IN THE UNITED STATES DISTRICT COURT FOR THE

NORTHERN DISTRICT OF FLORIDA

GAINESVILLE DIVISION

MICHAEL JEROME ANDERSON,

Plaintiff,

vs. CASE NO. 1:20-cv-121-GRJ

KILOLO KIJAKAZI,

Acting Commissioner of Social Security1,

Defendant.

 /

MEMORANDUM OPINION AND ORDER

Plaintiff appeals from a final decision of the Commissioner of Social 

Security (“the Commissioner”), denying his application for supplemental 

security income (“SSI”) benefits for lack of disability under Title XVI of the 

Social Security Act (“the Act”). ECF No. 1. The Commissioner has 

answered, ECF No. 17, and both parties have filed briefs outlining their 

respective positions. ECF Nos. 24, 25. For the reasons explained below, 

the decision of the Commissioner is affirmed.

1 In July of 2021, Dr. Kilolo Kijakazi was appointed Acting Commissioner of Social 

Security. The Clerk must correct the docket accordingly.

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 1 of 21
I. PROCEDURAL HISTORY

Plaintiff filed his Title XVI application on July 11, 2017, alleging a 

disability onset date of January 4, 2016, due to high blood pressure and 

heart problems. R. 170-81. Plaintiff’s claims were denied initially and upon 

reconsideration. A hearing was held before Administrative Law Judge 

(“ALJ”) Alisa M. Tapia on February 19, 2019. See R. 12-24. On May 14, 

2019, the ALJ found that Plaintiff has not engaged in substantial gainful 

activity since July 11, 2017 (the date Plaintiff applied for SSI). R. 17. The 

ALJ found that Plaintiff has the following severe impairments: morbid 

obesity, history of ischemic heart disease, and hypertension. Id. The ALJ 

also found that these impairments, or a combination thereof, do not meet or 

medically equal the severity of one of the listed impairments. R. 18.

After careful review of the entire record, the ALJ found that Plaintiff 

has the residual functional capacity (“RFC”) to perform light work with some 

limitations: He can never climb ladders, ropes or scaffolds; he can 

occasionally kneel, crouch, crawl and climb ramps and stairs; and he 

should occasionally avoid exposure to pulmonary irritants such as fumes, 

odors, dusts, gases, and poor ventilation. R. 19.

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 2 of 21
The ALJ further found that Plaintiff had no past relevant work. R. 22. 

Considering Plaintiff’s age, education, work experience, and RFC, the ALJ 

determined, relying upon the testimony from a vocational expert, jobs exist 

in significant numbers in the national economy that Plaintiff can perform, 

such as cafeteria attendant, cleaner housekeeper, and folder. R. 24. In 

light of these findings, the ALJ determined that Plaintiff has not been under 

a disability, as defined in the Act, since July 11, 2017. R. 25.

The Appeals Council denied review. R. 1-3. This appeal followed. 

Plaintiff asserts two related issues for review. First, Plaintiff says that the 

ALJ erred by failing to develop the record with opinion evidence regarding 

Plaintiff’s RFC. Second, because no opinion evidence as to Plaintiff’s RFC

exists in the record, Plaintiff argues that the ALJ erred by not ordering a 

consultative examination before making the RFC determination. 

II. STANDARD OF REVIEW

The Commissioner’s findings of fact are conclusive if supported by 

substantial evidence. See 42 U.S.C. § 405(g) (2012). Substantial evidence 

is more than a scintilla, i.e., the evidence must do more than merely create 

a suspicion of the existence of a fact and must include such relevant 

evidence as a reasonable person would accept as adequate to support the 

conclusion. Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995) (citing

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 3 of 21
Walden v. Schweiker, 672 F.2d 835, 838 (11th Cir. 1982), Richardson v. 

Perales, 402 U.S. 389, 401 (1971)); accord Edwards v. Sullivan, 937 F.2d 

580, 584 n.3 (11th Cir. 1991). 

Where the Commissioner’s decision is supported by substantial 

evidence, the district court will affirm, even if the reviewer would have 

reached a contrary result as finder of fact, and even if the reviewer finds 

that the evidence preponderates against the Commissioner’s decision.

Edwards, 937 F.2d at 584 n.3; Barnes v. Sullivan, 932 F.2d 1356, 1358 

(11th Cir. 1991). The district court must view the evidence as a whole, 

taking into account evidence favorable as well as unfavorable to the 

decision. Foote, 67 F.3d at 1560; accord Lowery v. Sullivan, 979 F.2d 835, 

837 (11th Cir. 1992) (holding that the court must scrutinize the entire record 

to determine reasonableness of factual findings); Parker v. Bowen, 793 

F.2d 1177 (11th Cir. 1986) (finding that the court must also consider 

evidence detracting from evidence on which the Commissioner relied). 

However, the district court will reverse the Commissioner’s decision on 

plenary review if the decision applies incorrect law, or if the decision fails to 

provide the district court with sufficient reasoning to determine that the 

Commissioner properly applied the law. Keeton v. Dep’t Health & Human 

Servs., 21 F.3d 1064, 1066 (11th Cir. 1994).

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 4 of 21
The law defines disability as the inability to do any substantial gainful 

activity by reason of any medically determinable physical or mental 

impairment that can be expected to result in death, or has lasted or can be 

expected to last for a continuous period of not less than twelve months. 42 

U.S.C. §§ 416(I), 423(d)(1) (2012); 20 C.F.R. §§ 404.1505, 416.905 (2015). 

The impairment must be severe, making Plaintiff unable to do his previous 

work, or any other substantial gainful activity which exists in the national 

economy. § 423(d)(2); 20 C.F.R. §§ 404.1505-404.1511, 416.905–416.911.

The ALJ must follow five steps in evaluating a claim of disability. 20 

C.F.R. §§ 404.1520, 416.920. The claimant has the burden of proving the 

existence of a disability as defined by the Social Security Act. Carnes v. 

Sullivan, 936 F.2d 1215, 1218 (11th Cir. 1991). First, if a claimant is 

working at a substantial gainful activity, he is not disabled. §§ 404.1520(b), 

416.920(b). Second, if a claimant does not have any impairment or 

combination of impairments which significantly limit his physical or mental 

ability to do basic work activities, then he does not have a severe 

impairment and is not disabled. §§ 404.1520(c), 416.920(c). Third, if a 

claimant's impairments meet or equal an impairment listed in 20 C.F.R. 

Part 404, Subpart P, Appendix 1, he is disabled. §§ 404.1520(d), 

416.920(d). Fourth, if a claimant’s impairments do not prevent him from 

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 5 of 21
doing past relevant work, he is not disabled. §§ 404.1520(e)-(f), 

416.920(e)-(f). Fifth, if a claimant’s impairments (considering his RFC, age, 

education, and past work) prevent him from doing other work that exists in 

the national economy, then he is disabled. §§ 404.1520(g), 416.920(g). 

The burden of proof regarding the plaintiff’s inability to perform past 

relevant work initially lies with the plaintiff. Walker v. Bowen, 826 F.2d 996, 

1002 (11th Cir. 1987); see also Doughty v. Apfel, 245 F.3d 1274, 1278 (11th

Cir. 2001). The burden then temporarily shifts to the Commissioner to 

demonstrate that “other work” which the claimant can perform currently 

exists in the national economy. Doughty, 245 F.3d at 1278 n.2.2

2 In Doughty, the Eleventh Circuit Court of Appeals explained the burden shifting 

process as follows:

In practice, the burden temporarily shifts at step five to the Commissioner. 

The Commissioner must produce evidence that there is other work 

available in significant numbers in the national economy that the claimant 

has the capacity to perform. In order to be considered disabled, the 

claimant must then prove that he is unable to perform the jobs that the 

Commissioner lists. The temporary shifting of the burden to the 

Commissioner was initiated by the courts, and is not specifically provided 

for in the statutes or the regulations.

Doughty, 245 F.3d at 1278 n.2.

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 6 of 21
III. SUMMARY OF THE RECORD

Because Plaintiff’s appeal focuses on the ALJ’s treatment of the 

evidence pertaining to his RFC, the Court’s discussion focuses on the 

records the ALJ considered in making her RFC determination. 

A. Medical Evidence

Prior to applying for SSI, Plaintiff presented to the emergency 

department (“ER”) at Capital Regional Medical Center (“CRMC”) in 

Tallahassee, Florida on three occasions between 2015 to 2016. See R. 

271-286, 287-318, 319-339.3 At those visits, Plaintiff was diagnosed with 

exacerbation of congestive heart failure, hypertension, and morbid obesity.

R. 273. Notwithstanding these diagnoses, Plaintiff has a history of chronic 

noncompliance and continued to smoke 1/3 pack of cigarettes per day, as 

he had done for 18 years. R. 296, 300. In August of 2016, an 

echocardiogram showed Plaintiff’s heart had an ejection fraction (“EF”) of 

20-25%. R. 293. Plaintiff also presented to the ER during this time frame, 

complaining of swollen lower legs. R. 291-92. The swelling intensified 

such that Plaintiff required hospitalization and surgery to prevent necrosis. 

R. 296-98, 307-08. 

3 During these visits, Plaintiff primarily complained about an ulcer on his foot and 

swelling in his lower legs. See R. 272, 273, 293. 

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 7 of 21
After Plaintiff applied for SSI, Plaintiff returned to the ER six times 

from July 2017 to August 2018. Each time, Plaintiff was examined and 

released as follows:

In July of 2017, Plaintiff complained of mild abdominal pain and

bilateral lower leg swelling, and he requested a refill for his hypertension 

medication. R. 403-12, 405. 

On August 30, 2017, Plaintiff complained of mild abdominal pain and 

leg swelling. R. 380-89. He reported injuries sustained while doing heavy 

lifting at work. R. 380, 382. On examination, Plaintiff’s left testicle was 

swollen, and he had edema in his legs. R. 385-86. All other examination 

findings were generally normal with no motor or sensory deficits. R. 386.

In February of 2018, Plaintiff was admitted to the hospital for 

treatment for pneumonia and subsequently released. R. 517-23, 529-31, 

537.

In April of 2018, Plaintiff complained of shortness of breath. R. 481-

87. Normal cardiovascular findings were noted at the time. R. 485. 

In June of 2018, Plaintiff complained of shortness of breath, leg

swelling, and mild pulmonary congestion. R. 444-49, 465-67. An EF of 20-

25 percent was noted. R. 448. 

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 8 of 21
In August of 2018, Plaintiff returned for a pacemaker check. R. 429-

32. During this visit, Plaintiff reported no symptoms related to his 

pacemaker, yet he admitted that he continued to smoke cigarettes. R. 429.

On examination, Plaintiff had normal cardiovascular findings and was 

diagnosed with mild cardiomegaly with no acute pathology. R. 426, 434 &

441. Plaintiff denied both chest pain and shortness of breath. R. 430. 

At the initial review stage, the Agency decisionmaker determined that 

there was insufficient evidence to evaluate Plaintiff’s claims, and thus found 

that Plaintiff was not disabled. R. 70-76. The decisionmaker noted the 

absence of any medical opinion from any medical source in the record and 

found no RFC assessments associated with Plaintiff’s claim. R. 75. The 

agency also concluded that a consultative examination was not required. R. 

73.

Upon reconsideration, Dr. Thomas Lawhorn (“Dr. Lawhorn”), a state 

agency physician, reviewed Plaintiff’s medical evidence and concluded the 

claim should be closed due to insufficient evidence. R. 79-86. Dr. Lawhorn

did find, however, that Plaintiff’s hypertension and ischemic heart disease 

were severe impairments, based on available records at the time. R. 84. 

Dr. Lawhorn further noted that no medical opinion from any medical source 

was present in the record, nor was there any RFC assessment associated 

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 9 of 21
with Plaintiff’s claims. R. 85. Dr. Lawhorn further noted that attempts to 

reach Plaintiff were unsuccessful and that Plaintiff had “failed to cooperate.” 

R. 83. Dr. Lawhorn also determined that a consultative examination was 

not required in this case. R. 82. 

At the hearing level, additional evidence was provided, as 

summarized by the ALJ. The new evidence included updated medical 

records and Plaintiff’s testimony regarding both his work history and his 

present symptoms.

B. Hearing Testimony

At the time of the hearing, Plaintiff was 48 years old. He was 6’6” tall 

and weighed 425 pounds. R. 34. Plaintiff had a college degree in 

accounting and lived at his deceased grandmother’s home. R. 36-37, 35. 

Plaintiff reported past work as a manager, cashier, security guard and fastfood worker. R. 37-46. At the hearing, Plaintiff was represented by 

counsel. Plaintiff’s counsel confirmed that he had reviewed the record and 

that he had no objections or additional submissions. R. 33. During the 

hearing, Plaintiff’s counsel did not raise any issue regarding missing 

evidence or the need to develop additional evidence. See R. 32-35, 56-59, 

68-69. 

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 10 of 21
Plaintiff testified at the hearing as follows: he experiences shortness 

of breath and cannot lift twenty pounds, R. 47; his legs go numb while 

sitting and he cannot sit for an eight-hour shift, R. 48; everything hurts all 

day, R. 50; he can walk twenty to twenty-five feet before he becomes 

winded, so he must sit three to five minutes before he can get up again, R. 

53; he rides in an electronic cart at Walmart and sits on a stool in the 

shower, R. 55-56; he can sit for fifteen to twenty minutes before he needs 

to stretch his legs, R. 53; he lies down once or twice a day for an hour or 

two to ease the swelling in his legs, R. 57; and that he must elevate his 

legs above his heart for at least an hour or two every day, R. 57-58. 

Plaintiff also testified that he continues to smoke seven to eight cigarettes 

per day. R. 51. 

The vocational expert (“VE”) also testified at the hearing. R. 59-69. 

The VE testified that Plaintiff’s prior jobs were performed at a light 

exertional level. R. 60. The VE thus opined that, given Plaintiff’s present 

limitations, he still could return to his four prior positions as manager, 

cashier, security guard, or fast-food worker. R. 61. The ALJ posited that,

were she to find no prior work, were there other jobs a person could 

perform with Plaintiff’s limitations? R. 62. The VE affirmed that other jobs 

in the national economy such as cafeteria attendant, cleaner/housekeeper,

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 11 of 21
and folder would apply. Id. Claimant’s counsel examined the VE as well. 

R. 68-69. During that examination, the VE testified that work would be 

precluded for an individual who must raise their legs over their waist for up 

to two hours per day. R. 68-69. 

IV. DISCUSSION

A. The Fourth Step: ALJ’s Assessment of Claimant’s RFC

At the fourth step, the ALJ must make an assessment of the 

claimant’s RFC. Castle v. Colvin, 557 F. App’x 849, 852 (11th Cir. 2014) 

(per curiam) (citing Phillips v. Barnhart, 357 F.3d 1232, 1238 (11th Cir.

2004)). The RFC is an assessment, based on all relevant medical and 

other evidence, of a claimant’s remaining ability to work despite his 

impairment. Id. (citing Lewis v. Callahan, 125 F.3d 1436, 1440 (11th

Cir.1997)). The claimant is responsible for providing medical evidence 

demonstrating an impairment and how severe the impairment is during the 

relevant time-period. See 20 C.F.R. § 404.1512(a). If a claimant’s 

impairment does not meet or equal a listed impairment, the Agency will 

assess and make a finding about a claimant’s RFC “based on all the 

relevant medical evidence in [the] case record.” 20 C.F.R. § 404.1520(e).

A claimant who is seeking to establish a disability based on subjective 

testimony of pain and other symptoms “must satisfy two parts of a threeCase 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 12 of 21
part test showing: (1) evidence of an underlying medical condition; and (2) 

either (a) objective medical evidence confirming the severity of the alleged 

pain; or (b) that the objectively determined medical condition can 

reasonably be expected to give rise to the claimed pain.” Wilson v.

Barnhart, 284 F.3d 1219, 1225 (11th Cir. 2002). See also Dyer v.

Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005). 

At the administrative hearing, the burden rests with the claimant to 

prove that he is disabled. See Castle, 557 F. App’x at 853. “The ALJ has a 

duty to develop the record where appropriate but is not required to order a 

consultative examination as long as the record contains sufficient evidence 

for the ALJ to make an informed decision.” Id. (quoting Ingram v. Comm’r 

of Soc. Sec. Admin., 496 F.3d 1253, 1269 (11th Cir. 2007) (internal 

quotation marks omitted). In Castle, the district court, relying on MansoPizarro v. Sec’y of Health & Human Servs., 76 F.3d 15, 17 (1st Cir. 1996),

concluded that the ALJ erroneously “played doctor” in assessing Plaintiff’s 

RFC when he should have ordered a consultative examination instead. 

The district court reached that conclusion because the record was devoid 

of any objective medical evidence confirming the severity of Plaintiff’s 

alleged knee pain. The Eleventh Circuit reversed. “Contrary to the district 

court’s reasoning, the ALJ did not “play doctor” in assessing [Plaintiff’s] 

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 13 of 21
RFC, but instead properly carried out his regulatory role as adjudicator 

responsible for assessing [Plaintiff’s] RFC.” Castle, 557 F. App’x at 853

(citing and quoting from 20 C.F.R. § 1545(a)(3)). The Court of Appeals 

explained that “the pertinent regulations state that the ALJ has the 

responsibility for determining a claimant’s RFC.” Castle, 557 F. App’x at 

853. The Court also distinguished Castle from Manso-Pizarro, which had 

ruled that an ALJ is not qualified to interpret raw data in a medical record. 

Castle, 557 F. App’x at 854. The medical records at issue in MansoPizarro were far more complicated than those at issue in the Castle case. 

Id. Even the Manso-Pizarro Court noted an exception to its holding: 

“’Where the medical evidence shows relatively little physical impairment, an 

ALJ permissibly can render a commonsense judgment about functional 

capacity even without a physician’s assessment.’” Castle, 557 F. App’x at 

854 (quoting Manso-Pizarro, 76 F.3d at 854). 

The Castle Court concluded that the ALJ in that case properly carried 

out his regulatory role in determining Plaintiff’s RFC, and that the ALJ’s

RFC finding was supported by substantial evidence. Id. 

B. Consultative Examinations & Full and Fair Record

In developing the record, the ALJ must order a consultative 

examination or obtain medical evidence or expert testimony where the 

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 14 of 21
record contains insufficient evidence for the ALJ to make an informed 

decision. See Wilson v. Apfel, 179 F.3d 1276, 1278 (11th Cir. 1999). An 

ALJ, however, is not required to order medical evidence to complete the 

record unless the record establishes that supplementation is necessary to 

enable the ALJ to render her decision. Holladay v. Bowen, 848 F.2d 1206 

(11th Cir. 1988); Kelly v. Heckler, 761 F.2d 1540, 1540 (11th Cir. 1985). 

Additionally, a consultative examination may be required in situations 

where the ALJ needs to resolve some conflict, ambiguity, or other 

insufficiency in the medical evidence. 20 C.F.R. §§ 404.1519(a)(2) (“When 

we purchase a consultative examination, we will use the report from the 

consultative examination to try to resolve a conflict of ambiguity if one 

exists. We will also use a consultative examination to secure needed 

medical evidence the file does not contain such as clinical findings, 

laboratory tests, a diagnosis or prognosis necessary for decision.”),

404.1519a(b) (“A consultative examination may be purchased when the 

evidence as a whole, both medical and nonmedical, is not sufficient to 

support a decision on your claim.”).

Finally, “there must be a showing of prejudice before it is found that 

the claimant’s right to due process has been violated to such a degree that 

the case must be remanded to the [Commissioner] for further development 

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 15 of 21
of the record.” Graham v. Apfel, 129 F.3d 1420, 1423 (11th Cir. 1997) 

(citing Brown v. Shalala, 44 F.3d 931, 934–25 (11th Cir. 1995)). Prejudice 

has been found when the record “has evidentiary gaps which result in 

unfairness or ‘clear prejudice.’” Brown, 44 F.3d at 935 (quoting Ware v. 

Schweiker, 651 F.2d 408 (5th Cir. Unit A July 1981)). 

C. ALJ’s RFC Finding Based on Fully and Fairly Developed 

Record; No Consultative Examination Was Required

Plaintiff argues that because the ALJ discounted Dr. Lawhorn’s report 

as unpersuasive, the ALJ should have ordered a consultative examination 

regarding Plaintiff’s RFCs. ECF No. 24 at 9-11. Plaintiff further contends 

that remand is required because no opinion evidence exists in this record

to support the ALJ’s RFC determination. The Court concludes, however,

that a vast amount of objective medical evidence in the record, spanning 

many years, provides substantial support for the ALJ’s RFC determination.

In assessing Plaintiff’s RFC, the ALJ followed the correct two-step 

inquiry. First, the ALJ determined whether there was an underlying 

medically determinable physical impairment that can be shown by medical 

opinion(s) and prior administrative medical finding(s) in accordance with the 

requirements of 20 C.F.R. § 416.920c. In the case at hand, the ALJ 

determined that Plaintiff’s medically determinable impairments of ischemic 

heart disease, hypertension and morbid obesity could reasonably be 

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 16 of 21
expected to cause Plaintiff’s alleged symptoms. R. 19. Second, the ALJ 

evaluated the intensity, persistence, and limiting effects of Plaintiff’s

symptoms to determine the extent to which they limit Plaintiff’s functional 

capacity. Id. Here, the ALJ concluded that Plaintiff’s statements 

concerning the intensity, persistence, and limiting effects of his symptoms 

were not entirely consistent with the medical evidence or other evidence in 

the record as discussed below. R. 20.

1. ALJ’s review of the objective medical evidence.

The ALJ reviewed all of Plaintiff’s visits to the ER on a number of 

occasions over several years. Imaging of his heart during those visits 

revealed only mild to moderate results. R. 20. Also, although an 

echocardiogram in August of 2016 showed an EF of 20-25%, only mild 

cardiomegaly was noted at the time. Id. Follow-up imaging in November of 

2016 revealed no acute chest disease and dilated cardiomyopathy. Id. 

Further, a chest x-ray and imaging taken on three occasions in 2018 

revealed no acute cardiopulmonary pathology, only mild cardiomegaly. Id. 

And, even though Plaintiff also complained, on occasion, of shortness of 

breath, he generally denied symptoms such as orthopnea, palpitation, 

dizziness, blurred vision, and syncopal attaches. Id.; see R. 465. 

Moreover, several references to non-compliance with medication, cigaretteCase 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 17 of 21
smoking, and motorcycle riding are found in within the record. R. 21, 405, 

429. Finally, Plaintiff’s cardiovascular screenings were generally normal 

throughout the record with normal heart sounds, no murmur, and a normal 

heart rate and rhythm. Id.

Accordingly, the ALJ concluded that the objective medical records did 

not support Plaintiff’s allegations regarding the intensity, persistence, and 

limiting effects of his symptoms. 

2. ALJ’s consideration of Plaintiff’s hearing testimony.

In looking at Plaintiff’s hearing testimony, the ALJ noted that Plaintiff

takes prescription medications and over the counter pain medication to 

alleviate his symptoms, and that elevating his legs also helps. R. 20. The 

ALJ found that Plaintiff’s “mild to moderate results do not correspond well 

to the [Plaintiff’s] extensive allegations in this case.” Id. Also, despite 

Plaintiff’s testimony regarding his substantial exertional limitations, the 

objective medical evidence revealed otherwise.

4 For example, Plaintiff 

reported injuries sustained while performing heavy lifting just one month 

after he applied for SSI. See R. 380, 382. As to Plaintiff’s testimony that he 

has been unable to work since January 2016, the record shows that 

4 The ALJ specifically found that Plaintiff’s testimony was inconsistent with the medical 

evidence in the record, and she further expressed doubt as to its veracity. R. 21. 

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 18 of 21
Plaintiff’s heavy-lifting injury was sustained while he was at work at Mike’s 

Bikes in August of 2017. Id. Finally, Plaintiff testified that he had not driven 

in years because of his inability to sit for long periods of time. R. 21. Yet, 

after the hearing, the ALJ observed Plaintiff “hop onto and drive away in 

his- at least 800 pound- cruiser motorcycle.” Id. (emphasis in original).

3. ALJ’s consideration of Dr. Lawhorn’s opinion evidence. 

In evaluating Dr. Lawhorn’s opinion evidence, the ALJ properly 

applied the new medical regulations as Plaintiff applied for SSI after March 

27, 2017. R. 21-22. The ALJ found Dr. Lawhorn’s conclusion that the 

evidence in the record was insufficient to determine disability to be 

unpersuasive. R. 22. That was because Dr. Lawhorn did not have access 

to updated medical records and Plaintiff’s own testimony about his work 

history and normal daily activities that were available at the hearing level, 

along with the VE testimony. Id. The ALJ did, however, accept Dr. 

Lawhorn’s finding that Plaintiff has severe impairments of hypertension and 

ischemic heart disease as that finding was consistent with a 2016 

echocardiogram and a 2017 chest X-ray. See R. 17.

So, after reviewing the objective medical evidence, the hearing 

testimony, and Dr. Lawhorn’s report, the ALJ determined that Plaintiff has 

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 19 of 21
the RFC to perform light work subject to enumerated limitations (which is a 

very low bar, indeed). 

Upon careful review of the record in this case, this Court concludes 

that the ALJ’s RFC determination is supported by substantial evidence. 

Additionally, Plaintiff has not pointed to any conflict in the record that 

warranted a consultative examination,

5 and Plaintiff has not demonstrated 

any evidentiary gaps that result in unfairness or prejudice. 

In sum, the ALJ had plenty of objective medical records regarding 

Plaintiff’s medical conditions to make an informed decision as to his RFC. 

See Castle 557 F. App’x at 854 (“Where the medical evidence shows 

relatively little physical impairment, an ALJ permissibly can render a 

commonsense judgment about functioning capacity even without a 

physician’s assessment.”) (quoting Manso-Pizarro 76 F.3d at 17). 

V. CONCLUSION

In view of the foregoing, it is ORDERED that the decision of the 

Commissioner is AFFIRMED. 

5 It is worth noting once again that Dr. Lawhorn determined that a consultative 

examination was not required in this case.

Case 1:20-cv-00121-GRJ Document 26 Filed 11/24/21 Page 20 of 21
DONE AND ORDERED on the 24th day of November 2021.

s/Gary R. Jones 

GARY R. JONES

United States Magistrate Judge

.

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