# Gonzalez Valentin v. Saul

> District Court, M.D. Pennsylvania · August 27, 2020

URL: https://www.frixlaw.com/law-library/cases/10409162

## Case

- **Court:** District Court, M.D. Pennsylvania
- **Decided:** August 27, 2020
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

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## How later opinions describe it (automated extraction)

- noting that the scope of review on legal matters is plenary

## Opinion text

IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA

AYDIL V. GONZALEZ, :
:
Plaintiff, : No. 3:19-cv-01482
:
v. : (SAPORITO, M.J.)
:
ANDREW SAUL,1 :
Commissioner of :
Social Security, :
:
Defendant. :

MEMORANDUM
This is an action brought under 42 U.S.C. §405(g), seeking judicial
review of the Commissioner of Social Security’s (“Commissioner”) final
decision denying Aydil V. Gonzalez (“Gonzalez”) claim for disability
insurance benefits under Title II of the Social Security Act. The parties
have consented to the jurisdiction of the undersigned United States
Magistrate Judge pursuant to the provisions of 28 U.S.C. § 636(c) and

1 Andrew Saul was sworn in as Commissioner of Social Security on June
17, 2019. He is automatically substituted as a party pursuant to Fed. R.
Civ. P. 25(d); see also Section 205(g) of the Social Security Act, 42 U.S.C.
§ 405(g)(action survives regardless of any change in the person occupying
the office of Commissioner of Social Security). The caption in this case is
amended to reflect this change.
Rule 73 of the Federal Rules of Civil Procedure. (Doc. ___, Doc. ___, Doc.

____). For the reasons stated herein, we AFFIRM the decision of the
Commissioner.
I. Background and Procedural History

Gonzalez is an adult individual born June 4, 1981, who was 34
years old at the time of her alleged onset date of disability—January 13,
2016. (Tr. 1150, 1280). Gonzalez’s age at the onset date makes her a

“younger person” under the Social Security Act. See 20 C.F.R. §
404.1563(c). Gonzalez is a high school graduate and completed her
associate degree in 2006 in Puerto Rico. (Tr. 1105, 1274). Additionally,

Gonzalez has past relevant work experience, working as a telemedic
nurse and a registered nurse in Puerto Rico. (Tr. 1107-08). On September
26, 2016, Gonzalez protectively filed for disability benefits pursuant to

Title II of the Social Security Act. (Tr. 44). In her application, Gonzalez
alleged that she became disabled beginning January 13, 2006, as a result
of severe persistent asthma, bronchitis, high blood pressure, diabetes,

sleep apnea, depression, anxiety, and severe morbid obesity. (Tr. 1273).
Gonzalez’s claim was initially denied on March 20, 2017. (Tr. 44).
Thereafter, Gonzalez filed a timely request for an administrative hearing
on August 1, 2017, and it was granted. (Id.). Gonzalez, represented by

counsel, appeared and testified before ALJ, Lawrence J. Neary, on
August 28, 2018, in Harrisburg, Pennsylvania. (Tr. 1098). In addition, an
impartial vocational expert (“VE”), Sheryl Bustin, also appeared and

testified during the administrative hearing. (Tr. 44, 1098). At the time of
the hearing, Gonzalez was 37 years old and resided with her family in
Lebanon, Pennsylvania. (Doc. 11, at 7).

In a written decision dated November 8, 2018, the ALJ denied
Gonzalez’s application for benefits. (Tr. 44). Gonzalez sought review of
her claims by the Appeals Council of the Office of Disability Adjudication

and Review, but her request was denied for review on August 14, 2019.
(Tr. 1). Gonzalez subsequently filed an appeal to this court on August 26,
2019, arguing that the ALJ’s decision was not supported by substantial

evidence. (Doc. 1). On November 1, 2019, the Commissioner filed his
answer, in which he maintains that the ALJ’s decision was correct and
in accordance with the law and regulations. (Doc. 4, at 4). This matter

has been fully briefed by the parties and is ripe for decision. (Doc. 11, Doc.
12).
On this score, Gonzalez’s treatment history discloses that Gonzalez
has a history of physical and mental health conditions, including asthma,

bronchitis, high blood pressure, diabetes, sleep apnea, obesity,
depression, and anxiety. (Tr. 49). The medical record reflects that
Gonzalez underwent imaging of her lumbar and cervical spines. (Id.). The

results revealed limited abnormal findings, including degenerative disc
disease and osteoarthritis at multiple levels, but overall the degenerative
changes were “mild” and “slight.” (Tr. 1403-36, 1437-85, 1523-25). The

medical record also reveals that Gonzalez suffers from radiculopathy, as
Gonzalez frequently complained of radiating pain in her legs and upon
examination, exhibited left-sided paraspinal tenderness with positive

straight leg raise testing indicative of pain in her legs. (Tr. 1765-1899).
Gonzalez further describes numbness and weakness, particularly in her
left leg, and reported in April 2018 that she had begun using a cane to

take the pressure off her back. (Tr. 1729-64). Gonzalez, however,
indicated some positive response to medication, and reported that
epidural steroid injections provided 60 percent pain relief in her back and

resolution of her leg pain. (Tr. 1729-64, 1765-1899).
In February 2017, in Puerto Rico, Gonzalez was examined by Dr.
Fernando Torres-Santiago (“Dr. Torres-Santiago”). (Tr. -1526-30). Upon
examination, Gonzalez complained of backaches that derived from the

wear and tear of her working years. (Tr. 1526). Gonzalez stated that she
experienced poor relief with the uses of common pain killer pills and
muscle relaxants, and that her medical conditions affected her activities

of daily living. (Id.). Dr. Torres-Santiago noted, however, that Gonzalez
did not use a walking aid; that her gait and station was normal; and that
she showed no signs of limb or joint pain. (Tr. 1528). Additionally, Dr.

Torres-Santiago noted minimal abnormal findings. (Id.). For example,
Gonzalez exhibited moderate trapezius muscle spasms, but adequate
range of motion in her cervical spine, and that Gonzalez demonstrated

discomfort with flexion-extension of her lumbar spine at 60 degrees, with
evidence of paravertebral muscle spasms. (Tr. 1529).
In April 2018, Gonzalez visited WellSpan Health. (Tr. 1749).

During the examination, Gonzalez complained of severe pain, rated as
10/10, located at the lumbosacral spine. (Id.). Gonzalez described her pain
as aching, sharp, with pressure that occurs constantly. (Id.). Gonzalez

indicated that the symptoms were exacerbated by standing, walking, and
movement of limb. (Id.). Other associated symptoms included weakness,
sensitivity to touch, and sleep disturbance. (Id.). Upon examination,
however, Gonzalez’s lumbar paraspinals and facet joints were tender to

palpation on the left and she had limited range of motion in the lumbar
spine particularly with flexion, and an increase in left-sided low back
pain with straight leg raise testing. (Tr. 50).

As for Gonzalez’s asthma, the medical record reflects that Gonzalez
suffers from recurrent symptoms that can be expected to limit her
extreme tolerance. For example, Gonzalez complained of exacerbation of

her symptoms on various occasions, reporting cough, shortness of breath,
and chest tenderness. (Tr. 1437-85, 1556-66, 1585-98). However, the
frequency of asthma-related hospitalization is not corroborated in the

record. Further, objective medical testing of record demonstrates
minimal abnormal findings. For example, in February 2017, spirometry
testing showed a normal forced vital capacity (FVC) and forced expiratory

volume (FEV). (Tr. 1548-53). Additionally, during Gonzalez’s February
2017 consultative examination, Gonzalez exhibited no rales or wheezing,
and no laborious breathing. (Tr. 1529). Moreover, while Gonzalez

exhibited wheezing in an April 2017 examination, Gonzalez’s respiratory
function was normal upon examination in November 2017. (Tr. 50).
Gonzalez further reported in a May 2018 examination that she was only
experiencing mild breathing issues, with off and on wheezing and chest

tightness. (Tr. 1926-27).
Based upon Gonzalez’s physical impairments, the State agency
medical consultants for the initial and reconsideration determinations

opined that Gonzalez could perform work at the light exertional level
involving frequent postural maneuvers and no concentrated exposure to
extreme temperatures, wetness, humidity, and pulmonary irritants. (Tr.

1140-42; 1157-59).
As for Gonzalez’s mental impairments, the medical record reflects
that Gonzalez’s mental health treatment has been fairly routine, with

few significant abnormalities during mental status examinations, and
good reported response to medication. (Tr. 1567, 1691-1728, 100-07). For
example, Gonzalez has occasionally demonstrated diminished

concentration, anxiety, or irritable moods, but has reported functioning
well at home with no side effects from her medication. (Tr. 1567, 1691-
1728, 100-07). In February 2017, Gonzalez was examined by Dr. Marisol

Santiago (“Dr. Santiago”). (Tr. 1535-45). Upon examination, Dr. Santiago
noted that Gonzalez was cooperative, appropriately dressed, but
appeared anxious with some anger, and was crying during the interview.
(Tr. 1541). Gonzalez revealed that she was upset that her medical

conditions prevent her from working and helping her husband with the
household expenses. (Tr. 1544). Despite her depressed and anxious
appearance, Dr. Santiago noted limited abnormal findings. (Tr. 1540-43).

For example, Gonzalez’s speech was normal, she repeated a group of
objects out of order, and could recall only three out of five objects after a
five-minute delay. (Tr. 1541-43). Additionally, Dr. Santiago noted that

while Gonzalez presented with signs and symptoms of depression, and
complained of physical symptoms from obesity, chronic asthma, and vocal
dysfunction, Gonzalez exhibited an adequate intellectual capacity to

solve problems; she was able to interact socially with others; and she was
capable of managing money. (Tr. 1544).
Based upon Gonzalez’s mental health impairments, the State

agency consultants for the initial and reconsideration determinations,
opined that Gonzalez had no severe mental impairments, with no more
than mild limitations in any of the “paragraph B” functional areas. (Tr.

1130-44, 1146-60).
II. Legal Standards
When reviewing the denial of disability benefits, the Court’s review
is limited to determining whether those findings are supported by

substantial evidence in the administrative record. See 42 U.S.C. § 405(g)
(sentence five); Id. § 1383(c)(3); Johnson v. Comm’r of Soc. Sec., 529 F.3d
198, 200 (3d Cir. 2008); Ficca v. Astrue, 901 F. Supp. 2d 533, 536 (M.D.

Pa. 2012). Substantial evidence “does not mean a large or considerable
amount of evidence, but rather such relevant evidence as a reasonable
mind might accept as adequate to support a conclusion.” Pierce v.

Underwood, 487 U.S. 552 (1988). Substantial evidence is less than a
preponderance of the evidence but more than a mere scintilla.
Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of evidence

is not substantial evidence if the ALJ ignores countervailing evidence or
fails to resolve a conflict created by the evidence. Mason v. Shalala, 994
F.2d 1058, 1064 (3d Cir. 1993). In an adequately developed factual record,

substantial evidence may be “something less than the weight of the
evidence, and the possibility of drawing two inconsistent conclusions
from the evidence does not prevent [the ALJ’s decision] from being

supported by substantial evidence.” Consolo v. Fed. Maritime Comm’n,
383 U.S. 607, 620 (1966). “In determining if the Commissioner’s decision
is supported by substantial evidence the court must scrutinize the record
as a whole.” Leslie v. Barnhart, 304 F. Supp. 2d 623, 627 (M.D. Pa. 2003).

The question before the Court, therefore, is not whether the claimant is
disabled, but whether the Commissioner’s finding that he or she is not
disabled is supported by substantial evidence and was reached based

upon a correct application of the relevant law. See Arnold v. Colvin, No.
3:12-CV-02417, 2014 WL 940205, at *1 (M.D. Pa. Mar. 11, 2014) (“[I]t has
been held that an ALJ’s errors of law denote a lack of substantial

evidence.”) (alterations omitted); Burton v. Schweiker, 512 F. Supp. 913,
914 (W.D. Pa. 1981) (“The [Commissioner]’s determination as to the
status of a claim requires the correct application of the law to the facts.”);

see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990) (noting that
the scope of review on legal matters is plenary); Ficca, 901 F. Supp. 2d at
536 (“[T]he court has plenary review of all legal issues . . . .”).

To receive disability benefits, a claimant must demonstrate an
“inability to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be

expected to result in death or which has lasted or can be expected to last
for a continuous period of not less than 12 months.” 42 U.S.C.
§ 423(d)(1)(A); Id. § 1382c(a)(3)(A); see also 20 C.F.R. § 404.1505(a); Id.
§ 416.905(a). To satisfy this requirement, a claimant must have a severe

physical or mental impairment2 that makes it impossible to do his or her
previous work or any other substantial gainful activity3 that exists in the
national economy. 42 U.S.C. § 423(d)(2)(A); Id. § 1382c(a)(3)(B); 20 C.F.R.

§ 404.1505(a); Id. § 416.905(a).
The Commissioner follows a five-step sequential evaluation process
in determining whether a claimant is disabled under the Social Security

Act. 20 C.F.R. § 404.1520(a); Id. § 416.920(a). Under this process, the
Commissioner must determine, in sequence: (1) whether the claimant is
engaged in substantial gainful activity; (2) whether the claimant has a

severe impairment; (3) whether the claimant’s impairment meets or
equals a listed impairment;4 (4) whether the claimant is able to do past
relevant work, considering his or her residual functional capacity

2 A “physical or mental impairment” is an impairment resulting from
“anatomical, physiological, or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic
techniques.” 42 U.S.C. § 423(d)(3); Id. § 1382c(a)(3)(D).
3 “Substantial gainful activity” is work that (1) involves performing
significant or productive physical or mental duties, and (2) is done (or
intended) for pay or profit. 20 C.F.R. § 404.1510; id. § 416.910.
4 An extensive list of impairments that warrant a finding of disability
based solely on medical criteria, without considering vocational criteria,
is set forth at 20 C.F.R., Part 404, Subpart P, Appendix 1.
(“RFC”);5 and (5) whether the claimant is able to do any other work,

considering his or her RFC, age, education, and work experience. Id.
§ 404.1520(a); Id. § 416.920(a). The claimant bears the initial burden of
demonstrating a medically determinable impairment that prevents him

or her from doing past relevant work. 42 U.S.C. § 423(d)(5); Id.
§ 1382c(a)(3)(H)(i); 20 C.F.R. § 404.1512; Id. § 416.912; Mason, 994 F.2d
at 1064. Once the claimant has established at step four that he or she

cannot do past relevant work, the burden then shifts to the Commissioner
at step five to show that jobs exist in significant numbers in the national
economy that the claimant could perform consistent with his or her RFC,

age, education, and past work experience. 20 C.F.R. § 404.1512(f); Id.
§ 416.912(f); Mason, 994 F.2d at 1064.
III. Discussion

In his November 2018, decision denying Gonzalez’s claim for
benefits, the ALJ evaluated Gonzalez’s application for benefits at each

5 “Residual functional capacity” is the most a claimant can do in a work
setting despite the physical and mental limitations of his or her
impairment(s) and any related symptoms (e.g., pain). 20 C.F.R.
§ 404.1545(a)(1); id. § 416.945(a)(1). In assessing a claimant’s RFC, the
Commissioner considers all medically determinable impairments,
including those that are not severe. Id. § 404.1545(a)(2); id.
§ 416.945(a)(2).
step of the sequential evaluation process. In that decision, the ALJ first

concluded that Gonzalez had met the insured status requirements of the
Social Security Act through December 31, 2021. (Tr. 46). At step one, the
ALJ concluded that Gonzalez had not engaged in substantial gainful

activity since January 13, 2016, the alleged onset date. (Id.). At step two,
the ALJ found that the following impairments were medically
determinable and severe during the relevant period: obesity, asthma,

diabetes, osteoarthritis, degenerative disc disease with radiculopathy,
cervicalgia, myofascial pain syndrome, moderate recurrent major
depression, and unspecified anxiety disorder. (Id.).

At step three, the ALJ found that Gonzalez did not have an
impairment or combination of impairments that met or medically
equaled the severity of an impairment listed in 20 C.F.R. Part 404,

Subpart P, Appendix 1, during the relevant period. (Tr. 47-48). Between
steps three and four, the ALJ fashioned an RFC considering Gonzalez’s
limitations from her impairments:

After careful consideration of the entire record, the
undersigned finds that [Gonzalez] has the [RFC] to perform
sedentary work as defined in 20 C.F.R. 404.1567(a) with the
following nonexertional limitations: [Gonzalez] can
occasionally perform postural activities; [Gonzalez] can have
no exposure to extreme heat, extreme cold, wetness, humidity,
fumes, odors, dusts, gases, and hazards such as machinery
and unprotected heights; [Gonzalez] can perform simple,
routine tasks involving no interaction with the public and only
occasional interaction with supervisors and coworkers.

(Tr. 48).

At step four, the ALJ found that Gonzalez had past relevant work
experience working as a telemetric nurse and a registered nurse. (Tr. 51).
At step five, the ALJ determined that based on Gonzalez’s age, education,
work experience, and RFC that there were a significant number of jobs
in the national economy that she could perform, including working as a
carding machine operator, final assembler, and dowel inspector. (Tr. 52).
Gonzalez contends that the decision of the ALJ is not supported by
substantial evidence of record and raises four issues on appeal attacking

various aspects of the ALJ’s decision. We shall address each argument
seriatim.
A. Substantial Evidence Supports the ALJ’s RFC Assessment

Gonzalez’s first claim of error, challenges the ALJ’s RFC
assessment. (Doc. 11, at 13-16). Specifically, Gonzalez argues that the
ALJ limited her to an RFC of sedentary work, which requires an

individual to stand or walk for no more than two hours in an eight-hour
workday. (Doc. 11, at 13).6 Gonzalez contends that the RFC does not

include any additional functional limitations to reflect her actual
limitations, which derive from her physical impairments. (Id.). Gonzalez
asserts that her physical impairments do not permit her to stand or walk

for two hours in an eight-hour workday as required under the sedentary
RFC. (Id.). Thus, Gonzalez argues that the sedentary RFC is not
supported by the record. (Id.). Gonzalez further contends that there were

no competent medical opinions upon which the ALJ properly relied in
formulating the RFC. (Id.).
Lastly, Gonzalez argues that the ALJ erroneously denied her

request to leave the record open. Gonzalez argues:
[At] the time of the hearing [Gonzalez] requested that the
record be left open following the hearing to submit records

6 The regulations define sedentary work as involving lifting no more than
ten pounds at a time and occasionally lifting or carrying articles like
docket files, ledgers, and small tools. Although sitting is involved, a
certain amount of walking and standing is often necessary in carrying
out job duties. Jobs are sedentary if walking and standing are required
“occasionally” and other sedentary criteria are met. 20 C.F.R.
404.1567(a); see also SSR 83-10p, 1983 WL 31251 at *5. By definition,
“occasionally” means occurring from very little up to one-third of the
time. Since being on one’s feet is required “occasionally” at the sedentary
level of exertion, periods of standing or walking should generally total no
more than about two hours of an eight-hour workday, and sitting should
generally total approximately six hours of an eight-hour work-day. SSR
83-10p, 1983 WL 31251 at *5.
regarding two upcoming surgeries, and despite the fact that
these would be occurring shortly after the hearing, the ALJ
denied [Gonzalez’s request] to leave the record open, stating
that the ALJ would expect that [Gonzalez] would recover from
these surgeries in less than one year. (Admin Tr. 1101). This
assumption by the ALJ as to the relevance of medical evidence
not yet of record, as well as his assumption that [Gonzalez]
will recover in a certain period of time, is an abuse of
discretion by the ALJ, who should have left the record open to
accept evidence. As the nature of the surgeries was to address
conditions noted to be severe by the ALJ, the records clearly
may have been relevant, particularly if there were
complications following the surgeries.

(Doc. 11, at 15).

In response, the Commissioner argues that the ALJ correctly
considered all of Gonzalez’s impairments and reasonably assessed an
RFC that was substantially supported by the evidence of record. (Doc. 12,
at 12). The Commissioner further contends that the ALJ did not abuse
his discretion by refusing to leave the record open until after her
surgeries. (Doc. 12, at 11). The Commissioner avers that Gonzalez did not
submit her evidence timely and the ALJ reasonably concluded, based on
her counsel’s proffer, that it was not likely to alter his decision. Therefore,
the Commissioner contends that the ALJ did not abuse his discretion.
The ALJ—not treating or examining physicians or State agency
consultants—must make the ultimate disability and RFC
determinations. Chandler v. Comm’r of Soc. Sec., 667 F.3d at 356, 361

(3d Cir. 2011). RFC is defined as “that which an individual is still able to
do despite the limitations caused by his or her impairment(s).’” Burnett
v. Comm’r of Soc. Sec., 220 F.3d 112, 121 (3d Cir. 2000) (quoting

Hartranft v. Apfel, 181 F.3d 358, 359(3d Cir. 1999)). It reflects the most
that an individual can still do, despite his or her limitations, and is used
at steps four and five to evaluate the claimant’s case. 20 C.F.R. §§

404.1520, 404.1545; SSR 96-8P, 1996 WL 374184 at *2. In assessing the
RFC, the ALJ must consider all the evidence of the record and, regardless
of its source, “evaluate every medical opinion . . . receive[d].” Burnett, 220

F.3d at 121 (internal citations omitted). The Court’s “review of the ALJ’s
assessment of the [claimant]’s RFC is deferential,” and the “RFC
assessment will not be set aside if it is supported by substantial

evidence.” Black v. Berryhill, No. 16-1768, 2018 WL 4189661 at *3 (M.D.
Pa. Apr. 13, 2018); see also Martin v. Comm’r of Soc. Sec., 547 F. App’x
153, 160 (3d Cir. 2013) (“We examine the ALJ’s conclusions as to a

claimant’s RFC with the deference required of the substantial evidence
standard of review.” (internal quotation marks omitted)).
Here, we find that substantial evidence supports the ALJ’s RFC

assessment. In crafting the RFC, the ALJ considered all of Gonzalez’s
physical and mental health impairments, including Gonzalez’s obesity,
asthma, diabetes, osteoarthritis, degenerative disc disease with

radiculopathy, cervicalgia, and myofascial pain syndrome. The ALJ
explained, however, that despite evidence of severe physical and mental
health impairments, the objective medical evidence revealed limited

abnormal findings. For example, while imaging of Gonzalez’s lumbar and
cervical spines revealed degenerative disc disease and osteoarthritis at
multiple levels, the overall degenerative changes were “mild” and

“slight.” (Tr. 1403-36, 1437-85, 1523-25). Further, the ALJ explained that
while the medical record revealed that Gonzalez suffered from
radiculopathy, as Gonzalez described numbness and weakness,

particularly in her left leg, the medical record also revealed that Gonzalez
experienced some positive response to medication, and that epidural
steroid injections provided 60 percent pain relief in Gonzalez’s back and

resolution of her leg pain. (Tr. 1729-64, 1765-1899). Moreover, upon
physical examinations it was noted that Gonzalez exhibited moderate
trapezius muscle spasms, but adequate range of motion in her cervical
spine; that she did not use a walking aid; that her gait and station was

normal; and that she showed no signs of limb or joint pain. (Tr. 1528).
As for her asthma, the medical record demonstrated that Gonzalez
complained of exacerbation of her symptoms on various occasions,

reporting cough, shortness of breath, and chest tenderness. (Tr. 1437-85,
1556-66, 1585-98). The ALJ explained, however, that the frequency of
Gonzalez’s asthma-related hospitalizations were not corroborated in the

record and that the medical record demonstrated minimal abnormal
findings. For example, in February 2017, spirometry testing showed a
normal forced vital capacity (FVC) and forced expiratory volume (FEV);

during her February 2017 consultative exam, Gonzalez exhibited no rales
or wheezing, and no laborious breathing; and during a May 2018
examination, Gonzalez only reported experiencing mild breathing issues,

with off and on wheezing and chest tightness. (Tr. 50, 1437-85, 1529,
1548-53, 1556-66, 1585-98, 1926-27).
With regard to Gonzalez’s mental health impairments, the ALJ

explained that the medical record reflected that Gonzalez’s mental health
treatment was fairly routine, with few significant abnormalities during
mental status examinations, and that Gonzalez had reported good
response to medication. (Tr. 1567, 1691-1728, 100-07). The ALJ further

explained that while the medical record demonstrated that Gonzalez
presented signs and symptoms of depression, and complained of physical
symptoms from obesity, chronic asthma, and vocal dysfunction, Gonzalez

exhibited an adequate intellectual capacity to solve problems; she was
able to interact socially with others; and she was capable of managing
money. (Tr. 1544).

The ALJ also considered the opinion evidence of record in
formulating the RFC. (See Admin. Tr. 50-51). With regard to Gonzalez’s
physical impairments, the ALJ considered the opinions of State agency

medical consultants, Dr. Pedro Nieves (“Dr. Nieves”) and Dr. Rafael
Queipo (“Dr. Queipo”). (Tr. 50). Both physicians opined that Gonzalez
was capable of performing work at the light exertional level, involving

frequent postural maneuvers and no concentrated exposure to extreme
temperatures, wetness, humidity, and pulmonary irritants. (Tr. 1140-42;
1157-59). The ALJ, however, afforded the opinions of Drs. Nieves and

Queipo “partial” weight, concluding that while their opinions reflected
appropriate areas of limitation, they did not reflect the full extent of
Gonzalez’s limitations. (Tr. 50).
With regard to Gonzalez’s mental health impairments, the ALJ

considered the opinions of State agency psychological consultants, Dr.
Jesus Soto (“Dr. Soto”) and Dr. Zulma Nieves (“Dr. Z. Nieves”) and
accorded their opinions “little” weight. (Tr. 50-51). Dr. Soto and Dr. Z.

Nieves both opined that Gonzalez had no severe mental impairments,
with no more than mild limitation in any of the “paragraph B” functional
areas. (Tr. 1139-40, 1155-56). The ALJ assigned “little” weight to the

opinions of Drs. Soto and Z. Nieves, concluding that their opinions were
not consistent with the evidence of record, which was sufficient in
establishing more than minimal difficulties related to Gonzalez’s mental

impairments. (Tr. 50-51).
Lastly, the ALJ considered other evidence in crafting the RFC,
including Gonzalez’s own statements. For example, Gonzalez testified

that she could not sit longer than 30 minutes due to her pain, that she
uses a rescue inhaler approximately four times per day, that she could
not continue working in Puerto Rico as she was missing a lot of work due

to her health issues, and that she has required the use of a cane since at
least November 2017. (Tr. 1105, 1109, 1112-1118). However, despite
alleging disabling symptoms stemming from her physical and mental
impairments, Gonzalez described her daily activities in terms that were

not wholly disabling. For example, Gonzalez reported that she could care
for most of her personal needs; she washes clothes with the help of her
family; she prepares meals for her husband and children; she drives; she

goes grocery shopping and goes to church; she is capable of paying bills,
and handling a checking account; she watches television and listens to
music; and she spends time with her family. (Tr. 1305-12, 1539-44).

Gonzalez argues that the ALJ erroneously limited her to an RFC of
sedentary work because she is unable to stand or walk for two hours in
an eight-hour workday as required under the sedentary work RFC. (Doc.

11, at 13). Gonzalez contends that the sedentary RFC fails to include any
additional functional limitations that account for her physical
impairments. (Id.). Gonzalez further contends that there are no

competent medical opinions upon which the ALJ properly relied in
formulating the RFC. (Id.). The Court is not persuaded by Gonzalez’s
arguments as to this issue. At the outset, the ALJ carefully considered

the evidence of record. The ALJ, however, was confronted by a record
marked with contrasting evidence, and inconsistencies regarding
Gonzalez’s abilities and limitations. Reconciling the discordant and
conflicting threads of evidence, the ALJ confined Gonzalez to an RFC of

sedentary work with additional limitations to address her impairments.
(Tr. 48). It is the right and responsibility of the ALJ to make such
assessments and we find that substantial evidence supported the ALJ’s

decision as to this matter.
Additionally, while Gonzalez argues that the RFC does not include
any additional functional limitations to adequately account for her

physical impairments, Gonzalez fails to indicate the functional
limitations that should have been included in the RFC or what evidence
the ALJ failed to consider. Moreover, Gonzalez contends that there were

no competent medical opinions upon which the ALJ properly relied in
crafting the RFC. However, we find that Gonzalez’s contentions on this
score are without merit. As mentioned above, the ALJ properly

considered the opinion evidence of record and assigned “partial” weight
to the opinions of Drs. Nieves and Queipo and assigned “little” weight to
the opinions of Drs. Soto and Z. Nieves. (Tr. 50-51). In doing so, the ALJ

provided valid reasons for his evaluations and based his conclusions on
substantial evidence. Thus, the Court finds no basis for disturbing the
ALJ’s determination on this matter.
Lastly, Gonzalez argues that the ALJ erroneously denied her

request to leave the record open to submit records concerning her two
upcoming surgeries. We disagree. As correctly asserted by the
Commissioner, Gonzalez did not submit her evidence timely. Thus, the

ALJ reasonably concluded, based on her counsel’s proffer, that leaving
the record open for submission of additional evidence pertaining to her
upcoming surgeries, would not likely alter his decision. See 20 C.F.R. §

404.935.
Further, it is longstanding precedent in this jurisdiction “that
evidence not presented to the [ALJ] should not be reviewed by the district

court nor be the basis of remand to the Commissioner, unless the
evidence is ‘new’ and ‘material,’ and there is ‘good cause’ [for the
claimant] not having produced the evidence earlier.” Matthews v. Apfel,

239 F.3d 589, 590 (3d Cir. 2001). Here, as correctly stated by the
Commissioner, Gonzalez has offered no specific argument as to how her
post-hearing submission is ‘new,’ ‘material,’ relates to the relevant

period, and creates a reasonable probability that it would change the
outcome of her case. (Doc 11, at 11-16). Thus, this evidence cannot be
used to challenge the ALJ’s decision on substantial evidence grounds.
To reiterate, this Court is not now tasked with revisiting these

factual issues, and we may not substitute our judgment of that of the
ALJ. Instead, we are limited to determining whether the ALJ provided
valid reasons for his evaluations and based his conclusions on substantial

evidence. Thus, finding that the ALJ provided adequate articulation for
these determinations which were grounded in substantial evidence, the
Court finds no basis for disturbing the ALJ’s determination on this issue.

B. Substantial Evidence Supports the ALJ’s Step Two
Evaluation and Any Alleged Error is Harmless on These
Facts

Gonzalez’s next claim of error, challenges the ALJ’s step two
evaluation. (Doc. 11, at 19). Specifically, Gonzalez argues that the
medical record confirms that she suffers from a number of conditions not
considered to be severe by the ALJ, including her sleep apnea, erosive
gastritis, diverticulitis, neuropathy in her hands and feet, lysis of
adhesions, and ovarian cysts. (Doc. 11, at 17). Gonzalez alleges that these
conditions cause more than a ‘slight limitation’ with regard to her

activities of daily living. Gonzalez contends:
[The] fact that the ALJ considered these disorders to be non-
severe in nature, and the fact that he offered little discussion
regarding these disorders, is further confirmation that the
ALJ did not consider these disorders, or limitations related
thereto, in setting forth [Gonzalez’s] RFC . . . these conditions
should have been considered to be severe, as they have more
than a minimal effect upon [Gonzalez], and should have been
factored into her RFC. Even if the ALJ had not considered
these conditions to be severe, they should have been
considered and analyzed by the ALJ, as even limitations from
non-severe impairments need to be considered in setting forth
a claimant’s RFC.

(Doc. 11, at 18-19).

In response, the Commissioner argues that the ALJ correctly
considered all of Gonzalez’s impairments and reasonably assessed an
RFC that was substantially supported by the evidence of record. (Doc. 12,
at 12). The Commissioner further contends that while the record contains
evidence that these impairments existed during the relevant time period,
there is no evidence of resulting significant work-related limitations as
averred by Gonzalez. (Doc. 12, at 14).
At step-two of the sequential analysis, the ALJ determines whether
a claimant has a medically severe impairment or combination of
impairments. Bowen v. Yuckert, 482 U.S. 137, 140-41 (1987). An
impairment is considered severe if it “significantly limits an individual’s
physical or mental abilities to do basic work activities. 20 C.F.R.

404.1520(c). An impairment is severe if it is “something beyond a slight
abnormality or a combination of slight abnormalities which would have
no more than a minimal effect on an individual’s ability to work.” McCrea

v. Comm’r of Soc. Sec., 370 F.3d at 357, 360 (3d Cir. 2004) (quoting SSR
85-28, 1985 WL 56856 (1985)). The Court of Appeals is clear that the
step-two inquiry is a de minimis screening device used to cast out

meritless claims. McCrea, 370 F.3d at 360; Newell v. Comm’r of Soc. Sec.,
347 F.3d 541, 546 (3d Cir. 2003). The burden is on the claimant to show
that an impairment qualifies as severe. Bowen, 482 U.S. at 146.

Applying the above standard, we find that the ALJ’s step two
evaluation is supported by substantial evidence. At step two, the ALJ
considered all of Gonzalez’s alleged impairments, including her severe

persistent asthma, bronchitis, high blood pressure, diabetes, sleep apnea,
depression, anxiety, and severe morbid obesity. The ALJ concluded,
however, that through the date last insured, Gonzalez had the following

severe impairments: obesity, asthma, diabetes, osteoarthritis,
degenerative disc disease with radiculopathy, cervicalgia, myofascial
pain syndrome, moderate recurrent major depression, and unspecified

anxiety disorder. (Tr. 46). The ALJ then concluded that Gonzalez had the
following nonsevere impairments: sleep apnea, erosive gastritis, and
gastroesophageal reflux disorder (GERD). (Id.). In forming this
determination, the ALJ considered Gonzalez’s treatment records and

testimony concerning her activities of daily living, as mentioned above.
(See Admin Tr. 49-51). The ALJ, however, found that these impairments
did not significantly limit Gonzalez’s physical or mental abilities to

perform basic work activities. (Id.). The ALJ explained that while all of
these conditions were nonsevere, he considered all of Gonzalez’s severe
and nonsevere impairments in crafting the RFC. (Id.). The ALJ further

explained that in crafting the RFC, he included the appropriate
exertional and nonexertional limitations to adequately address all of
Gonzalez’s severe and nonsevere impairments. (Tr. 46-47).

Gonzalez argues that the ALJ should have found her diverticulitis,
neuropathy in her hands and feet, lysis of adhesions, and ovarian cysts
to be severe impairments. However, Gonzalez never alleged that these

impairments limited her ability to work. Moreover, the ALJ did not deny
Gonzalez’s claim at step two of the sequential evaluation process.
Therefore, it is not necessary for the ALJ to have specifically found any

additional alleged impairments to be severe because the ALJ considered
the effects of these impairments at steps three through five of the
sequential evaluation process. See Naomi Rodriguez v. Berryhill,
No.1:18-CV-684, 2019 WL 2296582, at *10 (M.D. Pa. May 30, 2019)(citing

cases); see also Salles v. Comm’r of Soc. Sec., 229 Fed. Appx 140, 145 (3d
Cir. 2007). Thus, any possible error at step two of the sequential
evaluation process is harmless.

Hence, contrary to Gonzalez’s contentions, the ALJ considered her
impairments at step two of the sequential evaluation process, and
continued to consider them throughout this process in crafting the

sedentary work RFC. It appears that Gonzalez is requesting that this
Court re-weigh the evidence. This we may not do. See, Rutherford v.
Barnhart, 399 F.3d 546, 552 (3d Cir. 2005) (“In the process of reviewing

the record for substantial evidence, we may not ‘weigh the evidence or
substitute our own conclusions for those of the fact-finder.”’ (quoting
Williams v. Sullivan, 970 F.2d 1178, 1182 (3d Cir. 1992))). Because we

cannot re-weigh the evidence, we find the ALJ has not erred at step two
of the sequential evaluation process.
C. Substantial Evidence Supports the ALJ’s Consideration
of the Opinion Evidence of Record

Next, Gonzalez argues that the ALJ erred in formulating the RFC
assessment by assigning to much weight to the opinions of Drs. Nieves
and Queipo, State agency medical consultants, and Drs. Soto and Z.
Nieves, State agency psychological consultants. (Doc. 11, at 19).

Specifically, Gonzalez contends:
The exertional limitations set forth by the ALJ in many ways
mirror those provided in the Disability Determination
Transmittal, regarding [Gonzalez’s] exertional limitations at
the time of the initial claim. It is important to note that the
ALJ makes no reference to any medical opinions of record,
from a CE, ME, or treating source, in setting forth his
discussion in his decision regarding his rendering of
[Gonzalez’s] RFC. (See ALJ decision, generally). Regarding
the lack of any opinion of record which the ALJ relied upon
regarding [Gonzalez’s] exertional limitations, it is well
established that “rarely can a decision be made regarding a
claimant’s [RFC] without an assessment from a physician
regarding the functional abilities of the claimant. (Doak v.
Heckler, 790 F.2d 26, 29 (3d Cir. 1986). (“No physician
suggested that the activity Doak could perform was consistent
with the definition of light work set forth in the regulations,
and therefore the ALJ’s conclusion that he could is not
supported by the record.”). The only opinions of record in this
matter, which were relied upon by the ALJ, are from State
agency physicians, who never examined [Gonzalez].

(Doc. 11, at 22).

In response, the Commissioner argues that the ALJ did not rely on
the State agency reviewing medical consultants to assess Gonzalez’s
RFC. The Commissioner avers that the ALJ accorded “partial” weight to
the opinions of Drs. Nieves and Queipo, and accorded “little” weight to
the opinions of Drs. Soto and Z. Nieves. (Doc. 12, at 15). Thus, the ALJ
did not rely exclusively on these opinions to assess Gonzalez’s RFC. (Id.).
The Commissioner further contends that the ALJ is entitled to rely on

the opinions provided by State agency reviewing medical consultants.
The law is clear, “[s]tate agency physicians and psychologists are
considered to be ‘highly qualified physicians and psychologists who are

also experts in Social Security disability evaluations.” Poulos v. Comm’r
of Soc. Sec., 474 F.3d 88, 96 (3d Cir. 2007).
Further, the ALJ—not treating or examining physicians or State

agency consultants—must make the ultimate disability and RFC
determinations. Chandler, 667 F.3d at 361. In crafting the RFC, the ALJ
must consider all the evidence of record, including medical signs and

laboratory findings, daily activities, medical source statements, and a
claimant’s medical history. SSR 96-8p, 1996 WL 374184, at *5; see also
Mullin v. Apfel, 79 F. Supp. 2d 544, 548 (E.D. Pa. 2000). Upon considering

the opinion evidence of record, the ALJ is charged with a duty to evaluate
all the medical opinions in the record under the factors set forth in the
regulations and to resolve any conflicts. 20 C.F.R. § 404.1527. An ALJ

may give an opinion less weight or no weight if it does not present
relevant evidence or a sufficient explanation to support it, or if it is
inconsistent with the record as a whole. 20 C.F.R. § 404.1527(c). The ALJ
may choose which medical evidence to credit and which to reject as long

as there is a rational basis for the decision. Plummer, 186 F.3d at 429.
Here, we find that substantial evidence supports the ALJ’s
consideration of the opinion evidence of record. In crafting the RFC, the

ALJ considered the opinions of Drs. Nieves, Queipo, Soto, and Z. Nieves.
With regard to Gonzalez’s physical impairments, Drs. Nieves and Queipo
both opined for the initial and reconsideration determinations that

Gonzalez could perform work at the light exertional level involving
frequent postural maneuvers and no concentrated exposure to extreme
temperatures, wetness, humidity, and pulmonary irritants. (Tr. 1140-42;

1157-59). The ALJ, however, accorded the opinions of Drs.
Nieves and Queipo “partial” weight. (Tr. 50). The ALJ reasoned that
while their opinions reflected appropriate areas of limitation, their

opinions did not reflect the full extent of Gonzalez’s limitations. (Id.).
Thus, the ALJ accorded the opinions of Drs. Nieves and Queipo “partial”
weight.

As for her mental health impairments, the ALJ considered the
opinions of Drs. Soto and Z. Nieves and accorded their opinions “little”
weight. (Tr. 50-51). Both Drs. Soto and Z. Nieves opined for the initial
and reconsideration determinations that Gonzalez had no severe mental

impairments, with no more than mild limitations in any of the
“paragraph B” functional areas. (Tr. 1139-40, 1155-56). The ALJ accorded
Drs. Soto and Z. Nieves opinions “little” weight. The ALJ reasoned that

the opinions of Drs. Soto and Z. Nieves were not consistent with the
evidence of record, which was sufficient in establishing more than
minimal difficulties related to Gonzalez’s mental health impairments.

(Tr. 50-51). Thus, the ALJ accorded the opinions of Drs. Soto and Z.
Nieves “little” weight.
Gonzalez argues that the medical record lacks a proper medical

opinion from a medical examiner, consultative examiner, and treating
source. She concludes that the RFC is not supported by substantial
evidence because the ALJ had no proper medical opinion upon which to

rely. We disagree. As correctly asserted by the Commissioner, “[s]tate
agency physicians and psychologists are considered to be ‘highly qualified
physicians and psychologists who are also experts in Social Security

disability evaluations.’” Poulos v. Comm’r of Soc. Sec., 474 F.3d 88, 96 (3d
Cir. 2007). Further, as mentioned above, the ALJ—not treating or
examining physicians or State agency consultants—bears the exclusive
duty in making the ultimate disability and RFC determinations.

Chandler, 667 F.3d at 361. In fulfilling this responsibility, there is no
legal requirement that a physician have made the particular findings
that an ALJ adopts in the course of determining an RFC. Titterington v.

Barnhart, 174 Fed. App’x 6, 11 (3d Cir. 2006).
Therefore, because the ALJ provided valid reasons for his
evaluations and based his conclusions on substantial evidence, we find

that the ALJ did not err in weighing the opinion evidence of record.
D. The ALJ Did Not Err in His Consideration of Plaintiff’s
Use of a Cane in Crafting the RFC

Gonzalez’s final contention challenges the ALJ’s consideration of
her use of a cane in formulating the RFC. (Doc. 11, at 23-24). Specifically,
Gonzalez argues that the ALJ made a finding in his decision that she
used a cane for her upper dominant extremity to walk and stand. (Doc.
11, at 23). However, the ALJ offered no mention of her use of a cane to

walk and stand in the RFC. (Id.). Gonzalez contends that the ALJ
confined her to an RFC of sedentary work, which means she must engage
in walking and standing up to a combined one-third of the workday. (Id.).

Thus, Gonzalez contends that to perform work at the sedentary
exertional level, she would need a cane to walk or stand due to issues
with both her lower and upper extremities, which would render her

incapable of gainful employment. (Doc. 11, at 24).
As mentioned above, in assessing a claimant’s RFC, the ALJ must
consider all the evidence of the record, including medical signs and

laboratory findings, daily activities, medical source statements, and a
claimant’s medical history. SSR 96-8p, 1996 WL 374184, at *5; see also
Mullin v. Apfel, 79 F. Supp. 2d 544, 548 (E.D. Pa. 2000). However, “[t]o

find that a hand-held assistive device is medically required, there must
be medical documentation establishing the need for a hand-held assistive
device to aid in walking or standing, and describing the circumstances

for which it is needed.” SSR 96-9, 1996 WL 374185 at *7.
In this case, reviewing the record as a whole, we find that the ALJ
properly considered Gonzalez’s use of a cane in crafting the RFC. As

correctly asserted by Gonzalez, the ALJ noted in his decision that
Gonzalez uses a cane to take the pressure off her back. (See Admin. Tr.
49). Despite not appearing with or using an assistive device at her

administrative hearing, the ALJ nevertheless considered Gonzalez’s
testimony that she uses a cane to effectively ambulate. (See Admin. Tr.
1103).
Also, while Gonzalez testified that she requires an assistive device

to aid her in walking and/or standing, she fails to identify any medical
documentation establishing the need for a hand-held assistive device.
Therefore, because we find that Gonzalez has failed to carry her burden,

we find no basis for disturbing the ALJ’s determination on this matter.
An appropriate Order follows.

Dated: August 27, 2020 s/Joseph F. Saporito, Jr.
JOSEPH F. SAPORITO, JR.
United States Magistrate Judge

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10409162. Public record. Not legal advice.