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IN THE UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF TEXAS

DALLAS DIVISION

SILVES H., '

'

Plaintiff, ' 

'

' No. 3:22-cv-286-K-BN

KILOLO KIJAKAZI, Acting '

Commissioner of Social Security, '

'

Defendant. '

FINDINGS, CONCLUSIONS, AND RECOMMENDATION OF THE

UNITED STATES MAGISTRATE JUDGE

Plaintiff Silves H. seeks judicial review of a final adverse decision of the 

Commissioner of Social Security pursuant to 42 U.S.C. § 405(g). For the reasons 

explained below, the hearing decision should be remanded. 

Background

Plaintiff alleges that she is disabled as a result of cervical spinal stenosis and 

carpel tunnel syndrome in both hands. After her application for disability insurance 

benefits was denied initially and on reconsideration, Plaintiff requested a hearing 

before an administrative law judge (“ALJ”). That hearing was held on June 22, 2021. 

See Dkt. No. 10-1 at 79-103. At the time of the hearing, Plaintiff was 52 years old. 

She is a college graduate and has past work experience as a technical analyst. 

Plaintiff has not engaged in substantial gainful activity since May 30, 2018. 

The ALJ found that Plaintiff was not disabled and therefore not entitled to 

disability benefits. See id. at 14-23. Although the medical evidence established that 

Plaintiff suffered from obesity, degenerative disc disease of the cervical spine statusCase 3:22-cv-00286-K-BK Document 16 Filed 11/14/22 Page 1 of 11 PageID 635
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post fusion of C3-7, and carpal tunnel syndrome status-post bilateral release 

surgeries, the ALJ concluded that the severity of those impairments did not meet or 

equal any impairment listed in the social security regulations. The ALJ further 

determined that Plaintiff had the residual functional capacity to perform her past 

relevant work as a data processing technician analyst. 

Plaintiff appealed that decision to the Appeals Council. The Council affirmed. 

Plaintiff then filed this action in federal district court. In a single ground for 

relief, Plaintiff contends that the assessment of her residential functional capacity is 

not supported by substantial evidence.

The undersigned concludes that the hearing decision should be reversed and 

this case remanded to the Commissioner of Social Security for further proceedings 

consistent with these findings and conclusions.

Legal Standards

Judicial review in social security cases is limited to determining whether the 

Commissioner’s decision is supported by substantial evidence on the record as a 

whole and whether Commissioner applied the proper legal standards to evaluate the 

evidence. See 42 U.S.C. § 405(g); Copeland v. Colvin, 771 F.3d 920, 923 (5th Cir. 

2014); Ripley v. Chater, 67 F.3d 552, 555 (5th Cir. 1995). 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); accord Copeland, 771 F.3d at 923. The Commissioner, rather than 

the courts, must resolve conflicts in the evidence, including weighing conflicting 

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testimony and determining witnesses’ credibility, and the Court does not try the 

issues de novo. See Martinez v. Chater, 64 F.3d 172, 174 (5th Cir. 1995); Greenspan 

v. Shalala, 38 F.3d 232, 237 (5th Cir. 1994). This Court may not reweigh the evidence 

or substitute its judgment for the Commissioner’s but must scrutinize the entire 

record to ascertain whether substantial evidence supports the hearing decision. See 

Copeland, 771 F.3d at 923; Hollis v. Bowen, 837 F.2d 1378, 1383 (5th Cir. 1988). The 

Court “may affirm only on the grounds that the Commissioner stated for [the] 

decision.” Copeland, 771 F.3d at 923.

“In order to qualify for disability insurance benefits or [supplemental security 

income], a claimant must suffer from a disability.” Id. (citing 42 U.S.C. § 423(d)(1)(A)).

A disabled worker is entitled to monthly social security benefits if certain conditions 

are met. See 42 U.S.C. § 423(a). The Act defines “disability” as the inability to engage 

in substantial gainful activity by reason of any medically determinable physical or 

mental impairment that can be expected to result in death or last for a continued 

period of 12 months. See id. § 423(d)(1)(A); see also Copeland, 771 F.3d at 923; Cook 

v. Heckler, 750 F.2d 391, 393 (5th Cir. 1985). 

“In evaluating a disability claim, the Commissioner conducts a five-step 

sequential analysis to determine whether (1) the claimant is presently working; (2) 

the claimant has a severe impairment; (3) the impairment meets or equals an 

impairment listed in appendix 1 of the social security regulations; (4) the impairment 

prevents the claimant from doing past relevant work; and (5) the impairment 

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prevents the claimant from doing any other substantial gainful activity.” Audler v. 

Astrue, 501 F.3d 446, 447-48 (5th Cir. 2007).

The claimant bears the initial burden of establishing a disability through the 

first four steps of the analysis; on the fifth, the burden shifts to the Commissioner to 

show that there is other substantial work in the national economy that the claimant 

can perform. See Copeland, 771 F.3d at 923; Audler, 501 F.3d at 448. A finding that 

the claimant is disabled or not disabled at any point in the five-step review is 

conclusive and terminates the analysis. See Copeland, 771 F.3d at 923; Lovelace v. 

Bowen, 813 F.2d 55, 58 (5th Cir. 1987).

In reviewing the propriety of a decision that a claimant is not disabled, the 

Court’s function is to ascertain whether the record as a whole contains substantial 

evidence to support the Commissioner’s final decision. The Court weighs four 

elements to determine whether there is substantial evidence of disability: (1) 

objective medical facts; (2) diagnoses and opinions of treating and examining 

physicians; (3) subjective evidence of pain and disability; and (4) the claimant’s age, 

education, and work history. See Martinez, 64 F.3d at 174.

The ALJ has a duty to fully and fairly develop the facts relating to a claim for 

disability benefits. See Ripley, 67 F.3d at 557. If the ALJ does not satisfy this duty, 

the resulting decision is not substantially justified. See id. However, the Court does 

not hold the ALJ to procedural perfection and will reverse the ALJ’s decision as not 

supported by substantial evidence where the claimant shows that the ALJ failed to 

fulfill the duty to adequately develop the record only if that failure prejudiced 

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Plaintiff, see Jones v. Astrue, 691 F.3d 730, 733 (5th Cir. 2012) – that is, only if 

Plaintiff’s substantial rights have been affected, see Audler, 501 F.3d at 448.

“Prejudice can be established by showing that additional evidence would have been 

produced if the ALJ had fully developed the record, and that the additional evidence 

might have led to a different decision.” Ripley, 67 F.3d at 557 n.22. Put another way, 

Plaintiff “must show 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).

Analysis

Among the arguments Plaintiff makes is a single ground that compels remand 

– the ALJ’s RFC determination that Plaintiff can frequently handle and finger 

bilaterally is not supported by substantial evidence.1 Specifically, Plaintiff argues 

that the ALJ did not identify any medical opinion, medical evidence, or other evidence 

as the basis for her determination that Plaintiff could frequently handle and finger 

bilaterally and instead impermissibly substituted her own medical judgment to 

determine Plaintiff’s ability to work.

“It is the responsibility of the ALJ to interpret ‘the medical evidence to 

determine [a claimant's] capacity for work.’” Fontenot v. Colvin, 661 F. App'x 274, 277 

(5th Cir. 2016) (quoting Taylor v. Astrue, 706 F.3d 600, 603 (5th Cir. 2012). “The ALJ 

makes an RFC determination based on all the relevant medical and other evidence 

in the record,” Gonzales v. Colvin, No. 3:15-cv-685-D, 2016 WL 107843, at *9 (N.D. 

1 By recommending remand of this case for further administrative proceedings, the 

undersigned does not suggest that Plaintiff is or should be found disabled.

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Tex. Jan. 11, 2016) (citing 20 C.F.R. § 404.1545(a)(1)), and “is entitled to determine 

the credibility of medical experts as well as lay witnesses and to weigh their opinions 

and testimony accordingly.” Fontenot, 661 F. App'x at 277 (quoting Moore v. Sullivan, 

919 F.2d 901, 905 (5th Cir. 1990)). “Usually, the ALJ should request a medical source 

statement describing the types of work that the applicant is still capable of 

performing. The absence of such a statement, however, does not, in itself, make the 

record incomplete.” Ripley, 67 F.3d at 557 (citing 20 C.F.R. § 404.1513(b)(6)). “[W]here 

no medical statement has been provided, [the Court's] inquiry focuses upon whether 

the decision of the ALJ is supported by substantial evidence in the existing record.” 

Id.; accord Gutierrez v. Barnhart, No. 04-11025, 2005 WL 1994289, at *7 (5th Cir. 

Aug. 19, 2005) (citation omitted).

Here, the only medical opinions in the record were those of the State Agency 

Medical Consultants (“SAMCs”). 

On initial determination, Patty Rowley, M.D. determined Plaintiff could 

perform a limited range of light work. Dr. Rowley found Plaintiff had exertional and 

postural limitations. Specifically, she found Plaintiff could occasionally lift and/or 

carry twenty pounds and frequently lift ten pounds; stand and/or walk six hours and 

sit on a sustained basis more than six hours in an eight-hour workday; and 

occasionally crawl and climb ladders, ropes, and scaffolds. Dr. Rowley found Plaintiff 

had no limitations in climbing ramps and stairs, balancing, stooping, kneeling, or 

crouching. Dr. Rowley also found Plaintiff had manipulative limitations, specifically, 

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that Plaintiff’s ability to occasionally reach overhead to the left and right was limited, 

but she no limitations in handling, fingering, or feeling. See Dkt. No. 10-1 at 109-10.

On reconsideration, Amita Hedge, M.D.’s findings were the same as Dr. 

Rowley’s except Dr. Hedge found Plaintiff could occasionally crouch and Plaintiff’s 

ability to push and/or pull was limited in both upper extremities. See id. at 120-22.

The ALJ found the SAMCs’ opinions to be somewhat persuasive, with the 

opinion on reconsideration being more persuasive, because they were supported by 

the physicians’ analysis of the evidence at the time the opinions were rendered. But 

the ALJ found that evidence received at the hearing level supported further 

limitations. See id. at 21. 

The ALJ determined that Plaintiff retained the RFC to perform sedentary 

work in that she can lift and/or carry ten pounds occasionally and five pounds 

frequently; can stand and/or walk for two hours and sit for six hours in an eight-hour 

workday; can occasionally stoop, kneel, crouch, climb ladders, ropes, and scaffolds; 

can occasionally reach overhead with her left upper extremity; and can frequently 

handle and finger bilaterally. See Dkt. No. 10-1 at 19.

The ALJ explained that Plaintiff “can frequently handle and finger bilaterally 

due to her carpal tunnel syndrome and accompanying weakness in her upper 

extremities.” Id. at 22. Having found that Plaintiff had manipulative limitations in 

handling and fingering, the ALJ does not explain how she determined Plaintiff could

handle and finger frequently or the effect those limitations had on Plaintiff’s ability 

to work. 

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Nor does the ALJ identify any medical or other evidence as the basis for her 

finding that Plaintiff can handle and finger frequently. The ALJ refers to the “entire 

record” and Plaintiff’s ability to complete activities of daily living, but she does not 

identify or explain what evidence in the record or what activities of daily living 

support her finding that Plaintiff could handle and finger frequently.

In her discussion of activities of daily living, the ALJ notes that Plaintiff 

“indicated the difficulties with her hands and raising her arms posed trouble in 

washing and styling her hair, washing dishes, and chopping vegetables.” Id. at 20. 

The ALJ then describes the activities of daily living Plaintiff can perform, “such as 

cooking (albeit she uses a small pan), dusting, laundering clothing, watering her 

plants, talking to friends on the phone, shopping in stores (having help with heavier 

items), and driving.” Id. But the ALJ does not explain how the ability to perform those 

activities shows Plaintiff can handle and finger frequently 

Since the ALJ implicitly rejected the SAMCs’ opinions by finding that Plaintiff 

had manipulative limitations, there are no medical opinions concerning Plaintiff’s 

ability to handle and finger during an eight-hour workday. And the undersigned 

cannot determine whether the ALJ’s RFC finding concerning Plaintiff’s handling and 

fingering limitations is otherwise supported by substantial evidence in the record 

because the ALJ does not identify medical or other evidence as the basis for her 

finding. See Bowles v. Comm’r of Soc. Sec., No. 7:20-cv-112-O-BP, 2021 WL 7451148, 

at *3 (N.D. Tex. Oct. 19, 2021) (holding RFC must be supported by substantial 

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evidence even though adding limitations suggested the ALJ was simply giving the 

claimant the benefit of the doubt).

The ALJ has a responsibility “to adequately explain [her] reasoning in making 

the findings on which [her] ultimate decision rests, and in doing so must address all 

pertinent evidence.” Gonzalez v. Berryhill, No. 3:16-cv-1830-BN, 2017 WL 3492215, 

at *6 (N.D. Tex. Aug. 17, 2017); see also SSR 82-62 (S.S.A.), 1982 WL 31386 (“The 

rationale for a disability decision must be written so that a clear picture of the case 

can be obtained. The rationale must follow an orderly pattern and show clearly how 

specific evidence leads to a conclusion.”); SSR 83-14 (S.S.A.), 1983 WL 3154 (“There 

must be findings of fact and recitation of the evidence which supports each finding.”).

Here, the ALJ failed to explain the rationale or show how specific evidence led 

her to the conclusion that Plaintiff can frequently handle and finger bilaterally.

Although the ALJ identified the medical conditions on which the manipulative 

limitations in handling and fingering were based, the ALJ failed to make the required 

function-by-function assessment of the effect of those limitations on Plaintiff’s ability 

to perform work-related activities. See Myers v. Apfel, 238 F.3d 617, 620 (5th Cir. 

2001); SSR 96-8p (S.S.A.), 1996 WL 374184, at *1 

Instead, having rejected the only medical opinions in the record regarding the 

effects of Plaintiff’s impairments on her ability to work, the ALJ appears to have 

relied her own interpretation of the medical record and testimonial evidence, which 

she may not do. See Williams v. Astrue, 355 F. App'x 828, 832 n.6 (5th Cir. 2009);

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Ripley, 67 F.3d at 557. Consequently, substantial evidence does not support the ALJ’s 

mental RFC determination.

Moreover, the ALJ rejected the SAMCs’ medical opinions on Plaintiff’s 

limitations in handling and fingering because evidence adduced at the hearing 

suggested Plaintiff’s manipulative limitations were greater than those noted in the 

SAMC reports, rendering them stale. But having determined that the SAMC opinions 

did not accurately capture Plaintiff’s manipulative limitations, the ALJ did not 

request an updated medical opinion that would have accounted for changes in 

Plaintiff’s ability to handle and finger, and instead relied on her own lay 

interpretation of Plaintiff’s ability to work. Had she obtained an updated opinion, her 

determination of Plaintiff’s RFC would, conceivably, have included greater 

limitations. This, in turn, could have altered the ALJ’s findings at step five, at which 

the Commissioner bears the burden to identify gainful employment available in the 

national economy that Plaintiff can perform, and at which the ALJ determined 

Plaintiff was not disabled. 

Therefore, the ALJ erred by making an RFC determination without medical 

evidence addressing the effects of Plaintiff's manipulative impairments on her ability 

to work and Plaintiff was harmed by that error. Accordingly, substantial evidence 

does not support the ALJ's determination of Plaintiff's RFC.

Recommendation

The hearing decision should be reversed and this case remanded to the 

Commissioner of Social Security for further proceedings consistent with this opinion.

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A copy of these findings, conclusions, and recommendation shall be served on 

all parties in the manner provided by law. Any party who objects to any part of these 

findings, conclusions, 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 findings, conclusions, 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 Auto. Ass’n, 79 F.3d 1415, 1417 (5th Cir. 1996).

DATED: November 14, 2022

______________________________________________________________________________________________________________________

DAVID L. HORAN 

UNITED STATES MAGISTRATE JUDGE

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