Opinion

Wall v. Commissioner of Social Security

Court: District Court, M.D. Pennsylvania
Filed: Apr 3, 2025
Cited by: 0 cases
Authority: More cited than 34.7%

agreeing that “SSR 96–2p does not prohibit the ALJ from crediting some parts of a treating source's opinion and rejecting other portions”

How later courts described this case

agreeing that “SSR 96–2p does not prohibit the ALJ from crediting some parts of a treating source's opinion and rejecting other portions”
comparing the substantial-evidence standard to the deferential clearly- erroneous standard
“[T]he court has plenary review of all legal issues . . . .”

Written by the judges who cited it.

The opinion

IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF PENNSYLVANIA

LISA WALL, : Civil No. 3:23-CV-00850

Plaintiff, :

v. :

LELAND DUDEK,1 :

Acting Commissioner of Social Security : (Magistrate Judge Carlson)

Defendant. :

MEMORANDUM OPINION

I. Introduction

For Administrative Law Judges (ALJs) Social Security disability decisions

often entail an evaluation of the persuasive power of various medical opinions. An

ALJ undertakes this task guided by regulations which call upon the ALJ to assess

each medical opinion in terms of its consistency and supportability.

Once the ALJ has made this decision, on appeal it is the Court’s responsibility

to decide whether substantial evidence, fully articulated by the ALJ, supports the

1Leland 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).

disability determination. This “substantial evidence” test is a highly deferential

standard of review. As the Supreme Court has explained:

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 v. Berryhill, 139 S. Ct. 1148, 1154 (2019). Under this standard of review,

we are obliged to affirm the decision of the administrative law judge (ALJ) once we

find that it is “supported by substantial evidence, ‘even [where] this court acting de

novo might have reached a different conclusion.’” Monsour Med. Ctr. v. Heckler,

806 F.2d 1185, 1190–91 (3d Cir. 1986) (quoting Hunter Douglas, Inc. v. NLRB, 804

F.2d 808, 812 (3d Cir. 1986)).

In the instant case we are called upon to decide whether substantial evidence,

which was adequately articulated by the ALJ, supported the conclusion that the

medical opinion of a non-treating consultant, Dr. Sarah Vanes, was less persuasive

than two state agency expert opinions. Mindful of the fact that substantial evidence

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

adequate to support a conclusion,’” Biestek, 139 S. Ct. at 1154, we conclude that

substantial evidence supported the ALJ’s mental medical opinion findings in this

case. Therefore, for the reasons set forth below, we will affirm the decision of the

Commissioner denying this claim.

II. Statement of Facts and of the Case

A. Background

The administrative record of Wall’s disability application reveals the

following essential facts: In August of 2021, Wall applied for disability insurance

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

Security Act, alleging an onset of disability beginning November 16, 2020. (Tr. 29).

According to Wall, she was completely disabled due to a number of physical and

emotional impairments, including major depressive disorder; posttraumatic stress

disorder (PTSD); bipolar disorder; panic disorder; anxiety; and schizoaffective

disorder, bipolar type. (Tr. 32).2

Wall was born on June 26, 1978, and was 42 years old on the alleged disability

onset date, which defined her as a younger individual under the Commissioner’s

regulations. (Tr. 42). She had a limited school education and prior employment as a

resident care aide and an assistant manager. (Tr. 41-42).

B. Wall’s Clinical History

At the time of the alleged onset of her disability in November 2020, Wall was

both incarcerated3 and expecting the birth of a child. Following the birth of her child

and her release from custody, Wall was treated through the Geisinger Health System

for anxiety and depression. The records of this treatment revealed several consistent

themes. Wall was repeatedly diagnosed as suffering from anxiety and depression.

2 Wall’s disability application also listed a number of physical impairments in

addition to these emotional conditions. However, in this appeal Wall focuses

exclusively upon the ALJ’s consideration of her emotional impairments. Therefore,

we will limit our discussion to these emotional impairments.

3 Wall’s incarceration was related to her prior employment as a resident care aide.

According to her treatment records, in January of 2000 Wall was charged with abuse

of a care dependent person after she was captured on video throwing food on the

ground and then making a care dependent person pick up the discarded food and eat

it. (Tr. 737-39, 743-46). Wall pleaded guilty to two misdemeanor charges in

December of 2020 and was sentenced to home detention. (Tr. 750).

Her depression was consistently described as a moderate recurrent depressive

disorder. While treatment notes indicated that Wall occasionally voiced fleeting

thoughts of death and endorsed some suspicious and paranoid ideas, she was not

deemed a risk of self-harm. Moreover, Wall often reported improvement in her

symptoms when she adhered to her medication regime. Furthermore, the treatment

notes contained numerous references to normal or benign findings describing her as

fully oriented, with normal mood, affect, behavior, appearance, speech, judgment

and thought content.

Shortly after her state conviction and the birth of her child, on January 14,

2021, Wall was seen at Geisinger and was diagnosed with postpartum depression.

(Tr. 710-11). At a June 3, 2011, clinical encounter Wall reported worsening

depression, which was attributed in part to postpartum depression. (Tr. 699). Her

caregivers reported that her mental status was at baseline and described her condition

as a moderate episode of recurrent depressive disorder. (Tr. 703).

On December 15, 2021, Dr. Sarah Vanes conducted a consultative

examination of Wall as part of the disability determination process. (Tr. 948-54). At

that time Wall reported that she was still on home detention following her state

conviction. (Tr. 949). Wall described depression which “comes and goes” but denied

any suicidal ideation. (Id.) Wall was cooperative throughout the examination, (Id.)

Her appearance was appropriate; her speech was fluent; she was fully oriented; and

her thought processes were coherent and goal oriented. (Tr. 950). While she had a

flat affect, and testing revealed some impairment of her memory, concentration and

attention, her judgment and insight were both rated as fair. (Id.)

On January 22 and 28, 2022, Wall was seen at Geisinger. (Tr. 985-94). She

was described as irritable, diagnosed as experiencing a moderate episode of major

depressive disorder, and agreed to a psychological referral to Dr. Fran Angelella.

(Tr. 990-94). However, caregivers noted that she was fully oriented and her mood,

affect, and behavior were reported as normal. (Tr. 985-89). Records of Wall’s

clinical encounters with Dr. Angelella and her staff in February and March of 2022

indicated that Wall self-reported depression, mood swings, and anxiety. (Tr. 1026).

However, Wall also stated that she felt a slight improvement in her symptoms when

she took her medication. (Tr. 1027). Her affect was flat and her mood anxious, but

her appearance, behavior, and cognition were rated within normal limits. (Id.) Wall

was later described as neat in appearance, alert, engaged, cooperative and

purposeful. (Tr. 1029). Her recent memory was considered moderately impaired,

and her attention and concentration were impaired to a moderate to severe degree.

(Id.) During a March 14, 2022, clinical encounter, Wall was fully oriented, but

voiced fleeting thoughts of death while stating that her mood was somewhat better

when she took her medication. (Tr. 1038-42).

Wall reported similar symptoms, along with some suspicious and paranoid

thoughts, during an April 11, 2022, medical appointment. (Tr. 1136). At that time,

she was diagnosed with a moderate recurrent depressive disorder, and it was noted

that her attention, speech, and behavior were all normal. (Tr. 1141). Ten days later,

when she was seen for podiatric care, staff reported no evidence of depression or

anxiety and Wall’s mood, affect, judgment and thought content were considered

normal. (Tr. 1188-89).

In May of 2022, Dr. Angelella described Wall’s condition as stable, and

recorded that she felt better when she took her medications. (Tr. 1064). Her

appearance and behavior were found to be within normal limits. (Tr. 1065).

Likewise, treatment notes from May 11, 2022, stated that Wall’s affect, speech, and

behavior were normal, and that she reported having more energy since she began her

medication regime. (Tr. 1230-35). Her primary care physician assistant, Stephen

Gitkos, made similar findings during a June 9, 2022, appointment. (Tr. 1324-28).

While Wall continued to present as depressed, she stated that her medications were

helpful. She was fully oriented, and her cognition, memory, attention, perception,

speech, and behavior were normal. (Id.)

In July and August 2022, Wall experienced episodes of dizziness. (Tr. 1296,

1303-20). During her treatment encounters relating to these dizzy spells, it was noted

that she experienced moderately severe recurrent major depressive disorder, with

fleeting dark thoughts, but her speech, behavior, and attention were normal; she was

fully oriented; and her mental status was at baseline. (Id.) She was assessed as

negative for self-harm, and it was observed that she reported symptom improvement

when she took her medications. (Id.)

C. The Medical Opinion Evidence.

Given this clinical history, three medical sources opined regarding the degree

to which Wall’s emotional impairments were disabling. reaching starkly differing

conclusions on this issue. At the outset, on December 15, 2021, Dr. Sarah Vanes, a

consulting source, concluded based upon a one-time examination of Wall that she

was mildly impaired in terms of her ability to understand and carry out simple

instructions and moderately impaired when it came to carrying out more complex

instructions. (Tr. 952). Dr. Vanes also found that Wall would experience marked

limitations in interacting with others and adapting to workplace changes. (Tr. 953).

Two state agency experts who considered the same clinical evidence and had

the benefit of Dr. Vanes’ assessment, reached somewhat different conclusions. On

December 23, 2021, Dr. Karen Plowman assessed Wall’s mental residual functional

capacity. (Tr. 91-100). In this assessment, Dr. Plowman found that Wall was

moderately impaired in terms of her ability to concentrate, persist, or maintain pace

and understand, remember, or apply information. The doctor concluded that Wall

was only mildly impaired with respect to her ability to interact with others and adapt

or manage herself. (Tr. 93). According to Dr. Plowman, Wall’s ability to understand,

remember, and carry out detailed instructions as well as her ability to maintain

attention and concentration for extended periods was also moderately impaired. (Tr.

98). However, she was not significantly limited in any other spheres of intellectual

functioning. (Id.)

Dr. Plowman also specifically considered, and rejected, the more restrictive

opinion of Dr. Vanes, stating:

The findings of Dr. Vanes are not supported by the collateral MER or

her own narrative. She endorsed marked impairments in the clmt's

ability to interact with others and adapt to changes in the workplace.

While the clmt reports some social anxiety, she does socialize, shops in

stores and goes out into the community. Her ADLS are functional and

she is caring for three young children. It appears the CE overestimated

the clmt's limitations. The clmt is able to meet the mental demands for

simple, one to two step tasks on a sustained basis despite the limitations

associated with her impairments.

(Id.)

On reconsideration, Dr. Plowman’s views were endorsed by a second state

agency expert, Dr. Lisa Cannon. (Tr. 112-23). In March of 2022, Dr. Cannon found

that Wall was mildly impaired when it came to understanding, remembering, or

applying information and adapting or managing herself. The doctor opined that she

was moderately impaired in her ability to interact with others and concentrate,

persist, or maintain pace. (Tr. 115). Dr. Cannon also specifically found that Wall “is

able to meet the mental demands required for basic tasks on a sustained basis despite

the limitations resulting from the claimant’s impairment. [She] can understand,

retain and follow one and two–step instructions.” (Tr. 116). Finally, Dr. Cannon

carefully considered the opinion of Dr. Vanes and found it to be only partially

persuasive, observing that:

[The] medical source statements in the report concerning the

claimant’s abilities in the areas of making occupational adjustments and

making performance adjustments are fairly consistent with the other

evidence in file. However, the source statements regarding the abilities

in the areas of making personal and social adjustments and other work

related activities are not consistent with all of the medical and non-

medical evidence in the claims folder. The opinion is without

substantial support from the other evidence of record, which renders it

less persuasive.

(Id.)

It was against this medical background that Wall’s case came to be considered

by the ALJ.

D. The ALJ Decision

A hearing was conducted in Wall’s case on July 20, 2022. (Tr. 49-85).

Following this hearing, on September 29, 2022, the ALJ issued a decision in Wall’s

case. (Tr. 26-48). In that decision, the ALJ first concluded that Wall met the insured

requirements of the Act through September 30, 2022, and had not engaged in

substantial gainful activity since the alleged onset date of November 16, 2020. (Tr.

32). At Step 2 of the sequential analysis that governs Social Security cases, the ALJ

found that Wall had the following severe emotional impairments: major depressive

disorder; posttraumatic stress disorder (PTSD); bipolar disorder; panic disorder;

anxiety; and schizoaffective disorder, bipolar type. (Id.)

At Step 3, the ALJ determined that Wall did not have an impairment or

combination of impairments that met or medically equaled the severity of one of the

disability listing impairments. (Tr. 32-36). This Step 3 determination rested upon a

comprehensive review of Wall’s medical history. As the ALJ explained:

The severity of the claimant’s mental impairments, considered singly

and in combination, do not meet or medically equal the criteria of

listings 12.03, 12.04, 12.06, and 12.15. In making this finding, the

undersigned has considered whether the “paragraph B” criteria are

satisfied. To satisfy the “paragraph B” criteria, the mental impairments

must result in one extreme limitation or two marked limitations in a

broad area of functioning. An extreme limitation is the inability to

function independently, appropriately, or effectively, and on a

sustained basis. A marked limitation is a seriously limited ability to

function independently, appropriately, or effectively, and on a

sustained basis.

In understanding, remembering or applying information, the claimant

has a moderate limitation. The claimant alleges difficulties with

understating and memory deficits (Exhibits 3E, 7E). However, she also

reported that she does not need reminders to go places, care for her

personal hygiene, or take medication (Exhibits 3E, 7E). Additionally,

she reported that she is generally able to care for all of the needs of her

children, prepare and cook simple meals, perform household chores,

drive a motor vehicle, shop, and manage her personal finances (Exhibits

3E, 7E). A mental status examination in February 2022 notes moderate

recent memory and the consultative examination describes below

average cognitive functioning and somewhat limited fund of

information (Exhibits 10F, 13F). However, the consultative

examination also reflects only mildly impaired recent and remote

memory skills and coherent and goal directed thought processes

(Exhibit 10F). Additionally, treatment records otherwise generally

reflect intact memory skills and normal cognition (Exhibits 14F, 18F).

The consultative examiner opined that the claimant has mild limitation

in understanding, remembering, and carrying out simple instructions;

moderate limitation in understanding, remembering, and carrying out

complex instructions and making judgments on simple work-related

decisions; and marked limitation in making judgments on complex

work-related decisions (Exhibit 10F). However, both State agency

psychological consultants opined that the claimant has no more than

moderate limitation in this functional domain (Exhibits 2A, 4A, 5A,

7A). As such, the evidence wholly supports the finding that the

claimant’s mental impairments cause no more than moderate limitation

in understanding, remembering, or applying information.

In interacting with others, the claimant has a moderate limitation. The

claimant did not allege any specific difficulties getting along with

others (Exhibits 3E, 7E). However, she did report that she experiences

difficulty leaving her home, social anxiety, and a loss of interest in

going places (Exhibits 3E, 7E). Nevertheless, she also reported that she

spends time with others and that she shops in stores (Exhibits 3E, 7E).

Moreover, she reported no difficulties getting along with authority

figures and that she has never been fired from problems getting along

with others (Exhibits 3E, 7E). The consultative examination describes

cooperative attitude, adequate manner of relating, appropriate eye

contact, fluent speech, well-groomed appearance, and no evidence of

hallucinations, delusions, or paranoia (Exhibit 10F). Additionally,

treatment records generally describe neat and well-groomed

appearance, cooperative attitude, normal speech, normal behavior, and

thought content without hallucinations, delusions, or homicidal

ideations (Exhibits 13F, 16F, 18F). While the consultative examiner

opined that the claimant has marked limitation in interacting with

others, both State agency psychological consultants opined that the

claimant has no more than moderate limitation in this functional

domain (Exhibits 2A, 4A, 5A, 7A, 10F). As such, the evidence of

record wholly supports the finding that the claimant’s mental

impairments cause no more than moderate limitation in interacting with

others.

With regard to concentrating, persisting or maintaining pace, the

claimant has a moderate limitation. The claimant alleges difficulties

with concentration and completing tasks (Exhibits 3E, 7E). However,

she reported that she is generally able to care for all of the needs of her

children, prepare and cook simple meals, perform household chores,

drive a motor vehicle, shop, and manage her personal finances (Exhibits

3E, 7E). The consultative examination describes impaired attention and

concentration skills; however, it also notes coherent and goal directed

thought process with normal thought content (Exhibit 10F). A mental

status examination in February 2022 also reflects moderate attention

and concentration (Exhibit 13F). However, more recent mental status

examinations from April through July 2022 describe normal attention

(Exhibits 16F, p. 75; 18F, p. 27, 39-40). No treating, examining, or

reviewing source opined that the claimant has greater limitation in this

functional domain (Exhibits 2A, 4A, 5A, 7A, 10F).

As for adapting or managing oneself, the claimant has experienced a

mild limitation. The record is devoid of inpatient psychiatric

hospitalizations, participation in a partial hospitalization program, or

emergency room visits during the period at issue. Additionally, the

record is devoid of reported hallucinations, delusions, obsessions, or

homicidal ideations or apparent difficulties with impulse control. While

treatment records were positive for reported fleeting thoughts about

death; however, the records consistently reflect no plan or intent

(Exhibits 12F, 14F, 16F, 18F). Additionally, a mental status

examination in April 2022 was positive for paranoid though content,

but treatment records were otherwise devoid of the same and the

consultative examination was negative for paranoia (Exhibits 10F, 13F,

12F, 14F, 16F, 18F). Other than those clinical abnormalities noted

above, treatment records generally reflect variations in mood and affect,

but are relatively devoid of significant clinical abnormalities (Exhibits

13F, 14F, 15F, 16F, 18F). Additionally, the consultative examination

describes neutral mood, but flat affect and appropriate dress, well-

groomed appearance, fluent speech with adequate expressive and

receptive language skills, clear sensorium and full orientation, and

coherent and goal directed thought process (Exhibit 10F). The claimant

reported that she cares for all of her children’s needs (Exhibit 7E).

Moreover, the record reflects that the claimant can independently care

for her personal hygiene, prepare and cook simple meals, wash laundry

and perform some household chores, shop, manage money and drive

(Exhibits 3E, 7E, 10F, 11F). There is no evidence of an inability to set

realistic goals, make plans independent of others, travel to unfamiliar

places, avoid normal hazards, or take appropriate precautions. While

the consultative examiner opined that the claimant has limitations in

adapting and managing oneself, she did not specify the extent of the

same (Exhibit 10F). Additionally, both State agency psychological

consultants opined that the claimant has no more than mild limitation

in this functional domain (Exhibits 2A, 4A, 5A, 7A). As such, the

evidence of record wholly supports the finding that the claimant’s

mental impairments cause no more than mild limitation in adapting or

managing oneself.

Because the claimant’s mental impairments do not cause at least two

“marked” limitations or one “extreme” limitation, the “paragraph B”

criteria are not satisfied.

The undersigned has also considered whether the “paragraph C” criteria

are satisfied. In this case, the evidence fails to establish the presence of

the “paragraph C” criteria. The claimant is capable of self-sustainment

and the record reveals that the claimant is also capable of some

adjustment to minor changes in mental demands. The claimant has not

required psychiatric hospitalizations or emergency room visits for

psychologically related symptoms and mental status examinations fail

to show significant clinical abnormalities during the period at issue.

The limitations identified in the “paragraph B” criteria are not a residual

functional capacity assessment but are used to rate the severity of

mental impairments at steps 2 and 3 of the sequential evaluation

process. The mental residual functional capacity assessment used at

steps 4 and 5 of the sequential evaluation process requires a more

detailed assessment of the areas of mental functioning. The following

residual functional capacity assessment reflects the degree of limitation

the undersigned has found in the “paragraph B” mental function

analysis.

(T. 33-36).

Between Steps 3 and 4, the ALJ then fashioned a residual functional capacity

(“RFC”) for the plaintiff which considered all of Wall’s impairments as reflected in

the medical record, and found that:

After careful consideration of the entire record, the undersigned finds

that the claimant has the residual functional capacity to perform

sedentary work as defined in 20 CFR 404.1567(a) and 416.967(a)

except that the claimant can never push/pull with the lower extremities

or climb ladders, ropes, or scaffolds. The claimant is limited to

occasional climbing of ramps and stairs, balancing, stooping, kneeling,

crouching, and crawling. The claimant must avoid concentrated

exposure to extreme cold and heat, wetness, humidity, vibration,

hazards, and fumes, odors, dusts, gases, poor ventilation, and other

pulmonary irritants. The claimant is limited to work involving only

simple, routine tasks, involving only one to two-step instructions, but

not at a production rate pace, and no more than simple work-related

decisions. The claimant can tolerate no more than occasional changes

in the work setting and is limited to occasional interaction with

supervisors, coworkers, and the public.

(Tr. 36).

In fashioning this RFC, the ALJ considered the medical evidence, the expert

opinions, and Wall’s self-described limitations. (Tr. 36-41). This analysis

specifically considered the clinical and opinion evidence as it related to Wall’s

emotional impairments. On this score, the ALJ noted that:

As for the claimant’s alleged mental impairments, the evidence of

record does not support greater limitations than those provided herein.

Treatment records reflect a longitudinal history of mental impairments

beginning prior to the alleged onset date (Exhibit 7F). However, the

record is devoid of inpatient psychiatric hospitalizations, participation

in a partial hospitalization program, or emergency room visits during

the period at issue and the claimant’s treatment has generally consisted

of some limited outpatient counseling and psychotropic medication

prescribed by her primary care physician (Exhibits 1F, 6F, 7F, 8F, 14F).

Additionally, the record is devoid of reported hallucinations, delusions,

obsessions, or homicidal ideations or apparent difficulties with impulse

control. While treatment records were positive for reported fleeting

thoughts about death; however, the records consistently reflect no plan

or intent (Exhibits 12F, 14F, 16F, 18F). Additionally, a mental status

examination in April 2022 was positive for paranoid thought content,

but treatment records were otherwise devoid of the same and the

consultative examination was negative for paranoia (Exhibits 10F, 13F,

12F, 14F, 16F, 18F). Otherwise, treatment records generally reflect

variations in mood and affect, but fail to reflect significant clinical

abnormalities to support greater limitations (Exhibits 13F, 14F, 15F,

16F, 18F).

(Tr. 38-39).

Given this clinical history the ALJ found that the state agency opinions

regarding Wall’s emotional RFC were generally persuasive, observing that:

The State agency psychological consultant on initial review opined that

the claimant could understand, remember, attend to, and complete

simple tasks and that she could meet the mental demands for simple,

one to two-step tasks on a sustained basis despite the limitations

associated with her impairments (Exhibits 2A, 4A). The undersigned

finds this opinion mostly persuasive, as the evidence of record is

generally consistent with moderate mental functional limitations and

does not rise to the level of marked or extreme limitations. More

specifically, the consultative examination and treatment records from

February 2022 reflect some attention and concentration, memory, and

cognitive deficits, it also notes coherent and goal directed thought

process, adequate expressive and receptive language skills, fluent

speech, adequate manner of relating, and clear sensorium. Otherwise,

treatment records generally note variations in mood and affect, but were

otherwise devoid of significant clinical abnormalities to support greater

mental functional limitations.

The State agency psychological consultant on reconsideration opined

that the claimant could understand and remember simple tasks; make

simple decisions; carry out short, simple instructions; understand,

retain, and follow simple instructions (i.e. perform/follow one and two-

step tasks/instructions); and would not require special supervision in

order to sustain a routine (Exhibits 5A, 7A). The undersigned finds this

opinion mostly persuasive, as the evidence of record is generally

consistent with moderate mental functional limitations and does not rise

to the level of marked or extreme limitations. More specifically, the

consultative examination and treatment records from February 2022

reflect some attention and concentration, memory, and cognitive

deficits, it also notes coherent and goal directed thought process,

adequate expressive and receptive language skills, fluent speech,

adequate manner of relating, and clear sensorium. Otherwise, treatment

records generally note variations in mood and affect, but were

otherwise devoid of significant clinical abnormalities to support greater

mental functional limitations.

(Tr. 40).

The ALJ found Dr. Vanes’ consultative examination opinion unpersuasive

stating:

As for supportability, while the consultative examination itself

describes impaired attention and concentration skills, mildly impaired

recent and remote memory skills, below average cognitive functioning,

and somewhat limited fund of information, it was otherwise generally

within normal limits. However, as for consistency, treatment records

generally reflect variations in mood and affect, but were otherwise

generally within normal limits. As such, the evidence, when considered

in its entirety, including the claimant’s reported daily activities, is

inconsistent with the degree of limitation contained in the opinion.

(Tr. 41).

Having made these findings, the ALJ concluded that Wall was unable to

perform her past relevant work but retained the ability to perform other jobs that

existed in significant numbers in the economy. (Tr. 41-43). Accordingly, the ALJ

denied Wall’s claim of disability. (Id.)

This appeal followed. (Doc. 1). On appeal, Wall argues that the ALJ erred in

finding that the medical opinion of a non-treating consultant, Dr. Sarah Vanes, was

less persuasive than two state agency expert opinions. However, after a review of

the record, we find that substantial evidence supported the ALJ’s decision in this

case and therefore will affirm the decision of the Commissioner.

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]

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 recently 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. at 1154.

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

disabled, but rather whether the Commissioner’s finding that he 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 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 v. Barnhart, 399 F.3d 546, 552 (3d

Cir. 2005)). 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. 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); see also 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 activity that exists in the national economy. 42

U.S.C. §423(d)(2)(A); 20 C.F.R. §404.1505(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). 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).

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

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). 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).

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 have suggested 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 v. Acting Comm’r of Soc. Sec., 962 F. Supp. 2d 761, 778–79 (W.D. Pa. 2013)

(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: “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 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).

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 where a well-supported medical source has identified limitations

that 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 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 v. Barnhart, 174 F. App’x 6, 11 (3d Cir.

2006); Cummings v. Colvin, 129 F. Supp. 3d 209, 214–15 (W.D. Pa. 2015). 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 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

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

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

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 706-07. 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.

Wall 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

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.

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

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).

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

D. The ALJ’s Decision is Supported by Substantial Evidence.

In this setting, we are mindful that we are not free to substitute our

independent assessment of the evidence for the ALJ’s determinations. Rather, we

must simply ascertain whether the ALJ’s decision is supported by substantial

evidence, a quantum of proof which is less than a preponderance of the evidence but

more than a mere scintilla, Richardson, 402 U.S. at 401, and “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, 487 U.S.

at 565. Judged against these deferential standards of review, we find that substantial

evidence supported the ALJ’s evaluation of the medical opinion evidence regarding

Wall’s emotional impairments. Therefore, we will affirm this decision.

In this case, Wall challenges the substance of this medical opinion evaluation

and assails the ALJ’s articulation of the rationale behind this medical opinion

evaluation. However, we find that when the ALJ’s decision is read as a whole and

in a commonsense fashion substantial evidence which is well set forth by the ALJ

supports this decision.

On this score, with respect to medical opinions analysis: