IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF TEXAS

DALLAS DIVISIONS

NIKELA H., §

PLAINTIFF, §

 §

V. § CASE NO. 3:22-CV-939-N-BK

 § 

COMMISSIONER OF THE SOCIAL §

SECURITY ADMINISTRATION, §

DEFENDANT. §

FINDINGS, CONCLUSIONS AND RECOMMENDATION

OF THE UNITED STATES MAGISTRATE JUDGE

Pursuant to 28 U.S.C. § 636 and Special Order 3, this appeal of the denial of Plaintiff’s

application for social security disability benefits is before the undersigned magistrate judge for

findings and a recommended disposition. As detailed here, the Commissioner’s decision should

be AFFIRMED.

I. BACKGROUND

A. Procedural History1

Plaintiff seeks judicial review of a final decision of the Commissioner denying her claim

for supplemental security income under Title II of the Social Security Act (“Act”). Plaintiff filed

her original application for benefits in March 2012, alleging that she could no longer work as of

1 Unless otherwise noted, the facts are drawn from this Court’s prior opinion remanding for

further administrative proceedings due to the administrative law judge’s failure to adhere to the

strictures of Ripley v. Chater, 67 F.3d 552 (5th Cir. 1995). See Nikela H. v. Saul, 3:18-CV-1519-

G-BK, 2019 WL 4578925, at *1 (N.D. Tex. Aug. 30, 2019) (Toliver, J.), adopted by 2019 WL

4572781 (N.D. Tex. Sept. 20, 2019) (Fish, J.) (“Nikela I”).

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the preceding month. Following the denial of that claim, and prior to filing Nikela I, Plaintiff

filed a new application for benefits in March 2017 which also alleged a disability onset date of

February 2012. After that application was denied, the opinion in Nikela I issued and, on remand,

the administrative proceedings were consolidated. Doc. 14-1 at 12-13. Upon the denial of

Plaintiff’s consolidated application, she appealed to this Court pursuant to 42 U.S.C. § 405(g).

B. Factual Background

Plaintiff was 37 years old on her alleged onset date and has a high school equivalency

degree and past relevant work as a security guard and insurance contract reviewer. Doc. 14-1 at

51. In terms of her relevant medical history, Nurse Practitioner Natasha Simmons first saw

Plaintiff in December 2012. Plaintiff described feeling sad most of the day, crying spells,

agitation, and irritability following her separation from an abusive husband. She reported having

been molested by a brother and an uncle. NP Simmons diagnosed Plaintiff with major

depressive disorder and started her on an antidepressant.2

Throughout 2013, Plaintiff reported talking to her dead mother and hearing voices on a

daily basis, and although her thoughts were organized, her memory was not intact, and her

attention was impaired. NP Simmons increased her antidepressant and started her on

medications for insomnia and psychosis/auditory hallucinations. By October 2013, Plaintiff

reported crying spells, sleep disturbance, paranoia, chronic mood disturbance, racing thoughts,

hallucinations/delusions, and anger outbursts. Further, while Plaintiff reported improved

depression, she was also now hearing the voice of the brother who had molested her. 

2 During the relevant period, Plaintiff also had an extensive history of treatment for multiple

physical conditions. However, because the focus of Plaintiff’s brief is the ALJ’s mental residual

functional capacity (”RFC”) finding, the Court limits its discussion accordingly.

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In October 2013, Plaintiff’s primary attending physician, Dr. Zareena Raffi, M.D., and

NP Simmons opined that Plaintiff had a substantial loss3in the ability to (1) carry out detailed

but uninvolved written or oral instructions; (2) maintain concentration/attention for an extended

period (two hours); (3) perform at a consistent pace; (4) make simple work-related decisions and

ask simple questions; (5) accept instructions and respond appropriately to criticism from

supervisors; (6) get along with co-workers or peers without unduly distracting them or exhibiting

behavioral extremes; (7) respond appropriately to changes in a routine work setting and cope

with normal work stress; and (8) finish a normal work week without interruption from her

psychological symptoms. Dr. Raffi and NP Simmons diagnosed Plaintiff with major depressive

disorder, recurrent, severe with psychotic features, and opined Plaintiff would miss more than

four days of work a month due to her condition. 

In February 2014, Dr. Paul P. Schorr, D.O., examined Plaintiff and noted that she

described having auditory hallucinations of her father’s and brother’s voices and experiencing

anxiety and depression. Doc. 14-2 at 80. Dr. Schorr opined that Plaintiff’s pain, fatigue, and

other symptoms were severe enough to interfere with her attention, focus, and concentration

“nearly constantly” and her impairments were expected to last at least 12 months. Doc. 14-2 at

84. Dr. Schorr concluded that Plaintiff was incapable of even low stress work, would need to

take frequent, unscheduled breaks, and would likely be absent from work more than three times a

month. Doc. 14-2 at 84.

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“Substantial loss” is defined as the “loss of ability to perform the named activity in regular,

competitive employment [eight-hour day] and, at best, could do so only in a sheltered work

setting where special considerations and attention are provided.” Doc. 15-1 at 488.

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Plaintiff continued to demonstrate mental health issues thereafter, often presenting with

psychosis, auditory hallucinations, paranoia, anxiety, impaired attention, depression, unstable

mood, and memory problems, but these symptoms substantially improved—and many even

disappeared over time—when she consistently took her prescription medication. Doc. 14-2 at

660, 667, 674, 693, 699; Doc. 14-3 at 412-14, 441; Doc. 14-4 at 339-40, 343, 350; Doc. 14-5 at

4-5, 7, 12, 23, 25-26, 28; Doc. 14-5 at 349, 366. In February 2021, Dr. Shazia Basit, M.D.,

Plaintiff’s primary physician at Metrocare, completed a Functional Disability Assessment form

which essentially mirrored the October 2013 assessment by Dr. Raffi and NP Simmons. Doc.

14-5 at 380-81.

C. The ALJ’s Findings

In January 2022, the Administrative Law Judge (“ALJ”) issued a decision finding that

Plaintiff has the severe impairments of (1) status-post left ankle fracture with open reduction and

internal fixation and hardware removal; (2) status-post left small finger surgery post injury; (3)

degenerative joint disease of the knee; (4) degenerative disc disease of the lumbar spine; (5) prediabetes mellitus/diabetes mellitus; (6) obesity; and (7) depression with psychosis. Doc. 14-1 at

17. With respect to her mental abilities, the ALJ found that Plaintiff had (1) moderate limitations

in understanding, remembering, or applying information, interacting with others, and

concentrating/maintaining pace and (2) a mild limitation in her ability to adapt and manage

herself. Doc. 14-1 at 41-42. The ALJ then determined that Plaintiff could perform simple,

routine tasks and make simple decisions in an environment that involves few, if any, workplace

changes and no more than occasional contact with supervisors, coworkers, and the public. Doc.

14-1 at 43. The ALJ determined that Plaintiff had the RFC to perform a restricted range of light

work from her February 2012 onset date through the date of the decision. Doc. 14-1 at 43. 

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While Plaintiff could not perform any of her past work, the ALJ concluded she could perform

other work in the national economy and was thus not disabled. Doc. 14-1 at 54.

II. APPLICABLE LAW

An individual is disabled under the Act if, inter alia, 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 at least 12 months. 42 U.S.C. §

423(d)(1)(A). The Commissioner uses the following sequential five-step inquiry to determine

whether a claimant is disabled: (1) an individual who is working and engaging in substantial

gainful activity is not disabled; (2) an individual who does not have a “severe impairment” is not

disabled; (3) an individual who “meets or equals a listed impairment in Appendix 1” of the

regulations will be considered disabled without consideration of vocational factors; (4) if an

individual is capable of performing her past work, a finding of “not disabled” must be made; (5)

if an individual’s impairment precludes her from performing her past work, other factors

including age, education, past work experience, and RFC must be considered to determine if any

other work can be performed. Wren v. Sullivan, 925 F.2d 123, 125 (5th Cir. 1991) (per curiam)

(summarizing 20 C.F.R. §§ 404.1520(b)-(f), 416.920(b-(f)).

Under the first four steps of the analysis, the burden of proof lies with the claimant.

Leggett v. Chater, 67 F.3d 558, 564 (5th Cir. 1995). The analysis terminates if the

Commissioner determines at any point during the first four steps that the claimant is disabled or

is not disabled. Id. If the claimant satisfies her burden under the first four steps, the burden

shifts to the Commissioner at step five to show that there is other gainful employment available

in the national economy that the claimant can perform. Greenspan v. Shalala, 38 F.3d 232, 236

(5th Cir. 1994). This burden may be satisfied either by reference to the Grid Rules, vocational

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expert testimony, or other similar evidence. Fraga v. Bowen, 810 F.2d 1296, 1304 (5th Cir.

1987).

Judicial review of the Commissioner’s denial of benefits is limited to whether the

Commissioner’s position is supported by substantial evidence and whether the Commissioner

applied proper legal standards in evaluating the evidence. Greenspan, 38 F.3d at 236; 42 U.S.C.

§§ 405(g), 1383(C)(3). Substantial evidence is more than a scintilla, less than a preponderance,

and is such relevant and sufficient evidence as a reasonable mind might accept as adequate to

support a conclusion. Leggett, 67 F.3d at 564. Under this standard, the reviewing court does not

reweigh the evidence, retry the issues, or substitute its own judgment, but rather, scrutinizes the

record to determine whether substantial evidence is present. Greenspan, 38 F.3d at 236.

In considering the parties’ arguments, the Court has relied upon their assessment of and

citation to the evidence of record. The Court is not under any obligation to probe the record to

find supporting evidence for one side or the other.

III. ANALYSIS

As in Nikela I, Plaintiff argues that the ALJ’s assessment of her RFC is unsupported

because the ALJ made her own independent medical determinations about Plaintiff’s ability to

work without any supporting expert medical opinions and after rejecting the opinions of NP

Simmons, and Drs. Raffi, Schorr, and Basit in violation of Ripley. Doc. 17 at 22-29. Plaintiff

maintains that the error was prejudicial because the ALJ’s RFC assessment was not supported by

any underlying medical opinion evidence, and the outcome might have been different had the

ALJ obtained updated opinions from Plaintiff’s providers. Doc. 17 at 28-31.

Defendant responds that the ALJ properly interpreted the medical evidence in

determining Plaintiff’s capacity to work, and that substantial evidence supports the ALJ’s RFC

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decision, which reached a middle ground between the conclusions of Plaintiff’s providers and the

state agency medical consultants (“SAMCs”) which rated her abilities higher. Doc. 19 at 3-5, 8-

10. In particular, Defendant points to the 2017 opinions of Dr. Deborah D. Gambles, PsyD., and

SAMCs Dr. Matthew Turner, Ph.D., and Dr. Jean Germain, Ph.D. Doc. 19 at 5-6.

The RFC is an assessment, based on all relevant evidence, of a claimant’s ability to work,

despite her impairments. 20 C.F.R. § 416.945(a). Stated differently, it is the most a claimant can

do, notwithstanding her physical and mental limitations. Id. The RFC determination falls solely

to the ALJ, who is responsible for resolving any conflicts in the evidence. See Chambliss v.

Massanari, 269 F.3d 520, 522 (5th Cir. 2001) (per curiam). 

In Ripley v. Chater, 67 F.3d 552 (5th Cir. 1995), the ALJ ruled that a claimant could

perform sedentary work even though there was no medical evidence or testimony supporting that

conclusion. Ripley, 67 F.3d at 557. The appellate court noted that the claimant’s record

contained a vast amount of evidence establishing that he had a back problem, but did not clearly

establish what effect that condition had on his ability to work. Id. Thus, the court remanded the

case with instructions for the ALJ to obtain a report from a treating physician regarding the

effects of the claimant’s back condition on his ability to work. Id. at 557-58. The Ripley panel

explained, however, that “[t]he absence of such a statement . . . does not, in itself, make the

record incomplete.” Id. at 557. Rather, reversal is only appropriate if the claimant can show

prejudice, i.e., “that he could and would have adduced evidence that might have altered the

result.” Brock v. Chater, 84 F.3d 726, 728-29 (5th Cir. 1996).

Dr. Gambles’ review of the medical evidence was limited to March 2012 through April

2014. Doc. 14-2 at 225. Dr. Gambles stated that although Plaintiff’s symptoms were “severe,”

they did not meet or equal a Listing or “impede [her] ability to sustain gainful activity.” Doc.

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14-2 at 225. Dr. Turner opined that Plaintiff had only mild limitations in (1) understanding,

remembering, or applying information; (2) interacting with others; (3) concentrating, persisting,

and maintaining pace; and (4) adapting and managing herself. Doc. 14-1 at 201. Dr. Germain

concurred with this assessment. Doc. 14-1 at 214.

The ALJ concluded that the opinions of Dr. Schorr and Plaintiff’s treating sources were

generally inconsistent with the evidence of record, and she gave Dr. Schorr’s opinion “little

evidentiary weight,” instead finding the SAMC’s opinions “far more consistent” and “entitled to

greater evidentiary weight.” Doc. 14-1 at 49-50. In particular, the ALJ pointed to Plaintiff’s

inconsistent medication compliance, her hearing testimony, and her daily activities, which

included brief periods of employment and caring for several young children. Doc. 14-1 at 50.

As an initial matter, this case is distinguishable from Plaintiff’s prior appeal in which the 

SAMCs made no medical assessments because they determined she had no severe impairments, 

but the ALJ also rejected her treating physicians’ opinions. See Nikela I, 2019 WL 4578925 at

*3-4. By contrast, the ALJ here found the SAMCs’ and Dr. Gambles’ opinions largely 

persuasive and relied on them in formulating Plaintiff’s RFC. The ALJ also did not err by 

including additional restrictions in her RFC assessment. See Vasquez v. Comm’r of Soc. Sec., 

7:21-CV-00028-O-BP, 2022 WL 2975471, at *5 (N.D. Tex. June 30, 2022) (finding no error 

where the ALJ imposed more restrictions on than claimant’s activities than the limitations 

determined by the SAMCs), adopted by 2022 WL 2972240 (N.D. Tex. July 26, 2022); Ernest 

A.J. v. Saul, No. 1:18-CV-00194-BU, 2020 WL 6877706, at *14 (N.D. Tex. Oct. 19, 2020)

(same), adopted by 2020 WL 6873609 (N.D. Tex. Nov. 23, 2020); Michael L. v. Berryhill, No. 

3:18-CV-0010-G-BK, 2019 WL 1243866, at *5 (N.D. Tex. Feb. 20, 2019) (Toliver, J.) (same), 

adopted by 2019 WL 1244076 (N.D. Tex. Mar. 18, 2019); cf. Henline v. Commr., Soc. Sec.

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Admin., 3:20-CV-1944-D-BH, 2022 WL 850102, at *16 (N.D. Tex. Mar. 4, 2022), adopted by

2022 WL 847237 (N.D. Tex. Mar. 22, 2022) (Fitzwater, J.) (reversing based on Ripley where the

only evidence of record addressing the claimant’s ability to work was the SAMC’s opinion,

which the ALJ largely rejected when choosing to impose less restrictive RFC limitations).

Here, the ALJ’s RFC finding was based on substantial evidence in the form of more than

3,700 pages of medical records, Plaintiff’s ability to maintain substantial gainful employment as

a security guard for 11 months from 2018 to early 2019, her activities of daily living, which

included raising several children for her relatives, and the testimony given at the administrative

hearing. The ALJ set forth her findings in a detailed 45-page opinion, and nothing in the record

suggests that the ALJ needed any more medical information, such as updated opinions from

Plaintiff’s providers, to reach an informed decision about whether Plaintiff was disabled. See

Webster, 19 F.4th at 720.

Although the ALJ's mental RFC finding does not mirror the SAMC’s medical opinions,

“it cannot be said that [the] decision was not based on substantial evidence.” Webster v.

Kijakazi, 19 F.4th 715, 719 (5th Cir. 2021) (affirming where the ALJ rejected the testimony of

the claimant’s examining physician as inconsistent with the longitudinal medical evidence,

which showed improvement, and declined to adopt the SAMC’s more restrictive limitations

verbatim); see also Wills v. Kijakazi, No. 22-20609, 2023 WL 4015174, at *4 (5th Cir. June 14,

2023) (unpublished) (holding that the ALJ’s RFC determination was adequately supported

despite her imposition of additional restrictions beyond those noted by the SAMC). In sum, the

ALJ's decision here was adequately supported by substantial evidence based on a sufficiently

developed record.

 

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IV. CONCLUSION

For the foregoing reasons, the Commissioner’s decision should be AFFIRMED.

 SO RECOMMENDED on September 8, 2023.

INSTRUCTIONS FOR SERVICE AND

NOTICE OF RIGHT TO APPEAL/OBJECT

A copy of this report and recommendation shall be served on all parties in the manner

provided by law. Any party who objects to any part of this report and recommendation must file

specific written objections within 14 days after being served with a copy. See 28 U.S.C.

§ 636(b)(1); FED. R. CIV. P. 72(b). In order to be specific, an objection must identify the specific

finding or recommendation to which objection is made, state the basis for the objection, and

specify the place in the magistrate judge’s report and recommendation where the disputed

determination is found. An objection that merely incorporates by reference or refers to the

briefing before the magistrate judge is not specific. Failure to file specific written objections will

bar the aggrieved party from appealing the factual findings and legal conclusions of the

magistrate judge that are accepted or adopted by the district court, except upon grounds of plain

error. See Douglass v. United Services Automobile Ass’n, 79 F.3d 1415, 1417 (5th Cir. 1996).

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