RFC Excludes Appointment-Based Absenteeism: Only Impairment-Caused Functional Limits Belong in the Residual Functional Capacity

I. Introduction

In Afaf Malak v. Commissioner of Social Security (11th Cir. Mar. 18, 2025), the Eleventh Circuit addressed a recurring disability-litigation issue: whether an Administrative Law Judge (ALJ), when formulating a claimant’s Residual Functional Capacity (RFC), must include work-preclusive limitations based on the time a claimant would miss work to attend medical treatments (here, ketamine infusion therapy, epidural steroid injections, and medial branch blocks).

The claimant, Afaf Beshay Malak, sought Disability Insurance Benefits (DIB) for multiple physical conditions (including degenerative disc disease, fibromyalgia, chronic headaches, and rheumatoid arthritis). She argued the ALJ erred by failing to account for medically related absences and by failing to properly evaluate the type, dosage, and side effects of her treatments (including alleged drowsiness and asserted absenteeism).

The Eleventh Circuit affirmed the denial of benefits and, in a published opinion, announced a clear rule: medical appointments and appointment-driven absences are not appropriate factors in assessing RFC, which is limited to functional restrictions caused by medically determinable impairments and related symptoms.

II. Summary of the Opinion

The court affirmed on two principal grounds:

  1. Absenteeism: The ALJ did not err by excluding appointment-based absenteeism from the RFC. The court held that an RFC must be based on functional limitations caused by medically determinable impairments—not the logistical time demands of treatment attendance.
  2. Subjective complaints / treatment effects: The ALJ adequately considered Malak’s treatments and their effects. Substantial evidence supported the ALJ’s finding that Malak’s claimed intensity and limiting effects (including alleged medication drowsiness) were not fully consistent with the medical record, which reflected positive treatment responses and notes indicating no medication side effects.

III. Analysis

A. Precedents Cited

1. The sequential evaluation framework and “severity” gatekeeping

  • McDaniel v. Bowen, 800 F.2d 1026 (11th Cir. 1986): Cited for Step Two’s “threshold inquiry,” reinforcing that the disability analysis filters out only the most trivial impairments early, while the later RFC/Steps Four and Five address work capability in detail. This contextualizes that the RFC is the proper tool for translating impairments into functional terms—but only functional terms.

2. Standards of appellate review

  • Viverette v. Comm'r of Soc. Sec., 13 F.4th 1309 (11th Cir. 2021): Used to frame that, when the Appeals Council denies review, the ALJ decision is the Commissioner’s final decision and is reviewed for substantial evidence.
  • Raper v. Comm'r of Soc. Sec., 89 F.4th 1261 (11th Cir. 2024): Cited for de novo review of legal principles— important here because the absenteeism issue is primarily a legal boundary question: what belongs in the RFC as a matter of law.

3. Defining RFC as an administrative, impairment-based assessment

  • Lewis v. Callahan, 125 F.3d 1436 (11th Cir. 1997): Cited for the core definition of RFC as the claimant’s remaining ability to work despite impairments, considered with vocational factors.
  • SSR 96-8P, 1996 WL 374184 (July 2, 1996): Central to the court’s holding. The opinion relies on SSR 96-8P’s principle that it is incorrect to find limitations beyond those caused by medically determinable impairments. The court uses SSR 96-8P to draw a line between (a) functional limitations caused by impairment symptoms/treatment side effects and (b) the mere fact of having to attend appointments.

4. Appointment-based absenteeism: persuasive authority becomes binding rule

  • Cherkaoui v. Comm'r of Soc. Sec., 678 F. App'x 902 (11th Cir. 2017): An unpublished Eleventh Circuit decision previously rejecting the theory that frequent medical appointments themselves constitute a functional limitation for RFC purposes. The Malak court treats Cherkaoui’s reasoning as persuasive and elevates the underlying principle into a published, precedential holding.
  • Blackmon v. Comm'r of Soc. Sec., No. 23-12894, 2024 WL 3495022 (11th Cir. July 22, 2024) and Johnson v. Acting Comm'r of Soc. Sec., No. 24-11459, 2025 WL 671262 (11th Cir. Mar. 3, 2025): Unpublished decisions noted as consistent support for excluding absenteeism limits from the RFC absent impairment-caused functional constraints.
  • Barnett v. Apfel, 231 F.3d 687 (10th Cir. 2000): Cited for rejecting faulty extrapolations of missed workdays from the mere existence of medical visits, especially where the claimant assumes each appointment equals a full day missed.
  • Combs v. Kijakazi, 69 F.4th 428 (7th Cir. 2023): Cited for emphasizing the claimant’s burden to show that additional appointments would create unacceptable absenteeism and for the practical point that brief appointments do not necessarily require full workday absences.

5. Vocational expert testimony and completeness of hypotheticals

  • Winschel v. Comm'r of Soc. Sec., 631 F.3d 1176 (11th Cir. 2011) and Wilson v. Barnhart, 284 F.3d 1219 (11th Cir. 2002): Cited for the rule that vocational expert testimony constitutes substantial evidence only when the ALJ’s hypothetical includes all impairments. Malak uses these cases to underscore that, while vocational expert testimony about termination thresholds for absences may be relevant at Step Five, it does not expand what is legally permissible to include in the RFC.

6. Subjective symptoms and credibility articulation

  • Wilson v. Barnhart, 284 F.3d 1219 (11th Cir. 2002): Supplies the Eleventh Circuit’s three-part pain standard. The court applies this framework to evaluate Malak’s allegations about symptom intensity and treatment side effects.
  • Foote v. Chater, 67 F.3d 1553 (11th Cir. 1995): Cited for the requirement that an ALJ articulate specific, adequate reasons when discounting subjective pain testimony (or that the credibility finding be obvious from the record).

B. Legal Reasoning

1. The key doctrinal move: separating “functional limits” from “treatment logistics”

The court’s central reasoning turns on the nature and purpose of RFC. Under the regulations and SSR 96-8P, RFC is an administrative finding of work-related functional capacity despite medically determinable impairments and related symptoms. The court construes this as a categorical limitation: the RFC is about capability (what the claimant can still do physically/mentally), not about the schedule consequences of obtaining care.

Therefore, even if a vocational expert testifies that certain absenteeism levels would lead to termination, that testimony cannot transform appointment frequency into an RFC limitation—because appointment frequency is not a functional restriction “resulting from” the impairment in the sense demanded by the RFC framework.

2. What the ALJ must still consider: treatment effects as symptoms

The opinion is careful not to erase treatment realities altogether. It distinguishes appointment time from treatment effects: the ALJ must consider effectiveness and side effects of medication/treatment as part of symptom evaluation under 20 C.F.R. § 404.1529(c)(3)(iv). In other words, the sedating or cognitively impairing effects of ketamine (or recovery limitations after injections) may matter if they translate into functional restrictions—e.g., reduced concentration, inability to drive, need for additional breaks, or off-task time—supported by evidence.

Applying the pain standard, the court finds substantial evidence supported the ALJ’s conclusion that Malak’s alleged limiting effects were “not entirely consistent” with the medical record. The court emphasizes record notes from pain management indicating no medication side effects and the ALJ’s discussion of Malak’s positive response to treatment.

3. Burden and proof problems embedded in absenteeism arguments

Echoing Barnett and Combs, the court implicitly identifies why appointment-absence theories often fail evidentiary scrutiny: claimants frequently extrapolate full-day absences from the fact of appointments without proving (a) the duration, (b) the need to occur during work hours, (c) the recovery time required, and (d) the expected ongoing frequency. The opinion’s footnote underscores that Malak did not show her 9 appointments in 11 days would recur annually.

C. Impact

1. A binding Eleventh Circuit rule limiting RFC content

The most significant development is precedential clarity: in the Eleventh Circuit, ALJs do not include appointment-based absenteeism in RFC. This removes a line of argument that had circulated largely through unpublished decisions and district court disputes, and it narrows the scope of RFC challenges premised on treatment frequency alone.

2. Litigation strategy shifts: focus on functional sequelae, not appointment counts

After Malak, claimants are incentivized to develop evidence that the effects of treatment (sedation, cognitive slowing, post-procedure restrictions, pain flares, fatigue) produce measurable work-related limitations (off-task time, break requirements, exertional/postural restrictions), rather than arguing that attendance itself is disabling.

3. Step Five remains relevant, but within the impairment-based framework

Vocational expert testimony about employer tolerance for absences remains important only insofar as the absences are tied to impairment-caused functional limitations recognized under the regulations (e.g., unpredictable symptom flares causing incapacity), not the mere need to attend appointments. The decision effectively channels “absenteeism” disputes into the evidentiary question: is the claimant functionally unable to work on certain days because of medically supported symptomology or treatment side effects?

IV. Complex Concepts Simplified

  • Residual Functional Capacity (RFC): A legal finding about what work activities a person can still do (sitting, standing, lifting, concentrating, etc.) despite medically proven impairments. It is not a calendar of medical visits.
  • Medically determinable impairment: A condition shown by objective medical evidence (signs, laboratory findings), not solely by the claimant’s statements.
  • Substantial evidence: More than a mere scintilla, less than a preponderance—enough that a reasonable person could accept it to support the ALJ’s conclusion.
  • The “pain standard” (Eleventh Circuit): A structured test for evaluating subjective symptoms like pain. Even when an underlying condition exists, the ALJ may discount the alleged severity if inconsistent with objective evidence and other record indicators, so long as the ALJ gives adequate reasons.
  • Appointment-based absenteeism vs. functional limitation: Missing work to attend a doctor’s visit is a scheduling/logistics issue; being unable to work due to sedating medication effects or post-procedure limitations is a functional limitation. Only the latter belongs in RFC.

V. Conclusion

Afaf Malak v. Commissioner of Social Security establishes an important, precedential boundary in Eleventh Circuit disability law: an RFC does not incorporate limitations derived solely from the time required to attend medical appointments. The RFC must reflect only functional restrictions caused by medically determinable impairments and related symptoms.

At the same time, the court reaffirms that ALJs must evaluate treatment effectiveness and side effects as part of the claimant’s symptom analysis. Going forward, the decision is likely to reduce RFC reversals grounded in treatment-visit frequency and to concentrate disputes on whether the medical evidence substantiates functional after-effects of treatment that materially reduce work capacity.