 393 F.3d at
803. Even if different conclusions could be drawn on this issue, the conclusions of the
ALJ should be upheld because they are supported by substantial evidence on the record

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as a whole. See id. at 801. It is not for this Court to reweigh evidence. Accordingly, I
recommend that the District Court affirm this part of the ALJ’s decision.
IV.

CONCLUSION

For the foregoing reasons, I respectfully recommend that the District Court
AFFIRM the decision of the ALJ.
The parties must file objections to this Report and Recommendation within
fourteen (14) days of the service of a copy of this Report and Recommendation, in
accordance with 28 U.S.C. § 636(b)(1) and Fed. R. Civ. P. 72(b). Objections must
specify the parts of the Report and Recommendation to which objections are made, as
well as the parts of the record forming the basis for the objections. See Fed. R. Civ. P.
72. Failure to object to the Report and Recommendation waives the right to de novo
review by the District Court of any portion of the Report and Recommendation as well
as the right to appeal from the findings of fact contained therein. United States v. Wise,
588 F.3d 531, 537 n.5 (8th Cir. 2009).
DONE AND ENTERED this 7th day of March, 2025.

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