McDonald v. Bisignano

IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF PENNSYLVANIA

TASHAE MCDONALD, : Civ. No. 1:25-CV-122

:

Plaintiff, :

:

v. :

: (Chief Magistrate Judge Bloom)

FRANK BISIGNANO, :

Commissioner of Social Security,1 :

:

Defendant. :

MEMORANDUM OPINION

I. Introduction

Tashae McDonald filed a Title II application for a period of

disability and disability insurance benefits on January 3, 2023. (Tr. 42).

Following an initial hearing before an Administrative Law Judge

(“ALJ”), the ALJ found that McDonald was not disabled from her alleged

onset date of disability of September 1, 2021, through August 8, 2024, the

date of the ALJ’s decision. (Tr. 42, 51).

1 On May 7, 2025, Frank Bisignano became the Commissioner of Social

Security. Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure

and 42 U.S.C. § 405(g), Frank Bisignano is substituted as the defendant

in this suit.

1

McDonald now appeals this decision, arguing that the ALJ’s

decision is not supported by substantial evidence. After a review of the

record, we conclude that the ALJ’s decision is not supported by

substantial evidence. Therefore, we will remand this matter for further

consideration by the Commissioner.

II. Statement of Facts and of the Case

On January 3, 2023, McDonald applied for disability insurance

benefits, citing an array of physical and mental impairments, including

bipolar disorder, anxiety, depression, schizoaffective disorder, asthma,

fibromyalgia, insomnia, and sleep apnea. (Tr. 79). McDonald was 27

years old at the time of the alleged onset of disability, had at least a high

school education, and had past employment as a certified nursing

assistant (“CNA”). (Tr. 50).

With respect to these alleged impairments2 the record revealed the

following: McDonald presented to Penn State Health’s Milton Hershey

Medical Center’s general neurology clinic for new patient consultation in

2 Because McDonald’s appeal focuses on the ALJ’s treatment of evidence

related to her physical impairments, we will forego discussion and

analysis of McDonald’s mental health records and evaluations.

2

January of 2022. (Tr. 315). Her chief complaints were an abnormal

finding on a brain MRI, chronic migraine with aura, and balance issues

with tremors. ( ). She also reported tremors and weakness in her right

hand. ( ). In May of 2022, she reported pain, predominantly in her

hands and shoulders. (Tr. 408). In December, she explained that if she

did not take her hydroxychloroquine and methotrexate, her pain got

worse. (Tr. 425). She reported the pain was “all over” but worse in her

right shoulder, low back, right leg, and in the hands. ( ). In May of

2023, Dr. Miles McGovney at Penn State Health noted McDonald had

postural tremors of the hands. (Tr. 797).

In March of 2021, Dr. Anne Kantner noted McDonald had

generalized fatigue and body pain. (Tr. 656). A year later, in March of

2022, Dr. Bettina Aprile at Penn State Health noted McDonald reported

generalized fatigue and difficulty moving, and diagnosed fatigue. (Tr.

389-90). Dr. Sowmya Surapaneni also noted “on and off” fatigue in May

of 2022. (Tr. 408). In August of 2023, Dr. Surapaneni noted McDonald

had chronic fatigue, sleep apnea, and achiness in her hands. (Tr. 922).

3

It is against this factual backdrop that the ALJ conducted a hearing

in McDonald’s case on July 3rd, 2024. (Tr. 56). McDonald and a

vocational expert (“VE”) both testified at this hearing. McDonald

testified about her work as a CNA, her mental health challenges

including depression and psychosis, how fibromyalgia pain had

frusturated her efforts at full-time work, and difficulties with both

concentrating and standing for prolonged periods. (Tr. 60-69). The VE

in her testimony first classified McDonald’s past work, then answered

hypothetical questions about an individual with McDonald’s background

and specific types of limitations. (Tr. 69-72).

Following this hearing, on August 8, 2024, the ALJ issued a

decision denying McDonald’s application for benefits. (Tr. 42-51). In that

decision, the ALJ first concluded that McDonald met the insured status

requirement through December 31, 2028. (Tr. 44). At Step 2 of the

sequential analysis that governs Social Security cases, the ALJ found

McDonald suffered from the following severe impairments: fibromyalgia,

inflammatory polyarthritis, obesity, a schizoaffective disorder, and

anxiety. (Tr. 45). At Step 3 the ALJ determined that McDonald did not

4

have an impairment or combination of impairments that met or

medically equaled the severity of one of the listed impairments. (Tr. 46).

Between Steps 3 and 4 the ALJ concluded that McDonald retained

the residual functional capacity to:

[P]erform light work as defined in 20 CFR 404.1567(b) except

she is limited to frequent postural movements except she is

limited to occasional ladders, ropes, and scaffolds. She is

limited to simple and routine tasks, involving only simple,

work-related decisions and only occasional interaction with

supervisors and the public.

(Tr. 47).

In reaching this RFC determination, the ALJ made the following

findings: the ALJ considered McDonald’s reported, subjective symptoms,

and found that “claimant’s medically determinable impairments could

reasonably be expected to cause some of the alleged symptoms; however,

the claimant’s statements concerning the intensity, persistence and

limiting effects of these symptoms are not entirely consistent with the

medical evidence and other evidence in the record [.]” (Tr. 48). The ALJ

then reviewed the medical record evidence he found supported those

findings. (Tr. 48).

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The ALJ next considered the medical opinions on record. He was

persuaded by the opinion of Dr. Karel Keiter, who opined that McDonald

had no environmental limitations. (Tr. 49). The ALJ found this opinion

supported by and consistent with McDonald’s medical records. ( ). The

ALJ found the opinion of Dr. Mary Gavin generally persuasive, except for

her finding that McDonald needed environmental limitations due to her

asthma and her arthritis. ( ). The ALJ explained that those limitations

were not supported by Dr. Gavin’s mere references to those conditions

and were inconsistent with the opinion of Dr. Keiter. ( ). The ALJ

found the rest of Dr. Gavin’s opinion to be supported by the record and

consistent with Dr. Keiter’s findings. (Tr. 49-50).

The ALJ then found at Step 4 that McDonald could not perform her

past work but, at Step 5, found that she could perform other jobs that

existed in significant numbers in the national economy, such as laundry

folder, marker, and wrapper. (Tr. 50-51). Having reached these

conclusions, the ALJ determined that McDonald had not met the

demanding showing necessary to sustain this claim for benefits and

denied this claim. (Tr. 51).

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This appeal followed. (Doc. 1). On appeal, McDonald challenges

the adequacy of the ALJ’s decision arguing it is not supported by

substantial evidence. (Doc. 9).

As discussed in greater detail below, having considered the

arguments of counsel and carefully reviewed the record, we conclude that

the ALJ’s decision should be remanded for further consideration by the

Commissioner in accordance with this decision.

III. Discussion

A. Substantial Evidence Review – the Role of this Court

This Court’s review of the Commissioner’s decision to deny benefits

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); , 529 F.3d 198, 200 (3d Cir. 2008);

, 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.” , 487 U.S. 552,

565 (1988). Substantial evidence means less than a preponderance of the

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evidence but more than a mere scintilla. , 402 U.S.

389, 401 (1971).

A single piece of evidence is not substantial evidence if the ALJ

“ignores, or fails to resolve, a conflict created by countervailing evidence.”

, 994 F.2d 1058, 1064 (3d Cir. 1993) (quoting

, 710 F.2d 110, 114 (3d Cir. 1983)) (internal quotations

omitted). However, where there has been 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.”

, 383 U.S. 607, 620 (1966). The court must “scrutinize the record

as a whole” to determine if the decision is supported by substantial

evidence. , 304 F. Supp.2d 623, 627 (M.D. Pa. 2003).

The Supreme Court has explained the limited scope of our review,

noting that “[substantial evidence] means—and means only—‘such

relevant evidence as a reasonable mind might accept as adequate to

support a conclusion.’” , 139 S. Ct. 1148, 1154 (2019)

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(quoting , 305 U.S. 197, 229 (1938)).

Under this standard, we must look to the existing administrative record

to determine if there is “‘sufficient evidence’ to support the agency’s

factual determinations.” Thus, the question before us is not whether

the claimant is disabled, but rather whether the Commissioner’s finding

that he or she is not disabled is supported by substantial evidence and

was based upon a correct application of the law. , 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); , 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”);

, 900 F.2d 675, 678 (3d Cir. 1990) (noting that the scope

of review on legal matters is plenary); , 901 F. Supp. 2d at 536

(“[T]he court has plenary review of all legal issues . . . .”).

When conducting this review, we must remain mindful that “we

must not substitute our own judgment for that of the fact finder.”

, 777 F.3d 607, 611 (3d Cir. 2014) (citing ,

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399 F.3d 546, 552 (3d Cir. 2005)). Thus, we cannot re-weigh the evidence.

Instead, we must determine whether there is substantial evidence to

support the ALJ’s findings. In doing so, we must also determine whether

the ALJ’s decision meets the burden of articulation necessary to enable

judicial review; that is, the ALJ must articulate the reasons for his

decision. , 220 F.3d 112, 119 (3d

Cir. 2000). This does not require the ALJ to use “magic” words, but rather

the ALJ must discuss the evidence and explain the reasoning behind his

decision with more than just conclusory statements.

, 577 F.3d 500, 504 (3d Cir. 2009) (citations omitted).

Ultimately, the ALJ’s decision must be accompanied by “a clear and

satisfactory explication of the basis on which it rests.” ,

642 F.2d 700, 704 (3d Cir. 1981).

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

ALJ

To receive disability benefits under the Social Security Act, a

claimant must show that he or she is unable 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

10

lasted or can be expected to last for a continuous period of not less than

12 months.” 42 U.S.C. §423(d)(1)(A); 42 U.S.C. §1382c(a)(3)(A);

20 C.F.R. §§404.1505(a), 416.905(a). This requires a claimant to show a

severe physical or mental impairment that precludes her from engaging

in previous work or “any other substantial gainful work which exists in

the national economy.” 42 U.S.C. §423(d)(2)(A); 42 U.S.C.

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

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

she is under retirement age, contributed to the insurance program, 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, the ALJ follows a five-step

evaluation. 20 C.F.R. §§404.1520(a), 416.920(a). The ALJ must

sequentially determine whether the claimant: (1) is engaged in

substantial gainful activity; (2) has a severe impairment; (3) has a severe

impairment that meets or equals a listed impairment; (4) is able to do his

or her past relevant work; and (5) is able to do any other work,

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

functional capacity (“RFC”). 20 C.F.R. §§404.1520(a)(4), 416.920(a)(4).

Between Steps 3 and 4, the ALJ must also determine the 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).” , 220 F.3d at 121 (citations omitted); 20

C.F.R. § 404.1545(a)(1). In making this assessment, the ALJ must

consider all the claimant’s medically determinable impairments,

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

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

review of the ALJ’s determination of the plaintiff’s RFC is deferential,

and that determination will not be set aside if it is supported by

substantial evidence. 312 F.3d 113, 129 (3d Cir.

2002).

The claimant bears the burden at Steps 1 through 4 to show a

medically determinable impairment that prevents him or her from

engaging in any past relevant work. , 994 F.2d at 1064. If met, the

burden then shifts to the Commissioner to show at Step 5 that there are

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jobs in significant numbers in the national economy that the claimant

can perform consistent with the claimant’s RFC, age, education, and

work experience. 20 C.F.R. §§404.1512(f), 416.912(f); , 994 F.2d at

1064.

With respect to the RFC determination, courts have followed

different paths when considering the impact of medical opinion evidence

on this determination. While some courts emphasize the necessity of

medical opinion evidence to craft a claimant’s RFC,

962 F. Supp. 2d 761, 778–79 (W.D. Pa. 2013), other

courts have taken the approach that “[t]here is no legal requirement that

a physician have made the particular findings that an ALJ adopts in the

course of determining an RFC.” , 174 F. App’x 6,

11 (3d Cir. 2006). Additionally, in cases that involve no credible medical

opinion evidence, courts have held that “the proposition that an ALJ

must always base his RFC on a medical opinion from a physician is

misguided.” , 129 F. Supp. 3d 209, 214–15 (W.D. Pa.

2015).

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Given these differing approaches, we must evaluate the factual

context underlying an ALJ’s decision. Cases that emphasize the

importance of medical opinion support for an RFC assessment typically

arise in the factual setting where well-supported medical sources have

found limitations to support a disability claim, but an ALJ has rejected

the medical opinion based upon an assessment of other evidence. ,

962 F. Supp. 2d at 778–79. These cases simply restate the notion that

medical opinions are entitled to careful consideration when making a

disability determination. On the other hand, when no medical opinion

supports a disability finding or when an ALJ relies upon other evidence

to fashion an RFC, courts have routinely sustained the ALJ’s exercise of

independent judgment based upon all the facts and evidence.

, 174 F. App’x 6; 129 F. Supp. 3d at 214–15.

Ultimately, it is our task to determine, in light of the entire record,

whether the RFC determination is supported by substantial evidence.

312 F.3d 113.

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C. Legal Benchmarks for the ALJ’s Assessment of a Claimant’s

Alleged Symptoms

When evaluating lay testimony regarding a claimant’s reported

degree of pain and disability, the ALJ must make credibility

determinations. , 577 F.3d at 506. Our review of those

determinations is deferential. However, it is incumbent upon the ALJ

to “specifically identify and explain what evidence he found not credible

and why he found it not credible.” , 777 F.3d at 612 (citations

omitted). An ALJ should give great weight to a claimant’s testimony “only

when it is supported by competent medical evidence.” ,

150 F. Supp. 3d 406, 415–16 (M.D. Pa. 2015) (citations omitted). As the

Third Circuit has noted, while “statements of the individual concerning

his or her symptoms must be carefully considered, the ALJ is not required

to credit them.” 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.”).

The Social Security Rulings and Regulations provide a framework

for evaluating the severity of a claimant’s reported symptoms. 20 C.F.R.

§§ 404.1529, 416.929; SSR 16–3p. Thus, the ALJ must follow a two-step

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process: first, the ALJ must determine whether a medically determinable

impairment could cause the symptoms alleged; and second, the ALJ must

evaluate the alleged symptoms in light of the entire administrative

record. SSR 16-3p.

Symptoms such as pain or fatigue will be considered to affect a

claimant’s ability to perform work activities only if medical signs or

laboratory findings establish the presence of a medically determinable

impairment that could reasonably be expected to produce the alleged

symptoms. 20 C.F.R. §§ 404.1529(b), 416.929(b); SSR 16–3p. During the

second step of this assessment, the ALJ must determine whether the

claimant’s statements regarding the intensity, persistence, or limiting

effects of his or her symptoms are substantiated when considered in light

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; medical opinions provided by treating or examining sources

and other medical sources; and information regarding the claimant’s

symptoms and how they affect his or her ability to work. 20 C.F.R. §

404.1529(c), 416.929(c); SSR 16–3p.

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The Social Security Administration recognizes that individuals

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 set forth seven

factors that may be relevant to the assessment of the claimant’s alleged

symptoms. 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3). These factors

include: the claimant’s daily activities; the “location, duration, frequency,

and intensity” of the claimant’s pain or symptoms; the type, dosage, and

effectiveness of medications; treatment other than medications; and

other factors regarding the claimant’s functional limitations. 20 C.F.R.

§§ 404.1529(c)(3), 416.929(c)(3).

D. This Case Will Be Remanded.

As we have noted, the ALJ’s decision must be accompanied by “a

clear and satisfactory explication of the basis on which it rests,” ,

642 F.2d at 704, and the ALJ must “indicate in his decision which

evidence he has rejected and which he is relying on as the basis for his

finding.” ., 181 F. 3d 429, 433 (3d Cir.

17

1999). McDonald argues, , that the ALJ failed to properly

evaluate McDonald’s medically determinable impairment of

fibromyalgia. The Commissioner counters that the ALJ properly

considered “both subjective and objective evidence” in consideration of

fibromyalgia. After consideration, we conclude that the RFC is not

supported by substantial evidence, and so we will remand the case.

McDonald points to SSR 12-2p, which discusses the unique

evaluation process required when fibromyalgia is present, and argues

that because the ALJ did not cite this ruling, and did not provide specific

analysis of fibromyalgia symptoms anywhere within McDonald’s RFC,

the ALJ failed to properly evaluate this impairment. (Doc. 8 at 4-6).

McDonald further argues that crediting her subjective complaints about

fibromyalgia’s effects on her would have led to a finding that she was

disabled on account of expected absences. (Doc. 19 at 5).

SSR 12-2p counsels that an ALJ must “consider a longitudinal

record whenever possible because the symptoms of [fibromyalgia] can

wax and wane [.]” SSR 12-2p, 2012 WL 3104869 at *6. It also advises

that the pain, fatigue, and other symptoms associated with fibromyalgia

18

may result in exertional limitations, non-exertional physical or mental

limitations, and non-exertional environmental restrictions. .

McDonald asks us to follow the decision of the court, which

interpreted SSR 12-2p to mean that “objective medical results should

only ever be considered insofar as they ‘substantiate’ the claimant’s

subjective statements about the intensity, persistence and limiting

effects of his or her symptoms.” , No. 22-CV-3993,

2023 WL 5916461 at *14 (E.D. Pa. Sep. 11, 2023). Of course, just because

there are citations to objective medical results in the ALJ’s decision does

not mean the ALJ cited those results to discount

fibromyalgia, as almost all claimants have multiple medically

determinable impairments, but SSR 12-2p requires careful delineation in

such circumstances. Here, the ALJ’s decision relied on objective medical

evidence in discounting McDonald’s subjective statements about all her

symptoms, stating: “the claimant’s statements concerning the intensity,

persistence and limiting effects of these symptoms are not entirely

consistent with the medical evidence and other evidence in the record [.]”

(Tr. 48). A brief discussion of this evidence follows, stating that

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McDonald’s “treatment records do not fully support her subjective

complaints. Moreover, her work history from April 2023 through at least

her hearing date supports she is more functional than alleged.” The first

sentence references objective evidence, the second, subjective. It is

therefore that there was no error here, if only the subjective

evidence was used to discount fibromyalgia symptoms. But we cannot

say that is the case, because the ALJ’s decision does not suggest which

symptoms are being discounted by what evidence.

We are therefore constrained to assume that all symptoms were

discounted by the cited evidence, meaning the ALJ relied, at least in part,

on objective evidence to discount McDonald’s alleged symptoms. As SSE

12-2p implies, the court stated clearly, and other Circuit courts

have also held, that is an improper analysis of fibromyalgia symptoms.

983 F.3d 83, 98 (4th Cir. 2020) (“ALJs

may not rely on objective medical evidence (or the lack thereof)—even as

just one of multiple factors—to discount a claimant’s subjective

complaints regarding symptoms of fibromyalgia”). A reference to 12-2p

from the ALJ might have sufficed to explain if fibromyalgia symptoms

20

were properly discounted. Similarly, if a discussion of fibromyalgia

specifically appeared somewhere in the decision, that might have helped

us to trace the ALJ’s logic in discounting McDonald’s symptoms. But the

ALJ did neither. Therefore, on this record, we cannot be sure that

fibromyalgia was properly evaluated. Further, McDonald is correct that,

if her statements about her symptoms were credited, the VE’s testimony

makes clear that she would be unable to work, and so would qualify as

disabled. ( Tr. 71). McDonald has therefore demonstrated this error

was prejudicial to her.

Accordingly, we find the ALJ’s decision is not supported by

substantial evidence, and remand is required for further consideration of

these issues.3 While we reach this conclusion, we note that nothing in

this Memorandum Opinion should be deemed as expressing a judgment

on the ultimate outcome of this matter. Rather, that task is left to the

ALJ on remand.

3 Because we find that this issue necessitates remand, we decline to

analyze McDonald’s other claims of error.

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IV. Conclusion

For the foregoing reasons, the decision of the Commissioner will be

REMANDED for further consideration.

An appropriate order follows.

Submitted this 22nd day of August 2025.

Daryl F. Bloom

Chief United States Magistrate Judge

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