holding medical opinions that are inconsistent with and unsupported by the medical evidence are not persuasive or controlling
How later courts described this case
- holding medical opinions that are inconsistent with and unsupported by the medical evidence are not persuasive or controlling
- “The Social Security regulations impose no limit on how much time may pass between a report and the ALJ's decision in reliance on it.”
- ‘[S]omething less than the weight of the evidence, ... does not prevent [it] from being supported by substantial evidence.”
- holding that substantial evidence standard is 20 unmet when ALJ fails to resolve conflicts created by countervailing evidence
Written by the judges who cited it.
The opinion
UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF PENNSYLVANIA
YUITZA PAGAN, : No. 1:28-CV-1502
Plaintiff : (Caraballo, M.J.)
Vv. :
FRANK BISIGNANO,}! :
Commissioner of Social :
Security, :
Defendant :
MEMORANDUM
I. Introduction
Plaintiff Yuitza Pagan seeks judicial review of the final decision of
the Commissioner of Social Security (the “Commissioner’) denying her
application for disability benefits and supplement security income
benefits under Titles II & XVI of the Social Security Act. The Court has
jurisdiction pursuant to 42 U.S.C. § 405(g).
This matter comes before the Court on Pagan’s claims that
Administrative Law Judge (“ALJ”) Randy Riley erred when he: (1)
determined her residual functional capacity (“RFC”); (2) failed to find
Frank Bisignano was confirmed as the Commissioner of the Social Security
Administration on May 6, 2025. Pursuant to Rule 25(d) of the Federal Rules of Civil
Procedure and 42 U.S.C. § 405(g), Frank Bisignano is substituted for Kilolo Kijakazi
as the defendant in this suit.
several of Pagan’s limitations and health issues severe; and (8) found
opinion evidence from state agency consultants more persuasive than
those of Pagan’s treating physicians. Doc. 9 at 2, 13-15, 21-22, 27. The
matter is fully briefed and ripe for decision.
As explained below, the ALJ’s conclusions when addressing all
three challenged issues were supported by substantial evidence in the
record, coupled with sufficient reasoning to permit meaningful judicial
review. Accordingly, the Court will affirm the Commissioner’s decision
to deny Pagan’s claim for social security disability benefits and
supplement security income benefits.
II. Background
On March 10, 2021, Pagan applied for Title IT social security
disability benefits and Title XVI supplement security income benefits,
alleging complete disability from a myriad of impairments, including
mental health disorders, mini-strokes, migraines, a hernia, and vitamin
D deficiency. Doc. 16 at 184, 191 (hereinafter referred to as “Tr.”). The
Social Security Administration initially denied Pagan’s application in
July 2021, and upon reconsideration in November 2021. Tr. 184, 191,
205, 218. Pagan thereafter requested a hearing before an ALJ. Id. at
219.
On October 20, 2022, ALJ Riley presided over Pagan’s hearing.
The hearing concerned whether Pagan was disabled within the meaning
of the Social Security Act since August 7, 2019. Id. at 43, 60. At the
hearing, ALJ Riley received various evidence of record, including
clinical records, medical history, medical expert reports, vocational
expert testimony, and Pagan’s own testimony. Id. at 43-68.
On October 28, 2022, ALJ Riley issued a decision concluding that
Pagan was not disabled from August 7, 2019, to the date of the decision.
Id. at 15-17. ALJ Riley reached that conclusion by employing the five-
step analytical process required under the Social Security Act to
evaluate disability insurance and supplement security income claims.
See 20 C.F.R. § 404.1520(a)(4).
The process requires sequential consideration of: (1) whether the
claimant is engaged in substantial gainful work activity; (2) the medical
severity of the claimant’s impairments; (3) whether the impairment
meets or equals a defined list of impairments; (4) a comparison between
the claimant’s past relevant work and residual functional capacity, 7.e.,
,
the most work that a claimant can perform despite his or her
limitations on a regular and continuing basis, see 20 C.F.R.
§ 404.1545(a); and (5) an assessment of the claimant’s residual
functional capacity and his or her age, education, and work experience.
20 C.F.R. § 404.1520(a)(4)G)-(v). Should a claimant proceed past the
first three steps of the analysis, the Commissioner will not find the
claimant disabled when he or she can perform past relevant work, or
adjust to other work, under the third and fourth steps, respectively. Id.
at § 404.1520(a)(4)(iv)—(v), (f), (g).
Applying that analysis, ALJ Riley first determined that Pagan
met the insurance requirements of the Social Security Act, see 20 C.F.R.
§ 404.130, through June 30, 2020. Tr. 20. ALJ Riley also found that
Pagan had not engaged in substantial gainful activity between August
10, 2020, through the date of the decision. Id.
At the second step of the analysis, ALJ Riley found that Pagan
suffered from ten severe impairments: osteoarthritis of the bilateral
knees, obesity, obstructive sleep apnea, asthma, status post
cerebrovascular assault, migraine headaches, bipolar disorder,
depressive disorder/persistent mood disorder, anxiety disorder, and
insomnia. Id. at 21. ALJ Riley also identified several non-severe
impairments, including umbilical hernia, ankle sprain, dysmenorrhea,
hypertension, and gastroesophageal reflux disease. Jd. He found that
Pagan either suffered from these latter impairments for an insufficient
duration, t.e. less than a year, or the impairment failed to cause
“significant or ongoing symptoms ... during the relevant period” and
that the evidence did not otherwise “establish that [it] .. . caused more
than a minimal restriction on the claimant’s ability to perform basic
work activities.” Id.
Moving to the third step of the analysis, ALJ Riley determined
that Pagan’s severe impairments failed to meet or medically equal one
of the impairments listed in the Social Security Administration’s
regulations. Jd. at 22. Pagan thus did not automatically qualify as
disabled. See 20 C.F.R. § 404.1520(a)(4)Gii) (Tf you have an
impairment(s) that meets or equals one of our listings in appendix 1 of
this subpart and meets the duration requirement, we will find that you
are disabled.”).
Accordingly, ALJ Riley proceeded to determine Pagan’s residual
functional capacity, before addressing the final two steps in the
sequential analysis. Based on the medical evidence of record, ALJ Riley
concluded that Pagan could perform light work, subject to additional
limitations:
[T]he claimant has the residual functional capacity to perform
light work as defined in 20 CFR 404.1567(b) and 416.967(b)
except that she may occasionally balance, stoop, crouch, and
climb ramps or stairs, but must never kneel, crawl, or climb
ladders, ropes, or scaffolds. The claimant must avoid exposure
to extreme cold, vibrations, pulmonary irritants, excessive
noise (SCO level of 3), and hazards such as heights and
machinery. The claimant can understand and carry out
simple, routine, repetitive tasks involving only simple work
related decisions with few, if any, workplace changes. The
claimant can sustain attention for extended periods of two
hour segments while maintaining regular attendance and
being punctual within customary allowances, in an
environment free of fast paced production activity. The
claimant must never interact with the public.
Tr. 25.
In reaching that conclusion, ALJ Riley analyzed three areas
germane to this opinion. First, ALJ Riley considered Pagan’s
statements regarding her impairment symptoms:
The claimant asserts her conditions limit her ability to work.
She asserts her conditions limit her ability to care for her
personal care needs and prepare meals, and impact her ability
to sleep (Exhibit C9E). She also asserts that her conditions
limit her ability to lift, squat, bend, stand, reach, walk, sit,
kneel, climb stairs, and complete tasks (Exhibit C9E). With
regard to the claimant’s mental health conditions, she
indicates her conditions limit her ability to understand and
remember things, follow both written and spoken
instructions, concentrate, and get along with others (Exhibit
C9E). She also asserts that she has difficulty handling stress
and changes in routine (Exhibit C9E). The claimant notes that
she takes medication to treat her conditions, which cause side
effects of drowsiness (Exhibit C9E).
Id. at 25. ALJ Riley did not, however, find that testimony
convincing, stating:
After careful consideration of the evidence, the undersigned
finds that the claimant’s medically determinable impairments
could reasonably be expected to cause 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 for the reasons explained in this
decision.
Id. at 25-26.
Second, ALJ Riley surveyed the clinical evidence of record
regarding Pagan’s impairments and ultimately compared it to her
alleged symptoms, to explain his basis for deeming them inconsistent
with one another. First, he evaluated several of her physical ailments:
The record establishes the claimant is status post
cerebrovascular assault. The claimant experienced a stroke
prior to the relevant period that was remote in nature
(Exhibit C22F at 3). During the relevant period, she obtained
follow up care in the form of oral medication for stroke
prevention (Exhibit C1F at 3). The claimant reported memory
issues associated with her stroke (Exhibit C20F at 47).
Treatment records from June 2020 note the claimant reported
chronic disability due to residual effects related to her
condition (Exhibit C4F at 25). At the time, her physical
examination revealed normal coordination, a normal range of
motion, and normal strength (Exhibit C4F at 25). Thereafter,
treatment records from August 2021 note the claimant
reported experiencing speech difficulty that presented with
drooling and difficulty with ambulation related to her stroke
history (Exhibit C17F at 9). On examination, she had a
normal neurologic examination, with no difficulty upon gait
testing (Exhibit C17F at 9). Her treatment provider also noted
the claimant exhibited normal speech (Exhibit C17F at 9).
However, given her subjective reports of symptoms, the
claimant was referred to physical therapy (Exhibit C17F at
9). Notably, additional records from later in August 2021 note
the claimant reported that her speech difficulty resolved 24
hours later (Exhibit C8F at 4). She also reported improved
gait, but indicated she continued to walk into objects (Exhibit
C8F at 4). Thereafter, treatment records from March 2022
note that the claimant reported residual cognitive and mental
health limitations, but no residual physical deficits associated
with her stroke (Exhibit C19F at 260).
The record establishes the claimant has a history of
osteoarthritis of the bilateral knees. Treatment records note
the claimant also had a history of obesity. In December 2019,
the claimant reported experiencing weight gain as a side
effect to one of her medications (Exhibit C20F at 59). In June
2021, the claimant underwent a consultative examination
(Exhibit C6F). During the evaluation, the claimant did not
report bilateral knee pain, but had findings of a squat that
was 50% of full (Exhibit C6F at 3-4). The claimant’s limited
squat was attributed to her weight (Exhibit C6F at 4). The
examination also revealed a normal gait, but difficulty
walking on her heels and toes (Exhibit C6F at 5). In addition,
she maintained five out of five lower extremity strength
despite some limitations (Exhibit C6F at 6). Thereafter,
treatment records from July 2021 note that the claimant
presented to a treatment visit and reported left knee pain
(Exhibit C19F at 197). At the time, the claimant exhibited
edema and reported pain (Exhibit C19F at 200). During a
subsequent visit in September 2021, the claimant reported
right knee pain (Exhibit C10F at 6). Her treatment provider
attributed the symptoms to osteoarthritis in her weight-
bearing joints due to her high body mass index (Exhibit C10F
at 6). At the time, conserbative [sic] treatment in the form of
topical medications, heat, and aqua therapy was
recommended as necessary (Exhibit C10F at 6). Additional
records note the claimant did not report any knee conditions
during a functional capacity evaluation June 2022 (Exhibit
C22F at 3). The claimant maintained a normal gait pattern at
the evaluation (Exhibit C22F). At the time, the claimant’s
height was 5 feet 3 inches and she weighed 261 pounds
(Exhibit C22F at 2). Given the claimant’s height and weight,
her body mass index was a 46.2, which is indicative of morbid
obesity.
Id. at 26-27. Second, ALJ Riley addressed Pagan’s reoccurring
migraine headaches:
The record establishes the claimant has a history of migraine
headaches. Treatment records from October 2019 note the
claimant reported migraines nearly everyday (Exhibit C20F
at 54). Thereafter, treatment records from April 2020 note the
claimant reported frequent headaches of up to 15 to 20 days
per month that presented with light and noise disturbances
(Exhibit C1F at 3). As such, the claimant was prescribed
medication to help manage her condition (Exhibit C1F at 3).
Treatment records from June 2020 note the claimant’s
condition was stable (Exhibit C4F at 25). Thereafter,
treatment records from May 2021 continued to note that her
medication was helping her migraines and reduced frequency
to three or four times per month (Exhibit C17F at 17).
Additional records from December 2021 note that the
claimant reported migraines relatively well controlled on her
medication regimen, with a frequency of one to two headaches
per month (Exhibit C17F at 6)....In May 2022, the claimant
reported an increase in migraine headaches; however, the
record indicates the claimant never started her medication
regimen that had been approved since December 2021
(Exhibit C25F at 7). At the time, she admitted to never
picking up the medication and deferred additional
preventatives (Exhibit C25F at 7).
Id. at 27. Third, the ALJ reviewed Pagan’s various mental health
maladies:
The record establishes the claimant has a history of anxiety
disorder, depressive disorder, and insomnia. The claimant
was treated for the conditions prior to the relevant period and
continued to receive treatment after the amended alleged
onset date (Exhibit C5F at 9). Treatment records from August
2019 note the claimant reported chronic insomnia (Exhibit
C20F at 47). At the time, she also reported intermittent
irritability, mood fluctuations, and auditory hallucinations
(Exhibit C20F at 47). On examination, the claimant was
oriented to person, place, and time with a linear thought
process and appropriate thought content (Exhibit C20F at 49).
Treatment records from the time also note the claimant
maintained intact cognition and fair attention, judgment, and
insight (Exhibit C20F at 49). As a result of her reported
symptoms, the claimant received medication management
(Exhibit C20F at 50). However, in October 2019, the claimant
reported that her medication was not managing her sleep
(Exhibit C20F at 54). As a result, her medication regimen was
increased (Exhibit C20F at 55). Thereafter, treatment records
from December 2019 note the claimant reported the increased
helped to improve her sleep and mood (Exhibit C20F at 59).
The claimant continued to report intermittent symptoms of
insomnia in 2020 (Exhibit C1F at 6; C20F at 149). In October
2020, she also reported increased depression and anxiety that
presented with auditory hallucinations (Exhibit C20F at 160).
As a result of her ongoing symtpmoms [sic], her medication
10
regimen was adjusted (Exhibit C20F at 162). She reported
some improvement with the adjusted medication regimen in
December 2020 (Exhibit C20F at 169).
In September 2021, the claimant reported a continued ability
to manage her anxiety symptoms (Exhibit C14F at 3). At the
time, she also reported that her medication regimen was
helping her mood but that she experienced side effects of
swelling in her lower extremities (Exhibit C14F at 3). On
examination, the claimant was alert and oriented to person,
place, and time, with clear speech, a linear thought process,
appropriate thought content, intact memory, fair attention,
judgment, and insight, and intact cognitive functioning
(Exhibit C14F at 4-5). While the claimant noted some
irritability, she reported it as mild and at baseline (Exhibit
C14F at 4). During the visit, her behavior was noted as calm
and cooperative (Exhibit C14F at 4). Given the claimant’s
reported side effects to the medication, one of her medications
was discontinued. However, in November 2021, the claimant
reported the discontinuation of medication caused prior
symptoms of mood swings, irritability, and anxiety to
reappear (Exhibit C20F at 114). As a result, it was
recommended that she restart her medication given the lack
of correlation to lower extremity edema (Exhibit C20F at 116).
She reported an improvement in her symptoms in December
2021 (Exhibit C20F at 120). At the time, she had normal
findings related to her orientation, thought process, thought
content, speech, memory, attention, judgment, and insight
(Exhibit C20F at 121-122).
The claimant continued to treat her conditions in 2022.
Treatment records from February 2022 note the claimant
reported ongoing fluctuating moods that presented with low
motivation, as well as ongoing anxiety and visual and
auditory hallucinations (Exhibit C20F at 126). Notably, she
reported ongoing relief of her insomnia with her melatonin
(Exhibit C20F at 126). At the time, she had normal findings
related to her speech, orientation, thought process, thought
11
content, memory, attention, insight, and judgment (Exhibit
C20F at 127). As a result, her medication was adjusted to
better manage her symptoms (Exhibit C20F at 127). While
she continued to report ongoing symptoms later in February
2022, she elected to continue on her medication regimen
unadjusted and noted it was helping with the intensity and
frequency of symptoms (Exhibit C20F at 133). In May 2022,
the claimant reported doing well, noting that her anxiety was
manageable and her irritability well controlled (Exhibit C20F
at 138). Thereafter, treatment records from June 2022 note
the claimant underwent a functional capacity evaluation,
where she was able to follow instructions and maintain
concentration throughout the evaluation (Exhibit C22F at
10). At the time, her speech was normal and she did not have
difficulty communicating effectively (Exhibit C22F at 10). The
claimant continued to report doing well in July 2022 and
noted reduced depression (Exhibit C26F at 6).
Id. at 27-29. Following that analysis, ALJ Riley concluded:
Although the claimant asserts that her conditions prevent her
from engaging in substantial gainful activity, the overall
evidence of record establishes the claimant’s conditions are
not as debilitating as alleged. With regard to the claimant’s
status post cerebrovascular assault, treatment records note
the claimant was required to treat with preventative
medication to avoid recurrent episodes. While the claimant
reported subjective physical and mental health symptoms
associated with the condition, her reports of physical residual
symptoms were inconsistent during the relevant period, with
the claimant reporting residual effects at some treatment
visits and subsequently denying any physical effects related
to the condition during other visits (Exhibit C19F at 2538, 260;
C22F at 3). Moreover, despite the claimant’s reports of
physical and mental health limitations associated with her .
stroke, physical and mental status examinations were
generally normal during the relevant period. The undersigned
finds that the record supports a finding of a remote history of
12
the condition and ongoing treatment to manage the condition,
which was sufficient to find a severe impairment. However,
the record fails to establish any significant and ongoing
symptoms associated with her condition. With regard to the
claimant’s physical limitations, the undersigned again notes
that the claimant reported that she was not experiencing
physical limitations that she felt were disabling (Exhibit
C19F at 253, 260). The undersigned finds that her February
2022 reporting is consistent with the overall evidence of
record. While the record notes a history of asthma, treatment
records again note the claimant treated the condition
conservatively with the use of an inhaler. Nothing in the
record establishes the claimant experienced exacerbations
that required more aggressive treatment due _ to
abnormalities. Similarly, the claimant’s osteoarthritis was
treated conservatively with topical medication and heat
therapy, and notations of aqua therapy when needed. With
regard to the claimant’s obstructive sleep apnea, the record
indicates the claimant’s condition was diagnosed during the
relevant period and treated with CPAP therapy. Nothing in
the record establishes any significant and ongoing difficulty
despite CPAP treatment. With regard to the claimant’s
migraine headache, her condition improved to a point in
which the claimant tolerated her regimen and it was generally
controlling her symptoms. Notably, the claimant’s condition
was manageable to a point in which she declined additional
preventative measures. With regard to the claimant’s mental
health conditions, the overall record notes a history of mental
health conditions for which the claimant received treatment
during the relevant period. The record notes multiple
medication adjustments to manage her subjective symptoms
of mood fluctuations, irritability, hallucinations, racing
thoughts, and panic attacks. However, the overall evidence of
record fails to establish the symptoms caused any significant
limitations during mental status examinations. Instead, the
overall evidence of record notes the claimant generally
maintained normal orientation, thought processing, thought
content, memory, attention, judgment, insight, and cognitive
13
functioning during the relevant period. The undersigned has
also considered the overall impact of the claimant’s weight on
her underlying conditions.
Similarly, the claimant’s activities of daily living suggest that
the claimant’s conditions are not as debilitating as alleged.
The claimant is able to care for her personal care needs,
including her ability to dress, bathe, care for her hair, shave,
feed herself, and use the bathroom (Exhibit C9E). She is also
able to assist in providing care for her children, one of which
has special needs, and family pets (Exhibit C9E). In addition,
the claimant is able to preform [sic] housework, such as doing
the laundry and cleaning bathrooms (Exhibit C9E). The
claimant can go outside alone, shop in stores, and operate a
motor vehicle (Exhibit C9E).
Id. at 26-30 (errors in original).
ALJ Riley also evaluated the medical opinions in determining
the limitations imposed by Pagan’s physical impairments. Of relevance
to this report and recommendation, the ALJ specifically considered:
The undersigned considered the opinion of Richard Williams,
Ph.D., a state agency consultant. On June 38, 2021, Dr.
Williams determined the claimant had a moderate limitation
in her ability to concentrate, persist, or maintain pace and a
mild limitation in her ability to understand, remember, or
apply information, but no limitation in the ability to adapt or
manage herself (Exhibit C3A). The undersigned considered
the opinion of Molly Cowan, Psy.D., a state agency consultant.
On November 18, 2021, Dr. Cowan determined the claimant
had moderate limitations in her ability understand,
remember, or apply information, interact with others,
concentrate, persist, or maintain pace, and adapt or manage
herself (Exhibit C7A; C10A). She further determined the
claimant can perform one to two step routine tasks in a stable
14
environment (Exhibit C7A; C10A). To the extent that the
opinions find that the claimant has severe mental health
impairments, they are supported by and consistent with the
overall evidence of record, which notes a history of mental
health conditions that the claimant continued to treat during
the relevant period. They are also supported by and consistent
with the claimant’s subjective reports of symptoms and the
length and extent of treatment to manage her symptoms.
Given the frequency of medication adjustments to manage the
claimant’s symptoms, the undersigned finds that the record
more closely supports moderate limitations in each of the four
broad areas of functioning. Therefore, the opinion of Dr.
Cowan is more persuasive. Nonetheless, the opinions are
generally persuasive.
The undersigned considered the opinion of Kevin Hollick,
D.O., a state agency consultant. On July 14, 2021, Dr. Hollick
determined the claimant must avoid concentrated noise,
vibration, fumes, odors, dusts, gases, and poorly ventilated
areas (Exhibit C3A; C4A). The undersigned considered the
opinion of Angela Walker, M.D., a state agency consultant. On
November 22, 2021, Dr. Walker determined the claimant
could perform light work, except that she may occasionally
balance, stoop, crouch, and climb ramps or stairs but must
never kneel, crawl, or climb ladders, ropes, or scaffolds
(Exhibit C7A; C10A). She further determined the claimant
must avoid concentrated exposure to extreme cold, vibration,
fumes, odors, dusts, gases, poorly ventilated areas, and
hazards (Exhibit C7A; C10A). The opinions are supported by
and consistent with the overall evidence of record that notes
the claimant has a history of combined physical impairments
that caused subjective reports of pain and tenderness. They
are also supported by the record that notes, despite the
claimant’s subjective reports, she generally maintained her
gait, strength, and range of motion despite the presence of the
impairments. In addition, the opinion is supported by and
consistent with the claimant’s history of stroke and ongoing
15
weight in the obese range. Given the overall evidence, the
opinions are persuasive.
The undersigned considered the opinion of Denyse Allen, MD,
an independent medical examiner. On June 7, 2022, Dr. Allen
determined the claimant was in the sedentary workload
category (Exhibit C22F at 3). Dr. Allen specifically noted that
the claimant demonstrated the ability to lift 20 pounds and
carry 10 pounds on an occasional basis (Exhibit C22F at 15).
Of note, Dr. Allen reported the testing consistently
represented the claimant’s safe maximal performance
(Exhibit C22F at 3). However, the finding is inconsistent with
the evaluation findings that note the claimant had indicators
suggestive of submaximal effort with strength testing using
the Pinch Grip Key, UTM Cart Push, UTM Cart Pull (Exhibit
C22F at 8). In addition, the findings are not consistent with
the overall evidence of record, and also suggestive of
inconsistent effort, based on her discontinuing several tests
due to reports of pain in her left shoulder, hands, and bilateral
calf muscles (Exhibit C22F at 5). Notably, these symptoms
were not reported at treatment visits during the relevant
period (Exhibit C22F at 5). The claimant also stopped
positional testing due to lower back pain, which was also not
generally reported or treated during the relevant period
(Exhibit C22F). The undersigned finds that the opinion overly
accounted for the claimant’s subjective reports during testing
and, therefore, overly restricted her exertional abilities.
Therefore, the opinion is not persuasive.
Id. at 80-31. Finally, ALJ Riley concluded:
In sum, the above residual functional capacity assessment is
supported by the symptoms and medical conditions identified
by the claimant, which have been verified in the medical
evidence record, and the limitations identified by medical
providers.
16
Id. at 32.
Having determined Pagan’s residual functional capacity to
perform light work subject to limitations, and rejected several grounds
for further limitation, ALJ Riley proceeded to the fourth step of the
analysis to determine whether Pagan was disabled within the meaning
of the Social Security Act. Here, with assistance from a vocational
expert’s testimony, ALJ Riley compared Pagan’s past relevant work and
residual functional capacity, finding that Pagan was unable to perform
her prior employment as a forklift operator and home health aide. Jd. at
32.
Finally, in the fifth step of the sequential analysis process, ALJ
Riley considered Pagan’s age, education, work experience, and residual
functional capacity to perform light work, concluding that “there are
jobs that exist in significant numbers in the national economy that the
claimant can perform|.]” Jd. Here, ALJ Riley again leveraged testimony
from a vocational expert, reaching the specific conclusion that an
individual fitting Pagan’s parameters could perform the occupational
requirements of a router, marker, or document preparer. Tr. 38.
17
As a result of this analysis, ALJ Riley determined that Pagan was
not disabled and denied her application for disability benefits. Id.
Pagan unsuccessfully appealed the decision to the Social Security
Administration’s Appeals Council, which denied Pagan’s request to
review ALJ Riley’s decision on August 31, 2028. Id. at 1. Having
exhausted her administrative remedies, Pagan’s instant appeal to the
district court followed.
Pagan initiated this action with the Court on September 11, 2023.
Doc. 1. The Commissioner filed an answer denying Pagan’s claim of
error and provided the revised, operative transcripts from the disability
proceedings on January 8, 2024. Docs. 6, 16. The parties filed their
respective briefs on November 27, 2023, and J anuary 9, 2024. Docs. 9,
19.
In her brief, Pagan alleges three errors that warrant reversal or
remand. Doc. 9 at 1-2, 13, 21, 24. Specifically, Pagan alleges that ALJ
Riley: (1) failed to include more significant limitations in her RFC to
account for her severe impairments; (2) erred when he found several of
her issues were not severe impairments at step two; and (8) erred when
18
he evaluated certain medical opinion evidence. Jd. at 15-18, 21-23, 27—
29.
III. Discussion
A. Standard of Review
Review of the Commissioner’s decision denying a claimant’s
application for social security disability benefits is limited to
determining whether the factual findings of the final decisionmaker are
supported by substantial evidence in the record. See 42 U.S.C. § 405(g);
Johnson v. Comm’ of Soc. Sec., 529 F.3d 198, 200 (8d Cir. 2008).
Substantial in this context is “more than a mere scintilla of evidence
but may be less than a preponderance.” Brown v. Bowen, 845 F.2d 1211,
1213 (8d Cir. 1988) (citation omitted). Put more pointedly, it is “such
relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.” Pierce v. Underwood, 487 U.S. 552, 565 (1988)
(quoting Consol. Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)). In an
adequately developed record, this can mean “something less than the
weight of the evidence, and the possibility of drawing two inconsistent
conclusions from the evidence does not prevent [an ALdJ’s decision] from
19 .
being supported by substantial evidence.” Consolo v. Fed. Mar.
Comm 383 U.S. 607, 620 (1966) (citations omitted).
Under this deferential standard, “[f]actual findings which are
supported by substantial evidence must be upheld.” Ficca v. Astrue, 901
F. Supp. 2d 5388, 5386 (M.D. Pa. 2012) (citations omitted); 42 U.S.C.
§ 405(¢g). This court’s role is not to reweigh the evidence and make
factual determinations, but to simply review the record and ensure that
the ALJ provided “a discussion of the evidence and an explanation of
reasoning for his conclusion sufficient to enable meaningful judicial
review.” Diaz v. Comm’ of Soc. Sec., 577 F.3d 500, 504 (8d Cir. 2009)
(citations and quotations omitted). An ALJ meets that standard by
stating “in his decision which evidence he has rejected and which he is
relying on as the basis for his finding.” Schaudeck v. Comm’ of SSA,
181 F.3d 429, 433 (8d Cir. 1999) (citations omitted). Moreover, when
there is countervailing evidence, an ALJ must “give some reason for
discounting the evidence she rejects.” Plummer v. Apfel, 186 F.3d 422,
429 (8d Cir. 1999) (citation omitted); Mason v. Shalala, 994 F.2d 1058,
1064 (8d Cir. 1993) (holding that substantial evidence standard is
20
unmet when ALJ fails to resolve conflicts created by countervailing
evidence).
Here, ALJ Riley’s factual findings were supported by substantial
evidence in the record, and the reasoning underlying those conclusions
was sufficient to enable judicial review.
B. The ALJ’s Residual Functional Capacity Finding
Pagan first contends that ALJ Riley did not provide sufficient
limitations in her residual functional capacity to account for her severe
impairments. Doc. 9 at 15-18. Specifically, she avers that, in addition to
her current limitations, her severe impairments require limitations for
unscheduled breaks, absences, a sit/stand option, leg elevation, and
being off task. Jd. at 20. She argues that these limitations are supported
by the weight of the evidence and posits that they will be necessary to
account for future deficits caused by several of her severe impairments.
Id. at 15-18. She also argues that they are necessary to address issues
from her impairments not covered by the ALJ. Id. A review of the
record, however, reveals that ALJ Riley explicitly addressed the issues
Pagan alleges he did not, that his limitations are supported by
21
substantial evidence, and that his residual functional capacity
determination fully complied with applicable regulations.
In determining Pagan’s residual functional capacity, ALJ Riley
concluded that she was limited to performing “light work as defined in
20 C.F.R. 404.1567(b) except for the following limitations.” Tr. 25. The
ALJ then proceeded to list further limitations on Pagan’s ability to
perform certain activities, including, among others, her ability to
balance, stoop, crouch, climb, kneel, crawl, stay on task, and maintain
regular attendance. Jd. In particular, the ALJ provided that Pagan
“may occasionally balance, stoop, crouch, and climb ramps or stairs, but
must never kneel, crawl, or climb ladders, ropes, or scaffolds. .. . [and
she] can sustain attention for extended periods of two hour segments
while maintaining regular attendance and being punctual within
customary allowances, in an environment free of fast paced production
activity.” Id. ALJ Riley fashioned these limitations to accommodate -
Pagan’s alleged symptoms, at least to the extent that he found such
alleged symptoms supported by the evidence of record. Id. at 32.
As noted above, Pagan contends that these limitations are
inadequate, and advances three arguments in support. First, she argues
22
that the weight of the evidence supports more extensive limitations
than those included by ALJ Riley. Jd. at 15, 18-20; Doc. 19 at 26-29.
Second, she posits that by virtue of having bipolar disorder, depressive
disorder/persistent mood disorder, anxiety disorder, and insomnia
impairments, she allegedly will suffer deficits in the areas of
concentration and focus, thus making it difficult, if not impossible, to
perform work on a sustained basis. Id. at 15-16, 18; Doc. 19 at 25-26.
Third, she argues that the record evidence shows “additional issues” not
covered by the ALJ, such as “mental-health related treatment related to
feelings of hopelessness, daily mood swings, constant wor[ry] and
anxiety, with isolating behavior, excessive crying and feeling down,”
“ongoing issues with insomnia,” “body aches, dizziness and weight
gain,” and “bi-lateral leg swelling/edema.” Tr. 16-18; Doc. 19 at 27.
As a general rule, “the outcome of [a disability] c[laim] depends on
the demonstration of the functional limitations of the disease or
impairment ... [instead of] the mere diagnosis of the disease or name of
the impairment.” McKean v. Colvin, 150 F. Supp. 3d 406, 417 (M.D. Pa.
2015) (citing Alexander v. Shalala, 927 F. Supp. 785, 792 (D.N.J. 1995)
aff'd sub nom. Alexander v. Comm’r of Soc. Sec., 85 F.8d 611 (8d Cir.
23
1996)). Thus, “[a] diagnosis of impairment, by itself, does not establish
entitlement to benefits under the Act.” Phillips v. Barnhart, 91 F. App’x
775, 780 (8d Cir. 2004). Rather, the Social Security Act requires
“objective medical evidence showing the existence of an impairment
which could reasonably be expected to produce the claimed pain.” Id. at
781.
In assessing whether the objective medical evidence shows the
existence of an impairment which could reasonably be expected to
produce a claimant’s alleged pain, the ALJ “may properly accept some
parts of the .. . evidence and reject other parts, but she must consider
all the [probative] evidence and give some reason for discounting the
evidence she rejects.” Adorno v. Shalala, 40 F.3d 438, 48 (8d Cir. 1994).
This, importantly, does not mean that the ALJ must undertake an
exhaustive discussion of all of the evidence. See, e.g., Fargnoli v.
Massanari, 247 F.3d 34, 42 (3d Cir. 2001); Hur v. Barnhart, 94 F. App’x
130, 183 (8d Cir. 2004) (‘There is no requirement that the ALJ discuss
in her opinion every tidbit of evidence included in the record.”); Beety-
Monticelli v. Comm’r of Soc. Sec. 343 F. App’x 748, 747 (8d Cir. 2009)
(“[The ALJ] need not mention every piece of evidence in the record.”).
24
Consistent with these principles, a claimant’s “[a]llegations of
pain and other subjective symptoms must be supported by objective
medical evidence.” Hartranft v. Apfel, 181 F.3d 358, 362 (3d Cir. 1999)
(citing 20 C.F.R. § 404.1529). As such, when a claimant’s statements
about the severity of their impairment is not well-grounded in the
objective medical evidence, but the underlying impairment “could
reasonably be expected to produce” the complained of pain or symptoms,
the “ALJ must make a finding on the credibility of the individual’s
statements based on a consideration of the entire case record.” McKean,
150 F. Supp. 3d at 415-16.
This mandate to anchor both statements and credibility
determinations in the evidence of record overlaps with the regulatory
framework governing an ALJ’s assessment of alleged symptoms. The
regulations require consideration of all symptoms and the extent to
which such symptoms are reasonably consistent with the objective
medical and other evidence. 20 C.F.R. §§ 404.1529(a), 416.929(a). This
includes the claimant’s statements and descriptions from medical and
non-medical sources regarding how the symptoms affect the claimant’s
activities of daily living and ability to work. Id. At bottom, however, the
25
regulations require objective medical evidence from an acceptable
medical source showing the presence of an impairment that could
reasonably be expected to produce the symptoms alleged and that, when
considered with all the other evidence, would lead to a disability
determination. Id.
When evaluating a claimant’s symptoms, the ALJ must follow a
two-step process to (1) ascertain whether the claimant has a medically
determinable impairment that could reasonably be expected to produce
the claimant’s alleged symptoms, and (2) evaluate the intensity and
persistence of the claimant’s symptoms such as pain and determine the
extent to which they limit his ability to perform work-related activities.
SSR 16-3p, 82 Fed. Reg. 49462, 49463-62 (October 25, 2017). To assist
in the evaluation of a claimant’s subjective symptoms, the Social
Security Regulations identify several factors that may be relevant to the
assessment of the severity or limiting effects of a claimant’s
impairment. 20 C.F.R. §§ 416.929(c)(8), 404.1529(c)(8). 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
26
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.
Here, ALJ Riley properly weighed the objective medical evidence
and followed the two-step process for assessing Pagan’s credibility. He
found at the first step of the process that Pagan’s “medically
determinable impairments could reasonably be expected to cause” her
alleged symptoms. Tr. 25. In reaching this conclusion, ALJ Riley found
that the record, including treatment records and examinations,
established Pagan’s post cerebrovascular assault (stroke) status,
osteoarthritis of the bilateral knees, asthma, obstructive sleep apnea,
migraines, anxiety disorder, depressive disorder, and insomnia. Tr. 26—
29. The nature of these severe impairments, coupled with Pagan’s
allegations concerning her symptoms impeding her ability to work, care
for her personal needs, sleep, move, understand and remember,
concentrate, interact, and handle stress and medication side effects, led
ALJ Riley to find that the latter could reasonably cause the former. Id.
27
at 25. At the second step of the process, however, ALJ Riley found that
Pagan’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... .” Id. at 26.
In support of that determination, ALJ Riley evaluated the
location, duration, frequency, and intensity of Pagan’s symptoms,
activities of daily living, medications, and treatments she used to
alleviate her symptoms. He first evaluated Pagan’s symptoms,
treatments, and medications with regard to her post cerebrovascular
assault status, finding that while Pagan required “preventative
medication to avoid recurrent episodes” and that she had at times
“reported subjective physical and mental health symptoms associated
with the condition,” her reporting of these symptoms was inconsistent.
Id. at 29. He further found that “despite the claimant’s reports of
physical and mental health limitations associated with her stroke,
physical and mental status examinations were generally normal during
the relevant period.” Id. at 29. Likewise, he found that “[w]ith regard to
the claimant’s physical limitations, the undersigned again notes that
the claimant reported that she was not experiencing physical
28
limitations that she felt were disabling... .” Id. at 29. Ultimately, while
ALJ Riley recognized that the evidence at least supported a finding of
severe impairment, he found that the condition only had a limited
impact on Pagan’s functioning because the evidence “fails to establish
any significant and ongoing symptoms associated with her condition.”
Tr. 29.
Second, the ALJ evaluated Pagan’s symptoms, treatments, and
medications regarding her asthma, osteoarthritis, and sleep apnea, and
found that all three conditions had a limited impact on her functioning,
and were well under control with conservative treatments like inhalers,
topical medications, heat therapy, water therapy, and CPAP therapy.
Id. at 29-30. Moreover, he found that the record showed Pagan did not
require anything beyond such conservative treatments. Id.
Third, ALJ Riley evaluated Pagan’s symptoms, treatments, and
medications regarding her migraines, and found that the record showed
her condition did not drastically limit her functioning because it
“improved to a point in which the claimant tolerated her regimen and it
was generally controlling her symptoms. Notably, the claimant’s
condition was manageable to a point in which she declined additional
29
preventative measures.” Id. at 30. Fourth, the ALJ evaluated Pagan’s
symptoms, treatments, and medications regarding her anxiety disorder,
depressive disorder, and insomnia, and found that despite receiving
treatment for these disorders and at times having symptoms of “mood
fluctuations, irritability, hallucinations, racing thoughts, and panic
attacks|,]” the record failed to establish that the symptoms “caused any
significant limitations during mental status examinations.” Id.
Specifically, the record showed that, upon examination, Pagan
“generally maintained normal orientation, thought processing, thought
content, memory, attention, judgment, insight, and cognitive
functioning during the relevant period.” Id.
Lastly, ALJ Riley separately assessed Pagan’s activities of daily
living, and found that they tended to show her symptoms were less
debilitating than she alleged. His finding was based on the fact that the
record showed Pagan was “able to care for her personal care needs,
including her ability to dress, bathe, care for her hair, shave, feed
herself, and use the bathroom|[,]” care for children and pet’s needs,
perform housework, and “go outside alone, shop in stores, and operate a
motor vehicle[.]” Tr. 30.
30
Having found Pagan’s statements concerning the limiting effects
of her symptoms inconsistent with the relevant evidence of record, ALJ
Riley deemed her statements non-credible. Jd. at 29. This, in part,
informed the ALJ’s finding that Pagan can perform light work subject to
a host of other personally tailored limitations. Jd. at 25. Overall, that
thorough reasoning readily permits meaningful judicial review.
Pagan’s overarching argument that the limitations in her residual
functional capacity are inadequate to account for her impairments is
unavailing because, as outlined above, the method ALJ Riley used to
assess the limiting effects of her symptoms was sound. Preliminarily, to
the extent Pagan speculates that some of her impairments could or
would lead to an increase in symptoms based on the nature of the
impairments, and that she therefore requires greater limitations than
those found by ALJ Riley (Doc. 9 at 15-16, 18), that argument fails. As
the Commissioner correctly points out (Doc. 19 at 26), a diagnosis of
impairment, and whatever hypothetical problems may arise from it,
does not meaningfully move the needle on a disability determination.
Rather, a claimant must provide credible evidence showing “that the
impairment resulted in disabling limitations.” Phillips, 91 F. App’x at
31
780. Mere speculation, as offered by Pagan here, falls short of meeting
that burden.
Alternatively, to the extent that Pagan argues that the weight of
the evidence supports greater limitations, that contention also fails.
Where an ALJ’s factual findings are supported by substantial evidence,
the Court is required to uphold them. Ficca, 901 F. Supp. 2d at 536; see
also Consolo, 383 U.S. at 620 (‘[S]omething less than the weight of the
evidence, ... does not prevent [it] from being supported by substantial
evidence.”). Thus, assuming some evidence supports one of ALJ Riley’s
findings, then all he need do to comply with the substantial evidence
standard is state “which evidence he has rejected and which he is
relying on as the basis for his finding.” Schaudeck, 181 F.3d at 488.
That is precisely what ALJ Riley did here, when he laid out the
objective evidence relevant to assessing Pagan’s statements concerning
the limiting effects of her symptoms, and then assessed the credibility
of the statements by comparing the two. See supra at 27-80.
Although Pagan may disagree with the ALJ’s conclusions, his
assessment of her symptoms was supported by a large quantity of
evidence. See Tr. 508, 506, 671-72, 822, 826, 847, 888, 933-44, 952, 955,
32
963, 1326, 1329, 1382, 13889, 1450-68, 1517-19, 1524-25, 1529-30,
1536, 1541, 1552, 1568, 1565, 1572, 1621-24, 1627-29, 1634, 1861. In
addition, after surveying this evidence, the ALJ thoroughly explained
his reasons for rejecting Pagan’s statements regarding the limiting
effects of her symptoms in favor of the relevant objective evidence in
determining her limitations. Id. at 29-30. As such, ALJ Riley’s
limitation findings, insofar as they are based on this comprehensive
credibility assessment, must be upheld. Ficca, 901 F. Supp. 2d at 536;
Schaudeck, 181 F.3d at 483; Diaz, 577 F.3d at 506.
Lastly, Pagan’s argument that further limitations are necessary to
account for issues from her impairments not addressed by the ALJ, is
without merit. Critically, as the Commissioner points out (Doc. 19 at
27), Pagan’s contention that ALJ Riley did not address her issues with
respect to mental health treatment, insomnia, body aches, dizziness,
weight gain, and edema (Doc. 9 at 16-18), is directly refuted by the
opinion itself. See Tr. 26-30 (“[t]he claimant notes that she takes
medication to treat her conditions, which cause side effects of
drowsiness’; “the claimant reported experiencing weight gain as a side
effect to one of her medications’; “[t]reatment records from August 2019
33
note the claimant reported chronic insomnia”; “[t]reatment records from
April 2021 note the claimant reported her medications were not helping
as much, and noted experiencing increased depression, mood swings,
irritability, mania, racing thoughts, and a first time history of a panic
attack”; “she also reported that her medication regimen was helping her
mood but that she experienced side effects of swelling in her lower
extremities”). Moreover, Pagan’s secondary contention that ALJ Riley
failed to note certain records in his opinion (Doc. 9 at 17), is also
unavailing, because an ALJ is not required to undertake an exhaustive
discussion of all of the evidence. Fargnoli, 247 F.3d at 42. That rings
particularly true in this circumstance where, as explained above, the
ALJ expressly recognized the issues addressed in the medical records
Pagan now insists required special attention.
Accordingly, as a review of ALJ Riley’s opinion shows that his
limitation findings were based on substantial record evidence, and the
reasoning underlying those findings was sufficient to enable judicial
review, they will not be disturbed. Ficca, 901 F. Supp. 2d at 536; Diaz,
577 F.3d at 506.
34
C. The Evaluation of Pagan’s Stomach Pain, Memory
Loss, Panic Attacks, Hallucinations, Edema, Fatigue, and
Concentration
Pagan next argues that the ALJ erred in not finding that her
stomach pain, memory loss, panic attacks, hallucinations, edema,
fatigue, and concentration problems were severe impairments under the
second step of the Social Security Act’s sequential evaluation process.
Doc. 9 at 21-24. In the alternative, she appears to argue that these
seven maladies were not sufficiently discussed or addressed in the
ALJ’s limitation findings. Id. But, this argument yields no relief where,
as here, any potential error was harmless and the ALJ evaluated the
record and articulated his findings to a degree sufficient to permit
meaningful judicial review.
At step two of the sequential evaluation process, ALJ Riley found
that Pagan was afflicted with ten severe impairments: osteoarthritis of
the bilateral knees, obesity, obstructive sleep apnea, asthma, status
post cerebrovascular assault, migraine headaches, bipolar disorder,
depressive disorder/persistent mood disorder, anxiety disorder, and
insomnia. Tr. 21. He also considered evidence of several other alleged
impairments, including umbilical hernia, an ankle sprain,
35
dysmenorrhea, hypertension, and gastroesophageal reflux disease , but
found that these conditions were not severe. Id.
The second step of the Social Security Act’s sequential disability
analysis requires an ALJ to determine whether a claimant has a
medically severe impairment or combination of impairments. 20 C.F.R.
§ 404.1520(a)(4)Gi). An impairment is considered severe only if it
“significantly limits an individual’s physical or mental abilities to do
basic work activities.” 20 C.F.R. § 404.1520(c). Impairments are found
non-severe “when medical evidence establishes only a slight
abnormality or a combination of slight abnormalities which would have
no more than a minimal effect on an individual’s ability to work... .”
SSR 85-28, 1985 WL 56856, at *3 (1985).
At step two of the analysis, the burden lies on the claimant to
establish that she has a severe impairment. Bowen v. Yuckert, 482 U.S.
137, 146 (1987). The Court of Appeals has explained that the
evidentiary burden to show a “severe” impairment is relatively low,
because step two only functions as “a de minimis screening device to
dispose of groundless claims.” McCrea v. Comm’ of Soc. Sec., 370 F.3d
357, 360 (3d Cir. 2004) (quoting Newell v. Comm’ of Soc. Sec., 347 F.3d
36
541, 546 (8d Cir. 2003)). This means that “[o]nly those claimants with
slight abnormalities that do not significantly limit any ‘basic work
activity’ can be denied benefits at step two.” Newell, 347 F.3d at 546
(citing Bowen, 482 U.S. at 158 (O’Conner, J., concurring)).
However small the evidentiary burden at step two may be, there
still must be sufficient objective medical evidence to support a finding of
severe impairment. Kirk v. Comm’ of Soc. Sec., 177 F. App’x 205, 207
n.3 (38d Cir. 2006). Moreover, even in the event that an ALJ errs at step
two in finding a claimant’s condition is a non-severe impairment, that
error is harmless where the analysis nevertheless moved beyond step
two on account of a finding that the claimant had other severe
impairments. See Orr v. Comm’ Soc. Sec., 805 F. App’x 85, 88 (8d Cir.
2020) (“[Blecause the ALJ progressed to a later step, any error at Step
Two would not alter the remainder of the five-step process, much less
the overall outcome.”); Salles v. Comm of Soc. Sec., 229 Fed. App’x
140, 145 n.2 (8d Cir. 2007) (same).
Here, Pagan’s argument that ALJ Riley erred in not finding that
several of her documented conditions were severe impairments provides
no tenable grounds for relief. Even assuming Pagan is correct, and that
37
ALJ Riley erred when he found that her stomach pain, memory loss,
panic attacks, hallucinations, edema, fatigue, and concentration
problems were non-severe impairments (Doc. 9 at 21-24), it would have
been harmless. Importantly, despite not finding that those seven issues
were severe impairments, the ALJ still found that ten of Pagan’s
impairments were severe and continued beyond step two of the
sequential analysis on that basis. Tr. 21-33. This means that,
irrespective of any error at step two, Pagan would have suffered no
harm “because the ALJ progressed to a later step[.]” Orr, 805 F. App’x
at 88.
Furthermore, as the Commissioner notes, the seven issues Pagan
argues should have been deemed severe impairments are not even
cognizable as impairments. Doc. 19 at 30-32. Indeed, as SSR 96-4p
makes abundantly clear, “an individual’s symptoms, such as pain,
fatigue, shortness of breath, weakness, or nervousness, will not be
found to affect the individual’s ability to do basic work activities .. .
unless medical signs and laboratory findings show that there is a
medically determinable physical or mental impairment(s) that could
reasonably be expected to produce the symptom(s) alleged.” SSR 96-4p,
38
1996 WL 374187, at *2 (1996). In other words, unless there is sufficient
evidence of some associated diagnosed or diagnosable, symptoms like
pain, fatigue, general mental deficits and disturbances, and other
general maladies as here, cannot be deemed independently disabling.
As the Commissioner correctly avers (Doc. 19 at 31), the seven
general issues advanced by Pagan in her argument, including stomach
pain, memory loss, panic attacks, hallucinations, edema (i.e., swelling),
fatigue, and concentration problems, hew much more closely to
symptoms of underlying conditions rather than medically determinable
impairments. See, e.g., SSR 96-4p, 1996 WL 374187, at *2 (1996)
(“symptoms, such as pain, fatigue, ... or nervousness”); Kozick v.
Kijakazi, 2023 WL 6144850, at *8 (M.D. Pa. 2023), report and
recommendation adopted, 2023 WL 6143956 (M.D. Pa. 2023)
(“[Glenerally, auditory hallucinations are a symptom, not an
impairment.”); Williams v. Colvin, 2014 WL 4918469, at *8 (M.D. Pa.
2014) (“[A]n anxiety attack is a symptom, and not an impairment.”);
Murphy v. Asirue, 2013 WL 3964910, at *2 (D.N.J. 2013) ([T]he ALJ
also noted that [claimant]’s symptoms of leg edema and chest pain were
not ‘diagnostically related’ to her [condition].”); Neff v. Astrue, 875 F.
39
Supp. 2d 411, 424 (D. Del. 2012) (“Subjective symptoms, such as
memory loss, must be supported by objective medical evidence.”);
Mederos v. Colvin, 2015 WL 5167109, at *4 (D.N.J. 2015) (This
encompassed her subjective reported symptoms of uncontrolled diabetes
and other symptoms that included . .. concentration and memory
problems[.]”).
Likewise, the Commissioner is also correct that ALJ Riley’s
opinion refutes Pagan’s alternative argument that these seven issues
were not sufficiently discussed or addressed in the ALJ’s limitation
findings. Doc. 19 at 35-86; see Tr. 21-28 (“The record establishes the
claimant has a history of gastroesophageal reflux disease. Treatment
records from June 2020 note the claimant was referred to a
gastroenterologist”; “[d]uring the relevant period, she also reported...
auditory hallucinations”; “[t]he claimant asserts that her conditions
limit her ability to understand and remember things, follow both
written and spoken instructions, concentrate, and handle stress and
changes in routine”; “[d]uring a functional capacity evaluation in June
2022, the claimant reported symptoms of pain and fatigue that limited
her participation in work activities, leisure activities, and activities of
40
daily living|]’; “[t]reatment records from April 2021 note the claimant
reported her medications were not helping as much, and noted
experiencing ...a first time history of a panic attack[.]”).
In essence, Pagan asks the Court to reweigh the evidence in her
favor here, but “[c]ourts are not permitted to re-weigh the evidence or
impose their own factual determinations.” Chandler v. Comm’ of Soc.
Sec., 667 F.3d 356, 359 (8d Cir. 2011). Because any alleged error made
by ALJ Riley at step two would have been harmless, and because his
conclusions and accompanying findings concerning Pagan’s
impairments are supported by substantial evidence in the record and
are sufficiently articulated to permit judicial review, they will be
upheld. Orr, 805 F. App’x at 88; Kirk, 177 F. App’x at 207 n.8.
D. The ALJ’s Evaluation of the Medical Opinions of Dr.
Denyse Allen, Dr. Kevin Hollick, Dr. Angela Walker, and
Michael Riggi
Finally, Pagan contends that ALJ Riley erred in not assessing the
opinion given by Dr. Denyse Allen in an assessment form. Doc. 9 at 27.
Pagan also contends that the ALJ erred in assessing and rejecting the
opinion of occupational therapist Michael Riggi, and in assigning
persuasive weight to the opinions of Dr. Kevin Hollick and Dr. Angela
Al
Walker. Id. at 27-29. But Pagan’s disagreement with the ALJ’s
assessment of these opinions does not warrant remand where, as here,
those evaluations comported with all applicable regulatory
requirements.
On June 3, 2020, Dr. Allen completed an employability
assessment form related to his treatment of Pagan. Tr. 750-52. Of
relevance, he described Pagan as having a history of cerebral infarction,
bipolar disorder, obesity, and migraines. Jd. at 750. In consideration of
these conditions, Dr. Allen opined that Pagan was disabled as of that
date. Id. at 751.
On July 14, 2021, Dr. Hollick evaluated the medical evidence
pertaining to Pagan’s conditions and concluded that to accommodate
them, it was necessary for Pagan to avoid concentrated exposure to
noise, vibrations, fumes, odors, dusts, gases, and poor ventilation. Id. at
120-30. On November 22, 2021, Dr. Walker likewise reviewed the
medical evidence pertaining to Pagan’s conditions and concluded that
they limited her to light work, except that she could occasionally
balance, stoop, crouch, and climb ramps or stairs but never kneel, crawl,
or climb ladders, ropes, or scaffolds. Id. at 163-64. Dr. Walker also
42
found that it was necessary for Pagan to avoid concentrated exposure to
extreme cold, vibrations, fumes, odors, dusts, gases, poorly ventilated
areas, and hazards like machinery and heights. Jd. at 164.
On June 7, 2022, occupational therapist Michael Riggi tested
Pagan’s functional capacity in person. Tr. 1621—238. Based on his testing
of Pagan’s maximum exertional abilities, where it was observed that,
among other things, she could sit for 830 minutes at a time, stand for 15
minutes at a time, and lift 20 lbs. at a time, he opined that she was
limited to sedentary work. Id. at 1622.
Under the current regulations, medical opinions are not entitled
to any specific weighting, and are instead evaluated based on their
persuasiveness. 20 C.F.R. §§ 404.1520c(a), 404.1520c(b). An ALJ
determines the persuasiveness of a prior medical finding or medical
opinion by assessing five factors: (1) supportability; (2) consistency; (8)
relationship with the claimant; (4) specialization; and (5) other factors.
20 C.F. R. § 404.1520c(a)—(c). The factors related to the substance of
medical opinions—supportability and consistency—are the “most
important factors” for consideration. 20 C.F.R. § 404.1520c(b)(2).
Examining supportability entails a review of the opinion’s basis in
43
relevant “objective medical evidence and supporting explanations
presented by a medical source”; consistency is assessed based on how
consistent a finding or opinion is “with the evidence from other medical
sources and nonmedical sources in the claim[.]” 20 C.F.R.
§ 404.1520c(c)(1)-(2).
The Court of Appeals explained in Cotter v. Harris that when
weighing the record, an ALJ “cannot reject evidence for no reason or the
wrong reason” and must explain “why probative evidence has been
rejected ... so that a reviewing court can determine whether the
reasons for rejection were improper.” 642 F.2d 700, 706-07 (8d Cir.
1981). This does not mean, however, that the ALJ must undertake an
exhaustive discussion of all of the evidence. See, e.g., Fargnoli, 247 F.3d
at 42; Hur, 94 F. App’x at 133 (‘There is no requirement that the ALJ
discuss in her opinion every tidbit of evidence included in the record.”).
An ALJ also has no obligation to analyze or even consider evidence that
includes statements on issues, like disability status or severe
impairment status, that are exclusively reserved to the Commissioner.
See 20 C.F.R. §§ 404.1520b(c)(3)G@)—-Gi), 416.920b(c)(8)@)—G).
44
Here, ALJ Riley first found Dr. Hollick’s and Dr. Walker’s
opinions persuasive. He explained that their own limitation findings,
such as limiting Pagan to light work and only occasionally balancing,
stooping, crouching, and climbing up ramps or stairs, were “supported
by and consistent with the overall evidence of record... .” Tr. 31.
Specifically, he noted that the medical evidence showed Pagan’s
conditions caused subjective reports of pain and tenderness, but also
that “she generally maintained her gait, strength, and range of motion
despite the presence of the impairments.” Id. Moreover, ALJ Riley
found that their opinions were “supported by and consistent with the
claimant’s history of stroke and ongoing weight in the obese range.” Id. __
Given these things, he found the two opinions persuasive.
ALJ Riley later found the opinion of Michael Riggi, who he
misidentified as Dr. Allen, as unpersuasive. He noted that the examiner
in the report found Pagan could only perform sedentary work, and that
she “demonstrated the ability to lift 20 pounds and carry 10 pounds on
an occasional basis[.]” Jd. ALJ Riley however found that, although the
examiner “consistently represented” otherwise, Pagan had not been
giving her best efforts during the examination, casting doubt on the
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results. Id. He went on to say that “the findings are not consistent with
the overall evidence of record, and also suggestive of inconsistent effort,
based on her discontinuing several tests due to reports of pain in her
left shoulder, hands, and bilateral calf muscles[.|” Id. The ALJ indicated
that Pagan’s reports of pain in the shoulder, hand, calves, and lower
back during testing were suspiciously absent from any of her other
records, again casting doubt on her effort level. Jd. Based on these
things, ALJ Riley found the opinion unpersuasive. Tr. 31.
Despite Pagan’s argument to the contrary, ALJ Riley was well
within his regulatory authority when he did not consider Dr. Allen’s
June 3, 2020, employability assessment form. The regulations make it
clear that when, like here, evidence includes a statement on an issue
like disability status, the ALJ is under no duty to consider or analyze it.
See 20 C.F.R. §§ 404.1520b(c)(3)@)-Gi), 416.920b(c)(3)G)ii). ALJ Riley
thus committed no error when he did not consider Dr. Allen’s
employability assessment form.
Pagan’s arguments concerning the ALJ’s evaluation of the opinion
of Michael Riggi likewise yield no relief. First, ALJ Riley’s error when
he identified Riggi’s opinion as coming from Dr. Allen is largely
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irrelevant, because, as the Commissioner correctly notes (Doc. 19 at 42),
Pagan has failed to explain how this error made any difference in the
outcome. See Holloman v. Comm Soc. Sec., 639 F. App’x 810, 814 (8d
Cir. 2016) (“[Claimant] therefore must ‘explain []... how the... error
to which he points could have made any difference.’ □□ (quoting Shinseki
v. Sanders, 556 U.S. 396, 409 (2009)).
Second, Pagan’s argument that the ALJ failed to enumerate
several of Riggi’s findings is also irrelevant. As detailed above, the ALJ
evaluated Riggi’s opinion as a whole under the factors of consistency
and supportability (Tr. 31), and therefore his conclusion that the
opinion did not merit persuasive weight satisfied his regulatory duty.
See, e.g., Jones v. Sullivan, 954 F.2d 125, 129 (8d Cir. 1991) (holding
medical opinions that are inconsistent with and unsupported by the
medical evidence are not persuasive or controlling); Wright v. Sullivan,
900 F.2d 675, 683 (8d Cir. 1990) (same).
Similarly, Pagan’s argument that the ALJ erred by finding the
opinions of Dr. Hollick and Dr. Walker persuasive is without basis. As
explained above, ALJ Riley evaluated the opinions of Dr. Hollick and
Dr. Walker under the factors of consistency and supportability (Tr. 31),
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and so his conclusion that they merited persuasive weight met his
regulatory duty. Jones, 954 F.2d at 129; Wright, 900 F.2d at 683. The
fact that these opinions were delivered a year before the date of ALJ
Riley’s hearing, or that the opinions were not based on testing
observations, is beside the point. See Chandler, 667 F.3d at 361 (“The
Social Security regulations impose no limit on how much time may pass
between a report and the ALJ's decision in reliance on it.”); 20 C.F.R. §§
404.1520c(a), 404.1520c(b).
This Court’s role is not to re-weigh the evidence to make its own
factual determinations. Chandler, 667 F.3d at 359. Accordingly, because
ALJ Riley evaluated the relevant opinion evidence pursuant to his
regulatory duty to assess persuasiveness, his findings will not be
disturbed.
IV. Conclusion
Accordingly, the Court will affirm the decision of the
Commissioner and deny the Plaintiff's request for relief. A separate
order shall be issued.
Date: October 6, 2025 s/ Phillip J. Caraballo
Phillip J. Caraballo
United States Magistrate Judge
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