Brain v. Commissioner, Social Security Administration

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF COLORADO
Civil Action No. 25-cv-00248-KAS
A.B.1,
Plaintiff,
v.
FRANK BISIGNANO2, Commissioner of Social Security,
Defendant.
_____________________________________________________________________
ORDER
_____________________________________________________________________
ENTERED BY MAGISTRATE JUDGE KATHRYN A. STARNELLA
This matter is before the Court on the Social Security Administrative Record
[#7], filed March 21, 2025, in support of Plaintiff’s Complaint [#1] seeking review of the
decision 	of 	the 	Social 	Security 	Administration’s 	Commissioner 	(“Defendant” 	or
“Commissioner”), denying Plaintiff’s claim for social security disability insurance pursuant
to Title II of the Social Security Act (the “Act”), 42 U.S.C. § 401 et seq. Plaintiff filed an
Opening Brief [#9] (the “Brief”), Defendant filed a Response [#10] in opposition, and
Plaintiff filed a Reply [#15]. The Court has jurisdiction to review the Commissioner’s final
decision under 42 U.S.C. §§ 405(g) and 1383(c)(3). The Court has reviewed the entire
1 Pursuant to D.C.COLO.LAPR 5.2(b), “[a]n order resolving a social security appeal on the merits
shall identify the plaintiff by initials only.”
2 Frank Bisignano is the current Commissioner of Social Security and is substituted for former
Acting Commissioner Leland Dudek as Defendant in this case. See Fed. R. Civ. P. 25(d).
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case file and the applicable law. For the reasons set forth below, the decision of the
Commissioner is AFFIRMED.3
I. 	Background
On July 13, 2021, Plaintiff filed an application for disability and disability insurance
benefits under Title II. Tr. 33.4 Plaintiff alleged disability beginning January 12, 2020. Id.
His claim was denied on December 28, 2022, and again upon reconsideration on
September 18, 2023. Id. On April 25, 2024, an administrative law judge (ALJ) issued an
unfavorable decision. Tr. 30-48. On October 7, 2024, the Appeals Council denied
Plaintiff's request for review. Tr. 17-19.
The ALJ first determined that Plaintiff met the Act's insured status requirements
through September 30, 2022, and that he did not engage in substantial gainful activity
from January 12, 2020, the alleged onset date, through September 30, 2022, his date last
insured. Tr. 35. The ALJ then found that, through his date last insured, Plaintiff suffered
from the following severe impairments: (1) coronary artery disease/status-post coronary
artery bypass graft, (2) status-post cerebral vascular accident, (3) degenerative disc
disease of the lumbar and cervical spine, and (4) osteoarthritis of the left wrist. Tr. 36.
The ALJ also found Plaintiff's impairments, either separately or in combination, did not
meet or medically equal “the severity of one of the listed impairments in 20 CFR Part 404,
Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525 and 404.1526).” Tr. 38.
3 The parties consented to proceed before the undersigned for all proceedings pursuant to 28
U.S.C. § 636(c) and D.C.COLO.LCivR 72.2. See Consent [#8]; Reassignment [#12].
4 The Court refers to the Transcript of the Administrative Proceedings, located at Docket No. 7,
by the sequential transcript numbers instead of the separate docket numbers.
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The ALJ next concluded that Plaintiff had the residual functional capacity (“RFC”)
to perform light work,5 including
lifting and carrying up to 20 pounds occasionally and 10 pounds frequently,
sitting up to six hours and standing and walking up to four hours in an eight-
hour day, pushing and pulling as much as lifting and carrying, but is limited
to occasional climbing of ramps and stairs, never climbing ladders or
scaffolds, and occasional balancing, stooping, kneeling, crouching and
crawling. Claimant is also limited to frequent handling with the left hand.
Claimant is further limited to occasional exposure to extreme cold, extreme
heat, 	dust, 	odors, 	fumes, 	pulmonary 	irritants, 	and 	no 	exposure 	to
unprotected heights or moving mechanical parts.
Tr. 39. Based on the RFC and the testimony of an impartial vocational expert, the ALJ
found that, through his date last insured, Plaintiff could perform his relevant past work as
a programmer. Tr. 47-48. Therefore, the ALJ found that Plaintiff was not disabled at step
four. Id.
The ALJ’s decision is the Commissioner’s final decision for purposes of judicial
review. 20 C.F.R. § 404.981 (explaining that the ALJ’s decision becomes the final
decision when the Appeals Council denies a request for review).
II. 	Standard of Review and Applicable Law
Pursuant to the Act:
[T]he Social Security Administration (SSA) is authorized to pay disability
insurance benefits and Supplemental Security Income to persons who have
a “disability.” A person qualifies as disabled, and thereby eligible for such
benefits, “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,
5 “Light work” is defined as follows: “Light work involves lifting no more than 20 pounds at a time
with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted
may be very little, a job is in this category when it requires a good deal of walking or standing, or
when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To
be considered capable of performing a full or wide range of light work, you must have the ability
to do substantially all of these activities. If someone can do light work, we determine that he or
she can also do sedentary work, unless there are additional limiting factors such as loss of fine
dexterity or inability to sit for long periods of time.” 20 C.F.R. § 404.1567(b).
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considering his age, education, and work experience, engage in any other
kind of substantial gainful work which exists in the national economy.”
Barnhart v. Thomas, 540 U.S. 20, 21-22 (2003) (quoting 42 U.S.C. §§ 423(d)(2)(A),
1382c(a)(3)(B)). Under the applicable legal standard, a claimant is disabled if he or she
is unable “to engage in any substantial gainful activity by reason of any medically
determinable physical or mental impairment . . . 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). The
existence of a qualifying disabling impairment must be demonstrated by “medically
acceptable 	clinical 	and 	laboratory 	diagnostic” 	findings. 	42 	U.S.C. 	§§ 	423(d)(3),
423(d)(5)(A).
“When a claimant has one or more severe impairments the Social Security [Act]
requires the [Commissioner] to consider the combined effect of the impairments in making
a disability determination.” Campbell v. Bowen, 822 F.2d 1518, 1521 (10th Cir. 1987).
However, the mere existence of a severe impairment or combination of impairments does
not require a finding that an individual is disabled within the meaning of the Act; rather, to
be disabling, the claimant’s condition must be so functionally limiting as to preclude any
substantial gainful activity for at least twelve consecutive months. See, e.g., Kelley v.
Chater, 62 F.3d 335, 338 (10th Cir. 1995) (citing 42 U.S.C. § 423(d)(1)(A)).
The 	Court 	reviews 	the 	Commissioner’s 	final 	decision 	by 	examining 	the
administrative record and determining “whether the [ALJ’s] factual findings are supported
by substantial evidence in the record and whether the correct legal standards were
applied.” Wilson v. Astrue, 602 F.3d 1136, 1140 (10th Cir. 2010). However, the Court may
“neither reweigh the evidence nor substitute [its] judgment for that of the agency.” Casias
v. Sec’y of Health & Hum. Servs., 933 F.2d 799, 800 (10th Cir. 1991). In other words, the
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Court does not reexamine the issues de novo. Sisco v. U.S. Dep’t of Health & Hum.
Servs., 10 F.3d 739, 741 (10th Cir. 1993). Thus, even when some evidence could support
contrary findings, the Court “may not displace the agency’s choice between two fairly
conflicting views,” even if the Court may have “made a different choice had the matter
been before it de novo.” Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007) (internal
quotation marks and modification omitted).
A. 	The Five-Step Framework
The Social Security Administration uses a five-step framework to determine
whether a claimant meets the necessary conditions to receive Social Security benefits.
See 20 C.F.R. § 404.1520(a)(4). The claimant bears the burden of proof at steps one
through four, and if the claimant fails at any of these steps, consideration of any
subsequent step or steps is unnecessary. Williams v. Bowen, 844 F.2d 748, 750, 751
(10th Cir. 1988) (“If a determination can be made at any of the steps that a claimant is or
is 	not 	disabled, 	evaluation 	under 	a 	subsequent 	step 	is 	not 	necessary.”). 	The
Commissioner bears the burden of proof at step five. Bowen v. Yuckert, 482 U.S. 137,
146 n.5 (1987).
Step one requires the ALJ to determine whether the claimant is “presently engaged
in substantial gainful activity.” Allen v. Barnhart, 357 F.3d 1140, 1142 (10th Cir. 2004). If
not, the ALJ considers at step two whether the claimant has “a medically severe
impairment or impairments.” Id. “An impairment is severe under the applicable regulations
if it significantly limits a claimant’s physical or mental ability to perform basic work
activities.” Wall v. Astrue, 561 F.3d 1048, 1052 (10th Cir. 2009) (citing 20 C.F.R.
§ 404.1521). Next, at step three, the ALJ considers whether a claimant’s medically severe
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impairments are equivalent to a condition “listed in the appendix of the relevant disability
regulation,” i.e., the “Listings.” Allen, 357 F.3d at 1142. At step four, the ALJ must
determine the claimant’s residual functional capacity (“RFC”). 20 C.F.R. § 404.1520(e).
RFC is defined as “the most [the claimant] can still do despite [their] limitations” and it
considers the claimant’s “ability to meet the physical, mental, sensory, and other
requirements 	of 	work.” 	20 	C.F.R. 	§§ 	404.1545(a)(1), 	(a)(4). 	In 	making 	an 	RFC
determination, 	the 	ALJ 	must 	consider 	all 	the 	claimant’s 	impairments, 	including
impairments that are not severe. 20 C.F.R. § 404.1545(a)(2). Also, “the ALJ must
consider, at step four, whether a claimant’s impairments prevent [him] from performing
[his] past relevant work.” Wall, 561 F.3d at 1052. “Even if a claimant is so impaired, the
agency considers, at step five, whether [he or she] possesses the sufficient [RFC] to
perform other work in the national economy.” Id.
B. 	Substantial Evidence
An ALJ must consider all evidence and explain why he or she finds a claimant not
disabled. Clifton v. Chater, 79 F.3d 1007, 1009-10 (10th Cir. 1996). However, the ALJ
need not specifically “reference everything in the administrative record.” Wilson, 602 F.3d
at 1148. “Substantial evidence is such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.” Id. at 1140 (internal quotation marks and
citation omitted). “It requires more than a scintilla, but less than a preponderance.” Lax,
489 F.3d at 1084. A decision by the ALJ is not based on substantial evidence “if it is
overwhelmed by other evidence in the record or constitutes mere conclusion.” Musgrave
v. 	Sullivan, 	966 	F.2d 	1371, 	1374 	(10th 	Cir. 	1992). 	In 	other 	words, 	the 	Court’s
determination of whether the ALJ has supported his or her ruling with substantial evidence
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“must be based upon the record taken as a whole.” Broadbent v. Harris, 698 F.2d 407,
412, 414 (10th Cir. 1983). In addition, “if the ALJ failed to apply the correct legal test,
there is a ground for reversal apart from a lack of substantial evidence.” Thompson v.
Sullivan, 987 F.2d 1482, 1487 (10th Cir. 1993).
III. 	Analysis
Plaintiff argues that the ALJ erred (1) when evaluating and accounting for RFC
limitations arising from arthritis in his left wrist; (2) when determining the persuasiveness
of opinion evidence; and (3) failing to account for Plaintiff’s mild mental limitations. Brief
[#9] at 8-20.
A. 	The RFC
Plaintiff argues the ALJ erred by failing to include more restrictive fingering and
handling limitations in the RFC due to left wrist arthritis. Brief [#9] at 8-13. The RFC
includes no fingering limitations and permits frequent handling. Tr. 39. Plaintiff contends
that in reaching this determination, the ALJ omitted critical evidence and mischaracterized
the record in reaching this determination. Brief [#9] at 8-9.
The record does not support Plaintiff’s position. The ALJ thoroughly reviewed the
medical evidence and hearing testimony concerning Plaintiff’s left wrist arthritis. Tr. 40,
43-45, 47. At the administrative hearing, Plaintiff testified that he had experienced left
wrist pain since his first surgery in 1990. Tr. 40, 73. He also stated that, during the relevant
period from January 12, 2020, through September 30, 2022, he could generally lift 50 to
60 pounds, though arthritis sometimes prevented him from lifting anything with his left
wrist. Tr. 40, 73, 75-76. This testimony reflects intermittent limitations rather than a
consistent inability to use the wrist.
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The contemporaneous medical evidence likewise does not establish disabling
functional limitations. In June 2020, during an unrelated urgent care visit, Plaintiff reported
a prior diagnosis of rheumatoid arthritis in his left wrist with intermittent swelling. Tr. 42
(citing Tr. 905). He also reported that he had not attempted over-the-counter ibuprofen to
manage his symptoms. Tr. 905. This minimal treatment undermines his allegations of
severe, persistent limitations.
In November 2020, Plaintiff saw orthopedist Dr. Thomas Mordick, II, for increased
wrist pain and swelling. Tr. 43 (citing Tr. 1092-93). Dr. Mordick previously saw Plaintiff
three 	years 	prior 	for 	left 	wrist 	pain, 	suspected 	the pain 	was rheumatologic, 	and
recommended that Plaintiff see a rheumatologist, but Plaintiff never did. Tr. 43 (citing Tr.
1092). During the November 2020 visit, Plaintiff reported decreased function and severe
pain when placing weight on the wrist. Id. (citing Tr. 1092). However, the physical
examination showed largely intact functioning: full range of motion limited by pain and
swelling, full strength, normal sensation, negative Tinel’s sign, and good finger motion
with intact flexors and extensors. Id. (citing Tr. 1092). Plaintiff denied numbness or tingling
and acknowledged that he had not experienced finger joint pain in years because
“someone told him to self inject them with peptides, and that made everything go away.”
Tr. 1092. These findings do not support additional fingering limitations.
At that visit, Dr. Mordick again recommended a rheumatology consultation, which
Plaintiff declined, opting instead to pursue alternative injections from someone he knew.
Tr. 43 (citing Tr. 1092). Plaintiff’s refusal to follow recommended treatment further
undermines his allegations of finger and handling limitations. See Soc. Sec. Ruling 16-
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3p, 2017 WL 5180304, at *9 (Oct. 25, 2017) (explaining that an ALJ may consider a
claimant’s efforts to seek and follow treatment when evaluating symptom severity).
Notably, this November 2020 visit represents the only wrist-specific treatment
during the relevant period (January 12, 2020 through September 30, 2022). Nevertheless,
the ALJ considered some post-period evidence to the extent it sheds light on Plaintiff’s
wrist impairment before the date last insured. Tr. 44.
Substantial evidence supports the ALJ’s conclusion that the post-date-last-insured
evidence did not compel a finding of disability. In October 2022, X-rays showed severe
arthritis, and Dr. David Schnur advised that only a wrist fusion would provide significant
improvement. Tr. 44 (citing Tr. 1045, 1106). Plaintiff did not seek additional treatment for
his wrist until May 2023. Tr. 1050. At that time, Dr. Imran Choudhry diagnosed “advanced
end-stage osteoarthritis” and recommended total wrist fusion. Tr. 45 (citing Tr. 1050). On
appeal, Plaintiff repeatedly emphasizes this “end-stage” diagnosis. Brief [#9] at 12; Reply
[#15] at 1, 3, 5, 7. But a diagnosis alone does not establish disability. Nunez v. Colvin,
175 F. Supp. 3d 1258, 1267 (D. Colo. 2016) (citing Coleman v. Chater, 58 F.3d 577, 579
(10th Cir. 1995) (explaining the medical condition’s “mere presence” is insufficient; rather,
the 	condition 	“must 	render 	claimant 	unable 	to 	engage 	in 	any 	substantial 	gainful
employment”) (modification omitted)). Although the ALJ did not use the “end stage”
terminology, he considered Dr. Choudhry’s findings and treatment recommendations. Tr.
45.
In June 2023, Dr. Mordick again documented largely preserved function, including
50-degree extension, 30-degree flexion, full finger motion, full strength, and intact
sensation, while recommending a total wrist arthrodesis. Tr. 45 (citing Tr. 1091). He also
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noted that Plaintiff’s desire to lift weights made arthroplasty unsuitable. Id. (citing Tr.
1091). These findings continue to show functional capacity inconsistent with additional
fingering restrictions.
The ALJ reasonably concluded that the evidence did not support more restrictive
limitations during the relevant period. The record instead shows limited treatment, largely
normal strength and sensation, and Plaintiff’s repeated refusal to pursue recommended
care. Social Security Ruling 16-3p instructs that the Agency considers a claimant’s efforts
to seek and follow treatment when evaluating symptom intensity and persistence. Soc.
Sec. Ruling 16-3p, 2017 WL 5180304, at *9 (Oct. 25, 2017). Conversely, conservative
treatment or a failure to follow prescribed treatment may undermine allegations of severe
symptoms. Id. These factors reasonably undermine Plaintiff’s allegations of disabling
symptoms.
Plaintiff argues that the ALJ failed to consider all post-date-last-insured evidence
and never stated that he excluded evidence on that basis. Reply [#15] at 3. The record
contradicts this assertion. The ALJ expressly stated that he reviewed later evidence “to
the extent . . . it may provide information on impairments that existed” during the relevant
period. Tr. 44. The Court finds no error in the ALJ’s focus on evidence from and near the
relevant period, as Plaintiff must establish disability before the date last insured. See 20
C.F.R. § 404.131; Henrie v. U.S. States Dep’t of Health & Hum. Servs., 13 F.3d 359, 360
(10th Cir. 1993).
Moreover, Plaintiff’s reliance on records from August 2023 through February 2024
lacks persuasive force. In August 2023, nearly a year after the date last insured, Plaintiff
first reported radiating pain, numbness, and finger symptoms, which he attributed to a
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neck and spine injury from weightlifting. Tr. 1127. This record marks the first documented
complaint involving the fingers, especially notable given his November 2020 report that
he had not experienced finger joint pain in years. Tr. 1092. Subsequent records reflect
similar complaints, some improvement with therapy, and continued reluctance to pursue
recommended surgical treatment. Tr. 1218, 1225, 1228. In February 2024, Plaintiff
reported that three physicians had recommended additional surgery, but he wanted a
fourth opinion. Tr. 1218.
This evidence reflects a worsening condition rather than Plaintiff’s functioning
during the insured period. It does not clearly link the later-developed finger symptoms to
his earlier wrist arthritis and supports the ALJ’s decision to omit it.
The ALJ applied the correct legal standards and supported his findings with
substantial evidence. Lax, 489 F.3d at 1084. Accordingly, this assertion of error does not
provide a basis for relief on appeal.
B. 	Opinion Evidence
In his next issue on appeal, Plaintiff challenges both the state agency physician
opinions and the ALJ’s evaluation of those opinions. Brief [#9] at 15-16. As in his prior
argument, Plaintiff asserts that the agency physicians failed to consider post-date-last-
insured medical evidence relevant to his wrist arthritis and disability claim. Id. The Court
disagrees.
At the initial review level, the agency physician did not specifically address
Plaintiff’s wrist, despite listing arthritis among his impairments, and therefore included no
related limitations in the opinion. Tr. 86, 98-103. At reconsideration, however, the agency
physician conducted a thorough review and summary of the medical record, including
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evidence related to Plaintiff’s wrist. Tr. 107-09. Dr. Glenn Gade concluded that Plaintiff’s
limitations restricted him to frequent handling. Tr. 115-16. Plaintiff criticizes Dr. Gade for
relying on only three visits, November 2020, October 2022, and June 2023, when
assessing his wrist arthritis. Tr. 109. That criticism misses the mark.
Because the November 2020 visit constitutes the only wrist-specific treatment
during the relevant period, Dr. Gade reasonably relied on that record as the primary
contemporaneous evidence. Tr. 109. He also considered the October 2022 and June
2023 visits to evaluate whether later findings shed light on the severity of Plaintiff’s
condition during the insured period. Id. For the same reasons discussed above, medical
evidence after June 2023 does not provide substantial support for Plaintiff’s wrist
impairment or resulting limitations during the relevant period. Thus, Plaintiff’s challenge
to the substance of the reconsideration opinion fails.
Plaintiff next argues that the ALJ did not adequately explain the persuasiveness of
the agency physician opinions. Brief [#9] at 16. He contends that, although the ALJ
adopted the wrist-related limitation from Dr. Gade’s opinion, the ALJ failed to explain how
the opinion was supported by objective medical evidence and consistent with the record
as a whole. Id. (citing Tr. 47).
The governing regulations require less than Plaintiff suggests. An ALJ evaluates
medical opinions using five factors: supportability, consistency, relationship with the
claimant, specialization, and other factors. 20 C.F.R. § 404.1520c(c). “The two most
important factors are supportability and consistency with the entire record.” Roy o/b/o
Helton v. Comm’r, SSA, No. 22-5036, 2022 WL 17726702, at *3 (10th Cir. Dec. 16, 2022)
(citing 20 C.F.R. § 404.1520c(b)(2)).
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Regarding supportability, the ALJ must consider whether the medical source’s
opinions are supported by “objective medical evidence” and “supporting explanations.”
20 C.F.R. § 404.1520c(c)(1). “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). “The supportability analysis looks at whether the medical source’s
opinions are supported by the source’s own notes, diagnoses, and explanations.” R.L.M.
v. Kijakazi, No. 22-cv-03179-NYW, 2023 WL 8355963, at *8 (D. Colo. Dec. 1, 2023).
Regarding consistency, the ALJ must compare the medical source’s opinions and
“the evidence from other medical sources and nonmedical sources.” 20 C.F.R. §
404.1520c(c)(2). “The more consistent a medical opinion(s) . . . is with the evidence from
other medical sources and nonmedical sources in the claim, the more persuasive the
medical opinion(s) . . . will be.” 20 C.F.R. § 404.1520c(c)(2).
While the Regulations do not mandate at what depth the ALJ must discuss
supportability and consistency, the ALJ must at least “provide an explanation that allows
the reviewing court to follow [his] reasoning and communicates how [he] considered
[those two factors] for each medical source’s opinions.” R.L.M., 2023 WL 8355963, at *8
(internal quotation marks and citation omitted).
The Court does not read the ALJ’s assessment of the agency opinions in isolation.
Instead, the Court reviews the decision as a whole. The ALJ discussed examinations
showing full or near-full range of motion, full strength, normal sensation, and intact finger
function. Tr. 43-45 (citing Tr. 1045, 1049-50, 1091, 1092, 1106, 1275-77). He also noted
Plaintiff’s minimal treatment, delayed care, and repeated refusal to pursue recommended
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interventions such as injections and surgery. Id. These findings directly support the
conclusion that Plaintiff retained the capacity for frequent handling.
The ALJ further reinforced the consistency of the agency opinions by citing
Plaintiff’s activities during the relevant period, including frequent biking, such as a 30-mile
ride, and swimming up to 1.5 miles per day. Tr. 47 (citing Tr. 818-19, 1000). These
activities reasonably contradict allegations of disabling hand limitations and align with the
assessed RFC.
Read as a whole, the decision clearly explains why the ALJ found Dr. Gade’s
opinion persuasive. Plaintiff’s argument fails because it isolates a single paragraph rather
than engaging with the ALJ’s full analysis. The Tenth Circuit permits courts to rely on
findings from other sections of the decision and does not require the ALJ to repeat the
same analysis in multiple places. See Fischer-Ross v. Barnhart, 431 F.3d 729, 733 (10th
Cir. 2005); Webb v. Comm’r, Soc. Sec. Admin., 750 F. App’x 718, 721 (10th Cir. 2018)
(finding that the ALJ’s reference to “all [medical records] discussed above” in his decision
to discount a treating physician’s opinion still enabled the reviewing court to “follow the
adjudicator’s reasoning” and “determine that correct legal standards have been applied”)
(quoting Keyes-Zachary v. Astrue, 695 F.3d 1156, 1166 (10th Cir. 2012)).
C. 	Mild Mental Impairments
Plaintiff argues that the ALJ failed to account for his mild mental impairments in
the RFC. Brief [#9] at 17-20. He argues that the ALJ committed reversible error at step
four 	by 	not 	discussing 	mild 	limitations 	in 	mental 	functioning 	that 	the 	ALJ 	found
“persuasive” at step two. Id. at 18. Defendant counters that the governing regulations
require only that the ALJ consider non-severe impairments when assessing a claimant’s
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RFC and that the ALJ did so. Response [#10] at 2-3, 8. For reasons discussed below, the
Court finds no reversible error.
“[A]ll medically determinable impairments, severe or not, must be taken into
account at [the] later steps [of the ALJ’s sequential evaluation].” Grotendorst v. Astrue,
370 F. App’x 879, 883 (10th Cir. 2010) (emphasis omitted); Wells v. Colvin, 727 F.3d
1061, 1065 (10th Cir. 2013) (in the RFC assessment, “the ALJ must consider the
combined effect of all the claimant’s medically determinable impairments, whether severe
or not severe”) (emphasis omitted). “The governing SSA regulations do not mandate that
the ALJ specifically address the degree of functional limitations assessed at step two and
three when subsequently formulating a claimant’s RFC. Rather, the regulations require
only that the ALJ must consider the limitations resulting from a claimant’s severe and non-
severe impairments when subsequently assessing an RFC.” E.R.D. v. O’Malley, No. 23-
cv-02155-LTB, 2024 WL 3276158, at *5 (D. Colo. July 2, 2024) (citing 20 C.F.R. §§
404.1545(a)(2), 416.945(a)(2)).
At step two, the ALJ applied the “paragraph B” criteria as part of the psychiatric
review 	technique 	and 	found 	that 	Plaintiff 	had 	no 	more 	than 	mild 	limitations 	in
understanding, 	remembering, 	or 	applying 	information; 	interacting 	with 	others;
concentrating, persisting, or maintaining pace; and adapting or managing himself. Tr. 36.
The ALJ considered the psychological evaluation report prepared by Mac Bradley, PhD,
a consulting forensic psychologist. Tr. 37-38 (citing Ex. 13F). Dr. Bradley’s report noted
Plaintiff’s problems with short-term memory and attention and concentration, but Plaintiff’s
overall level of attention and concentration was sufficient for interview and testing
purposes. Tr. 37 (citing Tr. 1036). During the interview, Plaintiff appeared to have
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adequate long-term memory, and he did not demonstrate significant deficits in planning,
problem solving, thinking, reasoning, or judgment. Id. (citing Tr. 1037). On psychological
testing, Dr. Bradley noted that Plaintiff did not appear to have given maximum effort on
the test and, therefore, surmised that the results “may be a slightly low estimate of his
intellectual disabilities.” Id. (citing Tr. 1038). The ALJ noted that Dr. Bradley’s assessment
of Plaintiff did not indicate significant deficits, and Dr. Bradley diagnosed Plaintiff with mild
vascular neurocognitive disorder, without behavioral impairment, and found no more than
a mild limitation in any area of mental functioning. Id. (citing Tr. 1039-40). The ALJ found
Dr. Bradley’s opinions persuasive based on the psychological testing results, Plaintiff’s
presentation in the interview with Dr. Bradley, his independent ability to manage activities
of daily living, his part-time teaching position at a community college in 2022, and his
parti-time computer programming job in 2023. Id. The ALJ also noted that Plaintiff’s
medical records showed few mental health complaints, little or no mental health
treatment, and no findings of abnormal mental status, such as limitations in memory,
cognition, attention, concentration, thought process, hygiene, insight, judgment, or his
ability to interact with others. Tr. 38. Additionally, the ALJ noted that Dr. Bradley’s opinions
aligned with the findings of two state agency psychological consultants, who found no
more than a mild limitation in any paragraph B mental area. Id. At the conclusion of his
step two analysis, the ALJ expressly stated, “[t]he following residual functional capacity
assessment reflects the degree of limitation the undersigned has found in the ‘paragraph
B’ mental function analysis.” Tr. 38.
At step four, the ALJ included no mental limitations in the RFC. Tr. 39. That
omission does not establish error. In his decision, the ALJ expressly addressed Plaintiff’s
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non-severe mental impairment and explained that it caused no more than minimal
limitations in his ability to perform basic mental work activities. Tr. 36. He further explained
that Plaintiff’s mild limitations in the paragraph B areas did not translate into work-related
restrictions. Id. This analysis satisfies the ALJ’s obligation to consider non-severe
impairments when formulating the RFC. Although the ALJ did not repeat this explanation
in the RFC section, the Court can follow his reasoning without duplication. See Giles v.
Kijakazi, No. CIV-22-1075-STE, 2023 WL 4188204, at *4 (W.D. Okla. June 26, 2023)
(affirming ALJ’s step four conclusion that the plaintiff's mild mental limitations did not
warrant limitations in the RFC, although the ALJ’s comprehensive analysis of the plaintiff’s
mental impairments occurred at step two). The Tenth Circuit does not require an ALJ to
restate the same analysis in multiple sections of a decision. See Endriss v. Astrue, 506
F. App’x 772, 777 (10th Cir. 2012); Webb, 750 F. App’x at 721.
Plaintiff also contends that the ALJ erred by finding the state agency opinions
assessing mild mental limitations persuasive while failing to explain any inconsistency
between those opinions and the RFC. Brief [#9] at 19. This argument fails because the
RFC does not conflict with opinions assessing only mild mental limitations. Findings at
steps two and three do not automatically translate into work-related restrictions. Even
moderate limitations may not require RFC restrictions, depending on the evidence. See
Vigil v. Colvin, 805 F.3d 1199, 1203 (10th Cir. 2015) (explaining that a “finding of a
moderate limitation in concentration, persistence, or pace at step three does not
necessarily translate to a work-related functional limitation for the purposes of the RFC
assessment”); Beasley v. Colvin, 520 F. App’x 748, 754 (10th Cir. 2013) (same). Instead,
the ALJ must determine whether the claimant’s symptoms actually limit his ability to work.
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See Gallegos v. Kijakazi, No. 21-1169 DHU/GJF, 2023 WL 2553922, at *12 (D.N.M. Mar.
17, 2023). The ALJ did exactly that.
After evaluating the medical opinions and other evidence regarding Plaintiff’s
mental impairments, the ALJ concluded that Plaintiff’s mild limitations did not warrant
workplace restrictions. Tr. 38. He also specified that the RFC “reflects the degree of
limitation” identified in the paragraph B analysis. Id.
Plaintiff’s remaining argument is speculative. He suggests that a combined
analysis of his impairments “may have” resulted in additional mental limitations and a
different outcome. But he identifies no specific limitation the ALJ should have included
and no evidence the ALJ failed to consider. This omission proves fatal to his claim. See
Orso v. Colvin, 658 F. App’x 418, 420 (10th Cir. 2016) (criticizing the plaintiff’s failure “to
explain specifically what additional limitations were needed based on his anxiety or any
other impairment”). At most, Plaintiff disagrees with the ALJ’s conclusions. A “mere
difference of opinion does not empower [a] [c]ourt to usurp the SSA’s role as factfinder.”
Gallegos, 2023 WL 2553922, at *11. Accordingly, the Court finds no error in the ALJ’s
consideration of Plaintiff’s non-severe mental impairments.
IV. Conclusion
Based on the foregoing,
IT IS HEREBY ORDERED that the Commissioner’s decision in this case is
AFFIRMED.
IT IS FURTHER ORDERED that each party shall bear its own costs and attorney's
fees.
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IT IS FURTHER ORDERED that the Clerk of Court shall enter judgment in favor
of Defendant and close this case.
Dated: March 31, 2026 	BY THE COURT:
Kathryn A. Starnella
United States Magistrate Judge
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