Court Opinion

ID: 5122846
Source: CourtListenerOpinion
Date Created: 2021-11-03 14:00:35.294092+00
Date Added: 2024-06-11T08:22:30.288904
License: Public Domain

USCA11 Case: 19-14633     Date Filed: 11/03/2021     Page: 1 of 24

                                                   [PUBLISH]
                            In the
         United States Court of Appeals
                 For the Eleventh Circuit

                   ____________________

                         No. 19-14633
                   ____________________

MARIA TERESA PUPO,
                                              Plaintiff-Appellant,
versus
COMMISSIONER, SOCIAL SECURITY ADMINISTRATION,

                                            Defendant-Appellee.

                   ____________________

          Appeal from the United States District Court
              for the Southern District of Florida
               D.C. Docket No. 1:17-cv-23609-JB
                   ____________________
USCA11 Case: 19-14633       Date Filed: 11/03/2021    Page: 2 of 24

2                      Opinion of the Court               19-14633

Before WILSON, ROSENBAUM, and HULL, Circuit Judges.
WILSON, Circuit Judge:
       Maria Teresa Pupo appeals the district court’s order affirm-
ing the Commissioner of the Social Security Administration’s
(Commissioner) denial of her application for supplemental security
income (SSI). Pupo raises five issues on appeal: (1) the administra-
tive law judge (ALJ) erred by not considering whether to apply a
higher age category, (2) the Appeals Council erred by not consid-
ering additional medical evidence she submitted, (3) the ALJ erred
in assessing her residual functional capacity (RFC), (4) the ALJ
erred in not giving controlling weight to her treating doctor and
psychiatrist, and (5) the ALJ erred in finding her mental impair-
ments did not meet a listed impairment. We find that the Com-
missioner’s decision is not supported by substantial evidence for
two reasons. First, the ALJ erred by not addressing one of Pupo’s
medical diagnoses, her incontinence, when assessing her RFC. Sec-
ond, the Appeals Council erred by not considering the new medical
evidence submitted by Pupo following the ALJ’s denial of her SSI
claim. Accordingly, we reverse the district court’s decision affirm-
ing the ALJ’s decision and remand to the Commissioner to reeval-
uate Pupo’s claim consistent with this opinion.
                         BACKGROUND
      Before turning to the facts of the case, here is a brief over-
view of the process for obtaining social security benefits. The
claimant applies in writing to the Social Security Administration
USCA11 Case: 19-14633       Date Filed: 11/03/2021     Page: 3 of 24

19-14633               Opinion of the Court                        3

(SSA) and if the SSA denies the application, the claimant has sixty
days to seek reconsideration. See 42 U.S.C. § 405(b)(1). If the SSA
denies reconsideration, the claimant can request a hearing before
an ALJ.
      At the hearing, the ALJ performs a five-step analysis in de-
termining if the applicant is disabled. The steps are as follows:
   1. At Step One, the ALJ determines whether the claimant is en-
      gaged in substantial gainful activity. If the claimant is en-
      gaged in substantial gainful activity, then the claimant is not
      disabled. 20 C.F.R. § 416.920(a)(4)(i).
   2. At Step Two, the ALJ determines whether the claimant has
      a severe impairment. A claimant who does not have a se-
      vere impairment is not disabled. Id. § 416.920(a)(4)(ii).
   3. At Step Three, the ALJ determines whether the claimant has
      an impairment that meets or equals a listed impairment. A
      claimant who meets or equals a listed impairment is disa-
      bled. Id. § 416.920(a)(4)(iii).
   4. At Step Four, the ALJ determines whether the claimant has
      any impairments that prevent her from returning to her past
      relevant work. If the claimant has a severe impairment that
      does not equal or meet the severity of the listed impairment,
      the ALJ proceeds to Step Four and assesses the claimant’s
      RFC. If the claimant can return to her past or relevant work,
      then she is not disabled. Id. § 416.920(a)(4)(iv).
USCA11 Case: 19-14633        Date Filed: 11/03/2021    Page: 4 of 24

4                      Opinion of the Court                19-14633

    5. At Step Five, the ALJ determines whether the claimant’s im-
       pairment prevents her from doing any other work. If the
       claimant can adjust to other work, she is not disabled, but if
       she cannot adjust, she is disabled. Id. § 416.920(a)(4)(v).
       The claimant may also obtain judicial review of the ALJ’s
decision in a United States district court by commencing a civil ac-
tion within sixty days of notice of the decision. 42 U.S.C. § 405(g).
       Pupo first applied for SSI in June 2011, alleging that she was
unable to work due to depression, body tremors, and high blood
pressure. Her initial application was denied, but, in June 2015, her
case was remanded by the district court for further proceedings
pursuant to sentence four of 42 U.S.C. § 405(g). The Appeals Coun-
cil then vacated the Commissioner’s final decision and remanded
the case to an ALJ for the resolution of certain issues. The ALJ is-
sued a decision in August 2016, which is the subject of this appeal.
       I. Pupo’s Medical Evidence
       Pupo submitted medical and opinion evidence that reflects
numerous ailments over the years. In 2009, she was struck by a
vehicle and doctors treated her for a broken clavicle and minor in-
juries to other parts of her body. From 2011 to 2014, she visited
Dr. Omar Suarez routinely for physical exams with complaints of
headaches, episodes of weakness and fatigue, back pain, depres-
sion, and left foot pain.
        In July 2014, she began seeing Dr. Rolando E. Diaz, who,
after treating Pupo for a year and a half, completed a physical RFC
USCA11 Case: 19-14633        Date Filed: 11/03/2021      Page: 5 of 24

19-14633                Opinion of the Court                         5

questionnaire for Pupo, listing the following diagnoses: low back
pain, uterine prolapse, gastroesophageal reflux disease (GERD),
urinary incontinence, hypothyroidism, obesity, hyperlipidemia,
and diabetes mellitus type II. Pupo had never been hospitalized for
her medical impairments. She had several secondary side effects
from her medicines, including nausea and dizziness, but she had
responded to treatment as well as expected and no courses of treat-
ment had been discontinued because of side effects or ineffective-
ness. Her symptoms included fatigue, dizziness, and pain in her
low back, left clavicle, and left body side. This pain often interfered
with her attention and concentration. Despite these symptoms,
Dr. Diaz had not placed or requested any limitations on her activity
in the RFC questionnaire.
       When estimating Pupo’s functional limitations in a compet-
itive work situation, Dr. Diaz stated that Pupo could not walk far
without rest or experiencing severe pain and she could sit or stand
for forty-five minutes at one time before needing to change posi-
tions or walk around. Due to body pain, Pupo could rarely lift ten
pounds in a competitive work situation, but could use her hands
for simple grasping, pushing and pulling, and fine manipulation
and could use her feet for repetitive movements. Dr. Diaz noted
that Pupo’s impairments were not likely to produce “good days”
or “bad days” because her impairments consistently limited her
functional capacity on a day-to-day basis.
       From March 2011 to April 2016, Pupo visited several urolo-
gists and gynecologists with complaints of urinary incontinence.
USCA11 Case: 19-14633      Date Filed: 11/03/2021    Page: 6 of 24

6                     Opinion of the Court               19-14633

During these visits Pupo complained that she had to wear five pads
a day, her doctors noted that she had a prolapsed bladder, and her
symptoms were not responding well to medication.
       In addition to records on her physical impairments, Pupo
also submitted records about her psychological impairments. In
2011, Pupo was diagnosed with major depressive disorder after
completing a psychiatric evaluation. From May 2011 to February
2014, she visited a psychiatrist, Dr. Rosa Amurrio, regularly for
treatment. Dr. Amurrio prescribed Pupo a variety of medications
for her mental disorders. Pupo was briefly committed to inpatient
treatment for one week after she told Dr. Amurrio that she had
hallucinations and suicidal ideation. However, she later denied
having had these symptoms after being discharged. During her
regular visits, Dr. Amurrio reported that Pupo was casually
dressed, had good eye contact and fluent speech, and was oriented.
Her mood had improved slightly, but she still experienced forget-
fulness, lack of energy, and anxiety. Pupo had complained of anxi-
ety and depression after running out of her medications but re-
ported that she had an improved mood and was doing much better
while taking medications.
        In July 2012, Dr. Amurrio completed a psychiatric and psy-
chosocial evaluation of Pupo. She diagnosed Pupo with major de-
pressive disorder and severe and generalized anxiety disorder. Dr.
Amurrio had not placed or requested any limitations on Pupo’s ac-
tivities. Her impairments were likely to produce good and bad
days because her decreased mood could cause bad days. She
USCA11 Case: 19-14633         Date Filed: 11/03/2021     Page: 7 of 24

19-14633                Opinion of the Court                          7

suffered from depressive syndrome with the following clinical fea-
tures: anhedonia; appetite disturbance with change in weight; dif-
ficulty concentrating or difficulty thinking; hallucinations, delu-
sions, or paranoid thinking, and feelings of guilt or worthlessness.
Pupo’s condition did not result in a complete inability to function
independently outside of her home.
        Next, Dr. Amurrio reported that Pupo had the following re-
strictions for work-related mental activities: mild restrictions in car-
rying out short, simple instructions; moderate restrictions in un-
derstanding and remembering detailed instructions; moderate re-
strictions in carrying out detailed instructions; and mild restrictions
in the ability to make judgments on simple work-related decisions.
Pupo also had mild restrictions for interacting appropriately with
coworkers and marked restrictions for responding appropriately to
work pressures and changes in a usual work setting.
       II. The ALJ Hearing and Decision
       Pupo had an ALJ hearing in April 2016. She testified that she
was 54-years old and born in Cuba. She could not communicate in
English, and could not work due to depression, pain in her left clav-
icle and left leg, diabetes, high blood pressure, and urinary inconti-
nence. Her only work experience was a six-month stint in 2007–08
cleaning construction homes. She testified that she could stand or
walk for forty-five minutes to an hour, could sit for about an hour
before feeling increased pain, and could lift twenty pounds without
feeling an increase in pain. She did not do any housework, had
difficulty dressing herself because of her left arm pain, occasionally
USCA11 Case: 19-14633        Date Filed: 11/03/2021    Page: 8 of 24

8                      Opinion of the Court                19-14633

went grocery shopping with her husband, read the Bible for ten
minutes per day, and needed her husband to remind her to take her
medications. A vocational expert (VE) also testified about hypo-
thetical individuals with Pupo’s age, education, and past work ex-
perience who could perform work at the medium exertional level
and found that there were three jobs that she could do: industrial
cleaner, laundry worker, and hand packager.
       The ALJ issued a decision in August 2016 which concluded
that Pupo was not disabled. The ALJ made the following findings:
    • At Step One of the sequential analysis, Pupo had not en-
      gaged in substantial gainful activity since her application for
      benefits.
    • At Step Two, Pupo had numerous severe impairments: ma-
      jor depressive disorder, hypertension, hypothyroidism, dia-
      betes type II, and obesity.
    • At Step Three, Pupo did not have an impairment or combi-
      nation of impairments that met or medically equaled the se-
      verity of one of the listed impairments (a Listing) in 20 C.F.R
      Part 404, Subpart P, Appendix 1.
    • Pupo had the RFC to perform medium work except that she
      was limited to work that requires her to remember and im-
      plement simple instructions, have occasional contact with
      coworkers, and no contact with the general public. In mak-
      ing this determination, the ALJ noted that “the claimant’s
      statements concerning the intensity, persistence and
USCA11 Case: 19-14633       Date Filed: 11/03/2021    Page: 9 of 24

19-14633              Opinion of the Court                        9

      limiting effects of [her] symptoms are not entirely consistent
      with the medical evidence and other evidence in the rec-
      ord.”
   • At Step Four, Pupo had no past relevant work.
   • At Step Five, there were jobs that existed in significant num-
     bers in the national economy that Pupo could perform, con-
     sidering her age, education, work experience, and RFC.
   • Accordingly, the ALJ found that Pupo was “not disabled.”
       Notably, the ALJ did not identify Pupo’s stress urinary in-
continence as one of her severe impairments at Step Two and did
not address the effect of her stress urinary incontinence on her
physical abilities at Step Four. The ALJ’s Step Four finding that
Pupo had the RFC to perform “medium work” meant that she
could, among other things, lift up to fifty pounds at a time and
could frequently lift and carry up to twenty-five pounds. See 20
C.F.R. § 416.967(d). In making this RFC assessment, the ALJ “as-
sign[ed] minimal weight” to the opinion of Dr. Diaz, Pupo’s treat-
ing physician, in his RFC questionnaire. The ALJ explained that
objective medical evidence, including Dr. Diaz’s own “relatively
unremarkable” physical exams, did not support Dr. Diaz’s RFC
opinion.
       In October 2016, Pupo filed with the Appeals Council writ-
ten exceptions to the ALJ’s decision. She also submitted additional
evidence including her treatment records between May 2016 and
September 2016. The Appeals Council declined to assume
USCA11 Case: 19-14633           Date Filed: 11/03/2021         Page: 10 of 24

10                         Opinion of the Court                      19-14633

jurisdiction and found that the new evidence would not change the
outcome. Specifically, it stated “[w]e did not consider or exhibit
this evidence.” 1
      Pupo then filed a complaint in the district court requesting
review of the ALJ’s denial of benefits. The district court granted
the Commissioner’s motion for summary judgment, denied Pupo’s
motion for summary judgment, and affirmed the ALJ’s decision.
Pupo appealed to this court.
                       STANDARD OF REVIEW
       We review de novo the legal principles applied by the Com-
missioner in social security appeals. Moore v. Barnhart, 405 F.3d
1208, 1211 (11th Cir. 2005) (per curiam). However, we review the
resulting decision only to determine if it is supported by substantial

1 Ordinarily, a claimant appealing an ALJ’s decision files a request for review
with the Appeals Council. 20 C.F.R. §§ 416.1467, 416.1468. When, as here,
the claimant appeals an ALJ’s new decision after a district court remand, the
claimant instead files “written exceptions” to the ALJ’s new decision. 20
C.F.R. § 416.1484(a); see also SSA, Hearings, Appeals, and Litigation Law Man-
ual (HALLEX) I-4-8-5A (2020) (explaining that when there is a district court
remand, the claimant files written exceptions rather than a request for review).
         The Appeals Council “may assume jurisdiction” based on the claim-
ant’s written exceptions and applies the same “standard set forth in § 416.1470”
applicable to requests for review. 20 C.F.R. § 416.1484(a). The Appeals Coun-
cil also considers any additional evidence from the claimant “using the same
procedures as in request for review cases.” HALLEX I-4-8-25C. If the Appeals
Council declines to assume jurisdiction, it “issue[s] a notice to [the claimant]
addressing [the claimant’s exceptions] and explaining why no change in the
[ALJ’s] hearing decision is warranted,” and the ALJ’s new decision becomes
the final decision of the Commissioner. 20 C.F.R. § 416.1484(b)(2).
USCA11 Case: 19-14633           Date Filed: 11/03/2021        Page: 11 of 24

19-14633                  Opinion of the Court                              11

evidence. Id. “Substantial evidence is less than a preponderance”
and “such relevant evidence as a reasonable person would accept
as adequate to support a conclusion.” Id. The individual seeking
social security disability benefits bears the burden of proving that
she is disabled. Id. We will not decide the facts anew, make credi-
bility determinations, or re-weigh the evidence. Id.
                               DISCUSSION
      I. Whether the ALJ Erred by Failing to Consider Using the
Older Age Category in Assessing Pupo’s Ability to Adapt to Other
Work.
        Pupo’s first issue on appeal involves Step Five of the ALJ’s
analysis. After there has been a finding at Step Four that the claim-
ant cannot return to her past relevant work, 2 the burden shifts to
the agency to show that a significant number of jobs exist in the
national economy that the claimant could perform. Winschel v.
Comm’r of Soc. Sec., 631 F.3d 1176, 1180 (11th Cir. 2011). There
are two paths that the ALJ may take to make this determination.
First, the ALJ can turn to the Medical-Vocational Guidelines, re-
ferred to as the grids, which will direct a finding of “disabled” or
“not disabled.” See 20 C.F.R. Pt. 404, Subpt. P, App. 2. Second, if

2 In thiscase, the ALJ found at Step Four that Pupo had no past relevant work,
which means, in effect, she cannot return to any past relevant work. See 20
C.F.R. § 416.960(b) (defining “past relevant work” as work the claimant had
“done within the past 15 years, that was substantial gainful activity, and that
lasted long enough for [the claimant] to learn to do it”).
USCA11 Case: 19-14633        Date Filed: 11/03/2021     Page: 12 of 24

12                      Opinion of the Court                 19-14633

the grids do not apply because a claimant does not meet all the cri-
teria, then the grids should be used as a framework along with in-
dependent evidence. Id. § 200.00(d).
        The grids are comprised of a series of tables, referred to as
rules, with each table corresponding to a different RFC (sedentary,
light, medium). The regulations provide that “[w]here the findings
of fact made with respect to a particular individual’s vocational fac-
tors and residual functional capacity coincide with all of the criteria
of a particular rule, the rule directs a conclusion as to whether the
individual is or is not disabled.” Id. § 200.00(a). The vocational
factors considered include the claimant’s age, education, and work
experience. Under the regulations, “age” means a claimant’s
“chronological age.” 20 C.F.R. § 416.963(a). A person aged 50 to
54 is classified as “closely approaching advanced age,” and a person
aged 55 or older is classified as “advanced age.” Id. § 416.963(d)–
(e).
       In a sense, the grids function like an equation, where the ALJ
inputs the various factors, and an outcome is generated. See Gib-
son v. Heckler, 762 F.2d 1516, 1520 (11th Cir. 1985) (per curiam)
(describing the grids as “a series of matrices which correlate a set of
variables” to render a finding of disabled or not disabled). While
this method is clean and efficient, every claimant is unique and
sometimes the criteria in the grids do not accurately reflect the true
capabilities of a particular claimant. See id. To ensure that the ALJ
does not rely too heavily on the grids, we have proscribed the me-
chanical application of the grids based on the claimant’s age in
USCA11 Case: 19-14633       Date Filed: 11/03/2021    Page: 13 of 24

19-14633               Opinion of the Court                       13

determining whether the claimant can adapt to other work.
Walker v. Bowen, 826 F.2d 996, 1002 (11th Cir. 1987) (per curiam).
While the ALJ may use the claimant’s age in applying the grids, it
will not be conclusive. Reeves v. Heckler, 734 F.2d 519, 525 (11th
Cir. 1984) (per curiam). Before the ALJ relies on the age factor of
the grids in making his determination, the claimant should first be
allowed to proffer “substantial credible evidence that his ability to
adapt is less than the level established under the grids for persons
his age.” Id.
        Relevant to this case, the grids “may not be used when the
claimant’s non-exertional impairments are severe enough to pre-
clude a wide range of employment at the level indicated by the ex-
ertional impairments.” Walker, 826 F.2d at 1003 (emphasis omit-
ted). Examples of non-exertional impairments are nervousness or
anxiety, difficulty concentrating, or difficulty remembering de-
tailed instructions. 20 C.F.R. § 416.969a(c). The grids may still be
used as a framework in this situation, but the ALJ will need to pro-
vide independent evidence, preferably through VE testimony, to
assess the impact these limitations have on the claimant’s ability to
adapt to other work in the national economy. Wilson v. Barnhart,
284 F.3d 1219, 1227 (11th Cir. 2002) (per curiam). For the VE’s tes-
timony to meet the substantial evidence standard, “the ALJ must
pose a hypothetical question which comprises all of the claimant’s
impairments.” Id.
      Pupo argues that the ALJ erred at Step Five because he did
not consider whether the older age category should apply to Pupo.
USCA11 Case: 19-14633         Date Filed: 11/03/2021   Page: 14 of 24

14                        Opinion of the Court             19-14633

The Commissioner responds that the ALJ did not err for two rea-
sons: (1) Pupo did not offer any evidence that the older age cate-
gory should apply and (2) the ALJ did not mechanically apply the
age categories because he relied on VE testimony and only used
the grids as a framework. On the day the ALJ issued his decision,
Pupo was 66 days shy of her 55th birthday, which would have
placed her in the “advanced age” category. Thus, Pupo contends
that this case involves a borderline age situation.
       We have yet to address the borderline age situation in a pub-
lished opinion. The relevant regulation provides that the Commis-
sioner:
      will not apply the age categories mechanically in a
      borderline situation. If [the claimant is] within a few
      days to a few months of reaching an older age cate-
      gory, and using the older age category would result
      in a determination or decision that [the claimant is]
      disabled, [the Commissioner] will consider whether
      to use the older age category after evaluating the
      overall impact of all the factors of [the claimant’s]
      case.
20 C.F.R. § 416.963(b).
      At the outset, we reject the Commissioner’s argument that
Pupo was required to offer additional evidence that the older age
category should apply in a borderline age situation. The Commis-
sioner cites to our rule in Reeves in support of its argument.
USCA11 Case: 19-14633        Date Filed: 11/03/2021     Page: 15 of 24

19-14633                Opinion of the Court                        15

However, Reeves is distinguishable because it did not concern a
borderline age situation. There, the claimant was 37 and the next
higher age category began at 50. Reeves, 734 F.2d at 525. Further-
more, we held there that the burden is on the claimant to show
that the grids should not be applied mechanically based on the
claimant’s age. Id. In contrast, § 416.963(b) does not place the bur-
den on the claimant, but rather says the Commissioner “will con-
sider whether to use the older age category after evaluating the
overall impact of all the factors.” 20 C.F.R. § 416.963(b) (emphasis
added). Thus, not only are the facts in Reeves not directly on point
here but applying it in borderline age situations would be incon-
sistent with the language of the regulation.
       Nevertheless, we agree with the Commissioner that the ALJ
did not err in this case because he did not rely solely on the grids in
making his disability determination. The whole crux of the bor-
derline age regulation is that the Commissioner will not apply the
age categories, i.e., the grids, mechanically. We agree that the ALJ
could not have erred in failing to consider the borderline age situa-
tion because he did not apply the grids mechanically in this case,
but instead relied on VE testimony due to Pupo’s non-exertional
limitations.
       This is consistent with other circuits that have considered
the borderline age situation. For example, the Tenth Circuit in
Daniels interpreted the borderline age regulation to mean that the
Commissioner may not apply the age categories mechanically “in
relying on the grids to determine whether a claimant is disabled.”
USCA11 Case: 19-14633       Date Filed: 11/03/2021     Page: 16 of 24

16                     Opinion of the Court                 19-14633

Daniels v. Apfel, 154 F.3d 1129, 1136 (10th Cir. 1998) (emphasis
added); see also Kane v. Heckler, 776 F.2d 1130, 1134 (3d Cir. 1985)
(“Where a procrustean application of the grids results in a case that,
but for the passage of a few days, would be decided differently, such
an application would appear to be inappropriate.”).
       In sum, we hold that the ALJ did not mechanically apply the
age categories here because he did not rely on the grids, but instead
used the grids as a framework along with independent evidence
from VE testimony. This is consistent with the regulations and our
precedent for the proper analysis at Step Five. Accordingly, the ALJ
did not err by not addressing the borderline age situation and sub-
stantial evidence supports the ALJ’s decision in this regard.
       II. Whether the Additional Evidence Submitted to the Ap-
peals Council Was “New and Material” and Warrants Remand for
Further Consideration by the ALJ.
       Turning to the second issue on appeal, Pupo argues that the
Appeals Council erred in not considering additional medical rec-
ords she submitted after the ALJ issued his decision. Generally,
claimants are permitted to present new evidence at each stage of
their administrative process, including before the Appeals Council.
Ingram v. Comm’r of Soc. Sec. Admin., 496 F.3d 1253, 1261 (11th
Cir. 2007). The Appeals Council will review a case if it “receives
additional evidence that is new, material, and relates to the period
on or before the date of the hearing decision, and there is a reason-
able probability that the additional evidence would change the
USCA11 Case: 19-14633           Date Filed: 11/03/2021       Page: 17 of 24

19-14633                  Opinion of the Court                             17

outcome of the decision.” 20 C.F.R. § 416.1470(a)(5). 3 We review
de novo the Appeals Council’s refusal to consider new evidence.
Washington, 806 F.3d at 1320–21. “[W]hen the Appeals Council
erroneously refuses to consider evidence, it commits legal error
and remand is appropriate.” Id. at 1321.
       Here, the Appeals Council erred in refusing to consider
Pupo’s new, material, and chronologically relevant evidence.
Pupo submitted medical records showing that she had surgery be-
cause of her stress urinary incontinence nine days before the ALJ
issued his decision. This new evidence showed that her stress in-
continence was in fact severe and serious enough to require sur-
gery. At the time of the ALJ’s decision, the medical evidence in the
record indicated that, after more conservative medication treat-
ment for her stress incontinence had failed, Pupo’s urologist and

3 In 2016, 20 C.F.R. § 416.1470(a)(5) was amended, effective January 17, 2017,
but with compliance not required until May 1, 2017. See 81 Fed. Reg. 90987,
90996 (Dec. 16, 2016). In other words, the new regulation went into effect
after Pupo submitted her new evidence to the Appeals Council but before the
Appeals Council issued its decision refusing to consider it. The new version
of § 416.1470(a)(5) added the requirement that the new evidence show a rea-
sonable probability of a different outcome before the Appeals Council will re-
view the new evidence. Prior to this change, our precedent interpreted the
term “material” in § 416.1470(a)(5) to require the new evidence to show a rea-
sonable possibility of a different outcome. See Washington v. Soc. Sec. Ad-
min, Comm’r., 806 F.3d 1317, 1321 (11th Cir. 2015) (per curiam). Because the
parties do not dispute that the new version of § 416.1470(a)(5) applies to
Pupo’s new evidence, we assume, without deciding, that it does.
USCA11 Case: 19-14633      Date Filed: 11/03/2021     Page: 18 of 24

18                     Opinion of the Court               19-14633

gynecologists began discussing with her a possible surgical treat-
ment. However, no surgery had ever been performed.
        These new medical records showing Pupo in fact had sur-
gery for her stress incontinence constitute new and material evi-
dence that had a reasonable probability of changing the outcome
of the decision. This is particularly true when considered with the
ALJ’s findings at Step Four that Pupo had never been hospitalized
for any of her physical impairments and that her doctors’ physical
treatment notes had been “consistently unremarkable.” Both of
these findings now appear to be inaccurate with respect to her
stress incontinence when these new records are considered.
       These now-evident factual errors are compounded by the
fact that, at Step Four, the ALJ did not adequately consider the ef-
fects of Pupo’s stress incontinence on her ability to perform me-
dium work, especially the lifting requirements, as discussed below.
Considering this new objective medical evidence bearing on the
severity of her stress incontinence, a factfinder could reasonably
conclude that Pupo could not have lifted up to fifty pounds at a
time or frequently lifted and carried objects weighing up to twenty-
five pounds during the relevant time period. Moreover, the ALJ’s
hypothetical question to the vocational expert asked only about
medium work with no lifting restrictions. Given the foregoing, the
Appeals Council erred in concluding that this new evidence failed
to show a reasonable probability of a different outcome. See 20
C.F.R. § 416.1470(a)(5). Because the Appeals Council failed to
properly consider this new evidence submitted by Pupo, we
USCA11 Case: 19-14633       Date Filed: 11/03/2021    Page: 19 of 24

19-14633               Opinion of the Court                       19

remand for consideration of Pupo’s disability eligibility based on
the total record.
      III. Whether Substantial Evidence Supports the ALJ’s As-
sessment of Pupo’s Residual Functional Capacity (RFC).
        Pupo’s third issue concerns Step Four of the sequential anal-
ysis, where the ALJ must determine a claimant’s RFC by consider-
ing all relevant medical and other evidence. 20 C.F.R. § 416.920(e).
The RFC is an assessment of a claimant’s ability to do work despite
her impairments. Id. § 416.945(a). The ALJ makes this determina-
tion by considering the claimant’s ability to lift and carry weight,
sit, stand, push, pull, walk, etc., as well as the claimant’s mental
abilities. Id. § 416.945(b)–(c). The claimant’s RFC is then used to
determine her capability of performing various designated levels of
work (sedentary, light, medium, heavy, or very heavy). See id.
§ 416.967. As noted earlier, a person with the RFC to perform me-
dium work can lift “no more than 50 pounds at a time with fre-
quent lifting or carrying of objects weighing up to 25 pounds,” and
can also perform any sedentary or light work. Id. § 416.967(c). The
SSA has provided that:
      In assessing RFC, the [ALJ] must consider limitations
      and restrictions imposed by all of an individual’s im-
      pairments, even those that are not “severe.” While a
      “not severe” impairment(s) standing alone may not
      significantly limit an individual’s ability to do basic
      work activities, it may—when considered with
USCA11 Case: 19-14633       Date Filed: 11/03/2021     Page: 20 of 24

20                     Opinion of the Court                 19-14633

       limitations or restrictions due to other impairments—
       be critical to the outcome of a claim.
Social Security Regulation (SSR) 96-8p, 61 Fed. Reg. 34474, 34477
(July 2, 1996); see also Schink v. Comm’r of Soc. Sec., 935 F.3d 1245,
1268 (11th Cir. 2019) (per curiam) (“Consideration of all impair-
ments, severe and non-severe, is required when assessing a claim-
ant’s RFC.”).
       In Schink, we found that the ALJ’s decision was not sup-
ported by substantial evidence because the ALJ did not consider the
claimant’s mental impairments when evaluating the claimant’s
RFC, despite the ALJ stating he “considered all symptoms.”
Schink, 935 F.3d at 1269. Although the mental impairments were
non-severe, the ALJ was still required to consider them when as-
sessing the claimant’s RFC. Id. Since the ALJ provided no assess-
ment on the claimant’s mental impairments, we found the ALJ’s
overall assessment of the claimant’s RFC to be inadequate. Id. at
1270.
       Similarly, here, although the ALJ stated he “considered all
symptoms,” his decision demonstrates that he did not. The ALJ
did not consider Pupo’s stress urinary incontinence when he con-
ducted his RFC assessment. He noted that she had been treated for
incontinence in his decision but did not discuss how her inconti-
nence would impact her ability to perform work at the medium
level, especially how it would affect her ability to lift and carry
weight. This is particularly troubling given that the record shows
that Pupo saw numerous gynecologists and a urologist about her
USCA11 Case: 19-14633        Date Filed: 11/03/2021      Page: 21 of 24

19-14633                Opinion of the Court                         21

incontinence and uterine prolapse; she complained about inconti-
nence to multiple providers, noting that she had to wear five pads
a day; she was referred to have surgery in 2014 but was unable to
receive medical clearance; she complained of incontinence when
coughing or lifting weight; she had a positive cough test; and treat-
ment through medication had failed.
       Like the ALJ in Schink, the ALJ here was required to con-
sider all of Pupo’s impairments, severe or not, when evaluating her
RFC. The ALJ did this for Pupo’s other impairments, such as back
pain, obesity, and depression, but failed to mention any impact that
her incontinence might have had on her RFC during the relevant
time period.
        It is also worth noting that the ALJ did not rely on any opin-
ion evidence from a medical doctor regarding Pupo’s physical abil-
ities, such as sitting, standing, walking, lifting, and carrying, in de-
termining her RFC.
       To be sure, an ALJ’s RFC assessment is an administrative
finding based on all the relevant evidence, including both medical
and nonmedical evidence. See 20 C.F.R. § 416.945(a)(3); SSR 96-8p,
61 Fed. Reg. 34474, 34476–77. While medical opinion evidence as
to a claimant’s physical abilities and limitations is not required in
every case, it is particularly helpful in a complicated medical case
like Pupo’s, in which the claimant has many longstanding physical
and mental ailments. Moreover, the ALJ has a duty to “make every
reasonable effort to ensure that the file contains sufficient evidence
to assess RFC.” SSR 96-8p, 61 Fed. Reg. 34474, 34477; see also 20
USCA11 Case: 19-14633       Date Filed: 11/03/2021    Page: 22 of 24

22                     Opinion of the Court                19-14633

C.F.R. § 416.945(a)(3) (stating that the agency is “responsible for
developing [the claimant’s] complete medical history, including ar-
ranging for a consultative examination(s) if necessary, and making
every reasonable effort to help [the claimant] get medical reports
from [the claimant’s] medical sources”).
      Here, however, the record contains no opinion about
Pupo’s physical abilities and limitations from Pupo’s urologist or
any of her gynecologists who treated her incontinence or from a
consulting doctor who had either reviewed her medical records or
examined her. Further, the ALJ gave minimal weight to Dr. Diaz’s
opinion about Pupo’s physical abilities and limitations, leaving the
ALJ without any medical opinion on that issue at all.
        The absence of such medical opinion evidence is particularly
concerning here because the ALJ also failed to conduct a function-
by-function assessment of Pupo’s physical abilities and to explain
how the non-opinion evidence in the record—both medical and
nonmedical—supported his finding that Pupo could perform all the
physical requirements for medium work, including lifting as much
as fifty pounds at a time and frequently lifting up to twenty-five
pounds. See SSR 96-8p, 61 Fed. Reg. 34474, 34477–78 (requiring
the ALJ to perform a “function-by-function” RFC assessment to
avoid overlooking some of the claimant’s limitations or using the
incorrect exertional category and requiring the ALJ to include a
“narrative discussion describing how the evidence supports each
conclusion, citing specific medical facts (e.g., laboratory findings)
and nonmedical evidence (e.g., daily activities, observations)”).
USCA11 Case: 19-14633           Date Filed: 11/03/2021       Page: 23 of 24

19-14633                  Opinion of the Court                             23

Instead, the ALJ merely found, without explanation or citation to
supporting evidence, that “[t]he objective evidence does not sup-
port an RFC less than the medium exertional level.”
       Accordingly, given the combination of all these factors and
shortcomings, we conclude that substantial evidence does not sup-
port the ALJ’s finding that Pupo could perform medium work with
non-exertional limits because he did not adequately consider
Pupo’s incontinence in assessing her RFC.4
                             CONCLUSION
       We reverse the order of the district court affirming the deci-
sion of the Commissioner. We find that substantial evidence does
not support the Commissioner’s decision because the ALJ did not
consider Pupo’s incontinence when determining her RFC. Fur-
ther, the Appeals Council erred in not considering the new evi-
dence submitted by Pupo. Upon remand from the district court,
the ALJ must consider the effects of Pupo’s incontinence on her
RFC, including the new evidence submitted by Pupo on this con-
dition. In remanding this case, we offer no opinion as to whether
Pupo can ultimately establish that she is disabled within the mean-
ing of the Social Security Act. We have determined only that the

4 Pupo’s remaining issues on appeal challenge the ALJ’s decision to not give
controlling weight to her doctors’ opinions and finding that her mental im-
pairments did not meet a listed impairment. Because we remand on two of
her other issues, we offer no opinion as to whether the ALJ erred in these re-
gards. On remand from the district court, the ALJ is to reconsider Pupo’s
claim based on the entire record.
USCA11 Case: 19-14633     Date Filed: 11/03/2021   Page: 24 of 24

24                    Opinion of the Court              19-14633

ALJ and the Appeals Council did not adequately consider certain
issues and therefore the Commissioner’s decision is not supported
by substantial evidence.
      REVERSED and REMANDED.