Houser v. Bisignano

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IN THE UNITED STATES DISTRICT COURT
DISTRICT OF UTAH, CENTRAL DIVISION
REBECCA H.,
Plaintiff,
vs.
FRANK BISIGNANO,
Commissioner of Social Security,
Defendant.
Case No. 2:24-cv-00825-CMR
MEMORANDUM DECISION AND
ORDER AFFIRMING ALJ DECISION
Magistrate Judge Cecilia M. Romero
All parties in this case have consented to the undersigned conducting all proceedings (ECF
8). 28 U.S.C. § 636(c). Plaintiff Rebecca H. (Plaintiff), pursuant to 42 U.S.C. § 405(g), seeks
judicial review of the decision of the Commissioner of Social Security (Commissioner) denying
her claim for disability insurance benefits (DIB) under Title II of the Social Security Act (Act).
After careful review of the record (Certified Administrative Record (Tr.), ECF 10), the parties’
briefs (ECF 16, 22, 24), the undersigned concludes that the Commissioner’s decision is supported
by substantial evidence and free from reversible error. For the reasons discussed below, the court
hereby DENIES Plaintiff’s Motion for Review of Agency Action (ECF 16) and AFFIRMS the
decision of the Commissioner.
I. 	BACKGROUND
Plaintiff applied for DIB in March 2021 (Tr. 69). Plaintiff was 44 years old in September
2020, when she claimed that she became disabled due to recurrent major depressive disorder,
plantar fasciitis, hypothyroidism, obstructive sleep apnea, and chronic fatigue syndrome (id.). The
ALJ followed the Commissioner’s five-step sequential evaluation process for disability claims
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(Tr. 14–34). See 20 C.F.R. § 404.1520(a)(4). In a decision dated September 25, 2023, the ALJ
determined at step two that Plaintiff had severe impairments of bilateral carpal tunnel syndrome,
bilateral ulnar neuropathy, right thumb triggering, and obesity (Tr. 20). The ALJ found non-severe
medically determinable impairments of obstructive sleep apnea, orthostatic intolerance, vision
issues, depression, and anxiety (id.). The ALJ found mild limitations in paragraph B criteria of
understanding, remembering or applying information; concentrating, persisting, or maintaining
pace; and adapting or managing oneself, and no limitation in interacting others (id. at 21). See id.
§§ 404.1520a(d)(1), 404.1522(a).
At step three, the ALJ considered Plaintiff’s carpal tunnel syndrome under Listing 11.14
for peripheral neuropathies and Listing criteria in Appendix 1 for obesity impairments, finding
the criteria not met (Tr. 21). The ALJ then found that Plaintiff had the RFC to do a range of light
work (id. at 22). See id. §§ 404.1545(a)(1) (“Your [RFC] is the most you can still do despite your
limitations.”). At step four, the ALJ found that this RFC would allow Plaintiff to do her past
relevant work as a cashier, cafetoria worker, and customer service representative (id. at 27). The
ALJ thus concluded that Plaintiff was not disabled (id. at 28). See id. § 404.1520(a)(4)(iv). The
ALJ decision became the Commissioner’s final decision when the agency’s Appeals Council
denied her request for review. See 20 C.F.R. § 404.981.1 The court has jurisdiction under 42
U.S.C. § 405(g).
II. 	STANDARD OF REVIEW
“On judicial review, an ALJ’s factual findings [are] ‘conclusive’ if supported by
‘substantial evidence.’” 	Biestek v. Berryhill, 587 U.S. 97, 102 (2019) (quoting 42 U.S.C. §
405(g)). The substantial evidence threshold “is not high,” and “defers to the presiding ALJ, who
1 References to the Code of Federal Regulations (C.F.R.) are to the 2022 edition.
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has seen the hearing up close.” 	Id. at 103, 108. 	Substantial evidence is “more than a mere
scintilla” and “means—and means only—such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.” Id. at 103 (quoting Consolidated Edison Co. v. NLRB,
305 U.S. 197, 229 (1938)). Under this deferential standard, the court may neither reweigh the
evidence nor substitute its judgment for that of the ALJ. See Hendron v. Colvin, 767 F.3d 951,
954 (10th Cir. 2014). If the evidence is susceptible to multiple interpretations, the court “may not
displace the agency’s choice between two fairly conflicting views, even though the court would
justifiably have made a different choice had the matter been before it de novo.” Lax v. Astrue,
489 F.3d 1080, 1084 (10th Cir. 2007) (quoting Zoltanski v. F.A.A., 372 F.3d 1195, 1200 (10th
Cir. 2004)).
III. 	ARGUMENT
A. 	The ALJ reasonably found Plaintiff’s mental impairments non-severe at step 2.
Plaintiff argues that the ALJ’s finding that Plaintiff’s mental impairments were non-severe
at step two is not supported by substantial evidence (Pl. Br. at 10). Specifically, Plaintiff argues
that the ALJ’s step-two analysis does not “account for the waxing and waning nature of Plaintiff’s
mental symptoms” (id. at 11). The Commissioner responds that the ALJ’s step-two findings are
supported by the ALJ’s evaluation of the medical opinions and record evidence (Def. Br. at 6–8).
In assessing the severity of a mental impairment, an ALJ evaluates the claimant’s
limitations in four “paragraph B” categories of mental functioning (understanding, remembering
and applying information; interacting with others; concentrating, persisting, and maintaining pace;
and adapting and managing oneself) using a five-point scale (none, mild, moderate, marked, and
extreme). 20 C.F.R. §§ 404.1520a(c)(3), (4); 20 C.F.R. 404, Subpt. P, App’x 1 § 12.00(E), (F)(2).
A mild limitation only “slightly” affects one’s functioning. 20 C.F.R. 404, Subpt. P, App’x 1 §
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12.00(F)(2)(b). If a claimant’s paragraph-B limitations are only “mild,” the associated mental
impairment is generally non-severe. 20 C.F.R. § 404.1520a(d)(1).
Here, the ALJ found at step two that Plaintiff had medically determinable mental
impairments of depression and anxiety (Tr. 20). The ALJ found that these impairments were non-
severe because they did not cause more than minimal limitation in Plaintiff’s ability to perform
basic mental work activities (id.). See 20 C.F.R. § 404.1522(a). In reaching this finding, the ALJ
rated the B criteria, concluding that Plaintiff experienced mild limitations in understanding,
remembering or applying information; concentrating, persisting, or maintaining pace; and
adapting or managing oneself, and no limitation in interacting others (id. at 21). 	See id. §
404.1520a(d)(1).
Plaintiff argues that the ALJ erred in evaluating the opinion of Dr. Frank Gonzalez (Dr.
Gonzalez) that Plaintiff’s depression and anxiety were severe and resulted in a moderate limitation
in adapting and managing oneself (Pl. Br. at 10). An ALJ considers several factors in evaluating
the persuasiveness of a medical opinion, including supportability (how well the source explained
and supported an opinion) and consistency (how consistent the opinion is with other record
evidence). 20 C.F.R. § 404.1520c(b)(2), (c)(1)–(2). The ALJ in this case properly evaluated the
opinions of reviewing psychologists Dr. Gonzales and Dr. Joan Zone (Dr. Zone) based on
consistency and supportability in making the RFC determination (Tr. 25–26 (citing Tr. 71–72, Tr.
80–81)); 20 C.F.R. § 404.1520c(b)(2), (c)(1)–(2). See Endriss v. Astrue, 506 F. App’x 772, 777
(10th Cir. 2012) (“The ALJ set forth a summary of the relevant objective medical evidence earlier
in his decision and he is not required to continue to recite the same evidence again in rejecting
[an] opinion.”); see also Webb v. Comm’r, Soc. Sec. Admin., 750 F. App’x 718, 721 (10th Cir.
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2018) (The ALJ summarized relevant evidence earlier in the decision, and was not required to
repeat that summary in weighing an opinion).
Although the ALJ acknowledged that Dr. Gonzales provided some support for his opinion
that Plaintiff had severe mental impairments causing a moderate limitation in adjusting to
workplace changes, the ALJ reasonably deemed these findings inconsistent with the evidence
overall (Tr. 25–26 (citing Tr. 71–72, Tr. 80–81)). Instead, the ALJ found the overall record
consistent with Dr. Zone’s opinion that Plaintiff had no severe impairments and needed no mental
limitations in her RFC. The ALJ noted that Dr. Zone had supported her opinion by citing to
Plaintiff’s normal examination findings, including normal psychological examination results in
April 2020 and March 2021, as well as her responses to a Patient Health Questionnaire (PHQ) in
March and April 2021 indicating that her depression was non-severe (Tr. 26 (citing Tr. 81)).
Thus, the ALJ’s evaluation of these medical opinions rested on substantial evidence and
proper application of the supportability and consistency criteria. Plaintiff’s argument that the ALJ
should have weighed the opinions of Drs. Gonzales and Zone differently is unavailing. See Lax,
489 F.3d at 1084 (determination founded on substantial evidence must stand even if reviewing
court would have decided the matter differently); see also Alarid v. Colvin, 590 F. App’x 789, 795
(10th Cir. 2014) (plaintiff may not demand that reviewing court reweigh evidence).
Plaintiff also points to medical records that support Dr. Gonzalez’s opinion, such as
treatment notes showing Plaintiff’s reports of being depressed and having crying spells, insomnia,
difficulty concentrating, and low energy (Pl. Br. at 10–11) (citing Tr. 466, 476–479). However,
the ALJ reasonably found that Plaintiff’s reported symptoms were inconsistent with objective
medical evidence. See 20 C.F.R. § 404.1529(c)(4) (“[W]e will evaluate your statements in relation
to the objective medical evidence.”). Even in cases involving mental impairments, “objective
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medical evidence is a useful indicator to help make reasonable conclusions about the intensity and
persistence of symptoms[.]” Social Security Ruling (SSR) 16-3p, 2017 WL 5180304, at *5. The
ALJ highlighted Plaintiff’s normal results on objective examination, for example her normal mood
and affect in June 2021, September 2021, March 2022, and January 2023 (Tr. 21 (citing Tr. 555,
703, 727); Tr. 26 (citing Tr. 791); Tr. 27 (citing Tr. 623)). Plaintiff reported feeling normal on
examination in 2022 (Tr. 21 (citing Tr. 679–80)) and confirmed her ability to manage her finances,
prepare meals, do household chores, and drive (Tr. 21–22 (citing Tr. 340); Tr. 23 (citing Tr. 621)).
The ALJ also observed Plaintiff sought no specialized behavioral treatment (Tr. 21). See
SSR 16-3p, 2017 WL 5180304, at *5 (“[I]f the . . . extent of the treatment sought by [a disability
claimant] is not comparable with the degree of [her] subjective complaints, . . . we may find the
alleged intensity and persistence of [her] symptoms are inconsistent with1 the overall evidence of
record”). The ALJ thus considered Plaintiff’s allegations of debilitating mental impairment (Tr.
22, 27) 	and reasonably discounted them as inconsistent with the evidence detailed above,
including Dr. Zone’s opinion, normal examination results, and failure to pursue relevant
treatment.2
B. 	The ALJ’s RFC determination is supported by substantial evidence.
Plaintiff argues that the ALJ erred in failing to consider her mental impairments in
formulating her RFC (Pl. Br. at 11). In response, the Commissioner argues that ALJ adequately
addressed Plaintiff’s mental impairments in the RFC determination by evaluating the medical
opinions and discussing Plaintiff’s reported symptoms at step two (Def. Br. at 8).
2 The Commissioner also notes that the ALJ considered that Plaintiff worked during the relevant period, answering
calls for an insurance company in 2000 and working part-time as a cashier from November 2021 through at least
August 2023 (Tr. 20-21 (citing Tr. 45-46)). See Markham v. Califano, 601 F.2d 533, 534 (10th Cir. 1979) (claimant’s
ability to do some work not decisive but may be considered in evaluating whether a claimant is disabled).
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Plaintiff claims that the ALJ failed to “provide any meaningful discussion of Plaintiff’s
non-severe mental impairments” in the RFC determination because the ALJ’s evaluation of the
medical evidence “lacks any reference to the mental impairments” (Pl. Br. at 12).3 An ALJ must
consider the effects of all the claimant’s medically determinable impairments—including those
found severe and those found non-severe—when assessing the RFC. 20 C.F.R. § 404.1545(a)(2).
Here, as explained above, the ALJ explained the decision to include no mental limitations in
Plaintiff’s RFC by finding that Plaintiff’s mental impairments caused no more than minimal
interference with her ability to perform work-related activities (Tr. 20–21) and in discounting
Plaintiff’s 	allegations 	of 	depression-induced 	problems 	with 	memory, 	task 	completion,
concentration, understanding, and following instructions (id. at 22, 27).4 Combined with the ALJ’s
step-two reasoning for finding Plaintiff’s mental impairments non-severe, this explanation
provides this court a clear path of reasoning for including no mental limitations in Plaintiff’s RFC.
See Davis v. Erdmann, 607 F.2d 917, 918 n.1 (10th Cir. 1979) (ALJ sufficiently articulates her
reasoning if a court can discern its path).
Plaintiff also claims that the ALJ’s discussion of mental impairments is limited to step two
and this constitutes reversible error (Pl. Br.at 12). However, the findings and discussion by the
ALJ at step two are relevant to the symptom evaluation, which, in turn, is relevant to the RFC
3 Plaintiff relies on the Marin case to support her argument, which held that “[t]he ALJ’s failure to explain why the
claimant’s RFC excludes known mental limitations, interferes with this court’s ability to assess whether the ALJ did,
in fact, consider all the relevant evidence and all of the claimant’s medically determination impairments, including
non-severe mental limitations, when constructing the claimant’s RFC.” Marin v. Colvin, No. 14-cv-01331-KMT, 2015
WL 4999955, at *3 (D. Colo. Aug. 24, 2015). This case differs from the Marin case because as explained above, the
ALJ directly addressed Plaintiff’s mental limitations in the RFC determination when evaluating the medical opinions
of Drs. Gonzales and Zone (Tr. 25–26).
4 This finding is due great deference by the court. See White v. Barnhart, 287 F.3d 903, 910 (10th Cir. 2002) (“The
ALJ enjoys an institutional advantage in making the type of determination at issue here. Not only does an ALJ see far
more [S]ocial [S]ecurity cases than do appellate judges, he or she is uniquely able to observe the demeanor and gauge
the physical abilities of the claimant in a direct and unmediated fashion. As a result, the ALJ’s credibility findings
warrant particular deference.”).
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assessment: “Since the purpose of the credibility evaluation is to help the ALJ assess a claimant’s
RFC, the ALJ’s credibility and RFC determinations are inherently intertwined.” 	See Poppa v.
Astrue, 569 F.3d 1167, 1171 (10th Cir. 2009). As such, the court finds that the ALJ’s discussion
of this evidence at step two combined with the ALJ’s findings within the RFC determination were
sufficient to demonstrate that the ALJ considered Plaintiff’s non-severe mental impairments as
part of the RFC assessment. Substantial evidence therefore supports the ALJ’s RFC determination.
See Biestek, 587 U.S. at 103.
IV. 	CONCLUSION
Because the ALJ’s decision is supported by substantial evidence and legally sound, it is
AFFIRMED. Judgment shall be entered in accordance with Fed. R. Civ. P. 58, consistent with the
U.S. Supreme Court’s decision in Shalala v. Schaefer, 509 U.S. 292, 296–304 (1993).
DATED this 10 March 2026.
Magistrate Judge Cecilia M. Romero
United States District Court for the District of Utah
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