Higgins v. Social Security Administration

IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF OKLAHOMA
JESSICA HALEY FURR 	)
HIGGINS, 	)
)
Plaintiff, 	)
)
v. 	) 	Case No. 24-CV-480-GLJ
)
FRANK J. BISIGNANO,1 )
Commissioner of the 	)
Social Security Administration 	)
)
Defendant. 	)
OPINION AND ORDER
Claimant Jessica Haley Furr Higgins requests judicial review of a denial of benefits
by the Commissioner of the Social Security Administration pursuant to 42 U.S.C. § 405(g).
She appeals the Commissioner’s decision and asserts that the Administrative Law Judge
(“ALJ”) erred in determining she was not disabled. For the reasons discussed below, the
Commissioner’s decision is hereby REVERSED AND REMANDED.
Social Security Law and Standard of Review
Disability under the Social Security Act is defined as the “inability to engage in any
substantial gainful activity by reason of any medically determinable physical or mental
impairment[.]” 42 U.S.C. § 423(d)(1)(A). A claimant is disabled under the Social Security
1 On May 6, 2025, Mr. Bisignano became the Commissioner of Social Security. In accordance
with Fed. R. Civ. P. 25(d), Mr. Bisignano is substituted for Leland Dudek as the Defendant in this
action.
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Act “only if [her] physical or mental impairment or impairments are of such severity that
[s]he is not only unable to do his previous work but cannot, considering [her[ 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. See 20 C.F.R.
§§ 404.1520, 416.920.2
Section 405(g) limits the scope of judicial review of the Commissioner’s decision
to two inquiries: whether the decision was supported by substantial evidence and whether
the correct legal standards were applied. See Hawkins v. Chater, 79 F.3d 1007, 1009 (10th
Cir. 1996). Substantial evidence is “‘more than a mere scintilla. It means such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.’”
Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consol. Edison Co. v. NLRB,
305 U.S. 197, 229 (1938)). See also Clifton v. Chater, 79 F.3d 1007, 1009 (10th Cir. 1996).
The 	Court 	may 	not 	reweigh 	the 	evidence 	or 	substitute 	its 	discretion 	for 	the
2 Step one requires Claimant to establish that she is not engaged in substantial gainful activity.
Step two requires Claimant to establish that she has a medically severe impairment (or combination
of impairments) that significantly limits her ability to do basic work activities. If Claimant is
engaged in substantial gainful activity, or her impairments are not medically severe, disability
benefits are denied. If she does have a medically severe impairment, it is measured at step three
against the listed impairments in 20 C.F.R. Part 404, Subpt. P, App. 1. If Claimant has a listed (or
“medically equivalent”) impairment, she is regarded as disabled and awarded benefits without
further inquiry. Otherwise, the evaluation proceeds to step four, where Claimant must show that
she lacks the residual functional capacity (“RFC”) to return to her past relevant work. At step five,
the burden shifts to the Commissioner to show that there is significant work in the national
economy that Claimant can perform, given her age, education, work experience and RFC.
Disability benefits are denied if Claimant can return to any of her past relevant work or if her RFC
does not preclude alternative work. See generally Williams v. Bowen, 844 F.2d 748, 750-51 (10th
Cir. 1988).
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Commissioner’s. See Casias v. Sec’y of Health & Hum. Servs., 933 F.2d 799, 800 (10th
Cir. 1991). Instead, the Court must review the record as a whole, and “[t]he substantiality
of the evidence must take into account whatever in the record fairly detracts from its
weight.” Univ. Camera Corp. v. NLRB, U.S. 474, 488 (1951). See also Casias, 933 F.2d at
800-01.
Claimant’s Background and Procedural History
Claimant was 29 years old at the time of the administrative hearing. (Tr. 37). She
completed high school and alleges an amended onset date of April 14, 2020, due to
limitations imposed by generalized anxiety disorder with agoraphobia. (Tr. 37, 42). Her
date last insured (“DLI”) was March 31, 2023. (Tr. 284).
Procedural History
On May 3, 2021, Claimant applied for disability insurance benefits under Title II of
the Social Security Act, 42 U.S.C. §§ 401-434. (Tr. 18, 215-18). Administrative Law Judge
(“ALJ”) Michael Mannes held an administrative hearing and determined Claimant was not
disabled in a written opinion dated July 31, 2024. (Tr. 18-66). The Appeals Council denied
review, making the ALJ’s opinion the Commissioner’s final decision for purposes of this
appeal. (Tr. 1-7); See 20 C.F.R. §§ 404.971, 416.1481.
Decision of the Administrative Law Judge
The ALJ made his decision at step five of the sequential evaluation. (Tr. 28). At step
two he determined that Claimant had the severe impairments of general anxiety disorder,
panic disorder with agoraphobia, major depressive disorder, and bipolar disorder. (Tr. 21).
At step four he found Claimant had the residual functional capacity (“RFC”) to perform a
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full range of work at all exertional levels. (Tr. 24). Due to psychologically-based
limitations the ALJ found Claimant could understand, remember, and carry out simple and
detailed tasks, make occasional related judgments, concentrate for two hour periods with
routine breaks, persist for an eight hour work day and forty-hour work week, interact with
supervisors and coworkers but only tolerate incidental/occasional public contact, and adapt
to a work setting with some changes. (Tr. 24). The ALJ then concluded that Claimant was
not disabled because there was work she could perform in the national economy, i.e.,
laundry worker I, industrial sweeper cleaner, and linen room attendant. (Tr. 28).
Review
Claimant contends the ALJ erred by failing to: (1) account for Claimant’s sciatic
nerve pain, (2) properly evaluate Claimant’s obesity pursuant to Soc. Sec. R. 19-2p,
(3) comply with Soc. Sec. R. 16-3p in analyzing Claimant’s subjective symptoms,
(4) properly analyze the psychological opinions, and (5) develop the record. The Court
agrees with the first three arguments and finds this action should be reversed and remanded.
The relevant medical evidence reveals that in October 2018 Claimant established
care with Chelsea Berges, D.O. who noted Claimant was obese with a BMI of 46 with no
musculoskeletal pain and full range of motion and strength, bilaterally. (Tr. 408-09).
Claimant returned to her primary care physician in April 2020 reporting panic attacks over
minor issues at work and indicating that she had previously been diagnosed with bipolar
disorder, type II, at Carl Albert Community Mental Health Center (“Carl Albert”). (Tr.
425). Claimant continued to report anxiety and panic attacks induced by, inter alia,
thunderstorms, wind, proximity to others, leaving her home, and checking her mail. (Tr.
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425-50). Dr. Berges ultimately assessed Claimant with a panic disorder with agoraphobia.
(Tr. 452).
In November 2020, Claimant sought treatment with Carl Albert for her anxiety but
was 	discharged 	in 	June 	2021 	after 	missing 	several 	appointments. 	(Tr. 	751-52).
Nonetheless, Claimant continued to routinely follow-up with her primary care physician
for her anxiety, and it was noted Claimant had various nervous tics (e.g., finger and lip
picking, hand flapping, and rubbing legs) in addition to an anxiety related rash bilaterally
on her arms, legs, and feet. (Tr. 466, 472, 479, 493-94). In July 2023, Claimant presented
to the emergency department with a wound in her arm after cutting herself with a kitchen
knife as a means to relieve her anxiety because she was having intrusive thoughts about
self-harm and her boyfriend was not nice. (Tr. 660-68,773). Claimant was referred to Carl
Albert for inpatient treatment and a 72-hour hold but, after completing her intake
evaluation, she was released. (Tr. 773).
On May 29, 2023, Jodi Ray, L.P.C., conducted a psychological consultative
examination of Claimant, at which time Claimant presented with adequate communications
skills and appropriate thought process, but twirled her hair due to anxiety. (Tr. 516-17).
Counselor Ray opined Claimant is not capable of handling benefit payments because
Claimant’s mother paid her bills and Claimant reported she does not feel capable of doing
so. (Tr. 516-18).
As 	to 	Claimant’s 	physical 	impairments, 	the 	record 	reflects 	Claimant 	began
complaining of hip pain in April 2022 and was assessed with left sciatic nerve pain. (Tr.
638-40). Claimant was positive for hip pain and arthralgias upon examination in February
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2023, November 2023, and February 2024 (Tr. 646, 648, 775-779). 	In December 2023
Claimant established care with Mills Chiropractic complaining of neck and hip pain, and
neurological testing conducted in January 2024 revealed a positive kemps sign at L4-L5
and a positive foraminal compression test at C2-C7. (Tr. 788-91). 	The record further
reflects Claimant had a BMI ranging from 46 to 52 through her date last insured and she
was diagnosed with obstructive sleep apnea, which required a sleep study should Claimant
not be able to lose weight aggressively. (Tr. 411-43, 625, 783).
In 2023, state examiner Sarah Yokam, M.D. determined that Claimant had no severe
physical impairments. (Tr. 71). As relevant to this appeal, Dr. Yokam’s considered
Claimant’s obesity in finding Claimant had no severe physical impairments. (Tr. 71). State
agency psychological consultants Ryan Scott Ph.D., and Joan Holloway Ph.D., found
initially and on reconsideration that Claimant is able to concentrate and focus for two-hour
periods with routine breaks, pace and persist for an eight hour work day, interact with
coworkers and supervisors but only tolerate incidental/occasional contact with the public,
understand, recall and perform simple and detailed tasks but not complex tasks, complete
tasks that require some skills and judgment but that do not require doing complex work
duties. (Tr. 75). State agency psychologists also found Claimant could adapt to some
changes in the work setting but, due to uncontrolled psychological symptoms, Claimant
will have difficulties maintaining concentration for complex tasks and will experience
“some lapses on some tasks that require sustained attention.” (Tr. 75).
At the administrative hearing, Claimant testified she engaged in mental health
treatment through Carl Albert on a monthly basis. (Tr. 45). Her anxiety is triggered when
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she is near a large crowd or around people who are screaming. (Tr. 48). She goes shopping
once a week, drives daily to her parents’ house, and attends the gym with a friend on at
least a monthly, but sometimes weekly, basis. (Tr. 49-50). However, she often has
difficulty being around the people at the store, will frequently twirl her hair when she is
nervous, and may experience panic attacks. (Tr. 57) She further testified that she has nerve
pain in her hip area which she treats with gabapentin and naproxen but has not received
physical therapy or steroid injections. (Tr. 51). She attended chiropractic appointments
weekly in the past but recently had to stop due to cost. (Tr. 51). She has no difficulty
preparing meals or engaging in personal care, can walk, at most, two miles, and can lift
approximately 30-40 pounds. (Tr. 51-53). Since April 2020 she has gone fishing with her
son almost every weekend during the summer, and frequently visits parks. (Tr. 55, 57).
In his written opinion at step four, the ALJ extensively summarized Claimant’s
hearing testimony and most of the medical evidence of record. (Tr. 24-27). He then found
that Claimant’s statements about the intensity, persistence, and limiting effects of her
symptoms were not entirely consistent with treatment records, reasoning that they were
inconsistent with the longitudinal treatment record and Claimant’s activity level. (Tr. 26).
The ALJ found the opinion of counselor Ray unpersuasive, reasoning it was not presented
in vocationally relevant terms (Tr. 27). He found the state agency medical consultant’s
opinion persuasive concluding it was consistent with the longitudinal record and supported
with an in-depth explanation. (Tr. 27). Lastly, the ALJ found the opinions of Dr. Scott and
Dr. Holloway persuasive because they were (i) consistent with the record reflecting
conservative 	and 	sparse 	treatment 	consistent 	of 	medication 	which 	showed 	some
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improvement, and (ii) supported with “an in-depth explanation regarding the basis for the
findings, including noting her mental conditions being managed conservatively with
medication and a recent examination noting some indication of anxiety but was otherwise
normal.” (Tr. 26-27).
I. 	Sciatic Nerve Pain
Claimant argues the ALJ improperly evaluated her RFC. Particularly, Claimant
maintains the ALJ failed to discuss Claimant’s diagnosed sciatic nerve pain. The Court
agrees. The ALJ does not discuss or address Claimant’s diagnosis of nerve pain, the related
hip pain, arthralgias, or positive foraminal compression and kemp sign test stemming
therefrom at any point in his opinion.
The record reflects Claimant began experiencing sciatic pain prior to her DLI and,
although Claimant’s chiropractic visit and positive foraminal compression and kemps sign
tests were outside her DLI, they too should be considered to “the extent it clarifies
Claimant’s health prior to the expiration of her insured status.” Carnes v. Comm’r of Soc.
Sec. Admin., 2022 WL 794707, at *4 (E.D. Okla. Feb. 24, 2022) (“If evidence ‘sheds light
on the disability during the relevant time period,’ it should be considered.”) (citing Hamlin
v. Barnhart, 365 F.3d 1208, 1215 (10th Cir. 2004). Because the ALJ did find that the
claimant had severe impairments, any failure to find Claimant’s additional impairments
severe at step two is considered harmless error because the ALJ would nevertheless be
required to consider the effect of these impairments and account for them in formulating
Claimant’s RFC at step four. See, e.g., Carpenter v. Astrue, 537 F.3d 1264, 1266 (10th Cir.
2008) (“At step two, the ALJ must ‘consider the combined effect of all of [the claimant’s]
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impairments without regard to whether any such impairment, if considered separately,
would be of sufficient severity [to survive step two.] Nevertheless, any error here became
harmless when the ALJ reached the proper conclusion that Mrs. Carpenter could not be
denied benefits conclusively at step two and proceed to the next step of the evaluation
sequence.”) (quoting Langley v. Barnhart, 373 F.3d 1116, 1123-24 (10th Cir. 2004) and
20 C.F.R. § 404.1523). See also Hill v. Astrue, 289 Fed. Appx. 289, 292 (10th Cir. 2008)
(“Once the ALJ finds that the claimant has any severe impairment, he has satisfied the
analysis for purposes of step two. His failure to find that additional alleged impairments
are also severe is not in itself cause for reversal. But this does not mean the omitted
impairment simply disappears from the analysis. In determining the claimant’s RFC, the
ALJ is required to consider the effect of all of the claimant’s medically determinable
impairments, both those he deems ‘severe’ and those ‘not severe.’”) (emphasis in original).
The Commissioner, citing Brown v. Bowen, 801 F.2d 361, 362-63 (10th Cir. 1986),
argues that pain is not a functional limitation but an “issue for an ALJ to consider . . .
whether a claimant’s pain is so severe as to cause functional loss.” There is no indication
in this case that the ALJ considered Claimant’s sciatic nerve pain in any regard and that is
precisely what distinguishes this case from Brown wherein the “ALJ explicitly considered
Brown’s allegations of pain.” 801 F.2d at 363; Thompson v. Sullivan, 987 F.2d 1482, 1480-
91(10th Cir. 1993) (“pain, even if not disabling, is still a nonexternal impairment to be
taken into consideration, unless there is substantial evidence for the ALJ to find that the
claimant’s pain is insignificant.”). Here, outside of boilerplate language, there is no
suggestion that the ALJ accounted for Claimant’s sciatic pain at any point in his opinion
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or deemed it insignificant. Furthermore, although the ALJ relied on and adopted Dr.
Yoakam’s findings as it pertains to Claimant’s RFC, it appears that Dr. Yoakam also did
not consider Claimant’s records regarding sciatic pain. (Tr. 27, 71).
The ALJ’s error therefore was not harmless, because the ALJ entirely failed to
consider Claimant’s sciatic pain in his opinion, much less consider the “cumulative effect
of [C]laimant’s impairments,” at step four. Langley, 373 F.3d at 1123. See also Hamby v.
Astrue, 260 Fed. Appx. 108, 112 (10th Cir. 2008) (“In deciding Ms. Hamby’s case, the
ALJ concluded that she had many severe impairments at step two. He failed to consider
the consequence of these impairments, however, in determining that Ms. Hamby had the
RFC to perform a wide range of sedentary work.”) (unpublished). It is possible the ALJ
did consider Claimant’s sciatic pain and, by virtue of omission, deemed it was not a
medically determinable impairment, non-severe, or resulted in no functional limitations.
However, “the Commissioner’s regulations demand a more thorough analysis.” Wells v.
Colvin, 727 F.3d 1061, 1069; See 20 C.F.R. § 404.1523 (“[W]e will consider the combined
effect of all of your impairments without regard to whether any such impairment, if
considered separately, would be of sufficient severity.’”).
II. 	Obesity
The first error is carried through to the second, the ALJ’s evaluation of Claimant’s
obesity. Soc. Sec. R. 19-2p requires an ALJ to consider that “[t]he combined effects of
obesity with another impairment(s) may be greater than the effects of each of the
impairments considered separately.” Soc. Sec. R. 19-2p, 2019 WL 2374244, at *4 (May
20, 2019). “Obesity in combination with another impairment may or may not increase the
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severity or functional limitations of the other impairment(s).” Id. at *2. Here, it is clear the
ALJ considered Claimant’s obesity, determined it was non-severe, and concluded the
“longitudinal treatment record contains no evidence of any specific or quantifiable impact
of obesity on her musculoskeletal, respiratory or cardiovascular functioning.” (Tr. 22).
However, 	the 	record 	does 	reflect 	that 	Claimant 	was 	diagnosed 	with 	sciatic 	pain,
experienced arthralgias and hip pain prior to and after her DLI in addition to presenting
with a positive foraminal compression and kemp sign test in January 2024. (Tr. 636-38,
646-48, 771-75, 779-83, 791). The ALJ did not consider Claimant’s sciatic nerve pain,
singly, much less how it, as a coexisting impairment to Claimant’s obesity, affected the
RFC. See e.g., Fleetwood v. Barnhart, 211 Fed. Appx. 736, 741-42 (10th Cir. 2007) (“[the]
combined effect of obesity with other impairments can be greater than effects of each single
impairment considered individually[,] and . . . obesity must be considered when assessing
RFC.”) (citing Soc. Sec. R. 02-1p, 2002 WL 34686281, *1, *5-*7). Accordingly, the Court
finds the ALJ erred in not considering Claimant’s obesity with her other impairments.
III. 	Subjective Statements
Claimant 	next 	posits 	that 	the 	ALJ 	committed 	reversible 	error 	in 	analyzing
Claimant’s subjective statements as it pertains to both Claimant’s physical and mental
limitations. The Commissioner uses a two-step process to evaluate a claimant’s subjective
statements of pain or other symptoms:
First, 	we 	must 	consider 	whether 	there 	is 	an 	underlying 	medically
determinable physical or mental impairment(s) that could reasonably be
expected to produce an individual's symptoms, such as pain. Second ... we
evaluate the intensity and persistence of those symptoms to determine the
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extent to which the symptoms limit an individual's ability to perform work-
related activities . . .
Soc. Sec. Rul. 16-3p, 2017 WL 5180304, at *3 (October 25, 2017).3 Tenth Circuit
precedent is in alignment with the Commissioner’s regulations but characterizes the
evaluation as a three-part test. See e. g., Keyes-Zachary v. Astrue, 695 F.3d 1156, 1166-67
(10th Cir. 2012) (citing Luna v. Bowen, 834 F.2d 161, 163-64 (10th Cir. 1987)).4 As part
of the symptom analysis, the ALJ should consider the factors set forth in 20 C.F.R.
§§ 404.1529(c)(3), 416.929(c)(3), including: (i) daily activities; (ii) the location, duration,
frequency, and intensity of pain or other symptoms; (iii) precipitating and aggravating
factors; (iv) the type, dosage, effectiveness, and side effects of any medication the
individual takes or has taken; (v) treatment for pain relief aside from medication; (vi) any
other measures the claimant uses or has used to relieve pain or other symptoms; and
(vii) any other factors concerning functional limitations. See Soc. Sec. Rul. 16-3p, 2017
WL 5180304, at *7-8. An ALJ’s symptom evaluation is entitled deference unless the Court
finds that the ALJ misread the medical evidence as a whole. See Casias, 933 F.2d at 801.
An ALJ’s findings regarding a claimant's symptoms “should be closely and affirmatively
linked to substantial evidence and not just a conclusion in the guise of findings.” Kepler v.
3 SSR 16-3p is applicable for decisions on or after March 28, 2016, and superseded SSR 96-7p,
1996 WL 374186 (July 2, 1996). See SSR 16-3p, 2017 WL 5180304, at *1. SSR 16-3p eliminated
the use of the term “credibility” to clarify that subjective symptom evaluation is not an examination
of [a claimant's] character.” Id. at *2.
4 Analyses under SSR 16-3p and Luna are substantially similar and require the ALJ to consider
the degree to which a claimant's subjective symptoms are consistent with the evidence. See,
e.g., Paulek v. Colvin, 662 Fed. Appx. 588, 593-94 (10th Cir. 2016) (finding SSR 16-3p
“comports” with Luna) and Brownrigg v. Berryhill, 688 Fed. Appx. 542, 545-46 (10th Cir.
2017) (finding the factors to consider in evaluating intensity, persistence, and limiting effects of a
claimant's symptoms in 16-3p are similar to those set forth in Luna).
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Chater, 68 F.3d 387, 391 (10th Cir. 1995) (quotation omitted). The ALJ is not required to
perform a “formalistic factor-by-factor recitation of the evidence[,]” Qualls v. Apfel, 206
F.3d 	1368, 	1372 	(10th 	Cir. 	2000), 	but 	simply 	“recit[ing] 	the 	factors” 	is
insufficient. See Soc. Sec. Rul. 16–3p, 2017 WL 5180304 at *10.
As it pertains to Claimant’s mental health, Claimant argues the ALJ erred by not
discussing all the relevant medical evidence such as Claimant’s awkward social behavior
and nervous tics such as hand flapping, rubbing her legs, and self-mutilation when angry.
The Court does not find ALJ’s subjective statement analysis deficient in this regard.
Indeed, the ALJ discussed Claimant’s emergency department visit, her varied mood, affect,
and speech during her primary care visits, her specialized mental health treatment with Carl
Albert, and some of her nervous behavior, i.e., hair twirling. (Tr. 25-26). Ultimately, the
ALJ found Claimant’s statements about the intensity, persistence, and limiting effects of
her symptoms inconsistent noting, inter alia, the record indicated Claimant showed
improvement with medication, demonstrated signs of varied social functioning, and she
testified she could shop and engage in social activities with friends and family on a weekly
basis. (Tr. 26). The ALJ set out the appropriate analysis and cited evidence supporting his
reasons for finding Claimant’s subjective complaints were not believable to the extent
alleged at step four, i.e., he gave clear and specific reasons that were specifically linked to
the evidence in the record. There is no indication that the ALJ misread Claimant’s medical
evidence, taken as a whole, as it pertains to Claimant’s mental limitations at step four. See
Casias, 933 F.2d at 801.
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However, the ALJ did err in his subjective symptom analysis to extent he failed to
account for and address Claimant’s sciatic pain and hip pain. Indeed, the ALJ’s symptom
analysis only states the Claimant “can manage her personal care needs, perform household
tasks and chores and prepare her own meals[.]” The ALJ wholly failed to explain his
conclusion with affirmative links to the record, and his analysis of Claimant’s subjective
symptoms was therefore defective. See, e.g., Hardman v. Barnhart, 362 F.3d 676, 678-79
(10th Cir. 2004); See also Kepler, 68 F.3d at 391 (the ALJ must “explain why the specific
evidence relevant to each factor led him to conclude the Claimant’s subjective complaints
were not credible.”).
IV. 	Medical Opinions of Dr. Scott and Dr. Holloway
Claimant next argues that the ALJ failed to properly assess the medical opinions of
the state reviewing psychologists by not adequately addressing the consistency factor. The
Court disagreed and finds no error here.
For claims filed on or after March 27, 2017, medical opinions are evaluated pursuant
to 20 C.F.R. §§ 404.1520c and 416.920c. Under these rules, the ALJ does not “defer or
give any specific evidentiary weight, including controlling weight, to any medical
opinion(s)[.]” 20 C.F.R. §§ 404.1520c(a), 416.920c(a). Instead, the ALJ evaluates the
persuasiveness 	of 	all medical opinions and 	prior 	administrative 	medical 	findings 	by
considering a list of factors. See 20 C.F.R. §§ 404.1520c(b), 416.920c(b). The factors are:
(i) supportability, (ii) consistency, (iii) relationship with the claimant (including length of
treatment relationship, frequency of examinations, purpose and extent of treatment
relationship, and examining relationship), (iv) specialization, and (v) other factors that tend
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to support or contradict a medical opinion or prior administrative finding (including, but
not limited to, “evidence showing a medical source has familiarity with the other evidence
in the claim or an understanding of our disability program's policies and evidentiary
requirements.” 20 C.F.R. §§ 404.1520c(c), 416.920c(c). Supportability and consistency
are the most important factors in evaluating the persuasiveness of a medical opinion and
the 	ALJ 	must 	explain 	how 	both 	factors 	were 	considered. See 20 	C.F.R.
§§ 404.1520c(b)(2), 416.920c(b)(2). Generally, the ALJ is not required to explain how the
other 	factors 	were 	considered. Id. However, 	when 	the 	ALJ 	finds 	that 	two 	or
more medical opinions or prior administrative findings on the same issue are equally well-
supported and consistent with the record but are not exactly the same, the ALJ must explain
how “the other most 	persuasive factors in paragraphs (c)(3) through (c)(5)” were
considered. 20 C.F.R. §§ 404.1520c(b)(3), 416.920c(b)(3).
The supportability factor examines how well a medical source supported their own
opinion with “objective medical evidence” and “supporting explanations.” 20 C.F.R.
§§ 404.1520c(c)(1), 416.920c(c)(1). The consistency factor calls for a comparison between
the medical opinion and “the evidence from other medical sources and nonmedical
sources” in the record. 20 C.F.R. §§ 404.1520c(c)(2), 416.920c(c)(2). The ALJ in this case
stated that he found the state psychologists’ opinions persuasive and incorporated their
findings into his RFC, almost verbatim.
The Court finds the ALJ’s treatment of the state agency psychologists’ opinions was
thorough and sufficient. As to supportability, the ALJ found the opinions supported “with
an in-depth explanation regarding the basis for the findings, including noting her mental
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conditions being managed conservatively with medication and a recent examination noting
some indication of anxiety, but was otherwise normal.” (Tr. 27). Relatedly, the ALJ found
the opinions consistent with Claimant’s “mental health longitudinal treatment record being
conservative and sparse, consisting primarily of medication management through her
Primary Care Provider with some improvement.” (Tr. 27).
Claimant contends the ALJ failed to (i) explain why his opinion does not differ from
the psychological consultants’ in light of Claimant’s bipolar disorder, (ii) explain how an
individual with a history of self-harm retains the ability to handle conflicts with others or
accept criticism and instruction from supervisors; and (iii) discuss Claimant’s habits
indicative of anxiety, such as 	arm flapping, social awkwardness, and lip/finger picking.
Claimant does not, however, point to any substantial or functional differences between the
ALJ’s assessed RFC and the suggested mental RFC provided by the state reviewing
psychologists. The ALJ plainly acknowledged and discussed Claimant’s bipolar disorder
(as did Dr. Scot and Dr. Holloway), Claimant’s incident of self-harm, and some of
Claimant’s anxious habits. (Tr. 24-26). The evidence does not reflect that Claimant had
further mental limitations than those posed in the RFC, and the ALJ clearly considered the
findings within both Dr. Scott’s and Dr. Holloway’s reports while Claimant points to no
medical documentation providing further limitations. Because she points to no evidence,
the Court declines to find error here. Garcia v. Astrue, 2012 WL 4754919, at *8 (W.D.
Okla. Aug. 29, 2012) (“Plaintiff’s mere suggestion that a ‘slow gait’ might adversely affect
his ability to perform the standing and walking requirements of light work is not supported
by any authority.”).
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V. 	Duty to Develop the Record
Finally, Claimant argues the ALJ erred in failing to develop the record by not
ordering a consultative examination. The ALJ has an affirmative duty to fully and fairly
develop the record as to any impairment suggested by the evidence. See Hawkins, 113 F.3d
at 1164; Henrie v. U.S. Dep’t of Health & Hum. Servs., 13 F.3d 359, 360-61 (10th Cir.
1993). This duty exists even when a claimant is represented by counsel. Baca v. Dept. of
Health & Hum. Servs., 5 F.3d 476, 480 (10th Cir. 1993). The court, however, is not required
to act as a claimant's advocate, Henrie, 13 F.3d at 361, and an ALJ need not “exhaust every
possible 	line 	of 	inquiry 	in 	an 	attempt 	to 	pursue 	every 	potential 	line 	of
questioning.” Hawkins, 113 F.3d at 1168. Rather, she must use reasonably good judgment
to ensure that the record fully and fairly addresses material issues. See id. Here, no request
for a consultative examination was made by Claimant’s counsel at the administrative level,
and “[i]n the absence of such a request . . . [the Court] will not impose a duty on the ALJ
to order a consultative examination unless the need for one is clearly established in the
record.”). Hawkins v. Charter, 113 F.3d 1162, 1167 (10th Cir. 1997). Here, the need for a
consultative examination is not clearly established in the record. The ALJ reasonably relied
on the largely normal results of Dr. Yokam’s evaluation of Claimant. See Miller v. Comm’r
of Soc. Sec. Admin., 2024 WL 2844676, at *5 (10th Cir. June 5, 2024) (“[T]he ALJ could
reasonably have concluded that he had enough information to make a decision and that
developing the record with additional neurological testing was unnecessary.”). However,
the Court highlights that such an examination would have been helpful in this case to clarify
the extent of Claimant’s physical impairments along with their specific effects on her
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functional 	limitations, 	particularly 	when 	all 	her 	impairments 	are 	considered 	in
combination. See Fleetwood, 211 Fed. Appx. at 740-41 (“The ALJ’s inability to make
proper RFC findings may have sprung from his failure to develop a sufficient record on
which those findings could be based. The ALJ must make every reasonable effort to ensure
that the file contains sufficient evidence to assess RFC.”).
Nonetheless, because the ALJ failed to properly evaluate Claimant’s subject
symptoms, analyze her obesity, and ultimately account for all Claimant’s impairments,
including her sciatic nerve pain at step four, the decision of the Commissioner is reversed
and the case remanded to the ALJ for further analysis of all the Claimant’s impairments. If
such analysis results in any changes to Claimant’s RFC, the ALJ should re-determine what
work Claimant can perform, if any, and ultimately whether she is disabled.
Conclusion
In summary, the Court finds that the correct legal standards were not applied by the
ALJ, and the decision of the Commissioner is therefore not supported by substantial
evidence. The decision of the Commissioner of the Social Security Administration is
accordingly hereby REVERSED and the case REMANDED for further proceedings
consistent herewith.
DATED this 19th day of March, 2026.
______________________________________
GERALD L. JACKSON
UNITED STATES MAGISTRATE JUDGE
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