Younger v. Social Security Administration

Filing 17

OPINION AND ORDER by Magistrate Judge Jodi F Jayne ; affirming the Commissioner's decision. (kah, Chambers)

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IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF OKLAHOMA
MICHAEL C. Y.,

)
)
Plaintiff,
)
)
vs.
)
)
LELAND DUDEK,1
)
Acting Commissioner of Social Security, )
)
Defendant.
)

Case No. 24-CV-47-JFJ

OPINION AND ORDER
Plaintiff Michael C. Y. seeks judicial review of the decision of the Commissioner of the
Social Security Administration (“Commissioner”) denying his claim for disability benefits under
Title II and Title XVI of the Social Security Act (“Act”), 42 U.S.C. §§ 416(i), 423, and 1382c(a)(3).
In accordance with 28 U.S.C. § 636(c)(1) & (3), the parties have consented to proceed before a
United States Magistrate Judge.

For reasons explained below, the Court affirms the

Commissioner’s decision denying benefits. Any appeal of this decision will be directly to the
Tenth Circuit Court of Appeals.
I.

General Legal Standards and Standard of Review
“Disabled” is defined under the Act as an “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). A physical or mental impairment is an
impairment “that results from anatomical, physiological, or psychological abnormalities which are

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Effective February 19, 2025, pursuant to Federal Rule of Civil Procedure 25(d), Leland Dudek,
Acting Commissioner of Social Security, is substituted as the defendant in this action. No further
action need be taken to continue this suit by reason of the last sentence of 42 U.S.C. § 405(g).

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demonstrable by medically acceptable clinical and laboratory diagnostic techniques.”

Id.

§ 423(d)(3). A medically determinable impairment “must be established by objective medical
evidence,” such as medical signs and laboratory findings, “from an acceptable medical source,”
such as a licensed and certified psychologist or licensed physician; the plaintiff’s own “statement
of symptoms, a diagnosis, or a medical opinion [is not sufficient] to establish the existence of an
impairment(s).” 20 C.F.R. §§ 404.1521, 416.921. See 20 C.F.R. §§ 404.1502(a), 404.1513(a),
416.902(a), 416.913(a). A plaintiff is disabled under the Act “only if his physical or mental
impairment or impairments are of such severity that he is not only unable to do his previous work
but cannot, considering his age, education, and work experience, engage in any other kind of
substantial gainful work which exists in the national economy . . . .” 42 U.S.C. § 423(d)(2)(A).
Social Security regulations implement a five-step sequential process to evaluate a disability
claim. 20 C.F.R. §§ 404.1520, 416.920; Williams v. Bowen, 844 F.2d 748, 750-51 (10th Cir. 1988)
(explaining five steps and burden shifting process). To determine whether a claimant is disabled,
the Commissioner inquires: (1) whether the claimant is currently working; (2) whether the claimant
suffers from a severe impairment or combination of impairments; (3) whether the impairment
meets an impairment listed in Appendix 1 of the relevant regulation; (4) considering the
Commissioner’s assessment of the claimant’s residual functional capacity (“RFC”), whether the
impairment prevents the claimant from continuing his past relevant work; and (5) considering
assessment of the RFC and other factors, whether the claimant can perform other types of work
existing in significant numbers in the national economy. 20 C.F.R. §§ 404.1520(a)(4)(i)-(v),
416.920(a)(4)(i)-(v). If a claimant satisfies his burden of proof as to the first four steps, the burden
shifts to the Commissioner at step five to establish the claimant can perform other work in the
national economy. Williams, 844 F.2d at 751. “If a determination can be made at any of the steps

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that a claimant is or is not disabled, evaluation under a subsequent step is not necessary.” Id. at
750.
In reviewing a decision of the Commissioner, a United States District Court is limited to
determining whether the Commissioner has applied the correct legal standards and whether the
decision is supported by substantial evidence. See Grogan v. Barnhart, 399 F.3d 1257, 1261 (10th
Cir. 2005). Substantial evidence is more than a scintilla but less than a preponderance “and is such
relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” See id.
A court’s review is based on the administrative record, and a court must “meticulously examine
the record as a whole, including anything that may undercut or detract from the ALJ’s findings in
order to determine if the substantiality test has been met.” Id. at 1262. A court may neither reweigh the evidence nor substitute its judgment for that of the Commissioner. See Hackett v.
Barnhart, 395 F.3d 1168, 1172 (10th Cir. 2005). Even if a court might have reached a different
conclusion, the Commissioner’s decision stands if it is supported by substantial evidence. See
White v. Barnhart, 287 F.3d 903, 908 (10th Cir. 2002).
II.

Procedural History and the ALJ’s Decision
Plaintiff, then a 49-year-old male, applied for Title II benefits on December 6, 2021, and

Title XVI benefits on January 28, 2022. R. 199-213. In both applications, Plaintiff alleges he has
been unable to work since an onset date of December 6, 2021, due to rods, screws, and wire in
neck, degenerative issues in lower back, hypertension/high blood pressure, and heart problems. R.
223, 226. Plaintiff’s claims for benefits were denied initially and on reconsideration. R. 98-107,
110-118. Plaintiff then requested a hearing before an ALJ, and the ALJ conducted a telephonic
hearing on June 2, 2023. R. 37-68, 122-123. The ALJ issued a decision on August 25, 2023,
denying benefits and finding Plaintiff not disabled because he could perform other work existing

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in the national economy. R. 18-32. The Appeals Council denied review, and Plaintiff appealed to
this Court. R. 1-3; ECF No. 2.
The ALJ found that Plaintiff meets the insured status requirements of the Social Security
Act through December 31, 2027. R. 21. At step one, the ALJ found that Plaintiff had not engaged
in substantial gainful activity since the alleged onset date of December 6, 2021. Id. At step two,
the ALJ found that Plaintiff had the severe impairment of degenerative disc disease. R. 22. At
step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments
that met or medically equaled a listed impairment. R. 23-25. In assessing Plaintiff’s mental
impairments under the “paragraph B” criteria, the ALJ found Plaintiff had no limitations in the
area of understanding, remembering, or applying information; and mild limitations in the three
areas of (1) adapting or managing oneself; (2) interacting with others; and (3) concentrating,
persisting, or maintaining pace. R. 23.
After evaluating the objective and opinion evidence and Plaintiff’s statements, the ALJ
concluded that Plaintiff had the RFC to perform light work as defined in 20 C.F.R. §§ 404.1567(b),
416.967(b) with the following limitations: “The claimant frequently is able to climb ramps and
stairs, balance, stoop, kneel, crouch, and crawl. He should not climb ladders, ropes, or scaffolds.”
R. 25. At step four, the ALJ found Plaintiff was unable to perform his past relevant work as a
construction supervisor. R. 30-31. However, based on the testimony of a vocational expert
(“VE”), the ALJ found at step five that Plaintiff could perform other occupations existing in
significant numbers in the national economy, such as Folder, Mail Clerk, and Sorter. R. 31-32.
The ALJ determined the VE’s testimony was consistent with the information contained in the
Dictionary of Occupational Titles (“DOT”). R. 32. Accordingly, the ALJ concluded Plaintiff was
not disabled. Id.

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III.

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Issues
Plaintiff raises two points of error in his challenge to the denial of benefits: (1) the ALJ

failed to provide a narrative discussion explaining how the evidence supports Plaintiff’s RFC; and
(2) the ALJ failed to fully and fairly develop the record by not ordering a physical consultative
examination. ECF No. 12.
IV.

Analysis
A.

Evidence Related to Plaintiff’s Physical Impairments

The medical records in this case total only thirty-four pages. R. 275-309. These records
indicate that Plaintiff presented to Dr. Richard Drake on August 10, 2021. R. 275-278. Plaintiff
reported lumbar pain but denied any pain in his lower extremities. R. 275. On physical
examination, Plaintiff had an antalgic gait. R. 277. Plaintiff had tenderness, a mildly reduced
range of motion, and mild pain on range of motion in the lumbosacral spine. Id. Plaintiff exhibited
5/5 motor strength in all tested areas of the lower extremities, except for 4/5 strength in foot
eversion. Id. Plaintiff’s straight-leg raise testing was negative. Id. Dr. Drake noted that an x-ray
of Plaintiff’s lumbar spine revealed severe disc height loss at L1-2 and L5-S1. Id. Dr. Drake
further noted an MRI of Plaintiff’s lumbar spine revealed degenerative disc disease at L1-2 with
moderate central canal stenosis and L5-S1 with mild bilateral foraminal stenosis. Id. Dr. Drake
discussed surgical and non-surgical treatment options with Plaintiff and prescribed Plaintiff pain
medication. R. 278.
On September 7, 2021, Plaintiff presented to Dr. Christopher Martin. R. 279-282. Plaintiff
reported debilitating bilateral low back pain since March 2021 that worsens with sitting or twisting.
R. 279, 282. On physical examination, Plaintiff had an appropriate gait and normal station but his
sit to stand was mildly uncomfortable. R. 282. Plaintiff experienced general pain throughout the

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lumbosacral spine but exhibited a fair, but tender, range of motion with flexion and extension. R.
280. Plaintiff did not experience any tenderness to touch, rotation, or flexion in the lower
extremities. R. 280-281. Plaintiff’s straight-leg raise testing was negative, but Plaintiff did
experience some pain in the legs with lumbar extension. Id. Dr. Martin recommended a steroid
injection in Plaintiff’s back. R. 282.
From March 2022 to March 2023, Plaintiff reported every three months to his primary care
physician, Dr. James Pheonix, for controlled medication follow ups. R. 291-300, 304-309. During
these visits, Plaintiff reported that his average level of pain was a 4/10, except for one occasion in
September 2022, when he reported his average pain was an 8/10. R. 291, 295, 298, 304, 307. Dr.
Pheonix noted that Plaintiff’s low back pain was stable with medication management. R. 296,
300, 305, 309. No physical examinations were performed during these visits. Dr. Pheonix’s
treatment records reflect that Plaintiff had a neck surgery in 2014 and a cervical spine fusion in
2018. E.g., R. 291.
B.

Plaintiff’s RFC Was Supported by Substantial Evidence and Meets the
Requirements of SSR 96-8p.

Plaintiff asserts the ALJ’s RFC determination for a reduced range of light work was not
supported by substantial evidence and fails to comply with the “narrative discussion” requirement
of SSR 96-8p, 1996 WL 374184 (July 2, 1996). ECF No. 12 at 4-9.
A claimant’s RFC is his “maximum remaining ability to do sustained work activities in an
ordinary work setting” for 8 hours a day, 5 days per week despite his medical impairments and
symptoms. SSR 96-8p, at *2. In assessing the RFC, the ALJ must “include a narrative discussion
describing how the evidence supports each conclusion” as to the claimant’s work-related
limitations. Id. at *7. In other words, the ALJ must explain the basis for the limitations included
in the RFC determination with citations to “specific medical facts (e.g., laboratory findings) and

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nonmedical evidence (e.g., daily activities, observations).” Id. Additionally, the ALJ must
“explain how any material inconsistencies or ambiguities in the evidence . . . were considered and
resolved.” Id. If the RFC conflicts with a medical source opinion, the ALJ must “explain why the
opinion was not adopted.” Id.
The ALJ’s RFC determination meets these narrative requirements. The ALJ provided a
detailed summary of Plaintiff’s administrative hearing testimony, the imaging of record, and the
findings of his treating and reviewing physicians. R. 25-29. The ALJ then explicitly linked this
evidence to the decisional RFC. R. 28-29. In finding Plaintiff could perform the standing and
walking requirements of light work and the postural limitations outlined in the RFC, the ALJ
specifically discussed that: (1) Plaintiff denied that he experienced leg pain to Dr. Drake (R. 28
(citing R. 275)); (2) Plaintiff’s straight-leg raise testing was negative (id. (citing R. 277, 280-281));
(3) Dr. Martin observed that Plaintiff had an appropriate gait and normal station (id. (citing 282));
(4) Plaintiff had no tenderness to touch, rotation, and flexion in the lower extremities (id. (citing
R. 280-281)); and (5) Dr. Pheonix’s treatment records indicated that Plaintiff’s back pain was stable
with medication management (id. (citing R. 291-300, 304-309)). In finding Plaintiff could perform
the lifting and carrying requirements of light work, the ALJ specifically discussed Plaintiff’s 2014
neck surgery and 2018 cervical spine fusion, but found that the record showed “little, if any
treatment for neck pain and related symptoms, including numbness, in the upper extremities.” R.
29 (citing R. 291). The ALJ adequately explained the RFC determination as it related to Plaintiff’s
impairments, and the ALJ’s conclusions are supported by substantial evidence.
Plaintiff argues this case is similar to Veronica M. H. v. Kijakazi, where the undersigned
found the ALJ violated SSR 96-8p “by failing to explain how the medical and non-medical
evidence support[ed] the RFC assessment.” No. 20-CV-460-JFJ, 2022 WL 709184, at *4 (N.D.

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Okla. Mar. 9, 2022). This argument fails. In Veronica M. H., the ALJ merely summarized the
medical evidence and then summarily concluded that the decisional RFC “accommodates the
Plaintiff’s physical impairments and is adequate to address . . . the claimant’s bona fide symptoms.”
Id. The court reasoned that the ALJ’s general summary of the evidence did not equate to an
explanation as to how the plaintiff could perform a reduced range of light work. Id. (“[T]he ALJ
pointed to no medical opinion, testimony, or other evidence to support his RFC findings in the first
instance.”). Unlike the ALJ in Veronica M. H., the ALJ in this case explicitly explained how the
evidence informed the RFC determination. R. 28-29. For example, the ALJ found that Plaintiff
could perform the walking and standing requirements of light work based, in part, on Dr. Pheonix’s
treatment records that showed Plaintiff’s low back pain was stable with medication management,
and Dr. Martin’s examination that showed Plaintiff’s gait was appropriate and his station was
normal. R. 28 (citing R. 282, 296, 300, 305, 309).
Plaintiff also argues the ALJ’s decision is not supported by substantial evidence, because
the ALJ did not support the RFC with evidence of Plaintiff’s functioning. ECF No. 12 at 6. In
effect, Plaintiff is arguing the ALJ’s decision is not supported by substantial evidence because there
are no medical opinions in the record. See id. at 7-8. Plaintiff’s argument is unpersuasive for two
reasons. First, the ALJ’s RFC need not correspond directly to a specific medical opinion. Chapo
v. Astrue, 682 F.3d 1285, 1288-89 (10th Cir. 2012) (finding “there is no requirement in the
regulations for a direct correspondence between an RFC finding and a specific medical opinion on
the functional capacity in question,” and rejecting argument that there must be “specific,
affirmative, medical evidence on the record as to each requirement of an exertional work level
before an ALJ can determine RFC within that category”) (quotation omitted). See also Howard v.
Barnhart, 379 F.3d 945, 949 (10th Cir. 2004) (“[T]he ALJ, not a physician, is charged with

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determining a claimant’s RFC from the medical record.”); Robert Lee M. v. Saul, No. 18-2444,
2019 WL 3079384, at *5 (D. Kan. July 15, 2019) (explaining SSR 96-8p’s narrative discussion
requirement “does not require citation to a medical opinion”). Instead, the ALJ’s RFC only needs
to be supported with citations to “specific medical facts” and “nonmedical evidence.” SSR 96-8p,
at *7. As demonstrated above, the ALJ reviewed Plaintiff’s medical records and cited sufficient
evidence in support of the RFC.
Second, the absence of a medical opinion in this case is due to Plaintiff’s failure to submit
evidence. During Plaintiff’s initial and reconsideration disability determinations, the state agency
reviewers found there was “insufficient evidence to determine the severity of his conditions”
because Plaintiff failed to submit information regarding his activities of daily living or work
history. R. 71, 75, 80, 84. It is Plaintiff’s burden to prove that he is disabled. See 20 C.F.R. §§
404.1512, 416.912 (“In general, you have to prove to us that you are blind or disabled.”). If an
applicant for benefits fails to provide evidence, the SSA will make a decision based on the available
evidence. See 20 C.F.R. § 404.1516 (“If you do not give us the medical and other evidence that
we need and request, we will have to make a decision based on information available in your
case.”); § 416.916 (“You . . . must co-operate in furnishing us with, or in helping us to obtain or
identify, available medical or other evidence about your impairment(s). When you fail to cooperate
with us in obtaining evidence, we will have to make a decision based on information available in
your case.”). Plaintiff cannot fail to submit evidence and then argue his RFC is unsupported based
on this failure.
Despite Plaintiff’s contentions otherwise, the Court finds the ALJ considered the evidence
related to Plaintiff’s physical RFC and adequately explained how such evidence supported the
RFC determination. Specifically, the ALJ found that Plaintiff could perform a reduced range of

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light work based on treatment records that showed negative straight-leg raise testing; no tenderness
to touch, rotation, and flexion in the lower extremities; and stable back pain with medication
management. R. 28 (citing R. 277, 280-281, 291-300, 304-309). See Barnett v. Apfel, 231 F.3d
687, 689 (10th Cir. 2000) (“The ALJ is charged with carefully considering all the relevant evidence
and linking his findings to specific evidence.”). Plaintiff also fails to identify any evidence
undermining the ALJ’s conclusion that he could perform a reduced range of light work. Because
Plaintiff points to no evidence the ALJ overlooked, his arguments amount to a request that the
Court re-weigh evidence, which it cannot do. See Oldham v. Astrue, 509 F.3d 1254, 1257-58 (10th
Cir. 2007) (“We review only the sufficiency of evidence, not its weight. . . . Although the evidence
may also have supported contrary findings, we may not displace the agency’s choice between two
fairly conflicting views[.]”) (cleaned up).
C.

ALJ Did Not Err in Declining to Order a Consultative Exam

Plaintiff asserts the ALJ erred by failing to develop the record. Specifically, Plaintiff
contends the ALJ should have ordered a physical consultative examination (“CE”) following the
hearing. ECF No. 12 at 9-10. At the hearing, Plaintiff’s counsel requested a physical CE, but the
ALJ denied the request, as noted in her decision. R. 30, 46.
“The ALJ has a basic obligation in every social security case to ensure that an adequate
record is developed during the disability hearing consistent with the issues raised.” Cowan v.
Astrue, 552 F.3d 1182, 1187 (10th Cir. 2008) (quoting Henrie v. U.S. Dep’t of Health & Human
Servs., 13 F.3d 359, 360–61 (10th Cir.1993)). “This is true despite the presence of counsel,
although the duty is heightened when the claimant is unrepresented.” Id. “The duty is one of
inquiry, ensuring that the ALJ is informed about facts relevant to his decision and learns the
claimant’s own version of those facts.” Id. “The ALJ does not have to exhaust every possible line

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of inquiry in an attempt to pursue every potential line of questioning.” Hawkins v. Chater, 113
F.3d 1162, 1168 (10th Cir. 1997). Instead, the “standard is one of reasonable good judgment.” Id.
An ALJ may elect to develop the record by obtaining a CE. See 20 C.F.R. §§ 404.1519a(b),
416.919a(b) (explaining that “[w]e may purchase a [CE] to try to resolve an inconsistency in the
evidence, or when the evidence as a whole is insufficient to . . . determin[e] . . . your claim”); 20
C.F.R. §§ 404.1512(b)(2), 416.912(b)(2) (“Generally, we will not request a [CE] until we have
made every reasonable effort to obtain evidence from your own medical sources.”). A CE is “often
required” where (1) “there is a direct conflict in the medical evidence requiring resolution,” (2)
“the medical evidence in the record is inconclusive,” or (3) “additional tests are required to explain
a diagnosis already contained in the record.” Hawkins, 113 F.3d at 1166. The Tenth Circuit has
held that an “ALJ should order a [CE] when evidence in the record establishes the reasonable
possibility of the existence of a disability and the result of the [CE] could reasonably be expected
to be of material assistance in resolving the issue of disability.” Id. at 1169. Generally, an ALJ
has “broad latitude in ordering consultative examinations.” Id. at 1166.
The Court finds the ALJ did not commit error by failing to obtain a physical CE to assess
the extent of Plaintiff’s limitations. In the decision, the ALJ explained that she refused the CE
request because “the evidence in the file is sufficient,” specifically noting (1) the August and
September 2021 physical examinations, which occurred just a few months before Plaintiff’s
alleged onset date; (2) Dr. Martin’s discussion of the imaging reports on Plaintiff’s lumbar spine;
and (3) Dr. Pheonix’s treatment records that show Plaintiff’s low back pain was stable with
medication management. R. 30 (citing R. 275-278, 279-282, 291-300, 304-309).
Plaintiff cites to no evidence that would demonstrate the type of material inconsistency that
necessitates a CE. Plaintiff instead argues the record is incomplete because there is no medical

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opinion regarding Plaintiff’s functional limitations. However, as noted above, the ALJ did not
need a specific RFC opinion from a CE or other medical professional to assess Plaintiff’s
functional limitations. See Chapo, 682 F.3d at 1288; Howard, 379 F.3d at 949. See also Robert
Lee M., 2019 WL 3079384, at *5 (explaining the “mere lack of a medical opinion suggesting
specific physical functional limitations or of other medical evidence addressing specific physical
functional limitations does not make the evidence as a whole insufficient to allow the SSA to make
a decision”). Further, at the hearing, Plaintiff’s counsel did not claim the record was too
incomplete for the ALJ to make any disability finding. Rather, Plaintiff’s counsel argued there
was sufficient evidence to find Plaintiff disabled, but insufficient evidence to find Plaintiff not
disabled. See R. 46 (“I think there’s sufficient evidence to reach [the conclusion that Plaintiff is
disabled, but] we don’t have a medical opinion regarding functional capacity. . . . If, Your Honor,
is not persuaded by the record as it stands, I’d ask you consider a physical CE.”). It is unclear how
the record could be incomplete for an unfavorable decision yet complete for a favorable one.
The burden to fully develop the record was met in this case, and the ALJ had sufficient
information to determine Plaintiff’s RFC based on treatment records, imaging reports, and other
non-medical evidence. See Cowan, 552 F.3d at 1187 (finding “no need” to develop record with
CE because “sufficient information” existed for ALJ to make disability determination); Brammell
v. Colvin, No. 15-01202, 2016 WL 1170953, at *4 (D. Kan. Mar. 23, 2016) (rejecting argument
that “ALJ should have ordered [CE] simply because there was no opinion in the record as to [the
plaintiff’s] physical limitations due to her back impairment”). Cf. Baker v. Barnhart, 84 F. App’x
10, 14 (10th Cir. 2003) (finding ALJ had duty to develop the record where there was “no
substantial evidence upon which to base an RFC finding”).

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V.

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Conclusion
For the foregoing reasons, the Commissioner’s decision finding Plaintiff not disabled is

AFFIRMED.
SO ORDERED this 11th day of March, 2025.

J
ODIF.
J
AYNE,
MAGI
STRATEJ
UDGE
UNI
TEDSTATESDI
STRI
CTCOURT

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