Lee v. O'Malley

IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF PENNSYLVANIA

RASHIM LEE, : Civil No. 3:24-CV-00893

:

Plaintiff : (Magistrate Judge Carlson)

:

v. :

:

LELAND DUDEK, :

Acting Commissioner of Social Security,1 :

:

Defendant. :

MEMORANDUM OPINION

I. Introduction

Case law has long placed a duty of articulation upon Administrative Law

Judges when deciding Social Security disability claims. Thus, the ALJ's decision

must be accompanied by “a clear and satisfactory explication of the basis on which

it rests.” Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981). Conflicts in the evidence

must be resolved and the ALJ must indicate which evidence was accepted, which

evidence was rejected, and the reasons for rejecting certain evidence. Id. at 706-

1 Leland Dudek became the Acting Commissioner of Social Security on February 16,

2025. Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure, Leland Dudek

should be substituted for the previously named defendant in this suit. No further

action need be taken to continue this suit by reason of the last sentence of section

205(g) of the Social Security Act, 42 U.S.C. § 405(g).

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707. In addition, “[t]he 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., 181 F. 3d 429, 433 (3d Cir. 1999). A necessary corollary to

this duty of articulation is the concept that when a conflict in the evidence exists, the

ALJ may choose whom to credit but “cannot reject evidence for no reason or for the

wrong reason.” Mason v. Shalala, 994 F.2d 1058, 1066 (3d Cir. 1993). At a

minimum this obligation to articulate the basis of a disability determination means

that the ALJ’s ruling must correctly state the facts as they relate to the claimant’s

disabilities. Accordingly, when an ALJ’s decision rests upon a material

misapprehension concerning the facts, a remand is often necessary.

So it is here.

Rashim Lee was a fifty year old worker who applied for disability benefits

based upon the combined effects of a series of severe impairments, including

osteoarthritis; rotator cuff tear; cubital tunnel syndrome; diabetes; and neuropathy.

(Tr. 20). Lee’s treating physician reported that these impairments confined him to a

limited range of sedentary work. (Tr. 968-69). This view was shared by an

examining, consulting physician who also agreed that Lee could do no more than a

limited range of sedentary work. (Tr. 690-99). Thus, every physician who actually

treated or examined Lee agreed that he was limited to sedentary work due to his

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physical impairments. Moreover, the first state agency expert to consider Lee’s case

also found that he could only perform sedentary work, and therefore could not return

to his past relevant work. (Tr. 61-65). The only contrary view that deviated from this

medical consensus was the opinion of a second non-examining state agency source,

who found on reconsideration that Lee could perform light work. (Tr. 82-86).

Thus, the preponderance of the medical opinion evidence—including one

state agency expert opinion—clearly stated that Lee could only perform a limited

range of sedentary work. Notwithstanding this evidence, the ALJ found that Lee

could perform light work. (Tr. 21). In reaching this result the ALJ concluded—

incorrectly—that both state agency experts determined that Lee could perform light

work. (Tr. 23). The ALJ then relied upon this inaccurate recital regarding the medical

opinion evidence to support his residual functional capacity assessment, and his

finding that Lee was not disabled. (Tr. 26-27).

This conclusion rests on a misstatement of fact. The ALJ erroneously

characterized the medical opinion as being in equipoise with two medical opinions

supporting a light work RFC and two other opinions restricting Lee to sedentary

work. In fact, the preponderance of the medical opinion evidence from three of the

four medical sources agreed that Lee could only perform sedentary work. Since the

ALJ’s decision was grounded upon this potentially material factual error concerning

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the medical opinion evidence, we find that this decision’s evaluation of the medical

opinion evidence is based upon “the wrong reason.” Id. Accordingly, we will remand

this case for further consideration and evaluation of the medical opinion evidence.

II. Statement of Facts and of the Case

In November of 2021, Rashim Lee filed an application for a period of

disability and disability insurance benefits along with an application for

supplemental security income pursuant to Titles II and XVI of the Social Security

Act. on November 10, 2021. In both applications, Lee alleged an onset of disability

beginning January 2, 2020. (Tr. 17). According to Lee he had become disabled due

to the combined effects of the following severe impairments: osteoarthritis; rotator

cuff tear; cubital tunnel syndrome; diabetes; and neuropathy. (Tr. 20). Lee was born

on December 17, 1971, and was 50 years old, which under the Commissioner’s

regulations made him an individual closely approaching advanced age, on the

amended alleged disability onset date. (Tr. 25).

Lee’s disability application was supported by nearly 700 pages of clinical

records and medical opinions. (Tr. 355-1026). In particular, the record contained

four medical opinions, three of which found that Lee could do no more than

sedentary work.

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One of these opinions came from a treating physician, Dr. Mark Goedecker,

who provided physical assessment of Lee on February 9, 2023. (Tr. 968-69). In this

assessment Dr. Goedecker stated that Lee’s impairments would constantly interfere

with his ability to work; indicated that he would need at least four unscheduled

breaks during the workday; found that he could only lift ten or twenty pounds

occasionally; determined that Lee would be limited in reaching and fingering; and

reported that Lee would miss more than four days of work each month. (Id.) Thus,

at best, based upon his treating relationship with the plaintiff, Dr. Goedecker opined

that Lee could do no more than a confined scope of sedentary work.

Dr. Goedecker’s conclusions were echoed by a consulting examining

physician, Dr. Ahmed Kneifati, who conducted an examination of Lee on March 9,

2022. (Tr. 690-99). Based upon his examination, Dr. Kneifati found that Lee could

only occasionally lift of carry up to ten pounds; was limited in his right hand reaching

and feeling; and was subject to multiple postural and environmental limitations. (Tr.

694-97). Dr. Kneifati’s findings also clearly restricted Lee to no more than a limited

range of sedentary work.

This conclusion was also shared by the first state agency expert to examine

Lee’s case, Dr. Gerald Levandoski. (Tr. 56-66). On March 30, 2022, Dr. Levandoski

issued an opinion in Lee’s case. (Id.) Dr. Levandoski found that Lee could only

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occasionally life up to ten pounds. (Tr. 61). He also found that Lee would be subject

to an array of limitations in terms of reaching, fingering, stooping, balancing,

kneeling and crouching. (Tr. 61-2). Moreover, according to Dr. Levandoski Lee

would need to avoid extreme cold, vibrations and machinery hazards. (Tr. 63). Dr.

Levandoski specifically found that Lee was confined to sedentary work due to his

impairments. (Tr. 65).

Thus, the record reveals a broad medical consensus among treating,

examining, and state agency expert sources that Lee could do no more than a limited

range of sedentary work, a potentially significant finding given Lee’s status as a

worker closely approaching advanced age. The only outlier among these medical

opinions was a second non-examining state agency source, Dr. Angela Walker, who

opined on December 13, 2022, that Lee could perform light work. (Tr. 86).

It was against this clinical backdrop that an ALJ conducted a hearing

regarding Lee’s disability application on June 28, 2023, at which Lee and a

vocational expert testified. (Tr. 34-54). Following this hearing, on August 2, 2023,

the ALJ issued a decision denying Lee’s application for benefits. (Tr. 14-31). In that

decision, the ALJ first concluded that Lee met the insured status requirements of the

Social Security Act through December 31, 2023 and had not engaged in substantial

gainful activity since January 2, 2020, the alleged onset date. (Tr. 19-20). At Step 2

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of the sequential analysis that governs Social Security cases, the ALJ found that Lee

suffered from the following severe impairments: osteoarthritis; rotator cuff tear;

cubital tunnel syndrome; diabetes; and neuropathy. (Tr. 20). At Step 3 the ALJ

determined that Lee did not have an impairment or combination of impairments that

met or medically equaled the severity of one of the listed impairments. (Id.)

The ALJ then fashioned the following RFC for the plaintiff:

After careful consideration of the entire record, the undersigned finds

that the claimant has the residual functional capacity to perform light

work as defined in 20 CFR 404.1567(b) and 416.967(b) and he can

frequently handle, finger, and feel with his right upper extremity; and

occasionally reach, push, and pull with his right upper extremity. He

can occasionally crawl and never climb ladders, ropes, or scaffolds. He

should avoid concentrated exposure to extreme cold and vibrations and

even moderate exposure to dangerous machinery or unprotected

heights.

(Tr. 21).

In reaching this conclusion, which deviated from three out of the four medical

opinions in this case, the ALJ first concluded that the opinions of Doctors Kneifati

and Goedecker—the only physicians who had actually treated, examined, or seen

Lee—were unpersuasive. (Tr. 23-24). The ALJ then misstated and overstated the

state agency expert medical opinion evidence. According to the ALJ:

The record includes a March 2022 prior administrative medical finding

from a state agency medical consultant, Gerald Levandoski, MD. Dr.

Levandoski stated the claimant could perform light work; stand and/or

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walk two hours in an eight-hour workday; occasionally balance, stoop,

kneel, crouch, and climb ramps and stairs; never crawl and climb

ladders, ropes, or scaffolds; frequently handle and occasionally reach

overhead with his right upper extremity; limited far acuity and near

acuity in the right eye; and avoid concentrated exposure to extreme

cold, vibration, and hazards (2A/6-9; 4A/6-9). The record includes a

December 2022 prior administrative medical finding from a state

agency medical consultant, Angela Teresa Walker, MD. Dr. Walker

noted the claimant could perform light work; occasionally push, pull,

and operate hand controls with his right upper extremity; occasionally

crawl; never crawl and climb ladders, ropes, or scaffolds; frequently

handle, finger, or feel and occasionally reach with his right upper

extremity; avoid concentrated exposure to extreme cold and vibration;

and avoid moderate exposure to hazards (6A/5-7; 8A/6-9). Insofar as

they state the claimant can perform light work; frequently handle,

finger, and feel with his right upper extremity; and occasionally reach,

push, and pull with his right upper extremity; occasionally crawl; never

climb ladders, ropes, or scaffolds; should avoid concentrated exposure

to extreme cold and vibrations; even moderate exposure to dangerous

machinery or unprotected heights; these statements are supported by

the longitudinal treatment notes, which generally show the claimant is

in no acute distress with good range of motion, normal and symmetric

hands, capillary refill in less than two seconds, symmetric pulses, intact

cranial nerves, no atrophy, no focal deficit, no clubbing, no cyanosis,

and no edema (2F; 5F; 6F; 10F; 14F; 16F; 17F; 19F; 20F; 21F). These

statements are also consistent with the claimant’s activities of daily

living, which shows he helps care for his dog and can prepare simple

meals and shop in stores (3E; 9E). Further, Dr. Levandoski and Dr.

Walker are highly qualified experts who had the opportunity to review

the claimant’s records.

(Tr. 23) (emphasis added).

This description clearly misstated Dr. Levandoski’s opinion. Contrary to the

ALJ’s assertion, Dr. Levandoski never opined that Lee could perform light work.

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Instead, the doctor flatly stated that Lee was limited to sedentary work, thus

concurring in the opinions of the treating and examining sources. Moreover, the

ALJ’s factual misstatement erroneously altered the quantum of evidence in a way

which plainly prejudiced Lee. Instead of accurately describing the opinion evidence

as a broad consensus among treating, examining, and state agency sources restricting

Lee to sedentary work, with one outlying opinion, the ALJ suggested that the opinion

evidence was somehow evenly balanced between two experts who opined that Lee

could perform light work and two other experts who limited him to sedentary work.

Having erred in this fashion, the ALJ then chose to adopt a light work RFC for Lee,

even though the preponderance of the medical opinion evidence when accurately

understood, found that he could not perform light work. The ALJ then relied upon

this inaccurate recital regarding the medical opinion evidence to support his residual

functional capacity assessment, and his finding that Lee was not disabled. (Tr. 26-

27).

This appeal followed. (Doc. 1). On appeal, Lee challenges the ALJ’s

evaluation of this medical opinion evidence. Since we find that this medical opinion

evidence evaluation rests upon a material factual error, we agree that the ALJ’s

responsibility of adequately articulating the basis for a medical opinion evaluation

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has not been met in this this case. Therefore, we will remand this case for further

consideration and evaluation of the medical opinion evidence.

III. Discussion

A. Substantial Evidence Review – the Role of this Court

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

application for benefits, this Court’s review is limited to the question of whether the

findings of the final decision-maker are supported by substantial evidence in the

record. See 42 U.S.C. §405(g); 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, 565 (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). 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 decision]

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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 Supreme Court has underscored for us the limited scope of our review in

this field, noting that:

The phrase “substantial evidence” is a “term of art” used throughout

administrative law to describe how courts are to review agency

factfinding. T-Mobile South, LLC v. Roswell, 574 U.S. ––––, ––––,

135 S.Ct. 808, 815, 190 L.Ed.2d 679 (2015). Under the substantial-

evidence standard, a court looks to an existing administrative record

and asks whether it contains “sufficien[t] evidence” to support the

agency's factual determinations. Consolidated Edison Co. v. NLRB,

305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) (emphasis

deleted). And whatever the meaning of “substantial” in other contexts,

the threshold for such evidentiary sufficiency is not high. Substantial

evidence, this Court has said, is “more than a mere scintilla.” Ibid.; see,

e.g., Perales, 402 U.S. at 401, 91 S.Ct. 1420 (internal quotation marks

omitted). It means—and means only—“such relevant evidence as a

reasonable mind might accept as adequate to support a conclusion.”

Consolidated Edison, 305 U.S. at 229, 59 S.Ct. 206. See Dickinson v.

Zurko, 527 U.S. 150, 153, 119 S.Ct. 1816, 144 L.Ed.2d 143 (1999)

(comparing the substantial-evidence standard to the deferential clearly-

erroneous standard).

Biestek, 139 S. Ct. at1154.

The question before this Court, therefore, is not whether the claimant is

disabled, but rather whether the Commissioner’s finding that she is not disabled is

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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 Secretary’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 . . . .”).

Several fundamental legal propositions which flow from this deferential

standard of review. First, when conducting this review “we are mindful that we must

not substitute our own judgment for that of the fact finder.” Zirnsak v. Colvin, 777

F.3d 607, 611 (3d Cir. 2014) (citing Rutherford, 399 F.3d at 552). Thus, we are

enjoined to refrain from trying to re-weigh the evidence. Rather our task is to simply

determine whether substantial evidence supported the ALJ’s findings. However, we

must also ascertain whether the ALJ’s decision meets the burden of articulation

demanded by the courts to enable informed judicial review. Simply put, “this Court

requires the ALJ to set forth the reasons for his decision.” Burnett v. Comm'r of Soc.

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Sec. Admin., 220 F.3d 112, 119 (3d Cir. 2000). As the Court of Appeals has noted

on this score:

In Burnett, we held that an ALJ must clearly set forth the reasons for

his decision. 220 F.3d at 119. Conclusory statements . . . are

insufficient. The ALJ must provide a “discussion of the evidence” and

an “explanation of reasoning” for his conclusion sufficient to enable

meaningful judicial review. Id. at 120; see Jones v. Barnhart, 364 F.3d

501, 505 & n. 3 (3d Cir.2004). The ALJ, of course, need not employ

particular “magic” words: “Burnett does not require the ALJ to use

particular language or adhere to a particular format in conducting his

analysis.” Jones, 364 F.3d at 505.

Diaz v. Comm'r of Soc. Sec., 577 F.3d 500, 504 (3d Cir. 2009).

Thus, in practice ours is a twofold task. We must evaluate the substance of the

ALJ’s decision under a deferential standard of review, but we must also give that

decision careful scrutiny to ensure that the rationale for the ALJ’s actions is

sufficiently articulated to permit meaningful judicial review.

B. Initial Burdens of Proof, Persuasion, and Articulation for the ALJ

To receive benefits under the Social Security Act by reason of disability, 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); 42 U.S.C.

§1382c(a)(3)(A); see also 20 C.F.R. §§404.1505(a), 416.905(a). To satisfy this

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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

activity that exists in the national economy. 42 U.S.C. §423(d)(2)(A); 42 U.S.C.

§1382c(a)(3)(B); 20 C.F.R. §§404.1505(a), 416.905(a). To receive 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).

In making this determination at the administrative level, the ALJ follows a

five-step sequential evaluation process. 20 C.F.R. §§404.1520(a), 416.920(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), 416.920(a)(4).

Between Steps 3 and 4, the ALJ must also assess a claimant’s residual

functional capacity (RFC). 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

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of Soc. Sec., 220 F.3d 112, 121 (3d Cir. 2000) (citations omitted); see also 20 C.F.R.

§§404.1520(e), 404.1545(a)(1), 416.920(e), 416.945(a)(1). In making this

assessment, the ALJ considers all of the claimant’s medically determinable

impairments, including any non-severe impairments identified by the ALJ at step

two of his or her analysis. 20 C.F.R. §§404.1545(a)(2), 416.945(a)(2).

Once the ALJ has made this determination, our review of the ALJ's

assessment of the plaintiff's RFC is deferential, and that RFC assessment will not be

set aside if it is supported by substantial evidence. Burns v. Barnhart, 312 F.3d 113,

129 (3d Cir. 2002); see also Metzger v. Berryhill, No. 3:16-CV-1929, 2017 WL

1483328, at *5 (M.D. Pa. Mar. 29, 2017), report and recommendation adopted sub

nom. Metzgar v. Colvin, No. 3:16-CV-1929, 2017 WL 1479426 (M.D. Pa. Apr. 21,

2017); Rathbun v. Berryhill, No. 3:17-CV-00301, 2018 WL 1514383, at *6 (M.D.

Pa. Mar. 12, 2018), report and recommendation adopted, No. 3:17-CV-301, 2018

WL 1479366 (M.D. Pa. Mar. 27, 2018).

At Steps 1 through 4, the claimant bears the initial burden of demonstrating

the existence of a medically determinable impairment that prevents him or her in

engaging in any of his or her past relevant work. Mason, 994 F.2d at 1064. Once this

burden has been met by the claimant, it shifts to the Commissioner at Step 5 to show

that jobs exist in significant number in the national economy that the claimant could

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perform that are consistent with the claimant’s age, education, work experience and

RFC. 20 C.F.R. §§404.1512(f), 416.912(f); Mason, 994 F.2d at 1064.

There is an undeniable medical aspect to an RFC determination, since that

determination entails an assessment of what work the claimant can do given the

physical limitations that the claimant experiences. Yet, when considering the role

and necessity of medical opinion evidence in making this determination, courts have

followed several different paths. Some courts emphasize the importance of medical

opinion support for an RFC determination and state that “[r]arely can a decision be

made regarding a claimant's residual functional capacity without an assessment from

a physician regarding the functional abilities of the claimant.” Biller, 962 F.Supp.2d

at 778–79 (quoting Gormont v. Astrue, Civ. No. 11–2145, 2013 WL 791455 at *7

(M.D. Pa. Mar. 4, 2013)). In other instances, it has been held that “[t]here 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 F. App’x 6, 11

(3d Cir. 2006). Further, courts have held in cases where there is no evidence of any

credible medical opinion supporting a claimant’s allegations of disability that “the

proposition that an ALJ must always base his RFC on a medical opinion from a

physician is misguided.” Cummings v. Colvin, 129 F.Supp.3d 209, 214–15 (W.D.

Pa. 2015).

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These seemingly discordant legal propositions can be reconciled by

evaluation of the factual context of these decisions. Those cases which emphasize

the importance of medical opinion support for an RFC assessment typically arise in

the factual setting, like that presented here, where well-supported medical sources

have opined regarding limitations which would support a disability claim, but an

ALJ has rejected the medical opinion which supported a disability determination

based upon a lay assessment of other evidence. Biller, 962 F.Supp.2d at 778–79. In

this setting, these cases simply restate the commonplace idea that medical opinions

are entitled to careful consideration when making a disability determination,

particularly when those opinions support a finding of disability. In contrast, when

no medical opinion supports a disability finding or when an ALJ is relying upon

other evidence, such as contrasting clinical or opinion evidence or testimony

regarding the claimant’s activities of daily living, to fashion an RFC courts have

adopted a more pragmatic view and have sustained the ALJ’s exercise of

independent judgment based upon all of the facts and evidence. See Titterington,

174 F. App'x 6; Cummings, 129 F.Supp.3d at 214–15. In either event, once the ALJ

has made this determination, our review of the ALJ's assessment of the plaintiff's

RFC is deferential, and that RFC assessment will not be set aside if it is supported

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by substantial evidence. Burns v. Barnhart, 312 F.3d 113; see also Metzger v.

Berryhill, 2017 WL 1483328, at *5; Rathbun v. Berryhill, 2018 WL 1514383, at *6.

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

requisites. Most significant among these legal benchmarks is a requirement that the

ALJ adequately explain the legal and factual basis for this disability determination.

Thus, in order to facilitate review of the decision under the substantial evidence

standard, the ALJ's decision must be accompanied by “a clear and satisfactory

explication of the basis on which it rests.” Cotter v. Harris, 642 F.2d 700, 704 (3d

Cir. 1981). Conflicts in the evidence must be resolved and the ALJ must indicate

which evidence was accepted, which evidence was rejected, and the reasons for

rejecting certain evidence. Id. at 706-707. In addition, “[t]he 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., 181 F. 3d 429, 433 (3d Cir.

1999).

C. Legal Benchmarks for the ALJ’s Assessment of Medical Opinions

Lee filed his disability application following a paradigm shift in the manner

in which medical opinions were evaluated when assessing Social Security claims.

Prior to March 2017, ALJs were required to follow regulations that defined medical

opinions narrowly and created a hierarchy of medical source opinions with treating

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sources at the apex of this hierarchy. However, in March of 2017, the

Commissioner’s regulations governing medical opinions changed in a number of

fundamental ways. The range of opinions that ALJs were enjoined to consider were

broadened substantially, and the approach to evaluating opinions was changed from

a hierarchical form of review to a more holistic analysis. As one court has aptly

observed:

The regulations regarding the evaluation of medical evidence have been

amended for claims filed after March 27, 2017, and several of the prior

Social Security Rulings, including SSR 96-2p, have been rescinded.

According to the new regulations, the Commissioner “will no longer

give any specific evidentiary weight to medical opinions; this includes

giving controlling weight to any medical opinion.” Revisions to Rules

Regarding the Evaluation of Medical Evidence (“Revisions to Rules”),

2017 WL 168819, 82 Fed. Reg. 5844, at 5867–68 (Jan. 18, 2017), see

20 C.F.R. §§ 404.1520c(a), 416.920c(a). Instead, the Commissioner

must consider all medical opinions and “evaluate their persuasiveness”

based on the following five factors: supportability; consistency;

relationship with the claimant; specialization; and “other factors.” 20

C.F.R. §§ 404.1520c(a)-(c), 416.920c(a)-(c).

Although the new regulations eliminate the perceived hierarchy of

medical sources, deference to specific medical opinions, and assigning

“weight” to a medical opinion, the ALJ must still “articulate how [he

or she] considered the medical opinions” and “how persuasive [he or

she] find[s] all of the medical opinions.” Id. at §§ 404.1520c(a) and

(b)(1), 416.920c(a) and (b)(1). The two “most important factors for

determining the persuasiveness of medical opinions are consistency and

supportability,” which are the “same factors” that formed the

foundation of the treating source rule. Revisions to Rules, 82 Fed. Reg.

5844-01 at 5853.

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An ALJ is specifically required to “explain how [he or she] considered

the supportability and consistency factors” for a medical opinion. 20

C.F.R. §§ 404.1520c (b)(2), 416.920c(b)(2). With respect to

“supportability,” the new regulations provide that “[t]he more relevant

the objective medical evidence and supporting explanations presented

by a medical source are to support his or her medical opinion(s) or prior

administrative medical finding(s), the more persuasive the medical

opinions or prior administrative medical finding(s) will be.” Id. at §§

404.1520c(c)(1), 416.920c(c)(1). The regulations provide that with

respect to “consistency,” “[t]he more consistent a medical opinion(s) or

prior administrative medical finding(s) is with the evidence from other

medical sources and nonmedical sources in the claim, the more

persuasive the medical opinion(s) or prior administrative medical

finding(s) will be.” Id. at §§ 404.1520c(c)(2), 416.920c(c)(2).

Under the new regulations an ALJ must consider, but need not

explicitly discuss, the three remaining factors in determining the

persuasiveness of a medical source's opinion. Id. at §§ 404.1520c(b)(2),

416.920c(b)(2). However, where the ALJ has found two or more

medical opinions to be equally well supported and consistent with the

record, but not exactly the same, the ALJ must articulate how he or she

considered those factors contained in paragraphs (c)(3) through (c)(5).

Id. at §§ 404.1520c(b)(3), 416.920c(b)(3).

Andrew G. v. Comm'r of Soc. Sec., No. 3:19-CV-0942 (ML), 2020 WL 5848776, at

*5 (N.D.N.Y. Oct. 1, 2020).

Oftentimes, as in this case, an ALJ must evaluate various medical opinions.

Judicial review of this aspect of ALJ decision-making is still guided by several

settled legal tenets. First, when presented with a disputed factual record, it is well

established that “[t]he ALJ – not treating or examining physicians or State agency

consultants – must make the ultimate disability and RFC determinations.” Chandler

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v. Comm’r of Soc. Sec., 667 F.3d 356, 361 (3d Cir. 2011). Thus, when evaluating

medical opinions “ the ALJ may choose whom to credit but ‘cannot reject evidence

for no reason or for the wrong reason.’” Morales v. Apfel, 225 F.3d 310, 317 (3d

Cir. 2000) (quoting Mason, 994 F.2d at 1066). Therefore, provided that the decision

is accompanied by an adequate, articulated rationale, it is the province and the duty

of the ALJ to choose which medical opinions and evidence deserve greater weight.

Further, in making this assessment of medical evidence:

An ALJ is [also] entitled generally to credit parts of an opinion without

crediting the entire opinion. See Thackara v. Colvin, No. 1:14–CV–

00158–GBC, 2015 WL 1295956, at *5 (M.D. Pa. Mar. 23, 2015);

Turner v. Colvin, 964 F. Supp. 2d 21, 29 (D.D.C. 2013) (agreeing that

“SSR 96–2p does not prohibit the ALJ from crediting some parts of a

treating source's opinion and rejecting other portions”); Connors v.

Astrue, No. 10–CV–197–PB, 2011 WL 2359055, at *9 (D.N.H. June

10, 2011). It follows that an ALJ can give partial credit to all medical

opinions and can formulate an RFC based on different parts from the

different medical opinions. See e.g., Thackara v. Colvin, No. 1:14–CV–

00158–GBC, 2015 WL 1295956, at *5 (M.D. Pa. Mar. 23, 2015).

Durden v. Colvin, 191 F.Supp.3d 429, 455 (M.D. Pa. 2016).

Finally, with respect to assessing competing medical opinion evidence, it is

clear beyond peradventure that:

When a conflict in the evidence exists, the ALJ may choose whom to

credit but “cannot reject evidence for no reason or for the wrong

reason.” Mason v. Shalala, 994 F.2d 1058, 1066 (3d Cir.1993). The

ALJ must consider all the evidence and give some reason for

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discounting the evidence she rejects. See Stewart v. Secretary of

H.E.W., 714 F.2d 287, 290 (3d Cir.1983).

Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999).

It is against these legal benchmarks that we assess the instant appeal.

D. This Case Should Be Remanded for Further Consideration of the

Medical Opinion Evidence.

This case presents a striking circumstance. It is clear that the ALJ’s medical

opinion evidence evaluation rests upon a false premise, the notion that both state

agency experts agreed that Lee could perform light work.

This was error. The opinion evidence was not evenly divided as the ALJ

suggested in this decision. Rather, that opinion evidence revealed a broad consensus

among treating, examining, and state agency sources restricting Lee to sedentary

work, with only one outlying opinion. Because this error misstated the opinion

evidence in a fundamental, and fundamentally prejudicial way, a remand is

necessary here. This is not a novel conclusion on our part. Quite the contrary, it is

entirely in accord with our past practice when presented with ALJ decisions which

are based upon a misapprehension regarding the medical expert opinions. See e.g.,

Dunn v. Kijakazi, No. 1:21-CV-91, 2022 WL 17584231, at *11 (M.D. Pa. Dec. 12,

2022); Perfinski v. Saul, No. 1:20-CV-78, 2021 WL 1060360, at *8 (M.D. Pa. Mar.

19, 2021).

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Moreover, in the absence of some further explanation and articulation of its

rationale, the ALJ’s decision cannot be reconciled with the revised medical opinion

regulations that the ALJ was obliged to follow. Those regulations eschew any

hierarchical ranking of opinions, but call upon ALJ’s to evaluate medical opinions

against the following benchmarks:

(1) Supportability. The more relevant the objective medical evidence

and supporting explanations presented by a medical source are to

support his or her medical opinion(s) or prior administrative medical

finding(s), the more persuasive the medical opinions or prior

administrative medical finding(s) will be.

(2) Consistency. The more consistent a medical opinion(s) or prior

administrative medical finding(s) is with the evidence from other

medical sources and nonmedical sources in the claim, the more

persuasive the medical opinion(s) or prior administrative medical

finding(s) will be.

(3) Relationship with the claimant. This factor combines consideration

of the issues in paragraphs (c)(3)(i) through (v) of this section.

(i) Length of the treatment relationship. The length of time a

medical source has treated you may help demonstrate whether

the medical source has a longitudinal understanding of your

impairment(s).

(ii) Frequency of examinations. The frequency of your visits

with the medical source may help demonstrate whether the

medical source has a longitudinal understanding of your

impairment(s).

(iii) Purpose of the treatment relationship. The purpose for

treatment you received from the medical source may help

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demonstrate the level of knowledge the medical source has of

your impairment(s).

(iv) Extent of the treatment relationship. The kinds and extent

of examinations and testing the medical source has performed

or ordered from specialists or independent laboratories may

help demonstrate the level of knowledge the medical source has

of your impairment(s).

(v) Examining relationship. A medical source may have a better

understanding of your impairment(s) if he or she examines you

than if the medical source only reviews evidence in your folder.

20 C.F.R. § 404.1520c.

In this case, once the medical opinions are correctly described it is apparent

that there was a consensus among the treating and examining sources that Lee was

confined to a limited range of sedentary work. This consensus was also shared by

the first state agency expert who review this case, Dr. Levandoski. Thus, when we

consider the consistency of the medical opinions—one of the key factors which must

now be assessed—it is evident that the greater weight of consistent opinion evidence

favors a finding that Lee could only perform sedentary work. Moreover, these

opinions represented not only the preponderance of the medical opinion evidence,

two of the opinions were issued by treating or examining sources who had greater

opportunities to assess Lee’s limitations. In light of this significant medical evidence

which undermined the ALJ’s RFC determination, and the fact that this RFC seems

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to rest upon a basic misunderstanding regarding the true state of the medical

opinions, a remand is necessary in this case.

In sum, under the regulations governing evaluation of medical opinion

evidence, more is needed by way of explanation in this case. Since the ALJ’s burden

of articulation is not met in the instant case, this matter must be remanded for further

consideration by the Commissioner. Yet, while we reach this result, we note that

nothing in this Memorandum Opinion should be deemed as expressing a judgment

on what the ultimate outcome of any reassessment of this evidence should be. Rather,

the task should remain the duty and province of the ALJ on remand.

IV. Conclusion

Accordingly, for the foregoing reasons, IT IS ORDERED that the plaintiff’s

request for a new administrative hearing is GRANTED, the final decision of the

Commissioner denying these claims is vacated, and this case is remanded to the

Commissioner to conduct a new administrative hearing.

An appropriate order follows.

/s/ Martin C. Carlson

Martin C. Carlson

United States Magistrate Judge

DATED: March 10, 2025

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