Shawn R. v. Frank Bisignano, Commissioner of Social Security

• Court: District Court, M.D. North Carolina
• Decided: March 4, 2026
• Docket: 1:25-cv-00118
• Status: Unknown

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF NORTH CAROLINA

SHAWN R., ) ) Plaintiff, ) v. ) 1:25CV118 ) FRANK BISIGNANO, ) Commissioner of Social Security, ) ) Defendant. )

ORDER AND MEMORANDUM OPINION OF UNITED STATES MAGISTRATE JUDGE

The plaintiff, Shawn R. (“Shawn”), has sought review of a final decision of Shawn filed an application for the Commissioner of Social Security supplemental security income denying his claim for supplemental alleging a disability onset date of security income.1 The Court has September 7, 2021.2 (Tr. 202-08.) considered the certified The application was denied initially administrative record and dispositive and upon reconsideration. (Tr. 114- briefs from each party. Because the 19, 122-28.) After a hearing, the ALJ Administrative Law Judge’s (“ALJ”) determined on August 9, 2024 that decision does not allow for Shawn was not disabled under the meaningful judicial review, the Court Act. (Tr. 18-32.) The Appeals Council grants Shawn’s request for remand, as denied a request for review, making set forth below. the ALJ’s decision the final decision for review. (Tr. 1-6.) I. PROCEDURAL HISTORY

1 Transcript citations refer to the Civil Procedure 25(d), Frank Bisignano is Administrative Transcript of Record filed automatically substituted as the manually with the Commissioner’s defendant in this suit. Answer. See Docket Entry 5. By Order of Reference, this matter was referred to the 2 Shawn also filed an application for Undersigned to conduct all proceedings disability insurance benefits, but that in this case pursuant to 28 U.S.C. § claim was dismissed because he did not 636(c). See Docket Entry 8. Frank satisfy the insurance coverage Bisignano became the Commissioner of requirements. (Tr. 18, 32, 202-08.) the Social Security Administration on Shawn does not challenge this dismissal. May 7, 2025. Pursuant to Federal Rule of II. STANDARD OF REVIEW “The Commissioner uses a five-step process to evaluate disability claims.” While Section 405(g) of Title 42 of the Hancock v. Astrue, 667 F.3d 470, United States Code “authorizes 472-73 (4th Cir. 2012) (citing 20 judicial review of the Social Security C.F.R. §§ 416.920(a)(4), Commissioner’s denial of social 404.1520(a)(4)). security benefits,” see Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. Under this process, the 2006), the scope of that review is Commissioner asks, in specific and narrow, see Smith v. sequence, whether the Schweiker, 795 F.2d 343, 345 (4th claimant: (1) worked during the Cir. 1986). Specifically, review is alleged period of disability; (2) limited to determining if there is had a severe impairment; (3) substantial evidence in the record to had an impairment that met or support the Commissioner’s decision. equaled the requirements of a 42 U.S.C. § 405(g); Hunter v. listed impairment; (4) could Sullivan, 993 F.2d 31, 34 (4th Cir. return to her [or his] past 1992); Hays v. Sullivan, 907 F.2d relevant work; and (5) if not, 1453, 1456 (4th Cir. 1990). In could perform any other work reviewing for substantial evidence, in the national economy. the Court does not re-weigh conflicting evidence, make credibility Id. at 472. A finding adverse to the determinations, or substitute its claimant at any of several points in judgment for that of the this five-step sequence forecloses a Commissioner. Craig v. Chater, 76 disability designation and ends the F.3d 585, 589 (4th Cir. 1996). Put inquiry. Id. at 473. “Through the simply: the issue before the Court is fourth step, the burden of production not whether Shawn is disabled but and proof is on the claimant. If the whether the finding that he is not claimant reaches step five, the burden disabled is supported by substantial shifts to the Secretary to produce evidence and based upon a correct evidence that other jobs exist in the application of the relevant law. Id. national economy that the claimant can perform considering his age, III. THE ALJ’S DECISION education, and work experience.” Hunter, 993 F.2d at 35 (internal The ALJ followed the correct process, citations omitted). set forth in 20 C.F.R. § 416.920, to determine disability. See Albright v. The ALJ determined at step one that Comm’r of Soc. Sec. Admin., 174 F.3d Shawn had not engaged in substantial 473, 475 n.2 (4th Cir. 1999). gainful activity since the alleged onset date of September 7, 2021. (Tr. 20.) 2 The ALJ next found the following in the work setting, further severe impairments at step two: defined to mean a maximum “status-post motor vehicle accident noise setting of 3, which is with intestinal injury/hernia, partial moderate according to the bowel resection and irritable bowel Selected Characteristics of syndrome (IBS); migraines; status- Occupations (SCO). He is post sinus surgery with allergies; generally able to understand chronic obstructive pulmonary simple instructions and disease (COPD); hypertension; perform simple tasks; he can degenerative disc disease; depressive maintain concentration, disorder; post-traumatic stress persistence, and pace to stay on disorder (PTSD); substance use task for 2-hour periods over disorder.” (Tr. 21.) At step three, the [the] course of [a] typical 8- ALJ found that Shawn did not have an hour workday with normal impairment or combination of breaks in order to perform such impairments listed in, or medically tasks; in a low stress work equal to one listed in, Appendix 1. (Tr. setting, which is further 21.) defined, in addition to the type of work being performed, to The ALJ next set forth Shawn’s mean no production-pace or Residual Functional Capacity (“RFC”) quota-based work; rather, he and determined that he could perform requires a goal-oriented job light work with the following primarily dealing with things additional limitations: instead of people, with no more than occasional changes in the occasional climbing ladders, work setting, and no more than ropes or scaffolds and stooping occasional social interaction but frequent climbing ramps with supervisors, co-workers and stairs, balancing, kneeling, and/or the public as part of the crouching, and crawling. Avoid job. concentrated exposure to humidity and temperature (Tr. 25-26.) extremes of cold and heat. Avoid concentrated exposure to At the fourth step, the ALJ pulmonary irritants, such as determined that Shawn was unable to fumes, odors, dust, gases, poor perform his past relevant work. (Tr. ventilation and the like, and 30.) Last, at step five, the ALJ workplace hazards, such as concluded that there were other jobs dangerous moving machinery in the national economy that Shawn and unprotected heights. Avoid could perform. (Tr. 30.) concentrated exposure to noise IV. DISCUSSION 3 impairments).” Hall v. Harris, 658 In pertinent part, Shawn contends F.2d 260, 265 (4th Cir. 1981). that “[t]he ALJ failed to adequately account for the vocationally limiting “Social Security Ruling 96-8p effects of [his] chronic migraine explains that the RFC ‘assessment headaches in the RFC.” See Docket must include a narrative discussion Entry 10 at 5. Shawn further contends describing how the evidence supports that “[t]he ALJ erred by failing to each conclusion, citing specific evaluate [his] need for frequent medical facts (e.g., laboratory bathroom usage when assessing the findings) and nonmedical evidence RFC.” Id. at 15. As explained in (e.g., daily activities, observations).’” greater detail below, the Court agrees Monroe v. Colvin, 826 F.3d 176, 189 on both grounds and remands for (4th Cir. 2016) (internal quotations further administrative proceedings. omitted). An ALJ need not discuss every piece of evidence in making an A. Standard for the RFC RFC determination. See Reid v. Determination. Comm. of Soc. Sec., 769 F.3d 861, 865 (4th Cir. 2014). Yet, the ALJ “must The RFC measures the most a build an accurate and logical bridge claimant can do in a work setting from the evidence to [the] despite the physical and mental conclusion.” Brown v. Commissioner, limitations of his or her impairments 873 F.3d 251, 269 (4th Cir. 2017). and any related symptoms (e.g., pain). “The RFC assessment must first See 20 C.F.R. § 416.945; see also identify the individual’s functional Dunn v. Colvin, 607 Fed. App’x 264, limitations or restrictions and assess 272 (4th Cir. 2015) (claimant’s RFC is his or her work-related abilities on a “[a] medical assessment of what an function-by-function basis . . . . Only individual can do in a work setting in [then] may RFC be expressed in terms spite of the functional limitations and of the exertional levels of work, environmental restrictions imposed sedentary, light, medium, heavy, and by all of his or her medically very heavy.” SSR 96-8p, 1996 WL determinable impairment(s)”) 374184, at *1. (internal citation omitted); Hines v. Barnhart, 453 F.3d 559, 562 (4th Cir. The Fourth Circuit has held that 2006). The RFC includes both a “meaningful review is frustrated when “physical exertional or strength an ALJ goes straight from listing the limitation” that assesses the evidence to stating a conclusion.” claimant’s “ability to do sedentary, Thomas v. Berryhill, 916 F.3d 307, light, medium, heavy, or very heavy 311 (4th Cir. 2019) (explaining that “a work,” as well as “nonexertional proper RFC analysis has three limitations (mental, sensory or skin components: (1) evidence, (2) logical 4 explanation, and (3) conclusion”). As at 595-96. In so doing, the ALJ need noted earlier, the ALJ “must both not credit them if they conflict with identify evidence that supports his the objective medical evidence or if conclusion and ‘build an accurate and the underlying impairment could not logical bridge from [that] evidence to reasonably be expected to cause the his conclusion.’” Woods v. Berryhill, symptoms alleged. Id. Where the ALJ 888 F.3d 686, 694 (4th Cir. 2018) has considered the relevant factors, (alteration in original) (quoting see 20 C.F.R. § 416.929(c)(3), and Monroe, 826 F.3d at 189). An ALJ’s heard the claimant’s testimony and failure to do so constitutes reversible observed his or her demeanor, the error. See Lewis v. Berryhill, 858 F.3d Court will defer to the ALJ’s 858, 868 (4th Cir. 2017). Where an determination regarding those ALJ’s “analysis is incomplete and subjective complaints. Shively v. precludes meaningful review,” Heckler, 739 F.2d 987, 989 (4th Cir. remand is appropriate. Monroe, 826 1984). F.3d at 191. Those relevant factors include: Moreover, “[a]n ALJ assesses the credibility of a claimant’s subjective (i) [Plaintiff’s] daily statements about his condition as part activities; of the RFC assessment,” Ladda v. Berryhill, 749 F. App’x 166, 170 (4th (ii) The location, duration, Cir. 2018) (unpublished), using a two- frequency, and intensity part test: “First, there must be of [Plaintiff’s] pain or objective medical evidence showing other symptoms; ‘the existence of a medical impairment(s) which results from (iii) Precipitating and anatomical, physiological, or aggravating factors; psychological abnormalities and which could reasonably be expected to (iv) The type, dosage, produce the pain or other symptoms effectiveness, and side alleged,’” Craig, 76 F.3d at 594 (citing effects of any medication 20 C.F.R. §§ 416.929(b), [Plaintiff] take[s] or 404.1529(b)). [has] taken to alleviate his pain or other If such an impairment exists, the ALJ symptoms; must then consider, as the second prong of the test, all available (v) Treatment, other than evidence, including the claimant’s medication, [Plaintiff] statements about pain, to determine receive[s] or [has] whether the claimant is disabled. Id. received for relief of his 5 pain or other symptoms; source. Id. at *5. The ruling also notes that “the extent to which the person’s (vi) Any measures [Plaintiff] impairment-related symptoms are use[s] or [has] used to consistent with the evidence of relieve his pain or other record” will be considered and that symptoms (e.g., lying flat “[c]onsistency and supportability on [her] back, standing between reported symptoms and for 15 to 20 minutes objective medical evidence is key in every hour, sleeping on a assessing the RFC.” Id. at *8. board, etc.); and B. The ALJ’s Assessment Omitted (vii) Other factors concerning Certain Support for its RFC [Plaintiff’s] functional Finding. limitations and restrictions due to pain Shawn contends that “[t]he ALJ failed or other symptoms. to adequately account for the vocationally limiting effects of [his] Last, SSR 19-4p also provides chronic migraine headaches in the guidance on how to evaluate primary RFC.” See Docket Entry 10 at 5. As headache disorders, such as explained in greater detail below, this migraines, in disability claims. See objection is persuasive. SSR 19-4p, 2019 WL 4169635 at *2. The ruling notes that regulations Here, at step two, the ALJ found require medically determinable without elaboration that Shawn’s impairments be established by migraines were a severe impairment. objective medical evidence from an (Tr. 20.) At step three, the ALJ acceptable medical source; “a referenced Listing 11.02 (regarding person’s statement of symptoms, a epilepsy), Listing 11.00 (regarding diagnosis, or a medical opinion” will various forms of seizures), and SSR not be used to establish the existence 19-4p (regarding headaches) and of a medically determinable concluded without elaboration that impairment; and a finding of Shawn had not met or equaled a disability will not be made “based on listing. (Tr. 23.) As part of his step a person’s statement of symptoms three analysis, in pertinent part, the alone.” Id. The ruling indicates that a ALJ noted that “in February 2023, primary headache disorder is when he was evaluated for headaches, established as a medically no cognitive issues were determinable impairment “by demonstrated, and his memory was considering objective medical intact.” (Tr. 24, 233-40, 819-52, 1511- evidence (signs, laboratory findings, 15.) or both)” from an acceptable medical Next, the ALJ determined Shawn’s 6 RFC. The ALJ noted that Shawn period of time, currently impacts testified he stopped working after his quality of life. There are some features car accident in 2021 and that of cluster like episodes as well. thereafter he experienced migraines Normal elemental neurological several times a week with both light examination. Having at least and noise sensitivity. (Tr. 26.) The headache 15+ per month.”).) The ALJ ALJ acknowledged that Shawn next noted that during a January testified that his migraines could last 2024 consultative examination he from between two to three hours to an complained of weekly migraine entire day. (Tr. 26.) The ALJ then headaches though he did not appear observed that on November 4, 2022, to be in acute distress. (Tr. 28, 1518, Shawn complained of migraines that 1520.) occurred one to two times a week and did not respond to Excedrin. (Tr. 27 The ALJ then turned to evaluating the referencing Tr. 765 (“Bothering him medical opinions of record and made most right now are migraines. He one reference to often wakes up with bad ones, lately 1- headaches/migraines. Specifically, 2 times weekly. Takes excedrin [sic] the ALJ noted that on reconsideration without much improvement. Gets a non-examining state agency medical N/V, avoids light, sound, then consultant (Dr. Joan Redd) found eventually resolves.”).) The ALJ noted Shawn capable of light work with that, despite his complaints, Shawn postural and environmental did not appear to be in acute distress. restrictions. (Tr. 29, 92-95.) The ALJ (Tr. 27, 765.) concluded that this opinion was “generally persuasive” and noted in The ALJ further noted that in pertinent part that the need for February of 2023 Shawn was postural and environmental evaluated for headaches and stated restrictions was consistent with, that they occurred at least fifteen among other impairments, migraines. times a month. (Tr. 27 (“The same (Tr. 29, 92-95.) The ALJ’s RFC month, he was evaluated for limited Shawn’s exposure to noise but headaches. He said they occurred at did not include off task, absentee, or least 15 times per month.”) (internal light sensitive limitations. (Tr. 25-26.) citation omitted) referencing Tr. 826 (“presents for evaluation of headaches C. The ALJ’s Assessment of Shawn’s that meet . . . [the] criteria for Migraines and Headaches Does Migraine, present since, but Not Allow for Meaningful Review. significantly worse in both severity and frequency since a car accident The Court cannot conduct a with significant trauma including loss meaningful review of the ALJ’s of consciousness for undisclosed decision based on the analysis in the 7 record. into the RFC determination. Specifically, Dr. Redd indicated that First, the ALJ acknowledges Shawn’s Shawn should avoid concentrated testimony that he is sensitive to light exposure to extreme heat, cold, and noise, but then—without humidity, noise, fumes (odors, dusts, adequate explanation—only includes gases, and poor ventilation), and a noise limitation in the RFC. (Tr. 26, hazards (machinery and heights). (Tr. 49 (“My migraines, I get several times 93-94.) However, she explained after a week now. And they’re very extreme, this that Shawn should also avoid too, to where very sensitive to light concentrated exposure to and sound. I have to put myself in the “intense/flashing lights.” (Tr. 93.) bedroom and cut off all the lights and don’t let nobody in because it hurts so While the ALJ’s RFC determination bad, just the sound and light and it includes the other limitations set makes me sick.”).) forth above, it omits any limitation regarding light. (Tr. 26.) Given This disconnect alone would require Shawn’s testimony regarding light remand for additional administrative sensitivity, it is unclear from the proceedings. See Myers v. Saul, No. record whether this was an 1:20CV420, Docket Entry 16 at 8 intentional or accidental omission. (M.D.N.C. July 2, Regardless, it prevents substantial 2021), recommendation adopted, slip evidence review. See Harvey J. L. v. op. (M.D.N.C. July 20, 2021) (remand O’Malley, No. 1:23CV162, 2024 WL warranted for further findings related 6968939, at *5 (M.D.N.C. Jan. 23, to light sensitivity); Southard v. Saul, 2024) (remand warranted where ALJ No. CIV-19-307-STE, 2019 WL omitted restrictions in medical 7285554, at *4 (W.D. Okla. Dec. 27, opinions otherwise credited); Green 2019) (finding reversible error where v. Saul, No. 1:19CV1175, 2020 WL the ALJ failed to accommodate or 5633287, at *4 (M.D.N.C. Sept. 21, properly discount claimant’s well- 2020) (same), recommendation supported allegations of adopted by Slip Op. (Oct. 8, 2020); photophobia). Martin v. Berryhill, No. 1:16CV171, 2017 WL 728234, at *5 (M.D.N.C. Second, the ALJ further explained Feb. 23, 2017) (same) that he found the medical opinion of recommendation adopted by Slip Op. the non-examining state agency (March 24, 2017). physician (Dr. Joan Redd) who evaluated the record on Third, and most importantly, the ALJ reconsideration to be “generally made no findings about the frequency persuasive” (Tr. 29), and yet did not and severity of Shawn’s headache- incorporate one of its key findings related symptoms, which are critical 8 to the overall disability analysis has three components: (1) determination. See, e.g., Woody v. evidence, (2) logical explanation, and Kijakazi, No. 22-1437, 2023 WL (3) conclusion”).3 A remand is 5745359, at *1 (4th Cir. Sept. 6, 2023) therefore in order. (ALJ’s failure to reach an express conclusion on the “potentially The Commissioner’s arguments to the dispositive issue of whether the contrary are unavailing. The frequency and severity” of claimant’s Commissioner spends much of his headaches affected the RFC finding brief setting forth reasons for “is an error of law that necessitates affirming the ALJ’s decision that the remand”); see also generally Young v. ALJ never specifically set forth. Barnhart, 362 F.3d 995, 1002 (7th (Docket Entry 11 at 8-13.) These are Cir. 2004) (remanding where “[t]he impermissible post hoc agency ALJ [did] not sufficiently connect[] justifications. See Anderson v. Colvin, the dots between [the plaintiff’s] No. 1:10CV671, 2014 WL 1224726, at impairments, supported by *1 (M.D.N.C. Mar. 25, 2014) substantial evidence in the record, (concluding that the Court may not and the RFC finding”). consider post-hoc rationalizations and may only consider reasons first These omissions preclude judicial set forth by the administrative review. Shawn was assessed for agency) (citing Securities & Exch. several severe impairments including Comm'n v. Chenery Corp., 332 U.S. migraines. (Tr. 21.) The ALJ’s 194 (1947)). By way of non-exhaustive decision does not adequately address example, the Commissioner contends Shawn’s migraines and instead that Shawn had little treatment for merely partially summarizes the migraines and points out that he did record and then renders a conclusion, not identify migraines when skipping the formation of a logical completing disability paperwork. bridge between the RFC (Docket Entry 11 at 8-9.) But the ALJ determination and the medical never made such findings in his record. See Thomas, 916 F.3d at 311 decision.4 (explaining that “a proper RFC Beyond this, Shawn testified at his

3 See Myers v. Saul, No. 1:20CV420, (same), recommendation adopted, slip Docket Entry 16 at 12 (M.D.N.C. July 2, op. (M.D.N.C. Aug. 23, 2019). 2021) (remand warranted where it was impossible to trace the logical path of the 4 Despite the Commissioner’s objections ALJ’s reasoning), recommendation to the contrary (Docket Entry 11 at 8-13), adopted, slip op. (M.D.N.C. July 20, the ALJ also fails to address evidence that 2021); Porterfield v. Berryhill, No. would be logically related to the analysis 1:18CV319, Docket Entry 18 at 7 of Shawn’s migraine headaches, such as (M.D.N.C. Aug. 6, 2019) certain treatment modalities (like 9 hearing that he gets migraines suggests that these [diagnostic] tests “several times a week now,” that they can confirm either the existence of are “very sensitive to light and sound,” migraines or their likely severity.”) that some last a “whole day” and (citation omitted) (brackets omitted); others last “only two or three hours,” Harrington v. Colvin, No. 7:15-cv-20- that he puts himself in his “bedroom FL, 2016 WL 320144, at *4 (Jan. 4, and cut[s] off all the lights . . . because 2016 E.D.N.C.) (ALJ reliance on the it hurts so bad,” and that he has “to unremarkable result of CT scan stay in bed.” (Tr. 49.) The vocational “merely suggests that the cause of her expert testified that an individual off headaches cannot be identified task more than 15% of the work day or through such testing, not that she absent two or more days a month does not suffer from headaches.”); would be unable to work. (Tr. 59.) The Strickland v. Barnhart, 107 F. App’x dispositive question of migraines was 685, 689 (7th Cir. 2004) thus before the ALJ. (unpublished) (“The ALJ . . . appears to have thought, incorrectly, that the The Commissioner also points to [normal] neurological test results instances of Shawn’s normal mental somehow undercut [plaintiff’s] claims status findings upon examination as that her migraines are severely support for the ALJ’s RFC painful.”). determination, some of which the ALJ noted and some of which he did not. As noted, the larger problem here is (Docket Entry 11 at 9.) However, the that the ALJ goes straight from listing absence of objective findings of an this evidence to setting forth Shawn’s intermittent impairment during a RFC, which accommodates some of given medical examination is not his alleged limitations (phonophobia) necessarily dispositive of the issue of but omits others (photophobia, migraine pain. See, e.g., Patricia M. v. absenteeism, time off task) making it Bisignano, No. 1:24CV691, 2025 WL impossible to trace the ALJ’s 2697242, at *10 (M.D.N.C. Sept. 22, reasoning. (Tr. 25-30.) 2025) (“findings of normal attention, concentration, orientation, and fund The Commissioner also points to of knowledge had little probative Shawn’s activities of daily living force to detract from Plaintiff’s (Docket Entry 11 at 10) but again fails reports of disabling headaches”); to acknowledge that the intermittent Taylor v. Astrue, No. 7:10-cv-149-FL, nature of migraine headaches would 2011 WL 2669290 *3 (E.D.N.C. Jul. 7, only periodically impact daily 2011) (“[N]othing in the record activities. See Patricia M., 2025 WL

injections of Emgality for migraines (Tr. limitation described above). 844-45, 944, 1519, 48)) and opinion evidence (like Dr. Redd’s photophobia 10 2697242, at *9 (“[T]he ALJ failed to when assessing the RFC.” (Docket acknowledge the possibility that Entry 10 at 15.) As with its assessment Plaintiff engaged in the activities cited of Shawn’s migraine-related by the ALJ on days when Plaintiff did limitations, the ALJ’s summation of not experience a severe migraine that the evidence related to Shawn’s IBS required her to lie down in a dark lacks a logical bridge to his RFC room[.]”) (collecting cases). determination omitting extra bathroom breaks or time off-task. Finally, the Commissioner also points to the medical opinion evidence. More specifically, in his decision, at (Docket Entry 11 at 9.) However, as step two and without elaboration, the explained, Dr. Redd’s opinion actually ALJ noted that Shawn’s IBS was a sets forth a migraine-related severe impairment. (Tr. 21 (“The limitation to account for Shawn’s claimant has the following severe alleged light sensitivity, which the impairments: status-post motor ALJ failed to address. For all of these vehicle accident with intestinal reasons, and consistent with the injury/hernia, partial bowel resection practice of other judges in this district and irritable bowel syndrome (IBS) . . in similar circumstances,5 a remand . .”).) for further administrative proceedings is proper. Next, at step three, the ALJ noted that Shawn’s “gastrointestinal diseases D. The ALJ’s Assessment of Shawn’s have been considered under listings Bathroom Usage Does Not Allow 5.06 and 5.08.” (Tr. 24.) In support, for Meaningful Review. the ALJ set forth the pertinent criteria for each listing and stated without Shawn further contends that “[t]he elaboration or reference to the record ALJ erred by failing to evaluate [his] that it had not been met. (Tr. 24.) need for frequent bathroom usage Next, the ALJ assessed Shawn’s RFC.

5 See, e.g., Patricia M., 2025 WL WL 307347 (M.D.N.C. Jan. 27, 2025); 2697242, at *8-12; Myers, No. 1:20-cv- Darlene A. v. Colvin, No. 1:23CV976, 00420, Docket Entry 16 at 4- 2024 WL 5262869, at *4-7 (M.D.N.C. 13, recommendation adopted, slip op. Dec. 31, 2024); Thomas H. v. O’Malley, (M.D.N.C. July 20, 2021); Porterfield, No. 1:22CV876, 2024 WL 1350070, at No. 1:18-cv-00319, Docket Entry 18 at 3- *4-5 (M.D.N.C. Mar. 29, 2024); Stephen 10, recommendation adopted, slip op. B. v. O’Malley, No. 1:22CV1026, 2024 (M.D.N.C. Aug. 23, 2019); Victor R. v. WL 945065, at *6 (M.D.N.C. Mar. 5, Colvin, No. 1:24CV205, 2025 WL 33699, 2024); Jennifer V.T. v. Kijakazi, No. at *4-9 (M.D.N.C. Jan. 6, 2025), 1:22CV417, 2023 WL 6388203, at *8 recommendation adopted sub nom. (M.D.N.C. Sept. 29, 2023). Rivera v. Colvin, No. 1:24-CV-205, 2025 11 In pertinent part, the ALJ that in February of 2024, Shawn summarized Shawn’s testimony as presented to the emergency room for follows: “[t]he claimant testified he abdominal pain over his hernia site stopped working after his accident in and also complained of diarrhea. (Tr. 2021. He had bowel resection and had 28, 1543-72, 1546 (“Patient with a hernia. He experiences pain in his history of abdominal hernia presents stomach and has IBS.” (Tr. 26.) The with progressively worsening ALJ then correctly observed that abdominal pain, nausea, vomiting Shawn was involved in a motor and bowel incontinence that has been vehicle accident on his alleged onset going on since Monday but has gotten date. (Tr. 27, 310.) An “exploratory worse today.”).) The ALJ pointed out laparotomy was performed [which] that Shawn’s partner reported a revealed ileal mesentery with active possible overdose in that his oozing; the bowel was deemed non- symptoms began after taking an viable[;] and 15cm of the ileum was excessive amount of medication and resected.” (Tr. 27, 312-13.) Shawn was drinking heavily. (Tr. 28, 1549-50.) subsequently seen with complaints of Shawn denied this and left the rectal bleeding and diarrhea and was emergency room against medical found to have a ventral hernia and advice. (Tr. 28-29, 1543, 1548.) internal hemorrhoids that would eventually require repair. (Tr. 27, 759, The ALJ then considered the medical 772-74.) opinions. In pertinent part, the ALJ noted that the light work The ALJ then noted that on recommended by the non-examining November 4, 2022, Shawn state agency consultant was complained of “diarrhea (improved consistent with his “abdominal pain.” with cholestyramine).” (Tr. 27, 764.) (Tr. 29, 80-82, 92-95.) However, the In February of 2023, the ALJ pointed ALJ’s RFC did not accommodate any out, Shawn’s provider noted a need for additional bathroom breaks “concern for fecal incontinence and or time off task. (Tr. 25-26.) passing bowel movements without realizing it” though on examination In sum, the ALJ summarized evidence Shawn had mild tenderness related to and concluded that the RFC his hernia but an otherwise normal accommodates Shawn’s IBS. exam. (Tr. 27, 832-33.) The ALJ next However, Fourth Circuit precedent is noted that Shawn complained of clear that meaningful review is diarrhea and abdominal pain at a frustrated where an ALJ goes straight January 2024 consultation, where he from listing evidence to stating a could not toe walk due to abdominal conclusion. See Woods v. Berryhill, pain. (Tr. 28, 1518-20.) 888 F.3d 686, 694 (4th Cir. 2018). The ALJ also accurately pointed out And beyond this, the Fourth Circuit 12 has pointed out that “[o]bviously, the the day goes on, but his “extreme need to visit the bathroom many diarrhea all through the day does not times throughout the day impacts subside. I mean it keeps me going to one’s ability to work.” Dowling v. the bathroom.” (Tr. 51.) The Comm’r of Soc. Sec. Admin., 986 F.3d vocational expert testified that if an 377, 389 (4th Cir. 2021) (“[T]he ALJ individual were off task 15% of the should evaluate the frequency at workday, including bathroom breaks which Appellant needed to use the beyond customary breaks, he could bathroom and analyze how that not hold a job. (Tr. 58-59.) The restriction impacted her ability to vocational expert also testified that if work.”), superseded by regulation on an individual required between five to other grounds recognized by six unscheduled bathroom breaks Drumgold v. Comm’r of Soc. Sec., 144 lasting more than approximately 10 F.4th 596, 604 (4th Cir. 2025). minutes each time, he would not be able to perform competitive Thus, while the ALJ here did not employment. (Tr. 61.) necessarily have to include accommodations for bathroom However, despite its materiality to the breaks in the RFC, he did have an outcome of the case, the ALJ did not obligation to explain (and support analyze whether Shawn needed with substantial evidence) his implicit additional bathroom breaks when finding that bathroom breaks beyond assessing the RFC. (Tr. 25-30.) Nor normal breaks in a workday were did he make an allowance for time off unnecessary. See SSR, 1996 WL task or explain why an allowance was 374185, at *6 (characterizing eight- unnecessary (Tr. 25-30), even though hour workday as having “a morning he found that Shawn’s intestinal break, a lunch period, and an damage with bowel resection, hernia, afternoon break at approximately 2- and IBS constituted severe hour intervals”). impairments at step two and discussed evidence (summarized This error is not harmless. Shawn above) related to that impairment in testified that his intestinal damage the decision (Tr. 21). The ALJ’s since his car accident (including medical summary contains an removal of parts of his intestines) insufficient logical bridge to the RFC “keeps me sick and hurting on a daily which does not account for these basis where I use the bathroom five, issues. (Tr. 27-30.) six times a day. I have to run back and forth. I stay sick. Nauseated.” (Tr. 43.) Remand for further administrative Sometimes it is more frequent. (Tr. proceedings is therefore warranted. 48.) He alleged waking up nauseous See, e.g., Sharee B. v. Bisignano, No. and vomiting, which might subside as 5:25-CV-00045, 2025 WL 4065846, 13 at *16 (S.D.W. Va. Dec. 17, 2025) why Shawn did not require additional (remanding where ALJ “provided breaks or time off task beyond normal absolutely zero analysis regarding the breaks to account for his bathroom effect on Claimant’s RFC of the usage. (Docket Entry 11 at 18-19.) In ongoing Crohn’s-related symptoms” support, he points to medical or “any analysis as to whether or not evidence the ALJ relied upon, the ‘ongoing symptoms of Crohn’s indicating that Shawn reported disease’ post-bowel resection would improvement with his bowel cause her to be off-task a significant medication. (Id. at 19, Tr. 764-65.) portion of the workday”); Joanne P. v. Nevertheless, even if the ALJ Dudek, No. 5:24-CV-00384, 2025 WL accurately found that Shawn’s IBS 1510664, at *18 (S.D. W.Va. Apr. 22, related symptoms improved, the ALJ 2025) (remand appropriate where did not find that they ceased entirely. ALJ determination lacked basis for no The lack of explanation makes it RFC limitations regarding bathroom impossible for the Court to determine breaks); Laura J v. O’Malley, No. whether the ALJ’s determination is 7:22-CV-00402, 2024 WL 1954157, at supported by substantial evidence. *5 (W.D. Va. Feb. 14, 2024) (same) See Sharee B., 2025 WL 4065846, at (citation omitted); Sharp v. Comm’r *16 (relying on similar reasoning). of Soc. Sec., No. 1:21-CV-00015-FDW, 2022 WL 949873, at *4 (W.D.N.C. The Commissioner also points to Mar. 29, 2022) (same). roughly seven hundred pages of record evidence and contends that it And the Commissioner’s objections as demonstrates that Shawn “did not to this issue are not persuasive. While require ongoing or extensive the Commissioner asserts that treatment for bowel complaints or Shawn’s objection is no more than a urinary frequency during the relevant “disagreement with the conclusions period.” (Docket Entry 11 at 19 the ALJ drew from the evidence, referencing 743-852, 868-1510, 1527- which is not a valid basis for remand,” 42.) But the ALJ never made such a (Docket Entry 11 at 18), this is not finding in his decision and post hoc what Shawn is contending. Rather, explanations like this by the Shawn contends (and the Court Commissioner are not permitted. See agrees) that the ALJ’s analysis here Anderson, 2014 WL 1224726, at *1. lacks a logical bridge between the RFC and the omission or exclusion of time The Commissioner also points out off task or extra breaks to use the that no medical opinion in the record bathroom. (Docket Entry 10 at 15.) indicates that Shawn required additional breaks or off task time to Next, the Commissioner contends use the bathroom. (Docket Entry 11 at that the ALJ adequately explained 19.) However, it was the ALJ who 14 concluded that Shawn’s IBS was a decision has no preclusive effect, as it severe impairment at step two and is vacated and the new hearing is who therefore had an obligation to conducted de novo).°® provide a logical bridge between his RFC determination and the evidence V. CONCLUSION related to Shawn’s IBS. That did not occur here. IT IS THEREFORE ORDERED that the Commissioner’s decision In the end, the point here as to both finding no disability be REVERSED Shawn’s migraines and IBS is not that and that the matter be REMANDED the record necessarily compels to the Commissioner under sentence accommodation for light sensitivity, four of 42 U.S.C. § 405(g). The time off task, absenteeism, or extra Commissioner should be directed to breaks in the RFC, but that the remand the matter to the ALJ for evidence here triggers the ALJ’s duty proceedings consistent with this to explain their omission. Because the Order. To the extent that Shawn seeks ALJ did not adequately do so, remand an immediate award of benefits, the is required. Finally, the undersigned request is DENIED. declines consideration of the additional issue(s) raised by Shawn at A Judgment remanding this action this time. Hancock v. Barnhart, 206 will be entered contemporaneously F. Supp. 2d 757, 763-64 n.3 (W.D. Va. with this Order. 2002) (on remand, the ALJ’s prior J aGi McFadden United States Magistrate Judge March 8, 2026

6 Shawn’s final objection is that “[t]he correctly points out, the ALJ never ALJ erred by failing to perform a addressed a restriction imposed by one of function-by-function evaluation of [his] his physicians limiting him to lifting no contested and relevant abilities to lift, more than ten pounds. (/d. at 11-12, Tr. carry, push and pull weight.” See Docket 476.) Nevertheless, in limiting Shawn to Entry 10 at 10. Because remand is proper light work, the ALJ concluded that he for other reasons discussed above, there could lift up to twenty pounds. 20 CFR § is no need to address that final objection. 416.967(b). The Commissioner may, if he Nevertheless, the Court will note that, at so chooses, evaluate this apparent least on its face, Shawn’s argument discrepancy further on remand. seems to carry some force. As Shawn 15