referring to 20 C.F.R. § 404.1529
How later courts described this case
- referring to 20 C.F.R. § 404.1529
- agreeing that “SSR 96–2p does not prohibit the ALJ from crediting some parts of a treating source's opinion and rejecting other portions”
- “[T]he court has plenary review of all legal issues . . . .”
- “The Secretary’s determination as to the status of a claim requires the correct application of the law to the facts.”
Written by the judges who cited it.
The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
GINO FERNANDEZ, : Civil No. 4:24-CV-412
:
Plaintiff :
:
v. : (Magistrate Judge Carlson)
:
FRANK BISIGNANO,1 :
Commissioner of Social Security, :
:
Defendant. :
MEMORANDUM OPINION
I. Introduction
When considering Social Security appeals we are enjoined to apply a
deferential standard of review, a standard of review which simply asks whether there
is “substantial evidence” supporting the Administrative Law Judge’s (ALJ)
determination. With respect to this legal guidepost, 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-
1 Frank Bisignano became the Commissioner of Social Security on May 6, 2025.
Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure, Frank Bisignano
should be substituted as the 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).
1
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).
In the instant case, the plaintiff, Gino Fernandez, argues that the
Administrative Law Judge erred in failing to recognize that his emotional
impairments were per se disabling. According to Fernandez this legal error was a
product of another error in that the ALJ discounted the sole medical opinion which
would have supported a finding of disability as well as his own subjective
complaints. However, after a review of the record, and 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 findings in this case.
Therefore, for the reasons set forth below, we will affirm the decision of the
Commissioner.
2
II. Statement of Facts and of the Case
A. Procedural History
While Gino Fernandez has never engaged in substantial gainful employment,
he has amassed a substantial litigative history with the Social Security
Administration spanning nearly a quarter of a century. This history began in 2010
when Fernandez was found disabled as of August 12, 2008, due to anxiety and mood
disorder. (Tr. 76-78). However, after a periodic review in March 2015, it was
determined that his medical condition improved and that he was not disabled as of
January 1, 2015. (Tr. 88). Fernandez sought review of this determination, an ALJ
issued an unfavorable decision in September 2018, and the Appeals Council denied
his request for review. (Tr. 85, 105, 106).
B. Fernandez’s Current Disability Application—The Clinical Record
Approximately two years later, on May 14, 2021, Fernandez filed an
application for child’s insurance benefits.2 Fernandez also filed a Title XVI
application for supplemental security income on December 14, 2020. (Tr. 15). In
this latest application Fernandez alleged that he was disabled due to an array of
2 We note that the ALJ’s decision concluded that Fernandez had provided no new
evidence to support this childhood disability claim and denied the claim. (Tr. 15-
19). Fernandez does not appear to challenge this decision on appeal. Therefore, we
will limit our discussion to Fernandez’s Title XVI application.
3
emotional impairments, including obsessive compulsive disorder (OCD), opioid
dependence/use disorder, anxiety/generalized anxiety disorder (GAD), panic
disorder, depressive disorder, and post-traumatic stress disorder. (Tr. 20). Fernandez
was born on June 5, 1974 and was 46 years old, which is defined as a younger
individual, on the application date for supplemental security income. He had at least
a high school education but no prior employment history. (Tr. 26-27).
With respect to Fernandez’s presenting emotional impairments:
[T]he record shows that the claimant has been diagnosed with OCD,
opioid dependence/use disorder, GAD, panic and depressive disorders,
and PTSD (Exhibits D3F; D5F; D7F). The record shows that the
claimant was involved in methadone and Suboxone management
treatment in 2013 and from 2019 to March 2021 (Exhibits D4F; D5F).
Treatment records from Dr. Levinson’ office do note psychomotor
agitation, fidgeting of hands, and irritable mood (Exhibit D3F/13). The
claimant was last seen by Dr. Levinson in April 2020 (prior to the
protective filing date) (Exhibits D3F; D9F). The claimant had also been
seen by Clinical Outcome Group. In follow-up visits from April 2021
to August 2022, the record notes some signs of anxiety (Exhibit D13F).
Additionally, during his July 2021 consultative mental status
examination, the claimant exhibited an anxious mood and affect, rapid
and pressured voice, and mildly impaired attention, concentration, and
memory (Exhibit D7F). As such, this evidence supports the limitation
to simple, routine tasks, no complex tasks or fast-paced production
work, low-stress work environment, occasional interaction with
supervisors and co-workers, and no team type setting work or
interaction with the public.
Despite these impairments and positive examination findings, during
his last visit with Dr. Levinson’s office in April 2020, the claimant also
exhibited normal speech, normal thought processes and content,
cooperative and polite behavior, no hallucinations, suicidal, or
4
homicidal ideation, good insight and judgment, and no gross cognitive
deficits (Exhibit D3F/13). In follow-up visits from April 2021 to
August 2022, other than some signs of anxiety in September 2021, the
claimant still exhibited normal speech and his exams were noted as
stable. While there was some concern of overuse, there is no indication
of hospital admissions, emergency room visits, or other concerns
regarding his use (Exhibit D13F). During his July 2021 consultative
mental status examination, he also exhibited adequate expressive and
receptive language, fluent speech intelligibility, average intellectual
functioning, fair overall presentation, fair insight and judgment, full
orientation, cooperative behavior, appropriate eye contact, normal
thought processes, and normal motor behavior (Exhibit D7F).
Subsequent follow-up visits from September 2022 to January 2023
further note that the claimant was doing well, was stable with his
current dose, and had no audible problems (Exhibit D16F).
(Tr. 23-24).
C. The Opinion Evidence.
There appears to have been no treating source evidence opining regarding the
severity of Fernandez’s emotional impairments. Instead, with respect to this issue,
there were three medical opinions. Two of these opinions were provided by state
agency experts. First, in July of 2021, Dr, Susan Schwartz found that Fernandez was
moderately impaired in terms of understanding, remembering, or applying
information; interacting with others; concentrating, persisting, or maintaining pace;
and adapting or managing himself. (Tr. 136). Dr. Schwartz concluded that Fernandez
“is able to carry out very short and simple instructions. The claimant can make
simple decisions”; (Tr. 144), “can sustain an ordinary routine without special
5
supervision”; (Tr. 146), and “is able to meet the basic mental demands to complete
1-2 step tasks on a sustained basis despite the limitations resulting from the
claimant's mental health impairment.” (Tr. 147).
In April of 2022, on reconsideration Dr. William Anzalone, a second state
agency expert, reached similar conclusions regarding the severity of Fernandez’s
impairments. (Tr. 162). According to Dr. Anzalone: “In spite of a history of
difficulty interaction with the general public, the claimant has the ability to get along
with others. The clmt is able to meet the basic mental demands of simple skills and/or
tasks on a sustained basis despite the limitations resulting from the clmt's
impairment(s).” (Tr. 167). Notably, these opinions also considered the only other
medical opinion in the record, a consultative opinion of Dr. Leah Bielski. (Tr. 164).
There was one countervailing medical opinion from a consulting examining
source. On July 1, 2021, Dr. Leah Bielski conducted a mental status examination of
Fernandez. (Tr. 601-08). The results of this examination were mixed, and in some
instances contradictory. Thus, relying largely upon Fernandez’s self-reports, Dr.
Bielski described a number of significant symptoms experienced by the plaintiff.
(Tr. 602). However, she also found his presentation to be fair, his speech intelligible
and fluent, his thought processes coherent and goal-oriented, his insight and
judgment fair, his intellectual functioning to be average, and his memory only mildly
6
impaired. (Tr. 603-04). Given these equivocal findings, Dr. Bielski concluded that
Fernandez was only mildly impaired when it came to simple instructions;
moderately impaired in terms of following complex instructions; but markedly
impaired with respect to interacting with others and adapting to workplace change.
(Tr. 606-07).
C. The ALJ Hearing and Decision
It was against this equivocal medical backdrop that Fernandez’s disability
claim came to be heard by the ALJ on February 9, 2023. (Tr. 35-67). Following this
hearing, on February 28, 2023, the ALJ issued a decision denying Fernandez’s
application for benefits. (Tr. 12-34). In that decision, the ALJ first concluded that
Fernandez has not engaged in substantial gainful activity since June 5, 1992, the
alleged onset date. (Tr. 18). At Step 2 of the sequential analysis that governs Social
Security cases, the ALJ found that Fernandez had the following severe impairments:
obsessive compulsive disorder (OCD), opioid dependence/use disorder,
anxiety/generalized anxiety disorder (GAD), panic disorder, depressive disorder,
and post-traumatic stress disorder. (Tr. 20).
At Step 3, the ALJ determined that Fernandez did not have an impairment or
combination of impairments that met or medically equaled the severity of one of the
listed impairments, stating:
7
The severity of the claimant’s mental impairments, considered singly
and in combination, do not meet or medically equal the criteria of
listings 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 has been diagnosed with OCD,
opioid dependence/use disorder, GAD, panic and depressive disorders,
and PTSD (Exhibits D3F; D5F; D7F). However, a consultative mental
status examination has further shown mildly impaired memory, but
otherwise coherent and goal-directed thought processes, and average
intellectual functioning (Exhibit D7F). Additionally, State agency
psychological consultants for the Title XVI claim, indicated that the
claimant has a moderate limitation in this area (Exhibits D4A; D5A;
D8A; D9A). As such, the undersigned determines that the claimant has
a moderate limitation in understanding, remembering, or applying
information.
In interacting with others, the claimant has a moderate limitation. The
claimant reported that his impairments affect his ability to interact with
others (Hearing Testimony). However, he also indicated that he
remains able to grocery shop in stores once per week (Hearing
Testimony). A consultative mental status examination has further
shown cooperative behavior, fair overall presentation, normal motor
behavior, appropriate eye contact, fluent speech intelligibility, adequate
expressive and receptive language, coherent and goal-directed thought
processes, fair insight, and fair judgment, despite his anxious mood and
affect and rapid and pressured voice (Exhibit D7F). Additionally, State
agency psychological consultants for the Title XVI claim indicated that
the claimant has a moderate limitation in this area (Exhibits D4A; D5A;
D8A; D9A). As such, the undersigned determines that the claimant has
a moderate limitation in interacting with others.
8
With regard to concentrating, persisting, or maintaining pace, the
claimant has a moderate limitation. The claimant has been diagnosed
with OCD, opioid dependence/use disorder, GAD, panic and
depressive disorders, and PTSD (Exhibits D3F; D5F; D7F). However,
a consultative mental status examination has further shown mildly
impaired attention and concentration, but otherwise coherent and goal-
directed thought processes, full orientation, and average intellectual
functioning (Exhibits D7F). Additionally, State agency psychological
consultants for the Title XVI claim indicated that the claimant has a
moderate limitation in this area (Exhibits D4A; D5A; D8A; D9A). As
such, the undersigned determines that the claimant has a moderate
limitation in concentrating, persisting, or maintaining pace.
As for adapting or managing oneself, the claimant has experienced a
moderate limitation. The claimant reported that his impairments affect
his ability to interact with others, concentrate, and handle stress
(Hearing Testimony). However, he also indicated that he remains able
to grocery shop in stores once per week (Hearing Testimony). A
consultative mental status examination has further shown cooperative
behavior, fair overall presentation, normal motor behavior, mildly
impaired attention, concentration, and memory, appropriate eye
contact, fluent speech intelligibility, adequate expressive and receptive
language, coherent and goal-directed thought processes, full
orientation, fair insight, and fair judgment, despite his anxious mood
and affect and rapid and pressured voice (Exhibit D7F). Additionally,
State agency psychological consultants for the Title XVI claim
indicated that the claimant has a moderate limitation in this area
(Exhibits D4A; D5A; D8A; D9A). As such, the undersigned determines
that the claimant has a moderate 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.
(Tr. 20-21).
9
Between Steps 3 and 4, the ALJ fashioned a residual functional capacity
(“RFC”), considering Fernandez’s limitations from his impairment, stating that:
After careful consideration of the entire record, since the protective
filing date of December 14, 2020, the undersigned finds that the
claimant has the residual functional capacity to perform a full range of
work at all exertional levels but with the following nonexertional
limitations: The claimant can do simple, routine tasks but no complex
tasks in low stress work environment defined as occasional decision
making and occasional changes in work setting. The claimant can have
no fast-paced production work such as conveyor belt or quota-based
work. The claimant is limited to occasional interaction with supervisors
and coworkers, but no team type setting work and no interaction with
public.
(Tr. 22).
Specifically, in making the RFC determination, the ALJ considered the
clinical evidence, the medical opinions, and Fernandez’s self-described activities. In
particular, with respect to the medical opinions the ALJ observed that:
The undersigned also considered the opinions of the State agency
psychological consultants at the initial and reconsideration levels for
the Title XVI claim, who both indicated that the claimant has the
following mental functioning limitations: moderate in understanding,
remembering, or applying information; moderate in interacting with
others; moderate in concentrating, persisting, or maintaining pace; and
moderate in adapting or managing oneself. At the initial level, the
consultant also indicated that the claimant can understand, retain, and
follow simple instructions; perform simple, routine, and repetitive tasks
in a stable environment; carry out very short and simple instructions;
make simple decisions; would not require special supervision in order
to sustain a routine; perform the personal care functions needed to
maintain an acceptable level of personal hygiene; is capable of asking
simple questions and accepting instruction; sustain an ordinary routine
10
without special supervision; function in production oriented
environments requiring little independent decision making. At the
reconsideration level, the consultant also indicated that the claimant can
understand, retain, and follow simple job instructions; is able to carry
out very short and simple instructions; understand and remember
simple, one and two step instructions; function in production-oriented
jobs requiring little independent decision making; perform simple,
routine, repetitive tasks in a stable environment; perform the personal
care functions needed to maintain an acceptable level of personal
hygiene; and capable of asking simple questions and accepting
instruction (Exhibits D5A; D9A).
The undersigned finds these opinions persuasive, as they are supported
by and consistent with the medical evidence of record and activities of
daily living previously discussed. Specifically, although the claimant
has been diagnosed with OCD, opioid dependence/use disorder, GAD,
panic and depressive disorders, and PTSD, the evidence does not show
any inpatient psychological treatment around or since the protective
filing date, his consultative mental status examination despite anxiety
with rapid pressured speech had findings that included cooperative
behavior, fair overall presentation, normal motor behavior, mildly
impaired attention, concentration, and memory, appropriate eye
contact, fluent speech intelligibility, adequate expressive and receptive
language, coherent and goal-directed thought processes, full
orientation, fair insight, and fair judgment (Exhibit D7F), and he
remains able to grocery shop in stores once per week (Hearing
Testimony).
After examining the claimant in July 2021, consultative mental status
evaluator, Dr. Bielski, Psy.D., indicated that the claimant has mild
limitations in understanding, remembering, and carrying out simple
instructions and making judgments on simple work-related decisions;
moderate limitations in understanding, remembering, and carrying out
simple instructions and making judgments on complex work-related
decisions; marked limitations in interacting with the public,
supervisors, and co-workers; and marked limitation in responding
appropriately to usual work situations and to changes in a routine work
setting (Exhibit D7F/8-9). The undersigned finds this opinion only
11
partially persuasive. Specifically, the mild-to-moderate limitations in
the claimant’s ability to understand, remember, and carry out
instructions is supported by Dr. Bielski’s own examination findings of
only mildly impaired attention, concentration, and memory and
otherwise average intellectual functioning and coherent and goal-
directed thought processes (Exhibit D7F/5-6). Additionally, these
limitations are consistent with and supported by the other medical
evidence of record that shows no history of inpatient psychological
treatment within the last few years, and stability of his mental
impairments, along with the opinions of the State agency psychological
consultants (Exhibits D13F; D16F). That said, the marked limitations
are not consistent with or supported by this evidence of record. The
progress notes since April 2021, only indicated one time he had anxiety,
and even at that time maintained normal speech. Overall, the progress
notes through January 2023, noted he was stable. Additionally, these
marked limitations are not even fully supported by Dr. Bielski’s own
examination findings of cooperative behavior, fair overall presentation,
normal motor behavior, appropriate eye contact, fluent speech
intelligibility, adequate expressive and receptive language, coherent
and goal-directed thought processes, full orientation, fair insight, and
fair judgment, despite his anxious mood and affect and rapid and
pressured voice (Exhibit D7F/5-6). As such, the undersigned finds the
marked limitations to be unpersuasive.
(Tr. 24-25).
Having arrived at this RFC assessment, the ALJ found at Step 5 that there
were jobs which existed in substantial numbers in the national economy which
Fernandez could perform. (Tr. 28-29). Accordingly, the ALJ concluded that
Fernandez did not meet the stringent standard for disability set by the Act and denied
this claim. (Id.)
12
This appeal followed. (Doc. 1). On appeal, Fernandez contends that the ALJ
erred in assessing the medical opinion evidence and failed to recognize that he was
per se disabled due to his emotional impairments. This case is fully briefed and is,
therefore, ripe for resolution. For the reasons set forth below, we 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.
13
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 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.
14
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
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
15
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.
This principle applies with particular force to legal challenges, like the claim
made here, based upon alleged inadequacies in the articulation of a claimant’s
mental RFC. In Hess v. Comm’r Soc. Sec., 931 F.3d 198, 212 (3d Cir. 2019), the
United States Court of Appeals recently addressed the standards of articulation that
apply in this setting. In Hess, the court of appeals considered the question of whether
an RFC, which limited a claimant to simple tasks, adequately addressed moderate
16
limitations on concentration, persistence, and pace. In addressing the plaintiff’s
argument that the language used by the ALJ to describe the claimant’s mental
limitations was legally insufficient, the court of appeals rejected a per se rule which
would require the ALJ to adhere to a particular format in conducting this analysis.
Instead, framing this issue as a question of adequate articulation of the ALJ’s
rationale, the court held that, “as long as the ALJ offers a ‘valid explanation,’ a
‘simple tasks’ limitation is permitted after a finding that a claimant has ‘moderate’
difficulties in ‘concentration, persistence, or pace.’” Hess v. Comm’r Soc. Sec., 931
F.3d 198, 211 (3d Cir. 2019). On this score, the appellate court indicated that an ALJ
offers a valid explanation a mental RFC when the ALJ highlights factors such as
“mental status examinations and reports that revealed that [the claimant] could
function effectively; opinion evidence showing that [the claimant] could do simple
work; and [the claimant]’s activities of daily living, . . . . ” Hess v. Comm’r Soc.
Sec., 931 F.3d 198, 214 (3d Cir. 2019).
In our view, the teachings of the Hess decision are straightforward. In
formulating a mental RFC, the ALJ does not need to rely upon any particular form
of words. Further, the adequacy of the mental RFC is not gauged in the abstract.
Instead, the evaluation of a claimant’s ability to undertake the mental demands of
17
the workplace will be viewed in the factual context of the case, and a mental RFC is
sufficient if it is supported by a valid explanation grounded in the evidence.
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)
18
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
19
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
20
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
21
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
The plaintiff filed this disability application after 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 which defined
22
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 as 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.
23
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
24
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, where there is
no evidence of any credible medical opinion supporting a claimant’s allegations of
disability “the proposition that an ALJ must always base his RFC on a medical
opinion from a physician is misguided.” Cummings, 129 F.Supp.3d at 214–15.
25
D. Legal Benchmarks for the ALJ’s Assessment of a Claimant’s
Alleged Symptoms
The interplay between the deferential substantive standard of review that
governs Social Security appeals, and the requirement that courts carefully assess
whether an ALJ has met the standards of articulation required by law, is also
illustrated by those cases which consider analysis of a claimant’s reported pain.
When evaluating lay testimony regarding a claimant’s reported degree of pain and
disability, we are reminded that:
[T]he ALJ must necessarily make certain credibility determinations,
and this Court defers to the ALJ's assessment of credibility. See Diaz v.
Comm'r, 577 F.3d 500, 506 (3d Cir.2009) (“In determining whether
there is substantial evidence to support an administrative law judge's
decision, we owe deference to his evaluation of the evidence [and]
assessment of the credibility of witnesses....”). However, the ALJ must
specifically identify and explain what evidence he found not credible
and why he found it not credible. Adorno v. Shalala, 40 F.3d 43, 48 (3d
Cir.1994) (citing Stewart v. Sec'y of Health, Education and Welfare,
714 F.2d 287, 290 (3d Cir.1983)); see also Stout v. Comm'r, 454 F.3d
1050, 1054 (9th Cir.2006) (stating that an ALJ is required to provide
“specific reasons for rejecting lay testimony”). An ALJ cannot reject
evidence for an incorrect or unsupported reason. Ray v. Astrue, 649
F.Supp.2d 391, 402 (E.D.Pa.2009) (quoting Mason v. Shalala, 994 F.2d
1058, 1066 (3d Cir.1993)).
Zirnsak v. Colvin, 777 F.3d 607, 612–13 (3d Cir. 2014).
Yet, it is also clear that:
Great weight is given to a claimant's subjective testimony only when it
is supported by competent medical evidence. Dobrowolsky v. Califano,
606 F.2d 403, 409 (3d Cir. 1979); accord Snedeker v. Comm'r of Soc.
26
Sec., 244 Fed.Appx. 470, 474 (3d Cir. 2007). An ALJ may reject a
claimant's subjective testimony that is not found credible so long as
there is an explanation for the rejection of the testimony. Social
Security Ruling (“SSR”) 96–7p; Schaudeck v. Comm'r of Social
Security, 181 F.3d 429, 433 (3d Cir. 1999). Where an ALJ finds that
there is an underlying medically determinable physical or mental
impairment that could reasonably be expected to produce the
individual's pain or other symptoms, however, the severity of which is
not substantiated by objective medical evidence, the ALJ must make a
finding on the credibility of the individual's statements based on a
consideration of the entire case record.
McKean v. Colvin, 150 F.Supp.3d 406, 415–16 (M.D. Pa. 2015) (footnotes omitted).
Thus, we are instructed to review an ALJ’s evaluation of a claimant’s subjective
reports of pain under a standard of review which is deferential with respect to the
ALJ’s well-articulated findings but imposes a duty of clear articulation upon the ALJ
so that we may conduct meaningful review of the ALJ’s conclusions.
In the same fashion that medical opinion evidence is evaluated, the Social
Security Rulings and Regulations provide a framework under which the severity of
a claimant's reported symptoms are to be considered. 20 C.F.R. §§ 404.1529,
416.929; SSR 16–3p. It is important to note that though the “statements of the
individual concerning his or her symptoms must be carefully considered, the ALJ is
not required to credit them.” Chandler v. Comm’r of Soc. Sec., 667 F.3d 356, 363
(3d. Cir. 2011) (referencing 20 C.F.R. §404.1529(a) (“statements about your pain or
other symptoms will not alone establish that you are disabled”). It is well settled in
27
the Third Circuit that “[a]llegations of pain and other subjective symptoms must be
supported by objective medical evidence.” Hantraft v. Apfel, 181 F.3d 358, 362 (3d
Cir. 1999) (referring to 20 C.F.R. § 404.1529). When evaluating a claimant’s
symptoms, the ALJ must follow a two-step process in which the ALJ resolves
whether a medically determinable impairment could be the cause of the symptoms
alleged by the claimant, and subsequently must evaluate the alleged symptoms in
consideration of the record as a whole. SSR 16-3p.
First, symptoms, such as pain or fatigue, will only be considered to affect a
claimant's ability to perform work activities if such symptoms result from an
underlying physical or mental impairment that has been demonstrated to exist by
medical signs or laboratory findings. 20 C.F.R. §§ 404.1529(b), 416.929(b); SSR
16–3p. During the second step of this credibility assessment, the ALJ must determine
whether the claimant's statements about the intensity, persistence, or functionally
limiting effects of his or her symptoms are substantiated based on the ALJ's
evaluation of the entire case record. 20 C.F.R. § 404.1529(c), 416.929(c); SSR 16–
3p. This includes but is not limited to medical signs and laboratory findings,
diagnoses, and other medical opinions provided by treating or examining sources,
and other medical sources, as well as information concerning the claimant's
symptoms and how they affect his or her ability to work. Id. The Social Security
28
Administration has recognized that individuals may experience their symptoms
differently and may be limited by their symptoms to a greater or lesser extent than
other individuals with the same medical impairments, signs, and laboratory findings.
SSR 16–3p.
Thus, to assist in the evaluation of a claimant's subjective symptoms, the
Social Security Regulations identify seven factors which may be relevant to the
assessment of the severity or limiting effects of a claimant's impairment based on a
claimant's symptoms. 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3). These factors
include: activities of daily living; the location, duration, frequency, and intensity of
the claimant's symptoms; precipitating and aggravating factors; the type, dosage,
effectiveness, and side effects of any medication the claimant takes or has taken to
alleviate his or her symptoms; treatment, other than medication that a claimant has
received for relief; any measures the claimant has used to relieve his or her
symptoms; and, any other factors concerning the claimant's functional limitations
and restrictions. Id.; see Koppenaver v. Berryhill, No. 3:18-CV-1525, 2019 WL
1995999, at *9 (M.D. Pa. Apr. 8, 2019), report and recommendation adopted sub
nom. Koppenhaver v. Berryhill, No. 3:18-CV-1525, 2019 WL 1992130 (M.D. Pa.
May 6, 2019); Martinez v. Colvin, No. 3:14-CV-1090, 2015 WL 5781202, at *8–9
29
(M.D. Pa. Sept. 30, 2015); George v. Colvin, No. 4:13–CV–2803, 2014 WL
5449706, at *4 (M.D. Pa. Oct. 24, 2014).
E. The ALJ’s Decision is Supported by Substantial Evidence.
Fernandez’s appeal of this adverse decision faces a series of interlocking
obstacles. First, by arguing that the ALJ erred at Step 3 by failing to find that he was
per se disabled, Fernandez faces a daunting burden of proof and persuasion.
At Step 3 of this sequential analysis, the ALJ is required to determine whether,
singly or in combination, a claimant's ailments and impairments are so severe that
they are per se disabling and entitle the claimant to benefits. As part of
this step three disability evaluation process, the ALJ must determine whether a
claimant's alleged impairment is equivalent to a number of listed impairments,
commonly referred to as listings, that are acknowledged as so severe as to preclude
substantial gainful activity. 20 C.F.R. § 416.920(a)(4)(iii); 20 C.F.R. pt. 404, subpt.
P, App. 1; Burnett, 220 F.3d 112, 119.
In making this determination, the ALJ is guided by several basic principles
set forth by the social security regulations and case law. First, if a claimant's
impairment meets or equals one of the listed impairments, the claimant is considered
disabled per se and is awarded benefits. 20 C.F.R. § 416.920(d); Burnett, 220 F.3d
at 119. However, to qualify for benefits by showing that an impairment, or
30
combination of impairments, is equivalent to a listed impairment, a plaintiff bears
the burden of presenting “medical findings equivalent in severity to all the criteria
for the one most similar impairment.” Sullivan v. Zebley, 493 U.S. 521, 531 (1990);
20 C.F.R. § 416.920(d). An impairment, no matter how severe, that meets or equals
only some of the criteria for a listed impairment is not sufficient. Id.
Moreover, while the ALJ's treatment of this issue must go beyond a summary
conclusion, since a bare conclusion “is beyond meaningful judicial review,” Burnett,
220 F.3d at 119, case law “does not require the ALJ to use particular language or
adhere to a particular format in conducting his analysis. Rather, the function ... is to
ensure that there is sufficient development of the record and explanation of findings
to permit meaningful review.” Jones, 364 F.3d at 505. This goal is met when the
ALJ's decision, “read as a whole,” id., permits a meaningful review of the
SLJ's Step 3 analysis.
In addition, this question of per se disability is judged as a general matter
under a deferential standard of review. 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.
31
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.
Finally, when addressing the ALJ’s duty of articulation with regard to a
claimant’s emotional limitations, “as long as the ALJ offers a ‘valid explanation,’ a
‘simple tasks’ limitation is permitted after a finding that a claimant has ‘moderate’
difficulties in ‘concentration, persistence, or pace.’” Hess v. Comm’r Soc. Sec., 931
F.3d 198, 211 (3d Cir. 2019). On this score, the appellate court indicated that an ALJ
offers a valid explanation a mental RFC when the ALJ highlights factors such as
“mental status examinations and reports that revealed that [the claimant] could
function effectively; opinion evidence showing that [the claimant] could do simple
work; and [the claimant]’s activities of daily living, . . . . ” Hess v. Comm’r Soc.
Sec., 931 F.3d 198, 214 (3d Cir. 2019).
Judged against these deferential standards of review, we are constrained to
find that substantial evidence supported the decision by the ALJ that Fernandez was
not disabled. Therefore, we will affirm this decision.
In reaching this result we note at the outset, that to the extent Fernandez argues
that the ALJ failed to sufficiently explain her Step 3 findings, this argument fails in
light of the thorough analysis conducted here. The ALJ’s decision provided a careful,
32
and complete, articulation of the reasons why Fernandez had not established a per
se disability at Step 3. Drawing upon the clinical record, Fernandez’s activities of
daily living and the greater weight of the persuasive medical opinion evidence the
ALJ determined that Fernandez had not proven that he met all of the pertinent listing
criteria. This conclusion was supported by substantial evidence; that is, “such
relevant evidence as a reasonable mind might accept as adequate to support a
conclusion.” Pierce, 487 U.S. at 565. There was no error here.
Nor was the ALJ required to uncritically accept Fernandez’s subjective
reports regarding the severity of his symptoms when engaging in this Step 3
evaluation. Quite the contrary, the ALJ was obliged to assess those subjective reports
in light of the clinical evidence, Fernandez’s activities of daily living, and the
medical opinion evidence. In this case, that analysis yielded a conclusion that
Fernandez’s complaints were only partially credible and did not satisfy the exacting
standards prescribed at Step 3.
Finally, Fernandez contends that the ALJ erred at Step 3 in assessing the
medical opinion evidence and specifically argues that the ALJ should have been
bound by the extreme opinion of Dr. Bielski that he suffered from multiple marked
impairments. This final argument fails both as a matter of law and as a matter of fact.
33
First, as a matter of law, it is clear that “[t]he ALJ–not treating or examining
physicians or State agency consultants–must make the ultimate disability and RFC
determinations.” Chandler, 667 F.3d at 361. Further, in making this assessment of
medical opinion evidence, “[a]n ALJ is [also] entitled generally to credit parts of an
opinion without crediting the entire opinion.” Durden, 191 F.Supp.3d at 455.
Moreover, “[s]tate agent opinions merit significant consideration,” in this disability
analysis. Chandler, 667 F.3d at 361.
In the final analysis, the ALJ’s decision in this case, which found Dr. Bielski’s
opinion that Fernandez experienced multiple marked impairments to be
unpersuasive, was entirely consistent with settled caselaw, which holds that: “as long
as the ALJ offers a ‘valid explanation,’ a ‘simple tasks’ limitation is permitted after
a finding that a claimant has ‘moderate’ difficulties in ‘concentration, persistence,
or pace.’” Hess v. Comm’r Soc. Sec., 931 F.3d 198, 211 (3d Cir. 2019). On this
score, it is well-settled that an ALJ offers a valid explanation for a simple task RFC
when the ALJ highlights factors such as “mental status examinations and reports that
revealed that [the claimant] could function effectively; opinion evidence showing
that [the claimant] could do simple work; and [the claimant]’s activities of daily
living, which demonstrated that [s]he is capable of engaging in a diverse array of
‘simple tasks[.]’” Hess v. Comm’r Soc. Sec., 931 F.3d 198, 214 (3d Cir. 2019). The
34
ALJ fulfilled this duty here when she explained that these most extreme findings by
Dr. Bielski were inconsistent with clinical records, the plaintiff’s activities living,
and other more persuasive medical opinions. Substantial evidence supported the
ALJ’s conclusions in this regard. Thus, there was no error here.
In closing, the ALJ’s assessment of the evidence in this case complied with
the dictates of the law and was supported by substantial evidence. This is all that the
law requires, and all that a claimant can demand in a disability proceeding. Thus,
notwithstanding the argument that this evidence might have been viewed in a way
which would have also supported a different finding, we are obliged to affirm this
ruling 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)). Accordingly, under the deferential
standard of review that applies to appeals of Social Security disability
determinations, we find that substantial evidence supported the ALJ’s evaluation of
this case.
35
IV. Conclusion
Accordingly, for the foregoing reasons, the final decision of the
Commissioner denying these claims will be AFFIRMED.
An appropriate order follows.
s/ Martin C. Carlson
Martin C. Carlson
United States Magistrate Judge
DATED: May 15, 2025
36