Collins v. Saul

IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF PENNSYLVANIA

BRENDA COLLINS, : CIVIL NO.: 1:20-cv-01206

:

Plaintiff, : (Magistrate Judge Schwab)

v. :

:

KILOLO KIJAKAZI, :

Acting Commissioner of :

Social Security, :

:

Defendant. :

MEMORANDUM OPINION

I. Introduction.

This is a social security action brought under 42 U.S.C. § 405(g). The

plaintiff, Brenda L. Collins (“Collins”), seeks judicial review of the final decision of

the Acting Commissioner of Social Security (“Commissioner”) denying her claim

for disability insurance benefits under Title II of the Social Security Act.

This matter is before us, upon consent of the parties pursuant to 28 U.S.C.

§ 636(c) and Rule 73 of the Federal Rules of Civil Procedure. After reviewing the

parties’ briefs, the Commissioner’s final decision, and the relevant portions of the

certified administrative transcript, we find that the Commissioner’s final decision

does not sufficiently articulate the way the administrative law judge evaluated

evidence in this case. We, therefore, cannot determine if the Commissioner’s final

decision is supported by substantial evidence. Accordingly, the Commissioner’s

final decision will be remanded so that the administrative law judge can more clearly

explain how he arrived at his findings.

II. Background and Procedural History.

We refer to the transcript provided by the Commissioner. See docs. 13-1 to

13-19.1 On April 12, 2018, Collins protectively applied2 for disability insurance

benefits, alleging that she has been disabled since March 31, 2017. Admin. Tr. at 15.

After the Commissioner denied the claim at the initial level of administrative review,

Collins requested an administrative hearing, which was held before Administrative

Law Judge (“ALJ”) Richard E. Guida on June 12, 2019. Id.

The ALJ determined that Collins has not been disabled since March 31, 2017,

the date of her application, and so he denied her benefits. Id. at 27. Collins appealed

the ALJ’s decision to the Appeals Council, which denied her request for review on

June 2, 2020. Id. at 1. This makes the ALJ’s decision the final decision of the

Commissioner subject to judicial review by this court.

1 The facts of the case are well known to the parties and will not be repeated here.

Instead, we will recite only those facts that bear on Collins’s claims.

2 “Protective filing is a term for the first time an individual contacts the Social

Security Administration to file a claim for benefits.” Stitzel v. Berryhill, No. 3:16-

CV-0391, 2017 WL 5559918, at *1 n.3 (M.D. Pa. Nov. 9, 2017). “A protective

filing date allows an individual to have an earlier application date than the date the

application is actually signed.” Id.

Collins filed this action on July 14, 2020. Doc. 1. The Commissioner filed an

answer to the complaint and a transcript of the proceedings that occurred before the

Social Security Administration on December 9, 2020. Docs. 12-13. The parties then

filed briefs, see docs. 15, 16, 17, and this matter is ripe for decision.

III. Legal Standards.

A. Substantial Evidence Review—the Role of This Court.

When reviewing the Commissioner’s final decision denying a claimant’s

application for benefits, “the court has plenary review of all legal issues decided by

the Commissioner.” Ficca v. Astrue, 901 F. Supp. 2d 533, 536 (M.D. Pa. 2012). But

the court’s review of the Commissioner’s factual findings is limited to whether

substantial evidence supports those findings. See 42 U.S.C. § 405(g); Biestek v.

Berryhill, 139 S. Ct. 1148, 1152 (2019). “[T]he threshold for such evidentiary

sufficiency is not high.” Biestek, 139 S. Ct. at 1154. Substantial evidence “means—

and means only—‘such relevant evidence as a reasonable mind might accept as

adequate to support a conclusion.’” Id. (quoting Consol. Edison Co. of New York v.

N.L.R.B., 305 U.S. 197, 229 (1938)).

Substantial evidence “is less than a preponderance of the evidence but more

than a mere scintilla.” Jesurum v. Sec’y of U.S. Dep’t of Health & Human Servs., 48

F.3d 114, 117 (3d Cir. 1995). 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). But 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] finding 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 this court, therefore, is not whether Collins is disabled,

but whether substantial evidence supports the Commissioner’s finding that she is not

disabled and whether the Commissioner correctly applied the relevant law.

B. Initial Burdens of Proof, Persuasion, and Articulation.

To receive benefits under Title II of the Social Security Act, a claimant

generally 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); 20 C.F.R.

§ 404.1505(a). To satisfy this requirement, a claimant must have a severe physical

or mental impairment that makes it impossible to do his or her previous work or any

other substantial gainful work that exists in the national economy. 42 U.S.C.

§ 423(d)(2)(A); 20 C.F.R. § 404.1505(a). To receive disability insurance benefits

under Title II of the Social Security Act, a claimant must show that he or she

contributed to the insurance program, is under retirement age, and became disabled

prior to the date on which he or she was last insured. 42 U.S.C. § 423(a); 20 C.F.R.

§ 404.131(a).3

The ALJ follows a five-step sequential-evaluation process to determine

whether a claimant is disabled. 20 C.F.R. § 404.1520(a). Under this process, the ALJ

must sequentially determine: (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) whether the claimant

is able to do his or her past relevant work; and (5) whether the claimant is able to do

any other work, considering his or her age, education, work experience, and residual

functional capacity (“RFC”). 20 C.F.R. § 404.1520(a)(4)(i)–(v).

3 “Disability insurance benefits are paid to an individual if that individual is disabled

and ‘insured,’ that is, the individual has worked long enough and paid social security

taxes.” Jury v. Colvin, No. 3:12-CV-2002, 2014 WL 1028439, at *1 n.5 (M.D. Pa.

Mar. 14, 2014) (citing 42 U.S.C. §§ 415(a), 416(i)(1)). “The last date that an

individual meets the requirements of being insured is commonly referred to as the

‘date last insured.’” Id. (citing 42 U.S.C. § 416(i)(2)). Here, the ALJ determined that

Collins met the insured-status requirements through December 31, 2022. Admin. Tr.

at 17.

Between steps three and four, the ALJ must assess a claimant’s RFC. Hess v.

Comm’r of Soc. Sec., 931 F.3d 198, 198 n.2 (3d Cir. 2019). The RFC is ‘“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 n.1 (3d Cir. 1999)); see also 20 C.F.R.

§ 404.1545(a)(1). In making this assessment, the ALJ considers all the claimant’s

medically determinable impairments, including any non-severe impairment

identified by the ALJ at step two of his or her analysis. 20 C.F.R. § 404.1545(a)(2).

“The claimant bears the burden of proof at steps one through four” of the

sequential-evaluation process. Smith v. Comm’r of Soc. Sec., 631 F.3d 632, 634 (3d

Cir. 2010). But at step five, “the burden of production shifts to the Commissioner,

who must . . . show there are other jobs existing in significant numbers in the national

economy which the claimant can perform, consistent with her medical impairments,

age, education, past work experience, and residual functional capacity.” Fargnoli v.

Massanari, 247 F.3d 34, 39 (3d Cir. 2001).

The ALJ’s disability determination must also meet certain basic substantive

requisites. Most significantly, the ALJ must provide “a clear and satisfactory

explication of the basis on which” his or her decision rests. Cotter v. Harris, 642

F.2d 700, 704 (3d Cir. 1981). “The ALJ must indicate in his decision which evidence

he has rejected and which he is relying on as the basis for his finding.” Schaudeck v.

Comm’r of Soc. Sec. Admin., 181 F. 3d 429, 433 (3d Cir. 1999). The “ALJ may not

reject pertinent or probative evidence without explanation.” Johnson v. Comm’r of

Soc. Sec., 529 F.3d 198, 204 (3d Cir. 2008). Otherwise, ‘“the reviewing court cannot

tell if significant probative evidence was not credited or simply ignored.’” Burnett,

220 F.3d at 121 (quoting Cotter, 642 F.2d at 705).

IV. The ALJ’s Decision.

On June 28, 2019, the ALJ denied Collins’s claims for benefits. Admin. Tr.

at 27. First, the ALJ found that Collins meets the insured status requirements of the

Social Security Act through December 31, 2022. Id. at 17. At step one of the

sequential-evaluation process, the ALJ found that Collins did not engage in

substantial gainful activity between March 31, 2017 (the alleged onset date) and June

28, 2019 (the date of the decision). Id.

At step two of the sequential-evaluation process, the ALJ found that Collins

had the following severe impairments: status post rectal cancer, Achilles tendonitis,

degenerative disc disease, status post cervical spine fusion, fibromyalgia,

hypertension, migraine headaches, psoriatic arthritis, right rotator cuff tear, sleep

apnea, obesity, depression, and anxiety. Id. The ALJ also identified the following

medically determinable non-severe impairments: locking of the thumb, allergic

rhinitis, mild intermittent asthma, and GERD. Id. at 17-18.

At step three of the sequential-evaluation process, the ALJ found that Collins

did not have an impairment or combination of impairments that met or medically

equaled an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. Admin.

Tr. at 18. More specifically, the ALJ discussed Listings 1.02(A), 1.02(B), 1.04,

12.04, 12.06, and 14.09, and he determined that Collins did not meet any of those

listings. Id. at 18-19. In connection with his discussion of listings 12.04 and 12.06—

mental health listings—the ALJ concluded that Collins had moderate limitations in

understanding, remembering, or applying information; moderate limitations in

interacting with others; moderate limitations in concentrating, persisting, or

maintaining pace; and moderate limitations in adapting and maintaining oneself. Id.

at 18-19.

Between steps three and four, the ALJ determined that Collins has the RFC to

perform “light work,” as defined in 20 C.F.R. 404.1567(b), except with:

occasional postural activities except never climb ladders, ropes, or

scaffolds, frequent handling[,] fingering bilaterally, occasional

overhead reaching with the right upper extremity, avoid even moderate

exposure to dangerous machinery and unprotected heights. She can

perform work that is limited to simple and routine tasks, involving only

simple, work-related decisions, and with few, if any, work place

changes, no production pace work, and only occasional interaction with

supervisors, coworkers, and the public.

Id. at 19.

At step four of the sequential-evaluation process, the ALJ found that Collins

is unable to do her past relevant work as a cardiac monitor technician, which was

actually performed at the light, skilled exertional level; as a nurse assistant, which

was actually performed at the heavy, semi-skilled exertional level; as a medical

secretary, which was actually performed at the sedentary and light, skilled exertional

levels; and as a medical transcriber, which was actually performed at the light,

skilled exertional level. Admin. Tr. at 26.

At step five of the sequential-evaluation process, considering Collins’s age,

education, work experience, and RFC, as well as the testimony of a vocational

expert, the ALJ found that there were jobs—such as electrical accessories assembler,

office helper, and marker—that exist in significant numbers in the national economy

that Collins could perform. Id. at 27. In support of his conclusion, the ALJ relied on

the testimony of a vocational expert. That expert testified that a person with the

Collins’s RFC could engage in the following three representative occupations:

assembler, electrical accessories (DOT # 729.687-010); office helper (DOT #

239.567-010); and marker (DOT # 209.587-034).

In sum, the ALJ concluded that Collins was not disabled from March 31, 2017,

through the date of his decision on March 26, 2019. Id. Thus, he denied Collins’s

claims for disability insurance benefits. Id.

V. Discussion.

Collins raises the following issues in her statement of errors:

(1) Substantial evidence does not support the ALJ’s RFC

assessment.

(2) The ALJ failed to properly evaluate Collins’s migraines.

Doc. 15 at 1. Although these arguments are both framed as challenges to the ALJ’s

RFC assessment, they are more accurately construed as challenges to the way the

ALJ evaluated, and articulated his evaluation of, evidence in this case. Accordingly,

Collins’s brief, however, is construed as raising the following issues:

(1) Whether the ALJ properly evaluated Collins’s statements that

her migraine headaches caused impaired concentration;

(2) Whether the ALJ properly explained and supported his

conclusion that Plaintiff could engage in lifting and carrying

consistent with the definition of light work;

(3) Whether the ALJ clearly articulated a function-by-function RFC

assessment; and

(4) Whether the ALJ properly accounted for Collins’s obesity in the

RFC assessment.

A. Whether the ALJ properly evaluated Collins’s testimony about the

limiting effects of her migraines.

The Commissioner’s regulations define “symptoms” as the claimant’s own

description of his or her impairment. 20 C.F.R. § 404.1502(i). The ALJ is not only

permitted, but also required, to evaluate a claimant’s statements about all symptoms

alleged and must decide whether and to what extent a claimant’s description of his

or her limitations may be deemed credible. In many cases, this determination has a

significant impact upon the outcome of a claimant’s application, because the ALJ

need only account for those symptoms – and the resulting limitations – that are

credibly established when formulating his or her RFC assessment. Rutherford v.

Barnhart, 399 F.3d 546, 554 (3d Cir. 2005). To facilitate this difficult analysis, the

Commissioner has devised a two-step process that must be undertaken by the ALJ

to evaluate a claimant’s statements about his or her symptoms.

First, the ALJ must consider whether there is an underlying medically

determinable impairment that can be shown by medically acceptable clinical and

laboratory diagnostic techniques that could reasonably be expected to produce the

symptoms alleged. 20 C.F.R. § 404.1529(b). If there is no medically determinable

impairment that could reasonably produce the symptom alleged, the symptoms

cannot be found to affect the claimant’s ability to do basic work activities. 20 C.F.R.

§ 404.1529(b); SSR 16-3p, 2016 WL 1119029.

Second, the ALJ must evaluate the intensity, persistence, and limiting effects

of the symptoms which can be reasonably attributed to a medically determinable

impairment. 20 C.F.R. § 404.1529(c)(1). Symptoms will be determined to reduce a

claimant’s functional capacity only to the extent that the alleged limitations and

restrictions can reasonably be accepted as consistent with objective medical

evidence and other evidence of record. 20 C.F.R. § 404.1529(c)(4). However, an

ALJ should not reject statements about the intensity, persistence, or limiting effects

of a symptom solely because it is not substantiated by objective evidence. 20 C.F.R.

§ 404.1529(c)(3). Instead, the ALJ should evaluate the extent to which any

unsubstantiated symptoms can be credited based on the following factors: the

claimant’s daily activities; the location, duration, frequency, and intensity of the

claimant’s pain or other symptoms; any factor that precipitates or aggravates the

claimant’s pain or other symptoms; the type, dosage, effectiveness, and side effects

of any medication the claimant takes or has taken to alleviate his or her pain or other

symptoms; any treatment, other than medication, the claimant receives or has

received for relief of his or her pain or other symptoms; any measures the claimant

uses or has used to relieve his or her pain or other symptoms (e.g., lying flat on your

back, standing for 15 to 20 minutes every hour, sleeping on a board, etc.); and any

other factors concerning functional limitations and restrictions due to pain or other

symptoms. 20 C.F.R. § 404.1529(c)(3).

An ALJ’s findings based on the credibility of a claimant are to be accorded

great weight and deference, since an ALJ is charged with the duty of observing a

witness’s demeanor and credibility. Frazier v. Apfel, No. 99-CV-715, 2000 WL

288246, at *9 (E.D. Pa. Mar. 7, 2000) (quoting Walters v. Comm’r of Soc. Sec., 127

F.3d 525, 531 (6th Cir. 1997)). However, an ALJ is not free to discount a claimant’s

statements about his or her symptoms or limitations for no reason or for the wrong

reason. Rutherford, 399 F.3d at 554.

In this case, Collins testified that she experiences migraines twice per week,

with each migraine lasting for twenty-four hours. Admin. Tr. at 44-45. Collins also

testified that during a migraine, focusing is a challenge. Id. at 44. She has prescribed

medication that she can take two times a day during a migraine. Collins reported

that the medication helps, but it does take time to work. Id. In response to a

questionnaire from the Social Security Administration, Collins reported that her

headaches interfere with her ability to pay attention. Id. at 204.

Although the ALJ acknowledged Collins’s migraine headaches while

summarizing the medical evidence,4 the ALJ did not discuss whether nor to what

extent migraine headaches interfere with Collins’s ability to pay attention nor any

other functional restriction resulting from Collins’s migraine headaches.

In her supporting brief, Collins argues:

The ALJ determined that Ms. Collins migraine headaches [were] a

severe medically determinable impairment. (Tr. 17) The RFC

4 See Admin. Tr. at 21 (“She also complained of daily headaches with no

improvement with over the counter medications. She acknowledged that she

clenches her jaw at night and has not been using her bite guard . . . . [Melissa

Wolfe, PA-C,] recommended that the claimant significantly reduce her caffeine

intake to help improve her sleep and headaches, as the claimant reported drinking

40oz of Pepsi and at least 20oz of tea per day.”); Id. at 22 (“[T]he claimant[]

reported ongoing daily headaches and migraine headaches once or twice a week

with no improvement with the use of Excedrin migraine.”); Id. at 23 (“[C]laimant

had improvement with both tension and migraine headaches with her headache

diary showing headaches occurring two to three times per week and of lesser

severity than previously.”).

assessment, however, did not include any functional restrictions that

addressed Ms. Collins migraines. (Tr. 19)

Treatment notes consistently document her complaints of migraine

headaches. (Tr. 485, 506, 509, 835, 838, 883, 1047) She received

continuing treatment for migraine headaches, including medications

like gabapentin and physical therapy. (Tr. 509, 885) In a function report

from June 2018, Ms. Collins stated that migraine headaches affected

her ability to work. (Tr. 204) Despite the evidence regarding the effects

of her headaches, the ALJ failed to properly evaluate Ms. Collins

migraine headaches and include appropriate restrictions in the RFC

assessment and in the hypothetical question to the vocational expert.

The ALJ did not assess frequency with which Ms. Collins migraines

occurred and did not include any related functional restrictions in RFC

assessment. The ALJ did not determine if the migraines occurred with

lesser frequency than Ms. Collins alleged and did not establish how,

even if she did suffer migraines but not with the frequency that she

alleged, how those migraines would affect ability to work.

The ALJ did not determine the frequency with which Ms. Collins

suffered migraines, the length of each migraine, or the methods that Ms.

Collins pursued in order to alleviate pain/symptoms of migraines. Moon

v. Colvin, 763 F.3d 718, 723 (7th Cir. 2014) (The ALJ failed to

adequately consider the claimant’s migraines in determining the

claimant’s RFC.); Heredia v. Colvin, 2015 WL 3819181 *4 (N.D. Ill.

2015); Phillips v. Astrue, 601 F.Supp.2d 1020, 1034 (N.D. Ill. 2009)

(ALJ failed to properly assess claimant’s headaches and her need to lie

down when she experienced a headache). The ALJ’s error was not

harmless, for, had the ALJ found that, due to migraines, Ms. Collins

needed to be away from her workstation or was distracted by severe

pain from Collins may have been off-task in excess of the percentage

of the workday that employers typically allowed. See McKinzey v.

Astrue, 641 F.3d 884, 892 (7th Cir. 2011) (Where the ALJ has erred by

failing to build a “logical bridge,” the Court looks at the evidence in the

record to determine whether it can predict with great confidence what

the result on remand will be.)

Doc. 15 at 14-15.

In response, the Commissioner argues:

Here, the ALJ specifically considered Plaintiff’s allegation of

headaches in reviewing her subjective complaints and cited to her

hearing testimony and Function Report that contain her alleged

frequency, intensity, and limiting effects of headaches (Tr. 20, referring

to Tr. 36-52, 199-208). However, the ALJ concluded that Plaintiff’s

“statements concerning the intensity, persistence and limiting effects of

these symptoms are not entirely consistent with the medical evidence

and other evidence in the record.” (Tr. 20).

In reviewing the medical evidence, the ALJ acknowledged Plaintiff’s

reports of headaches to her treatment providers and the consultative

examiner (Tr. 21-23). However, the ALJ also observed that a brain MRI

showed only a few tiny white matter hyperintensities that could be seen

in patients with migraines but could also be normal for her age (Tr. 21,

referring to Tr. 390) and that Plaintiff had largely normal objective

neurological examination findings (Tr. 21-22). Plaintiff’s neurologist

documented normal cranial nerves, intact fine finger movements and

cerebellar functioning, and symmetrical deep tendon reflexes (Tr. 508).

Likewise, Plaintiff was alert and oriented with no deficits of speech or

repetition and was able to follow simple, crossed, and complex

commands (Id.). Her sleep specialist, to whom Plaintiff first reported

headaches, also noted that she had normal balance and gait (Tr. 385)

and the consultative examiner observed no neurological deficits on

examination (Tr. 488). Further, as the ALJ noted, Plaintiff’s

psychologist observed logical though process and intact associative

thinking, short- and long-term memory, attention span, concentration,

and judgment (Tr. 21-22, referring to Tr. 463).

The ALJ also considered the longitudinal treatment record showing that

Plaintiff’s sleep specialist initially advised her to significantly reduce

her caffeine intake to help improve both sleep and headaches (Tr. 21)

and that her neurologist later prescribed Gabapentin and physical

therapy (Tr. 22). While Plaintiff initially reported daily headaches and

migraines once or twice a week (Tr. 383, 506), within a few months of

starting medication (Gabapentin) and physical therapy, she

subsequently reported that they seemed to be working, her headaches

had lessened, and she was happy with her current treatment (Tr. 873).

Similarly, as the ALJ noted, use of Gabapentin caused no side effects

and resulted in improvement with both tension as week as migraine

headaches, to the point of having headaches two to three times a week,

rather than daily, and to a lesser severity than previously (Tr. 883).

Other than increasing her Gabapentin dose because it was helping,

Plaintiff’s neurologist did not prescribe any other medication, including

any abortive medication, for headaches or perform injections.

After comparing Plaintiff’s subjective symptoms with regard to her

headaches to the medical and other evidence and determining that her

allegations were not entirely consistent, the ALJ assessed Plaintiff’s

RFC in terms of the most she can do on a regular and continuing basis,

meaning eight hours a day, 5 days a week. See SSR 96-8p. Specifically,

the ALJ limited Plaintiff to light work and provided additional

limitations, including with regard to exposure to hazards as well as

mental limitations to simple, routine tasks and simple work-related

decisions; few, if any workplace changes; and no productive pace work

(Id.). Plaintiff can point to no opinion suggesting greater limitations

resulting from her migraines than those adopted by the ALJ.

The ALJ’s evaluation of Plaintiff’s headaches/migraines and the

resulting limitations is sufficient to permit meaningful review. See

Barnhart, 364 F.3d at 505. Plaintiff has not met her burden of proving

that she had greater functional limitations than those already included

in the RFC. As substantial evidence supports the ALJ’s RFC

assessment, it should be affirmed.

Doc. 16 at 21-24.

In her reply brief, Collins argues: (1) the MRI cited by the Commissioner is

not inconsistent with her testimony that migraine pain would result in impaired

concentration and being off task; (2) although her pain improved, even with

improvement her three weekly migraines may still preclude employment; and (3)

the ALJ did not consider the frequency, duration of symptoms, and methods used to

control migraine pain before discounting Collins’s statements. Doc. 17 at 3-4.

Collins essentially argues that the ALJ’s evaluation of her statements about

the limiting effects of her migraine headaches under 20 C.F.R. § 404.1529 and SSR

16-3p compels remand in this case because it is too vague to permit judicial review.

This obligation originates in Cotter v. Harris, 642 F.2d 700, 706 (3d Cir. 1981). In

Cotter the Third Circuit recognized that there is “a particularly acute need for some

explanation by the ALJ when s/he has rejected relevant evidence or when there is

conflicting probative evidence in the record.” Id. In defining the parameters of this

obligation, the Circuit explained:

[i]n our view and examiner’s findings should be as comprehensive and

analytical as feasible and, where appropriate, should include a

statement of subordinate factual foundations on which ultimate factual

conclusions are based, so that a reviewing court may know the basis for

the decision. This is necessary so that the court may properly exercise

its responsibility under 42 U.S.C. § 405(g) to determine if the

Secretary’s decision is supported by substantial evidence.

Id. at 705 (quoting Baerga v. Richardson, 500 F.2d 309, 312 (3d Cir. 1974). In its

opinion denying a rehearing in Cotter, the Circuit elaborated that “in most cases, a

sentence or short paragraph would probably suffice.” Cotter, 650 F.2d at 482.

There appears to be no dispute that Collins’s testimony about the frequency,

duration, and limiting effects of her headaches is relevant. During the ALJ’s

explanation of the RFC determination, however, the ALJ makes only the following

statements with regard to Collins’s migraine headaches:

“[Collins] complained of daily headaches with no improvement with

over the counter medications. She acknowledged that she clenches her

jaw at night and has not been using her bite guard . . . . [Melissa Wolfe,

PA-C,] recommended that the claimant significantly reduce her

caffeine intake to help improve her sleep and headaches, as the claimant

reported drinking 40oz of Pepsi and at least 20oz of tea per day.”), 22

Admin. Tr. at 21. The ALJ stated that Collins “reported ongoing daily headaches

and migraine headaches once or twice a week with no improvement with the use of

Excedrin migraine.” Id. at 22.

[Collins] had improvement with both tension and migraine headaches

with her headache diary showing headaches occurring two to three

times per week and of lesser severity than previously . . . . [Dr.

Kozochonok] recommended that [Collins] increase gabapentin to

300mg three times daily, continue to keep a headache diary, stay well-

hydrated, maintain a regular sleep schedule, and weight loss and regular

physical activities (Exhibit 31F).”

Id. at 23. The ALJ also noted that Jean Santo, MD, “noted [Collins’s] complaints of

chronic neck pain in addition to shoulder pain, headaches . . . .” Id. Collins

underwent an MRI related to her migraine headaches, which the ALJ summarized

thusly: “The claimant’s February 28, 2018 brain MRI showed a few tiny T2/FLAIR

white matter hyperintensities, which can be consistent with migraines versus normal

for age. There was no evidence of acute ischemia and no abnormal enhancement

(Exhibits 7F and 31F).” Id. at 21.

The ALJ made no other observations or findings related to Collins’s migraine

headaches or their interference with Collins’s ability to pay attention. With regard

to Collins’s migraine headaches, the ALJ “summarized the record evidence and then

concluded, without any real explanation, that this evidence supported the RFC.”

Koshir v. Kijakazi, No. CV 20-1441, 2022 WL 992529, at *4 (W.D. Pa. Mar. 31,

2022). The ALJ may have met his duty to survey the medical evidence. Titterington

v. Barnhart, 174 F. App'x 6, 11 (3d Cir. 2006) (“Surveying the medical evidence to

craft an RFC is part of the ALJ's duties.”). But the ALJ has a further duty to provide

an explanation of how the evidence serves as the basis for his RFC determination.5

“[A]n examiner's findings should be as comprehensive and analytical as feasible and,

where appropriate, should include a statement of subordinate factual foundations on

which ultimate factual conclusions are based, so that a reviewing court may know

the basis for the decision.” Koshir, 2022 WL 992529, at *4 (quoting Fargnoli, 247

F.3d at 41 (quoting Cotter, 642 F.2d at 705)) (internal quotation marks omitted). In

the absence of this explanation, this Court is unable to determine how the ALJ

evaluated the evidence of Collins’s migraine headaches and any lack of focus they

caused and how the headaches factored into the RFC determination made by the

ALJ.

This Court cannot find the absence of explanation harmless because the

absence leaves the Court unable to review the decision. This Court cannot make

5 See Fargnoli, 247 F.3d at 41 (quoting Cotter, 642 F.2d at 704) (An RFC

determination must “must ‘be accompanied by a clear and satisfactory explication

of the basis on which it rests.’ ”); S.S.R. 96-8p, 1996 WL 374184 (S.S.A.), at *7

(“The RFC assessment must include a narrative discussion describing how the

evidence supports each conclusion, citing specific medical facts (e.g., laboratory

findings) and nonmedical evidence (e.g., daily activities, observations).”); Koshir,

2022 WL 992529, at *6 (quoting Gamret v. Colvin, 994 F. Supp. 2d 695, 698

(W.D. Pa. 2014) (citation omitted)) (“[T]he Court is unable to review the ALJ's

findings where the ALJ failed to ‘build an accurate and logical bridge between the

evidence and the result.’”).

assumptions about how and why the ALJ decided the RFC; “it is not the role of the

Court to look at the evidence and determine whether it would lead to the conclusions

to which the ALJ came.” Koshir, 2022 WL 992529, at *6 (citing Fargnoli, 247 F.3d

at 44 n.7 (“The grounds upon which an administrative order must be judged are those

upon which the record discloses that its action was based.”) (quoting SEC v. Chenery

Corporation, 318 U.S. 80, 87 (1943))).

If the ALJ failed to consider Collins’s migraine headaches or the lack of focus

Collins has alleged her headaches to cause, proper consideration of the headaches

and lack of focus may have caused a lack of significant numbers of jobs which

Collins is able to do. In her brief, Defendant states: “[T]he ALJ noted, use of

Gabapentin caused no side effects and resulted in improvement with both tension as

week as migraine headaches, to the point of having headaches two to three times a

week, rather than daily, and to a lesser severity than previously.” Doc. 16 at 23.

Collins testified that she experiences migraines twice per week, with each migraine

lasting for twenty-four hours. Admin. Tr. at 44-45. If the ALJ were to have found

Collins’s migraine headaches to distract her from work and to occur, as Collins

alleges, twice per week for twenty-four hours each time, the ALJ’s findings would

indicate that Collins might be distracted as much as 40% of a work week.6

6 This Court does not decide whether Collins’s migraines would occur on workdays

but does estimate this percentage by assuming five eight-hour workdays each

week.

At the administrative hearing, the vocational expert testified that the

maximum off-task behavior from an employee a typical employer will tolerate is

fifteen percent, or nine minutes per hour, of a workday. Admin. Tr. at 58. When

questioned further about whether an employee could maintain a job if the employee

would be off task more than fifteen percent or need extra absences, the vocational

expert testified that, for such a person, there would be “no work, no jobs.” Id.

Here, if the ALJ were to have credited Collins’s assertions that her migraine

headaches occur twice a week and distract her from work, the ALJ may have found

Collins could not work. Because the ALJ did not provide an explanation of his

consideration of the evidence related to Collins’s headaches for the RFC

determination, this Court cannot review it.

Because the Commissioner’s final decision lacks sufficient explanation of

the RFC determination, this Court cannot determine whether substantial evidence

supports the ALJ’s RFC assessment nor whether the ALJ failed to properly

evaluate Collins’s migraines. Accordingly, the Commissioner’s final decision will

be remanded so that the ALJ can more clearly explain how he arrived at his

findings.

VI. Conclusion.

For the foregoing reasons, we will vacate the Commissioner’s decision and

remand the case to the Commissioner for further proceedings pursuant to sentence

four of 42 U.S.C. §405(g).

Because we conclude that the Commissioner’s decision must be vacated and

the case remanded based on the ALJ’s failure to adequately analyze, or articulate

the reasons for finding unpersuasive, the evidence of Collins’s migraines and

alleged consequential lack of focus, we will not address Collins’s remaining claims

of error. “Plaintiff’s additional claims of error may be remedied through the case’s

treatment on remand.” Brown v. Saul, No. CV 3:18-1619, 2020 WL 6731732, at *7

(M.D. Pa. Oct. 23, 2020), report and recommendation adopted, 2020 WL 6729164,

at *1 (M.D. Pa. Nov. 16, 2020). “A remand may produce different results on these

claims, making discussion of them moot.” Id.

An appropriate order follows.

S/Susan E. Schwab

Susan E. Schwab

United States Magistrate Judge