# RODRIGUEZ v. COMMISSIONER OF SOCIAL SECURITY

> District Court, D. New Jersey · March 30, 2023

URL: https://www.frixlaw.com/law-library/cases/10275172

## Case

- **Court:** District Court, D. New Jersey
- **Decided:** March 30, 2023
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

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## Opinion text

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF NEW JERSEY

WILLIAM R.,
Plaintiff,
Civ. No. 22-00690 (KM)
v.
OPINION
KILOLO KIJAKAZI, Acting
Commissioner of Social Security,
Defendant.

KEVIN MCNULTY, U.S.D.J.:
Plaintiff William R. brings this action to review a final decision of the
Commissioner of Social Security (“Commissioner”) denying his claims for Title
II Disability Insurance Benefits (“DIB”) and Title XVI Supplemental Security
Income (“SSI”). He argues that the ALJ’s determination that he is not disabled
as defined by Title II of the Social Security Act was not supported by
substantial evidence. For the reasons stated below, the Commissioner’s
decision is AFFIRMED.
I. BACKGROUND1
William R. applied for DIB pursuant to Sections 216(i) and 223(d) of the
Social Security Act (“SSA”) on August 7, 2018. He claimed a period of disability

1 Citations to the record are abbreviated as follows:
“DE” = docket entry
“R. _” = Administrative Record (DE 5)
“Pl. Br.” = William R.’s moving brief (DE 8)
“Def. Br.” = SSA Commissioner’s opposition brief (DE 9)
Claimant’s moving brief was filed many months late, in response to a reminder from
the clerk. The government responded timely to the claimant’s brief. Doubtless the
claimant’s late filing resulted from an innocent oversight. As a result, however, the
Court could meet its own periodic six-month deadline under the Civil Justice Reform
Act only by filing its decision before an optional reply brief would have been due. If
beginning on June 20, 2017, based on the following physical impairments: 1)
degenerative disc disease of the lumbar spine, 2) degenerative disc disease of
the cervical spine, 3) fluctuating hearing loss of the right ear, 4) hypertension,
5) obesity, 6) diabetes mellitus, and 7) tinnitus of the right ear.2 (R. 23-24.) His
application was denied initially and upon reconsideration. (R. 61, 70.) On
February 11, 2020, he had a hearing before an Administrative Law Judge
(“ALJ”) to review his application de novo. (R. 36-60.) ALJ Beth Shillin heard
testimony from the plaintiff, who was represented by counsel, and from a
vocational expert. On March 2, 2020, ALJ Shillin issued a decision finding that
William R. has the residual functional capacity to perform medium work
activities with postural, environmental, and communicative limitations. (R. 18-
35.) The Appeals Council denied Plaintiff’s request for review on December 15,
2021, rendering the ALJ’s decision a final decision of the Commissioner. (R. 1–
6.) This appeal followed.
II. DECISION FOR REVIEW
A. The Five-Step Process and this Court’s Standard of Review
To qualify for Title II DIB benefits, a claimant must meet the insured
status requirements of 42 U.S.C. § 423. To qualify, a claimant must show that
she is unable to engage in substantial gainful activity by reason of any
medically determinable physical or mental impairment that can be expected to
result in death or that has lasted (or can be expected to last) for a continuous
period of not less than twelve months. 42 U.S.C. §§ 423(c), 1382(a).
Under the authority of the SSA, the Social Security Administration (the
“Administration”) has established a five-step evaluation process for determining
whether a claimant is entitled to benefits. 20 C.F.R. §§ 404.1520, 416.920.
This Court’s review necessarily incorporates a determination of whether the

necessary, the Court will consider an informal motion for reconsideration
incorporating any additional arguments the claimant may wish to assert in reply.
2 William R. originally alleged disability beginning May 20, 2017, but later revised
his alleged onset date to June 20, 2017, to correspond with the date he last worked.
(R. 21.)
ALJ properly followed the five-step process, which is prescribed by regulation.
The steps may be briefly summarized as follows:
Step 1: Determine whether the claimant has engaged in substantial
gainful activity since the onset date of the alleged disability. 20 CFR §§
404.1520(b), 416.920(b). If not, move to step two.
Step 2: Determine if the claimant’s alleged impairment, or
combination of impairments, is “severe.” Id. §§ 404.1520(c),
416.920(c). If the claimant has a severe impairment, move to step
three.
Step 3: Determine whether the severe impairment meets or equals
the criteria of any impairment found in the Listing of Impairments.
20 CFR Pt. 404, Subpt. P, App. 1, Pt. A. If so, the claimant is
automatically eligible to receive disability benefits (and the analysis
ends); if not, move to step four. Id. §§ 404.1520(d), 416.920(d).
RFC and Step 4: Determine the claimant’s “residual functional
capacity” (“RFC”), meaning “the most [the claimant] can still do
despite [her] limitations.” 20 C.F.R. § 404.1545(a)(1). Caraballo v.
Comm’r of Soc. Sec., 2015 WL 457301, at *1 (D.N.J. Feb. 3, 2015).
Decide whether, based on his RFC, the claimant can return to her
prior occupation. 20 C.F.R. § 1520(a) (4)(iv); Id. §§ 404.1520(e)–(f),
416.920(e)–(f). If not, move to step five.
Step 5: At this point, the burden shifts to the Administration to
demonstrate that the claimant, considering his age, education,
work experience, and RFC, is capable of performing jobs that exist
in significant numbers in the national economy. 20 CFR §§
404.1520(g), 416.920(g); see Poulos v. Comm’r of Soc. Sec., 474
F.3d 88, 91–92 (3d Cir. 2007). If so, benefits will be denied; if not,
they will be awarded.
On appeal, the Court conducts a plenary review of the legal issues. See
Schaudeck v. Comm’r of Soc. Sec., 181 F.3d 429, 431 (3d Cir. 1999). Factual
findings are reviewed “only to determine whether the administrative record
contains substantial evidence supporting the findings.” Sykes v. Apfel, 228
F.3d 259, 262 (3d Cir. 2000). Substantial evidence is “less than a
preponderance of the evidence but more than a mere scintilla.” Jones v.
Barnhart, 364 F.3d 501, 503 (3d Cir. 2004) (citation omitted). “It means such
relevant evidence as a reasonable mind might accept as adequate to support a
conclusion.” Id. When substantial evidence exists to support the ALJ’s factual
findings, this Court must abide by the ALJ’s determinations. See id. (citing 42
U.S.C. § 405(g)).
This Court may, under 42 U.S.C. § 405(g), affirm, modify, or reverse the
Commissioner’s decision, or it may remand the matter to the Commissioner for
a rehearing. Podedworny v. Harris, 745 F.2d 210, 221 (3d Cir. 1984); Bordes v.
Comm’r of Soc. Sec., 235 F. App’x 853, 865–66 (3d Cir. 2007). Outright reversal
with an award of benefits is appropriate only when a fully developed
administrative record contains substantial evidence that the claimant is
disabled and entitled to benefits. Podedworny, 745 F.2d at 221–222; Morales v.
Apfel, 225 F.3d 310, 320 (3d Cir. 2000).
Remand is proper if the record is incomplete, or if there is a lack of
substantial evidence to support a definitive finding on one or more steps of the
five-step inquiry. See Podedworny, 745 F.2d at 221–22. Remand is also proper
if the ALJ’s decision lacks adequate reasoning or support for its conclusions, or
if it contains illogical or contradictory findings. See Burnett v. Comm’r of Soc.
Sec., 220 F.3d 112, 119–20 (3d Cir. 2000); Leech v. Barnhart, 111 F. App’x 652,
658 (3d Cir. 2004) (“We will not accept the ALJ's conclusion that Leech was not
disabled during the relevant period, where his decision contains significant
contradictions and is therefore unreliable.”). It is also proper to remand where
the ALJ’s findings are not the product of a complete review which “explicitly
weigh[s] all relevant, probative and available evidence” in the record. Adorno v.
Shalala, 40 F.3d 43, 48 (3d Cir. 1994) (internal quotation marks omitted).
B. The ALJ’s Decision
ALJ Damille undertook the necessary step-by-step inquiry.
Step 1
The ALJ concluded William R. had not engaged in substantial gainful
activity from June 20, 2017, the alleged onset date. (R. 23.)
Step 2
The ALJ found that through the date last insured, William R. had the
following severe impairments: mild degenerative disc disease of the lumbar
spine, degenerative disc disease of the cervical spine, and mild to moderate
high frequency fluctuating hearing loss of the right ear. (R. 23 (citing 20 CFR
404.1520(c).)
Appropriately citing to the medical evidence and administrative record,
the ALJ found that the following claimed conditions had, at most, a minimal
impact on the claimant’s ability to perform basic work activities: hypertension,
obesity, diabetes mellitus, and tinnitus of the right ear. (R. 24.)
Step 3
With respect to the impairments found to be severe, the ALJ determined
that William R. did not have an impairment or combination of impairments
that met or medically equaled the severity of the listed impairments in 20
C.F.R. Part 404, Subpart P, Appendix 1. (R. 24.) In particular, the ALJ’s
discussion of the evidence focused on Listings 1.04 (disorders of the spine)3
and 2.10 (hearing loss not treated with cochlear implantation)4.5
RFC and Step 4

3 1.04 Disorders of the spine (e.g., herniated nucleus pulposus, spinal
arachnoiditis, spinal stenosis, osteoarthritis, degenerative disc disease, facet arthritis,
vertebral fracture), resulting in compromise of a nerve root (including the cauda
equina) or the spinal cord. With:
A. Evidence of nerve root compression characterized by neuro-anatomic
distribution of pain, limitation of motion of the spine, motor loss (atrophy with
associated muscle weakness or muscle weakness) accompanied by sensory or
reflex loss and, if there is involvement of the lower back, positive straight-leg
raising test (sitting and supine);
OR
B. Spinal arachnoiditis, confirmed by an operative note or pathology report of
tissue biopsy, or by appropriate medically acceptable imaging, manifested by
severe burning or painful dysesthesia, resulting in the need for changes in
position or posture more than once every 2 hours;
OR
C. Lumbar spinal stenosis resulting in pseudoclaudication, established by
findings on appropriate medically acceptable imaging, manifested by chronic
nonradicular pain and weakness, and resulting in inability to ambulate
effectively, as defined in 1.00B2b.C. Lumbar spinal stenosis resulting in
pseudoclaudication, established by findings on appropriate medically
acceptable imaging, manifested by chronic nonradicular pain and weakness,
and resulting in inability to ambulate effectively, as defined in [Listing]
1.00B2b.
4 2.10 Hearing loss not treated with cochlear implantation.
A. An average air conduction hearing threshold of 90 decibels or greater in the
better ear and an average bone conduction hearing threshold of 60 decibels or
greater in the better ear (see [Listing] 2.00B2c).
OR
B. A word recognition score of 40 percent or less in the better ear determined
using a standardized list of phonetically balanced monosyllabic words (see
[Listing] 2.00B2e).
5 Since the time of the ALJ’s decision in this case, the Social Security
Administration passed rules revising its criteria for examining spinal disorders,
replacing Listing 1.04 with two new Listings, 1.15 (Disorders of the skeletal spine
resulting in compromise of a nerve root(s)) and 1.16 (Lumbar spinal stenosis resulting
in compromise of the cauda equina).
Next, ALJ Shillin defined the claimant’s RFC:
5. After careful consideration of the entire record, I find that the
claimant has the residual functional capacity to perform medium
work as defined in 20 CFR 404.1567(c) except no ladders,
scaffolds, ropes, heavy machinery, or heights; frequent stairs,
ramps, crouching, crawling, stooping, kneeling, and balancing; and
due to hearing loss, only occasional contact with the general
public, co-workers, and supervisors.
(R. 25.) The ALJ analyzed at length the evidence supporting that RFC
determination. (R. 25-29.)
Based on the RFC, the ALJ concluded at Step 4 that William R. is
capable of performing past relevant work as a warehouse worker. (R. 29.)
As required, the ALJ considered William R.’s position both as he actually
performed it and as it is generally performed. Because the ALJ found
William R. is capable of performing past relevant work, she concluded
her analysis at Step 4 and did not move on to Step 5.
III. DISCUSSION
In his appeal, William R. asserts that the ALJ’s RFC assessment was
flawed in two ways. First, he contends that the assessment is not supported by
substantial evidence because the ALJ did not “engage in the required
functional analysis,” i.e., she did not identify William R.’s functional limitations
or restrictions and assess his work-related abilities on a function-by-function
basis. (Pl. Br. 12 (citing SSR 96-8p).) Second, and relatedly, he argues that the
assessment is unsupported because the ALJ’s decision did not “define the
tasks and abilities that must be sustained in order to perform medium work
activity.” (Id. 12-13 (citing SSR 83-10.) I address each of these arguments in
turn.
A. Functional Analysis
I find that ALJ Shillin engaged in an extensive functional analysis in
performing her RFC assessment and determining that William R. was capable
of performing medium work, as defined in 20 C.F.R. 404.1567(c), subject to
certain postural and environmental limitations. Her detailed examination of the
objective medical evidence pertaining to “the intensity, persistence, and limiting
effects” of William R.’s symptoms indicates that her RFC determination is
supported by substantial evidence and indeed resulted from “careful
consideration of the entire record.” (R. 25.)
First, ALJ Shillin addressed William R.’s June 20, 2017 visit to the
emergency department after a piece of marble hit him on the back and knocked
him to the ground during work. (Id.) She noted that a CT scan of William R’s
head showed no acute intracranial hemorrhage and that during follow-up
examinations in August 2017 and September 2017, William R. denied
experiencing any headaches, head injury, joint pains, tingling, numbness,
paresthesia, weakness, or dizziness. (Id.).
Second, ALJ Shillin considered the results of William R.’s primary care
examinations through the end of September 2017, finding no remarkable
physical limitations. (Id. 27.) She noted multiple occasions in which William
R.’s primary care physician, Dr. Ombola Abiodun Oji, found that William R.
had normal range of motion of the cervical and lumbar spine with normal
straight leg raise testing and no cervical or lumbar tenderness. (Id.) In addition,
ALJ Shillin noted that Dr. Oji routinely found William R. to have normal range
of motion of the lower extremities along with normal bilateral motor strength,
sensation, coordination, and gait. (Id.) In her decision, ALJ Shillin remarks that
these findings, as they relate to William R.’s functional limitations, were
consistent with those from another physical examination performed by Dr.
Anthony Tarasenko during September 2017, which demonstrated that William
R. had “full range of motion, no deformity, no tenderness, and normal strength
of his bilateral shoulders, arms, elbows, wrists, hands, fingers, lower
extremities, cervical spine, thoracic spine, and lumbosacral spine.” (Id. 27.)
Third, ALJ Shillin considered the results of William R.’s orthopedic
examinations with Dr. Patricio Grob in 2017, observing that they were
generally “benign.” (Id.) She noted that although Dr. Grob observed that
William R. had decreased range of motion of the lumbar spine with poor lower
extremity flexibility in September 2017, the following month Dr. Grob observed
that William R.’s range of motion improved. (Id.)
Fourth, ALJ Shillin considered notes from William R.’s physical therapy
sessions in late 2017, which indicated little to no physical limitation. The notes
indicate that William R. had nearly full range of motion of the cervical and
lumbar spine, intact sensation, and intact and symmetrical deep tendon
reflexes. (Id.) In addition, William R. reported to his physical therapist that his
neck and back pain improved with treatment. Moreover, the notes indicate that
William R. reported being able to go on 30 minute walks, use stairs to reach his
third-story home, and exercise with a weighted vest at home while walking. (Id.)
Most significantly, William R.’s physical therapist noted observing William R.
1) completing 10 repetitions of lifting 40 pounds, 2) pushing/pulling 110
pounds, 3) sitting for 30 minutes and ambulating for 20 minutes, and 4)
ascending and descending stairs and a ladder. (Id.)
Fifth, ALJ Shillin considered records from William R.’s medical
consultative examination with Dr. Betty Vekhins, during which William R. was
able to walk without an assistive device, walk on heels and toes, and squat.
(Id.) These records also reflected Dr. Vekhins’ observations that William R. ha a
full range of motion of the cervical spine, no vertebral tenderness, no abnormal
tilt. Dr. Vekhins also observed that William R. had nearly full range of motion
of the lumbar spine, with no worsening pain on straightening, and negative
straight leg raise testing in the seated and spine positions. (Id.) In addition,
William R. had full range of motion of his bilateral shoulders, elbows, wrists,
and hands with normal grip strength and no sensory loss, and Dr. Vekhins
also noted that he had full range of motion of his bilateral hips, knees, and
ankles, with no focal weakness, no sensory loss, and no swelling or deformity.
(Id.)
Sixth, ALJ Shillin discussed a series of examinations by William R.’s
orthopedist, Dr. Daniel Harrington. (Id. 28.) In October 2019, Dr. Harrington
observed that William R. had reduced range of motion of the lumbar spine with
tenderness to palpation diffusely throughout. (Id.) However, Dr. Harrington
found that William R. had intact strength, sensation, and deep tendon reflexes.
Dr. Harrington also noted that although an x-ray of William R.’s lumbar spine
showed mild degenerative changes, these changes appeared to be age-related,
as the imaging did not show any sign of previous trauma. Dr. Harrington
recommended physical therapy for generalized strengthening of the low back
and extremities. (Id.) In November 2019, William R. returned to Dr. Harrington
with additional complaints of neck and right shoulder pain. (Id.) Dr. Harrington
found that William R. had reduced range of motion of the cervical spine, but
was neurovascularly intact. (Id.) During return visits in December 2019 and
January 2020, Dr. Harrington observed similarly mild functional limitations,
again noting a reduced range of motion of the lumbar spine with midline
tenderness and left sacroiliac joint pain but documenting that William R.
possessed intact strength and sensation.6 (Id.)
Seventh, ALJ Shillin examined evidence regarding William R.’s functional
limitations resulting from his hearing disorder. September 2019 audiometry
testing demonstrated mild to moderate sensorineural hearing loss in William
R.’s right ear. (Id.) In terms of functional findings, the audiometry testing
revealed that William R.’s right ear speech reception was 96 percent and his
left ear speech reception was 100 percent. (Id.) All other findings with respect
to William R.’s hearing were normal, as he demonstrated no ear effusion, and
no speech problems. (Id.)
William R. does not contest the objective evidence ALJ Shillin considered,
nor does he argue ALJ Shillin failed to consider other evidence that does not
appear in her decision. Instead, he merely disagrees with ALJ Shillin’s ultimate
assessment that he is capable of medium work, i.e., “lifting no more than 50

6 During William R.’s January 2020 visit with Dr. Harrington, an MRI of the
lumbar spine demonstrated mild disc disease with an anterior spondylolisthesis of L4
and L5 and mild bilateral lateral recess stenosis at L4-5. (R. 28.) Notably, Dr.
Harrington’s records document that there was no significant change compared to the
findings from prior imaging in October 2017. (Id.)
pounds at a time with frequent lifting or carrying of objects weighing up to 25
pounds.” 20 C.F.R. 404.1567(c). William R. points to a handful of excerpts in
ALJ Shillin’s decision that he “regards as significant evidence contradicting a
medium work RFC,” none of which I find persuasive. (Pl. Br. 15-17.) The only
listed excerpts that bear on William R.’s functional limitations pertain to
William R.’s reduced range of motion of the lumbar and cervical spine, poor
lower extremity flexibility, tenderness to palpation, as well as neck and joint
pain, all of which ALJ Shillin considered within the context of the objective
medical record. None of these issues, which ALJ Shillin determined to be mild
in severity and persistence, indicates that William R. is incapable of medium
work. In fact, taken together, the excerpts highlighted by William R. support the
ALJ’s RFC assessment. For instance, William R. points out that his “physical
therapist observed that he could do ten repetitions of lifting 40 pounds and
pushing/puling 110 pounds; stand and sit for 30 minutes and ambulate for 20
minutes in duration; and he was able to ascend and descend stairs and a
latter.” (Pl. Br. 16 (citing R. 27).)
The objective medical record includes ample evidence demonstrating that
William R. is capable of performing medium work, consistent with the ALJ’s
RFC assessment.7 As for the process by which ALJ arrived at her RFC
determination, the excerpts William R. lists in his brief show that ALJ Shillin
engaged in the very functional analysis that William R. claims she failed to
conduct.

7 William R. also appears to take issue with the ALJ’s finding that his obesity is
not a severe medically determinable impairment. (Pl. Br. n. 7.) However, the only
evidence he proffers to suggest that this finding was erroneous is a treatment plan Dr.
Harrington prescribed to William R. that consisted of “low impact exercise and weight
loss.” (Id.) The fact that a medical professional directed William R. to exercise and lose
weight does not warrant a finding that his obesity is severe. In fact, ALJ Shillin
specifically observed that the objective medical record contained “no evidence of any
specific or quantifiable impact on pulmonary, musculoskeletal, endocrine, or cardiac
functioning.” (R. 24.) Substantial evidence supports the ALJ’s finding that William R.’s
obesity, considered alone or in combination with other impairments, is not severe.
B. Defining Medium Work Tasks and Abilities
I find that ALJ Shillin did not err by declining to specifically define all the
“tasks and abilities that must be sustained in order to perform medium work.”
(Pl. Br. 12-13.) In addition to 1) “lifting no more than 50 pounds at a time with
frequent lifting or carrying of objects weighing up to 25 pounds,” these tasks
and abilities include 2) “standing or walking, off and on, for a total of
approximately 6 hours in an 8-hour workday;” 3) “use of the arms and hands []
to grasp, hold, and turn objects; 4) “frequent bending [and] stooping; and 5)
“flexibility of the knees and torso.” (Pl. Br. 13-14 (citing SSR 83-10).) William R.
contends that the ALJ’s RFC assessment is not supported by substantial
evidence because it does not articulate William R.’s ability to perform each of
these tasks. Although ALJ Shillin did not list each of these tasks and abilities
in her decision, her examination of the objective medical evidence clearly
addressed all five categories:
First, ALJ Shillin addressed William R.’s lifting ability when she
examined his 2019 physical therapy records that documented William R. being
able to complete “ten repetitions of lifting 40 pounds and pushing/pulling 110
pounds.” (R. 27.)
Second, ALJ Shillin addressed William R.’s walking ability when she
examined his 2017 physical therapy records noting that William R. “reported
that he was able to go on 30 minute walks, use stairs to get to his third story
home, and exercise with [a] weighted vest at home while walking,” as well as
being able to “ascend and descend stairs and a ladder.” (Id.) The ALJ also
reviewed evidence from William R.’s medical consultative examination with Dr.
Vekhins during which William R. “walked without an assistive device and
walked on heels and toes.” (Id.)
Third, ALJ Shillin also addressed William R.’s ability to grasp and hold
objects when she reviewed the evidence from his visit with Dr. Vekhins, during
which William R. had “full range of motion of his bilateral shoulders, elbows,
wrists, and hands with normal grip strength and no sensory loss.” Id.
Finally, ALJ Shillin addressed William R.’s bending and stooping ability,
as well as the flexibility of his knees and torso, when she considered Dr.
Vekhins’ notes that William R. was able to squat and had “full range of motion
of his bilateral hips, knees, and ankles, no focal weakness, no sensory loss,
and no swelling or deformity.” (Id.) These findings were corroborated by
additional evidence ALJ Shillin considered, including notes from William R.’s
physical therapy sessions, during which he climbed stairs and a ladder, as well
as routine normal straight leg raise testing. (Id. 27-28.)
Given that ALJ Shillin’s RFC assessment addressed all of the tasks and
abilities associated with medium work, her failure to refer to those tasks and
abilities by name did not constitute error.
* * *
In sum, I find that ALJ Shillin conducted a thorough functional analysis
based on the objective medical record and, in doing so, addressed the five
categories of tasks and abilities listed in SSR 83-10 as being associated with
medium work. While the claimant disagrees with the ALJ’s assessment and
cites contrary evidence, the ALJ’s decision is supported by substantial evidence
and therefore will be upheld.
IV. CONCLUSION
For the reasons set forth above, the Commissioner’s decision is
AFFIRMED. A separate order will issue.
Dated: March 30, 2023
/s/ Kevin McNulty
___________________________________
Hon. Kevin McNulty
United States District Judge

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10275172. Public record. Not legal advice.