Case Name in Social Security Case - Unavailable

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IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF GEORGIA
MACON DIVISION
T.J.G., 	:
:
Plaintiff, 	:
:
v. 	: 	Case No. 5:24-cv-00398-CHW
:
COMMISSIONER 	:
OF SOCIAL SECURITY, 	: 	Social Security Appeal
:
Defendant. 	:
___________________________________ :
ORDER
This is a review of a final decision of the Commissioner of Social Security denying Plaintiff
T.J.G.’s application for disability benefits. The parties consented to have a United States
Magistrate Judge conduct all proceedings in this case, and as a result, any appeal from this
judgment may be taken directly to the Eleventh Circuit Court of Appeals in the same manner as
an appeal from any other judgment of the United States District Court. Because the ALJ did not
sufficiently articulate which portions of an inconsistent medical source opinion he found
persuasive, the resulting RFC is not supported by substantial evidence. Plaintiff’s case is
REMANDED.
BACKGROUND
Plaintiff applied for Title II disability benefits on March 9, 2021, alleging disability
beginning on December 8, 2020, based on a total colectomy and severe pains in both feet with
standing for long periods. (Ex. 1A). His date last insured (DLI) was December 31, 2024. (R. 30,
107). After Plaintiff’s applications were denied initially and on reconsideration at the state agency
level of review (Exs. 1A-4A), Plaintiff requested further review before an administrative law judge
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(ALJ). The reviewing ALJ held hearings on July 13, 2023 and February 27, 2024. (R. 43-67, 68-
96). The ALJ issued an unfavorable opinion on June 7, 2024. (R. 25-42). Plaintiff’s request for
review of that decision by the Appeals Council was denied on September 11, 2024. (R. 12-17).
The case is now ripe for judicial review. See 42 U.S.C. § 405(g).
STANDARD OF REVIEW
Judicial review of a decision of the Commissioner of Social Security is limited to a
determination of whether that decision is supported by substantial evidence, as well as whether the
Commissioner applied the correct legal standards. Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176,
1178 (11th Cir. 2011). “Substantial evidence” is defined as “more than a scintilla,” and as “such
relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Id. The
Eleventh Circuit has explained that reviewing courts may not decide the facts anew, reweigh the
evidence, 	or 	substitute 	their 	judgment 	for 	that 	of 	the Commissioner. 	Id. 	Rather, 	if 	the
Commissioner’s decision is supported by substantial evidence, the decision must be affirmed even
if the evidence preponderates against it.
EVALUATION OF DISABILITY
Social Security claimants are “disabled” if they are unable 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).
The Social Security Regulations outline a five-step sequential evaluation process for
determining whether a claimant is disabled: “(1) whether the claimant is currently engaged in
substantial gainful activity; (2) whether the claimant has a severe impairment or combination of
impairments; (3) whether the impairment meets or equals the severity of the specified impairments
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in the Listing of impairments; (4) based on a residual functional capacity (“RFC”) assessment,
whether the claimant can perform any of his or her past relevant work despite the impairment; and
(5) whether there are significant numbers of jobs in the national economy that the claimant can
perform given the claimant’s RFC, age, education, and work experience.” Winschel, 631 F.3d at
1178 (citing 20 C.F.R. §§ 404.1520(a)(4)(i)-(v); 416.920(a)(4)(i)-(v)).
MEDICAL AND ADMINISTRATIVE RECORD
Plaintiff’s challenge focuses on the ALJ’s treatment of the consultative psychological
examiner’s opinions when developing Plaintiff’s RFC. Therefore, while the entire record has been
reviewed, this summary focuses on the portions of the record most germane to Plaintiff’s
challenge.
As part of Plaintiff’s disability application, Dr. Michael Rose conducted a consultative
psychological exam in August 2023. (Ex. 11F). Dr. Rose recounted the reasons for Plaintiff’s
disability application and found Plaintiff to be a good historian of his conditions. (R. 676). Aside
from Plaintiff’s various medical conditions, Plaintiff suggested that “social issues” would interfere
with his ability to work with others. (Id.) Plaintiff admitted to having had no formal mental health
treatment or services, even as part of his VA disability rating. (R. 677). Plaintiff disclosed suicidal
ideations and overmedicating, such as taking ten sleeping pills without incident. (Id.) Plaintiff
reported constant worrying and lack of sleep due to nightmares and body pain. (Id.) Plaintiff also
had experienced panic attacks since 2018. (Id.) While Dr. Rose saw no indication of bias during
testing, he believed that Plaintiff exaggerated some of the mental health issues. (R. 679).
Plaintiff’s social interactions, other than with family, were limited to social media. (R.
677). Plaintiff’s mother shopped for groceries and other items that Plaintiff may need. (Id.) While
his pain and need for breaks limited his ability to do chores, Plaintiff reported being able to help
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sweep, mop, vacuum, fix simple meals, and take out the trash. (Id.) Plaintiff had, at times, needed
help with personal hygiene tasks. (Id.) Dr. Rose observed Plaintiff to be well-groomed. (R. 678).
Plaintiff 	displayed 	a 	constricted, 	blunted 	affect 	and 	depressed 	mood 	during 	the
examination. (R. 678). Plaintiff was attentive during the examination with good eye contact and
responded to questions, but he needed reminders for a 3-step command. (Id.) Plaintiff displayed
no unusual reactions to failure or success during the examination. (Id.) Dr. Rose described
Plaintiff’s mental energy and pace as slow, but Plaintiff was able to complete the exam within
normal time limits and to read and complete his intake form. (Id.) Dr. Rose rated Plaintiff’s exam
performance as borderline. (Id.) Dr. Rose assessed Plaintiff with somatic symptom disorder,
insomnia, persistent depressive disorder, generalized anxiety disorder, and panic disorder. (R.
679).
In his narrative summary, Dr. Rose explained that Plaintiff had the ability to understand
and carry out simple 1 or 2-step instructions, would have a moderate impairment in maintaining
focus, and would be capable of performing a repetitive unskilled job for a brief period of time. (R.
679). He would likely have a moderate level of impairment for tolerating normal stress within a
work environment. (Id.). Accompanying Dr. Rose’s narrative report was a medical source
statement which featured a series of check-box and narrative prompts. (R. 680-682). This form
largely tracked Dr. Rose’s written narrative, however Dr. Rose checked that there would be no
limitations on Plaintiff’s ability to understand and remember simple instructions, carry out simple
instructions, and make judgments on simple work-related decisions. (R. 680). Dr. Rose then made
the following handwritten note: “[Plaintiff’s] stated pain complaints and ongoing emotional
distress would hinder to a moderate degree his ability to maintain focus and attention across an
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eight-hour shift. There would not be any impairment for his ability the [sic] understand and carry
out simple repetitive job responsibilities.” (Id.)
Hearing Testimony
The ALJ held two in-person hearings in Plaintiff’s case. (R. 43-67, 68-96). At the first
hearing, Plaintiff recounted his education and work history, including his service in the Air Force
as an aerospace maintenance technician. (R. 75-76). He last worked in 2020 as a stocker but was
fired for calling out for treatment. (R. 75). Plaintiff testified about how depression and fatigue limit
his ability to work and go about his day, but he acknowledged his lack of psychological treatment.
(R. 74, 80-81, 86-87). The hearing closed with the ALJ acknowledging that additional records
would be forthcoming before a decision would be made. (R. 95).
Plaintiff was sent to Dr. Rose following the first hearing, after which his counsel requested
a second hearing. (R. 45, 48). At the time of the second hearing, Plaintiff still had not sought
psychological treatment despite routine visits to the VA for other treatment. (R. 50). Plaintiff did
not think mental health treatment would help him and might actually make his condition worse.
(R. 50-52). The ALJ encouraged Plaintiff to seek treatment. (R. 52, 67). Plaintiff continued to
struggle with sleep and focus and to limit his social interactions to online friends. (R. 53-55).
Function Report
Plaintiff completed a function report with the assistance of his mother. (Ex. 4E). The report
largely mirrored his hearing testimony in that he struggled with sleep, interacted with others
through the phone or computer, and limited going places on a regular basis. (Id.) Plaintiff limited
his ability to complete tasks because he was unable to stand or walk for a long time. (R. 281). He
explained that he could follow spoken and written instructions and get along with people. (Id.)
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Plaintiff placed no limitations on his own work ability due to any mental health conditions. See
generally (Ex. 4E).
Plaintiff’s mother did not complete a third-party function report, but she wrote a letter in
support of Plaintiff’s application in which she described his decline in physical and mental health.
(Ex. 12E). She described her efforts to encourage Plaintiff to seek mental health treatment after
observing the toll that his medical condition had taken on him. (Id.)
Post-Hearing Treatment
Following the second hearing before the ALJ, Plaintiff had a mental health assessment at
the VA. (R. 735-742). Plaintiff admitted that he presented for the assessment at the encouragement
of his mother and the ALJ. (R. 736). He appeared guarded and defensive with a mildly depressed
mood and flat affect. (R. 740). However, he displayed organized and coherent through processes
with good insight and judgment. (R. 741). Plaintiff reported nightmares, flashbacks, and intrusive
memories and suggested his traumas impacted his social and occupational functioning. (R. 738-
739). Mirroring his hearing testimony, Plaintiff limited his social interactions to his mother, some
close friends, and online contacts, and he noted that he struggled with sleep (R. 739, 740). Plaintiff
reported hallucinations in the form of hearing footsteps when he is alone and ringing in his ear. (R.
741). Plaintiff was assessed with major depressive disorder. (R. 741). While he appeared receptive
to receiving mental health services, Plaintiff told the evaluator that he would need time to think
about participating in treatment. (R. 741).
DISABILITY EVALUATION
Following the five-step sequential evaluation process, the reviewing ALJ made the
following findings in this case. At step one, the ALJ found that Plaintiff had not engaged in
substantial gainful activity since December 8, 2020, the alleged onset date. (R. 30). Plaintiff’s date
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last insured was December 31, 2024. (Id.) At step two, the ALJ found that Plaintiff suffered from
the following severe impairments: obesity, history of Lynch syndrome, pes planus of the bilateral
feet, hidradenitis, suppurativa, somatic symptom disorder, major depressive disorder, generalized
anxiety disorder, and panic disorder. (Id.) At step three, the ALJ found that Plaintiff did not have
an impairment or combination of impairments meeting or medically equaling the severity of one
of the listed impairments. (R. 31-32). Plaintiff was found to have moderate limitations in each of
the “paragraph B” factors, except understanding, remembering or applying information for which
he had a mild limitation. (R. 31). Therefore, the ALJ assessed Plaintiff’s RFC and determined that
Plaintiff could perform light work with the following considerations:
[Plaintiff] can occasionally climb ramps and stairs, balance, stoop, kneel, crouch,
or crawl. He should never climb ladders, ropes or scaffolds. He should avoid
concentrated exposure to heat, to humidity, and to caustic chemicals. He can
understand, remember and carry out simple tasks and instructions in a routine work
environment. He can occasionally interact with the public and co-workers and
frequently interact with supervisors. Changes to the worksite and procedures should
be no more than occasional.
(R. 32).
Based on this RFC, the ALJ found at step four that Plaintiff is not capable of performing
any past relevant work. (R. 36). Pursuant to step five, the ALJ determined that there are jobs
existing which Plaintiff can perform, such as marker, garment sorter, assembler II, printed circuit
board screener, final inspector, and food and beverage order clerk. (R. 37). As a result, the ALJ
determined that Plaintiff was not disabled within the meaning of the Social Security Act at any
time from December 8, 2020, through the date of the decision. (Id.).
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ANALYSIS
Plaintiff argues that the ALJ’s decision contains legal errors and is not supported by
substantial evidence because the ALJ failed to explain the discrepancies between Dr. Rose’s
persuasive opinion and the resulting RFC. (Doc. 14). He argues that the failure to address the
discrepancy violates agency regulations and, thus, that the resulting RFC is not supported by
substantial evidence. (Id.) The Court need not fully address Plaintiff’s arguments because, as a
threshold matter, the ALJ failed to address the internal inconsistencies in Dr. Rose’s opinion. As
a result, the Court is unable to decipher why he incorporated only certain portions of the opinion,
and the resulting RFC cannot be found to be supported by substantial evidence.
For applications filed on or after March 27, 2017, there is no requirement to give treating
physicians deference. See 20 C.F.R. § 404.1520c. The weight given to all medical opinion
evidence – even those opinions from Plaintiff’s own treating physicians – is now governed by 20
C.F.R. § 404.1520c. Under these regulations, the agency no longer defers or gives any specific
evidentiary weight to any medical opinion, even those from a claimant’s own medical sources. 20
C.F.R. § 404.1520c(a). The decision instead must articulate how persuasive the medical opinions
and prior administrative findings were found to be. 20 C.F.R. § 404.1520c(b). The ALJ recognized
and complied with the updated regulations and found Dr. Rose’s opinion persuasive:
Michael Rose, Ph.D., examined the claimant on August 8, 2023. During the
evaluation, the claimant was alert and oriented. He had slow gross motor speed. He
had normal speech. He had depressed mood and constricted affect. He had
appropriate eye contact. The claimant could recall two of four words. Dr. Rose
opined that the claimant has mild limitations in understanding and moderate
limitation in the three other domains. (See Exhibit 11F). The opinion of Dr. Rose
is persuasive, as it aligns with the results of the claimant’s evaluation, and it is
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supported by his testimony of his mental health symptoms, despite his lack of
treatment.
(R. 35).
The ALJ incorporated the following mental health limitations into the RFC: “[Plaintiff] can
understand, remember and carry out simple tasks and instructions in a routine work environment.
He can occasionally interact with the public and co-workers and frequently interact with
supervisors. Changes to the worksite and procedure should be no more than occasional.” (R. 32).
Plaintiff argues that because the ALJ found Dr. Rose’s opinion persuasive, he was required
to adopt the opinion’s suggested limitations or adequately explain the reasons for excluding them,
but because the ALJ did neither, he committed reversible error. (Doc. 14) (relying primarily on
Social Security Ruling (SSR) 96-8p (1996 WL 374184) and Weidlich v. Comm’r, Soc. Sec. 2023
WL 8015753 (11th Cir. 2023)). Plaintiff specifically highlights the ALJ’s failure to limit Plaintiff
to “1 or 2-step instructions” or recognize that Plaintiff could only perform a repetitive unskilled
job for a brief period of time. (Doc. 14, p. 8, 13-19); (R. 679 under the “Impressions/Summary”
heading). The Commissioner counters that Plaintiff ignores both that an RFC is the most a plaintiff
can do and that the RFC appropriately accounts for the limitations in Dr. Rose’s medical source
statement. (Doc. 17); see also (R. 680-682 “Medical Source Statement”). The parties accurately
cite Dr. Rose’s examination in their briefs, which demonstrates that Dr. Rose’s medical statement
form and narrative summary conflicts are, on their face, inconsistent. This inconsistency makes it
difficult to determine what Dr. Rose’s opinion is regarding Plaintiff’s limitations, much less which
portions of the opinion the ALJ found persuasive such that substantial evidence would support the
decision.
The distinction between “understanding and carrying out simple 1 or 2-step instructions”
and “understanding, remembering, and carrying out simple tasks and instructions in a routine work
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environment” can matter in terms of the representative jobs a claimant like Plaintiff can do. In
most scenarios, no conflict exists between an RFC that limits a claimant’s ability to “understand,
carry-out, and remember simple instructions” and jobs requiring a reasoning level of two, which
applies to most of the jobs listed in the ALJ’s decision. Buckwalter v. Acting Comm’r of Soc. Sec.,
5 F.4th 1315, 1323 (11th Cir. 2021); (R. 37). This is because “‘simple’ does not plainly contradict
‘detailed’” as required by jobs with a reasoning level of two. Id. (summarizing that level one
reasoning requires a worker to “apply commonsense understanding to carry out simple one- or
two-step instructions” while level two reasoning requires “commonsense understanding to carry
out detailed but uninvolved written or oral instructions”). Instead, the “primary difference”
between levels one and two is the length of the instructions—not the complexity.” Id. (emphasis
in the original) (also noting that level two reasoning is not limited in length). The Buckwalter court
ultimately affirmed the claimant’s RFC, but unlike in Buckwalter, Dr. Rose’s records suggest that
Plaintiff is capable of carrying out simple 1- or 2-step instructions. Such a limitation, if supported,
would go to the length of the instructions instead of the complexity, and thus implicate jobs
requiring level one reasoning. The ALJ needed either to explain why this limitation was not
supported by the record or to have incorporated this limitation into a hypothetical when
questioning the vocational expert at the hearing. He did neither. Therefore, the Court is not able
to determine from the decision or from the record as whole whether substantial evidence supports
the ALJ’s RFC assessment.
Because Dr. Rose’s opinion is internally inconsistent about the types of tasks to which
Plaintiff was limited, the decision should have specified which portions of Dr. Rose’s opinion the
ALJ found persuasive – the narrative description of Plaintiff’s abilities or the limitations described
in the medical source statement – and why. The resulting RFC closely tracks the limitations noted
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in Dr. Rose’s medical source statement, which suggests the ALJ found that portion persuasive.
However, that connection and conclusion would be based upon the Court’s conjecture. The
decision and record provide no guidance to determine whether the ALJ acknowledged, much less
rejected, the limitations in Dr. Rose’s narrative in favor of the less restrictive limitations found in
the medical source statement. Even under the substantial evidence standard, “when the ALJ fails
‘to state with at least some measure of clarity the grounds for his decision,’ [the Court] will decline
to affirm ‘simply because some rational might have supported the ALJ’s conclusion.’” Winschel,
631 F.2d at 1179 (citations omitted). The ALJ failed to sufficiently specify which limitations from
Dr. Rose’s inconsistent records he found persuasive, and thus the resulting RFC is not supported
by substantial evidence.
CONCLUSION
Based 	on 	the 	foregoing, 	it 	is 	ORDERED 	that 	the 	Commissioner’s 	decision 	be
REMANDED pursuant to sentence four of 42 U.S.C. §405(g).
SO ORDERED, this 24th day of November, 2025.
s/ Charles H. Weigle
Charles H. Weigle
United States Magistrate Judge
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