Unreported / Non-Citable
Background
Melissa Danielle Martinez filed applications for disability insurance benefits and supplemental security income in February and March 2021, alleging a disability onset date of March 28, 2019, due to degenerative disc disease of the cervical spine, migraines, right shoulder degenerative joint disease, and status post left knee arthroscopic surgery. After initial and reconsideration denials, an ALJ held hearings in February and August 2023, issuing an unfavorable decision on September 11, 2023. The Appeals Council denied review, and the district court ordered an agreed remand in October 2024. Following a new hearing in November 2025, the ALJ again found Martinez not disabled on December 19, 2025, and the Appeals Council denied review. Martinez filed the current complaint on February 25, 2026.
At step one, the ALJ found Martinez had not engaged in substantial gainful activity since the alleged onset date. At step two, the ALJ identified severe impairments of cervical degenerative disc disease, migraines, right shoulder degenerative joint disease, and left knee status post arthroscopic surgery. At step three, the ALJ concluded these impairments did not meet or equal a listed impairment. Prior to step four, the ALJ assessed an RFC for light work with limitations: frequent pushing and pulling with the right dominant upper extremity; occasional climbing of ramps and stairs but never ladders, ropes, or scaffolds; frequent kneeling, crouching, and crawling; occasional overhead reaching; and no exposure to extreme cold, unprotected heights, or dangerous moving machinery. At step four, the ALJ found Martinez could perform past relevant work as a salesclerk. At step five, relying on vocational expert testimony, the ALJ alternatively found she could perform other jobs existing in significant numbers, including cashier, fast food worker, and housekeeping cleaner.
The Court’s Holding
The court upheld the ALJ's evaluation of medical opinions from PA Wharton and Dr. Sanchez, who opined Martinez could not lift over 5-10 pounds, could not work overhead, and could not climb ladders or work at heights. The ALJ found these assessments did not qualify as medical opinions under 20 C.F.R. §§ 404.1513(a)(2) and 416.913(a)(2) because they detailed what Martinez could not do rather than what she could do. Even if considered opinions, the ALJ found them unsupported because the assessed limitations became more restrictive over time while observed capabilities remained steady or improved, citing improved right shoulder range of motion from 95 degrees abduction with pain to 170 degrees painless, and full flexion to 180 degrees. The ALJ also found the opinions inconsistent with the longitudinal record showing full bilateral upper extremity strength and a normal left arm capable of meeting modest exertional demands alone.
The court affirmed the ALJ's rejection of PA Everett's opinions, which included a 10-pound occasional lift/carry limit, unscheduled breaks, less than one hour each of sitting, standing, and walking, inability to hold head stationary, and more than four unexcused absences monthly. The ALJ found these opinions unsupported by objective medical evidence, relying instead on diagnoses and subjective symptom reporting, and inconsistent with the longitudinal record showing full upper extremity strength and range of motion documented by PA Everett herself in January 2024. The ALJ also discounted Dr. Everett's manipulative and reaching limitations as inconsistent with objective findings of full bilateral strength and nearly full right shoulder range of motion. Regarding subjective symptoms, the ALJ found Martinez's impairments could reasonably cause her alleged symptoms but her statements about intensity, persistence, and limiting effects were not entirely consistent with the medical evidence. The court found the ALJ provided clear and convincing reasons supported by substantial evidence, noting Martinez acknowledged significant pain relief after epidural injections (pain dropping to zero for months) and objective exams repeatedly showed full arm strength contrary to her testimony of extreme weakness.
Key Takeaways
- The ALJ properly applied the post-2017 medical opinion regulations by evaluating supportability and consistency without deferring to treating source opinions, and provided specific, evidence-based reasons for assigning little weight to treating provider assessments.
- Medical opinions that describe only limitations without assessing residual functional capacity may not qualify as 'medical opinions' under Social Security regulations, though they remain part of the longitudinal record.
- An ALJ may find medical opinions unsupported when assessed restrictions become more restrictive over time while objective clinical findings show stable or improved function.
- Subjective symptom testimony can be rejected with clear and convincing reasons when inconsistent with objective medical evidence showing significant treatment response (e.g., pain dropping to zero after injections) and normal strength findings contradicting alleged extreme limitations.
- The RFC need only accommodate limitations supported by substantial evidence; the ALJ's light work RFC with specific postural and environmental restrictions adequately accounted for Martinez's documented impairments.
Why It Matters
This decision illustrates the practical application of the 2017 revisions to 20 C.F.R. § 404.1520c, which eliminated the treating physician rule and require ALJs to evaluate all medical opinions based on supportability and consistency. The court's deference to the ALJ's comparative analysis of serial examination findings—showing improved range of motion despite increasingly restrictive provider assessments—demonstrates how objective clinical data can outweigh provider opinions under the new framework. The ruling also reinforces that subjective symptom credibility determinations require specific, clear, and convincing reasons tied to the record, and that temporary treatment side effects and fluctuating pain levels do not necessarily establish disabling limitations when the overall record shows functional capacity for light work.