Edwards v. Kijakazi

UNITED STATES DISTRICT COURT

MIDDLE DISTRICT OF PENNSYLVANIA

SABOURAH EDWARDS, : NO. 3:23-CV-01590

Plaintiff, :

:

v. :

: (CAMONI, M.J.)

COMMISSIONER OF SOCIAL :

SECURITY, :

Defendant. :

MEMORANDUM OPINION

This is an action brought under 42 U.S.C. § 1383(c)(3), seeking

judicial review of the final decision of the Commissioner of Social Security

denying Plaintiff Sabourah Edwards’s claim for supplemental security

income benefits under Title XVI of the Social Security Act. The Court has

jurisdiction to review this matter pursuant to 42 U.S.C. § 1383(c)(3)

(incorporating 42 U.S.C. § 405(g) by reference). For the reasons stated

herein, the Court affirms the decision of the Commissioner.

I. BACKGROUND

A. Procedural History

On November 30, 2018, Edwards protectively filed a Title XVI

application for supplemental security income benefits, alleging disability

beginning November 1, 2018. Complaint, Doc. 1 ¶ 5; Tr., Doc. 9-2 at 12.

The Social Security Administration initially denied Edwards’s claims

(Doc. 9-4 at 2), so Edwards appealed the denial, exhausting the

administrative appeals procedure and filed a civil action in this Court.

See Doc. 1 ¶¶ 6–11; Memo. Op., Edwards v. Kijakazi, No. 21-615, Doc. 24

at 22. In that prior civil action, Magistrate Judge Arbuckle issued an

opinion and order, remanding the case. See No. 21-615, Doc. 24 at 22

(finding a single error warranting remand because the ALJ failed to cite

a proper basis for discounting Edwards’s psychologist’s opinion).

Pursuant to the remand order, the Administrative Law Judge

(“ALJ”) held a second hearing on March 28, 2023, and issued a “partially

favorable” decision, finding Edwards disabled as of May 8, 2023, but not

disabled before that date. Second Tr., Doc. 10 at 2, 5, 19. The ALJ’s

decision, therefore, became final. 42 U.S.C. § 405(g). Pending before this

Court is Edwards’s appeal of that decision. Doc. 1.

B. The Disability Determination Process

To receive disability benefits under the Social Security Act (“Act”),

a claimant must be unable to “engage in any substantial gainful activity

by reason of any medically determinable . . . impairment which can . . .

result in death or which has lasted or can be expected to last for a

continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A).

Under the Act, a claimant is disabled “only if his . . . impairments are of

such severity that he is not only unable to do his previous work but

cannot, considering his age, education, and work experience, engage in

any other kind of substantial gainful work which exists in the national

economy.” § 423(d)(2)(A). An impairment is one that “results from

anatomical, physiological, or psychological abnormalities which are

demonstrable by medically acceptable clinical and laboratory diagnostic

techniques.” § 423(d)(3).

Social Security regulations provide a “five-step sequential

evaluation process” to determine if a claimant is disabled. 20 C.F.R.

§ 416.920(a)(1). The claimant bears the burden of persuasion through

step four, while at step five, the burden shifts to the Secretary to show

that the claimant can perform substantial gainful employment other

than the claimant’s past relevant work. Williams v. Sullivan, 970 F.2d

1178, 1181 (3d Cir. 1992) (citing Bowen v. Yuckert, 482 U.S. 137, 146 n.5

(1987)).

At the first step, the claimant must establish that he has not

engaged in substantial gainful activity since the onset of the alleged

disability. See § 416.920(a)(4)(i). At the second step, claimant must

establish that he suffers from a “severe medically determinable . . .

impairment that meets the duration requirement in § 416.909

(“impairment . . . must have lasted or must be expected to last for a

continuous period of at least 12 months”).” § 416.920(a)(4)(ii). At the third

step, the claimant must provide evidence that his impairment “meets or

equals one of our listings in appendix 1.” § 416.920(a)(4)(iii). If the

claimant demonstrates his impairments meet those listings, he is

considered to be disabled. See id.; § 416.920(d). If he cannot establish

severity of impairment at the third step, the eligibility analysis proceeds

to step four in which the ALJ determines whether the claimant’s residual

functional capacity (“RFC”) allows the claimant to continue his previous

employment. § 416.920(a)(4)(iv). RFC “is the most [a claimant] can still

do despite” impairments. § 404.1545(a)(1). To prevail on step four,

claimant’s “impairment(s) must prevent [the claimant] from doing [the

claimant’s] past relevant work.” § 416.920(f). At the fifth step, the

Commissioner bears the burden to demonstrate that the claimant’s RFC

and his “age, education, and work experience . . . [allows] adjustment to

other work.” § 416.920(a)(4)(v). If the Commissioner cannot satisfy this

burden, the claimant’s claim is granted. See § 416.920(g).

C. The ALJ’s Decision

Here, the ALJ determined that Edwards “has been disabled under

. . . the Social Security Act beginning on May 8, 2023.” Doc. 10 at 19. The

ALJ reached this conclusion after proceeding through the five-step

sequential analysis required by the Social Security Act.

§ 416.920(a)(4)(i)–(v); see Doc. 10 at 7–19.

At step one, the ALJ determined Edwards “has not engaged in

substantial gainful activity since . . . the alleged onset date.” Doc. 10 at

7. At step two, the ALJ found Edwards has the following severe

impairments: degenerative disc disease and spondylosis of the cervical

spine, carpal tunnel syndrome on the right, major depressive disorder,

anxiety, and panic attack. Id. At step three, the ALJ determined that

none of Edwards’s impairments, considered individually or in

combination, met or equaled the listed impairments in 20 C.F.R. part

404, subpart P, appendix 1. Id. at 8.

Further, the ALJ found that since the onset of her disabilities,

Edwards has the following RFC:

[T]o perform light work as defined in 20 CFR 416.967(b) . . . .

She can understand, remember and carry out simple

instructions; can perform simple, routine and repetitive tasks

and can perform jobs that would be considered “low stress” in

that they would involve only occasional, simple decision

making, and only occasional, gradual changes in the work

duties and work setting.

Id. at 10. At step four, the ALJ determined Edwards is unable to perform

any past relevant work since the onset of her disabilities. Id. at 17. At

step five, the ALJ partially denied Edwards’s claims because, after

considering her “age, education, work experience, and residual functional

capacity,” the ALJ found that “there were jobs that existed in significant

numbers in the national economy that the claimant could have

performed” before May 8, 2023, the date the claimant’s age category

changed. Id. at 18 (citing § 416.969); see also Medical-Vocational

Guidelines Rule 202.06 (determining disability based on an individual

reaching the age of fifty-five, the “advanced age.”).

D. Issues Presented

Edwards challenges the ALJ’s RFC finding and step five

determination, making three arguments on appeal: the ALJ (1) rejected

the opinion of the treating neurologist for erroneous reasons; (2) rejected

the opinion of the examining psychologist for erroneous reasons; and (3)

failed to incorporate all of Plaintiff’s limitations in the hypothetical

question he posed to the vocational expert. Pl.’s Br., Doc. 13 at 7, 15, 18.

At bottom, Edwards contends that the ALJ erred in his assessment of the

opinion of the treating sources, Drs. Gross and Betts. See Doc. 13 at 7–

19. This case is fully briefed (Docs. 13, 17, 18) and ready for resolution.

The parties consented to the jurisdiction of a United States Magistrate

Judge to conduct all proceedings in this case, pursuant to 28 U.S.C.

§ 636(c) and Federal Rule of Civil Procedure 73, including entry of final

judgment. Consent Form, Doc. 7. The Court, adhering to the deferential

standard of review outlined below, affirms the decision of the

Commissioner.

II. LEGAL STANDARD

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

application for benefits, the Court is limited to determining whether the

findings of the final decision-maker are supported by substantial

evidence in the record. See 42 U.S.C. § 1383(c)(3) (incorporating 42

U.S.C. § 405(g) by reference); Johnson v. Comm’r of Soc. Sec., 529 F.3d

198, 200 (3d Cir. 2008); Ficca v. Astrue, 901 F. Supp. 2d 533, 536 (M.D.

Pa. 2012). Under the substantial-evidence standard, a court examines an

existing administrative record and asks whether it contains sufficient

evidence to support the agency’s factual determinations. Biestek v.

Berryhill, 587 U.S. 97, 102 (2019). 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.” Id. at 103; see also Pierce v. Underwood, 487 U.S. 552, 565

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

but more than a mere scintilla. Richardson v. Perales, 402 U.S. 389, 401

(1971). A single piece of evidence is not substantial evidence if the ALJ

ignores countervailing evidence or fails to resolve a conflict created by

the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). In an

adequately developed factual record, however, substantial evidence may

be “something less than the weight of the evidence, and the possibility of

drawing two inconsistent conclusions from the evidence does not prevent

[the ALJ’s decision] from being supported by substantial

evidence.” Consolo v. Fed. Mar. Comm’n, 383 U.S. 607, 620 (1966). “In

determining if the Commissioner’s decision is supported by substantial

evidence the court must scrutinize the record as a whole.” Leslie v.

Barnhart, 304 F. Supp. 2d 623, 627 (M.D. Pa. 2003). In reviewing the

record for substantial evidence, “[n]either the district court nor [the Third

Circuit] is empowered to weigh the evidence or substitute its conclusions

for those of the fact-finder.” Williams, 970 F.2d at 1182. To reverse the

ALJ’s findings and decision, the Court “must find that the evidence not

only supports [a contrary] conclusion but compels it.” Immigr. &

Naturalization Serv. v. Elias-Zacarias, 502 U.S. 478, 481 n.1 (1992).

The question before the Court, therefore, is not whether Edwards

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

disabled is supported by substantial evidence and was reached based

upon a correct application of the relevant law. See Arnold v. Colvin, No.

12-2417, 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.”); Burton v. Schweiker, 512 F. Supp. 913, 914 (W.D. Pa.

1981) (“The [Commissioner]’s determination as to the status of a claim

requires the correct application of the law to the facts.”); see also Wright

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

review on legal matters is plenary); Ficca, 901 F. Supp. 2d at 536 (“[T]he

court has plenary review of all legal issues decided by the

Commissioner.”). In determining that question, the Court must evaluate

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 beyond stating bare conclusions. Burnett v. Comm’r of Soc.

Sec., 220 F.3d 112, 119 (3d Cir. 2000).

III. DISCUSSION

Edwards filed for supplemental security income benefits on

November 30, 2018, after the March 27, 2017, amendment to the

regulations, which brought about “a paradigm shift in the manner in

which medical opinions were evaluated when assessing Social Security

claims.” Mercado v. Kijakazi, 629 F. Supp. 3d 260, 279–80 (M.D. Pa.

2022). The Court first explains the post-March 2017 governing regulation

applicable to Edwards’s case before turning to the legal issues.

A. Legal Benchmarks for the ALJ’s Assessment of Medical

Opinions under 20 Code of Federal Regulations

§ 416.920c

For claims filed “on or after March 27, 2017, the rules in this section

apply.” 20 C.F.R. § 416.920c. Under this regulation, the Social Security

Administration “will not defer or give any specific evidentiary weight, . . .

to any medical opinion(s) or prior administrative medical finding(s),

including those from [a claimant’s] medical sources.” § 416.920c(a).

Instead, the new regulations require an ALJ to determine and “articulate

. . . how persuasive” a medical opinion is based on several factors:

supportability, consistency, relationship with the claimant,

specialization, and other factors tending to support or contradict a

medical opinion. §§ 416.920c(b), (c)(1)–(5). The regulations provide that

the “most important factors” when an ALJ considers “the persuasiveness

of medical opinions and prior administrative medical findings are

supportability . . . and consistency.” § 416.920c(a). Because of the

importance of those factors in determining persuasiveness, the ALJ must

explain the considerations for “supportability and consistency factors for

a medical source’s medical opinions or prior administrative medical

findings in [a claimant’s] determination or decision.” § 416.920c(b)(2).

The ALJ may, “but [is] not required to,” explain the considerations for

the other factors under subsection (c). Id. Further, the ALJ is “not

required to articulate how [the ALJ] considered each medical opinion or

prior administrative medical finding from one medical source

individually.” § 416.920c(b)(1).

B. Substantial evidence supports the ALJ’s determination

of Drs. Gross and Betts’s opinions as unpersuasive.

1. The ALJ’s evaluation of Dr. Gross’s medical opinion

Edwards first argues that the ALJ erred in finding the medical

opinions of Dr. Gross unpersuasive. See Doc. 13 at 7. Primarily, Edwards

contends that the ALJ “failed to consider the consistency of Dr. Gross’s

opinion with the evidence from other medical or nonmedical sources,

instead finding it not consistent with Dr. Gross’s own findings.” Id. at 11;

Pl.’s Reply Br., Doc. 18 at 2 (“[T]he ALJ fail[ed] even to mention

consistency”).

First, it is permissible for an ALJ to find a treating source’s opinion

inconsistent with the source’s own treatment records. See, e.g., Swank v.

O’Malley, No. 23-1244, 2024 WL 4858586, at *10 (M.D. Pa. Nov. 21, 2024)

(finding no error in an ALJ’s analysis of the consistency factor where the

ALJ noted that a claimant’s treating source’s opinion was internally

inconsistent and was at odds with many treatment notes); see also

Solberg v. O’Malley, No. 23-2639, 2024 WL 1943328, at *6 (E.D. Pa. Apr.

30, 2024) (finding an ALJ’s consistency assessment, which determined a

medical opinion unpersuasive because it was inconsistent with the

source’s own treatment notes, “well-reasoned and adequate”). Here, the

ALJ made no error by finding Dr. Gross’s opinion unpersuasive by

reasoning that the doctor’s “own treatment records [] generally show

rather objective findings including 5/5 strength in all extremities, intact

coordination and normal gait” was inconsistent with Dr. Gross “limiting

the claimant’s ability to stand and walk for only two hours and to sit for

only four hours.” Doc. 10 at 17.

Second, an administrative judge is not required to use specific

terminology to provide a reasonable explanation under the regulations.

The Court of Appeals for the Third Circuit explains that to satisfy the

articulation requirements for supportability and consistency, “a judge

need not reiterate the magic words ‘support’ and ‘consistent’ for each

doctor.” Zaborowski v. Comm’r of Soc. Sec., 115 F.4th 637, 639 (3d Cir.

2024). Instead, it is sufficient for an ALJ to “weave supportability and

consistency throughout her analysis of which doctors were persuasive.”

Id. Here, the ALJ did exactly that.

Contrary to Edwards’s contention that the “ALJ clearly considered

only Dr. Gross’s records, not the records of other medical providers,” Doc.

18 at 2, the ALJ began his RFC explanation by reviewing and discussing

treatment records from Drs. Carlo de Luna, Darren Jacobs, and Gregory

Weiner, Doc. 10 at 11–12 (citing to Exs. D3F, D12F). That review led the

ALJ to conclude that since Edwards’s “alleged onset date, treatment has

been relatively conservative” and that the “majority of her doctors all

agree that she is not experiencing radiculopathy,” and finding that

Edwards’s “combination of impairments would reasonably limit her to a

range of light work.” Id. at 12–13. The ALJ then found support for

concluding that Edwards is “reasonably limit[ed] to a range of light

work,” id. at 13, from nurse practitioner Cywinski and state agency

medical consultant Dr. Bonita’s opinions, among other sources. See id. at

13, 16. The ALJ discussed nurse practitioner Cywinski’s consultative

report and opinion, which stated that Edwards could “sit for six hours,

stand for six and walk for six.” Id. at 13. The ALJ determined that “the

sitting/standing and walking limitations are supported by the records.”

Id. The ALJ also found generally persuasive Dr. Bonita’s opinion, which

noted that Edwards “could perform a range of light exertional work

where she could occasionally perform postural activities but could never

climb on ladders, ropes or scaffolds.” Id. at 16; see id. (finding Drs.

Bermudez and Calise’s opinions that claimant could perform a range of

light exertional work generally consistent with the treatment records and

thus persuasive).

After the discussion of treatment records and medical opinions, the

ALJ addressed Dr. Gross’s opinion, finding it unpersuasive. Id. at 17. The

ALJ explained that Dr. Gross’s findings “do not support nor are they

consistent with limiting the claimant’s ability to stand and walk for only

two hours and to sit for only four hours,” because the doctor’s “own

treatment records [] generally show rather objective findings including

5/5 strength in all extremities, intact coordination and normal gait.” Id.

Thus, the ALJ satisfied the requirement to articulate his consideration

of supportability and consistency. Following an extensive review of the

treatment records from various doctors, and the persuasive medical

opinions of CRNP Cywinski, Drs. Bonita, Bermudez, and Calise, the ALJ

“did weave supportability and consistency throughout her analysis of

which doctors were persuasive.” Zaborowski, 115 F.4th at 639. The Court,

therefore, finds that the ALJ’s determination as to the persuasiveness of

the medical opinions of Dr. Gross is supported by substantial evidence.

2. The ALJ’s evaluation of Dr. Betts’s medical opinion

The Court also finds no error in the ALJ’s determination that Dr.

Betts’s opinion is partially persuasive. See Doc. 10 at 15. The ALJ found

that Dr. Betts’s opinion as to “the marked limitations are not persuasive,”

explaining in depth how it conflicts with the mental status findings from

the treatment records. Id. For example, the ALJ reviewed and cited to

Edwards’s treatment records which showed clinical findings that are

generally normal. Id., citing Exs. D12F, D17F, D25F, D26F. And the ALJ

explained that Edwards’s “cognitive functioning was considered to likely

be in the average range and both her insight and judgment fair.” Id.

Moreover, the ALJ reviewed and discussed opinions from Drs. Murphy

and Vigna, finding their opinions as to the limitations “generally

consistent with the treatment records including the Northeast

Counseling records and . . . from Geisinger Behavioral Health.” Id. at 16.

Thus, the Court finds that the ALJ’s determination as to the

persuasiveness of the medical opinions of Dr. Betts is supported by

substantial evidence. See Zaborowski, 115 F.4th at 639–40 (finding an

ALJ’s articulation sufficient as to the opinions of psychologists where the

ALJ explained how the opinions “fit with other evidence”).

C. Substantial evidence supports the ALJ’s determination

at step five.

Edwards’s third argument contains two parts. The first part

challenges the ALJ’s “hypothetical question [which] improperly omitted

credibly established limitations. Specifically, . . . the limitations assessed

by Dr. Betts and Dr. Gross.” Doc. 13 at 19. Mindful of the deferential

standard of review and having determined above that substantial

evidence supports the ALJ’s evaluation of the persuasiveness of Drs.

Betts and Gross’s opinions, the Court does not find that the ALJ’s

hypothetical question improperly omitted credibly established

limitations. See Williams, 970 F.2d at 1182 (“Neither the district court

nor [The Third Circuit] is empowered to weigh the evidence or substitute

its conclusions for those of the fact-finder.”).

Next, Edwards argues that there is an apparent conflict between

the ALJ’s RFC determination and the three occupations identified at step

five. See Doc. 13 at 19–20. As part of the RFC finding, the ALJ limited

the claimant to jobs that require that she can “understand, remember

and carry out simple instructions; can perform simple, routine and

repetitive tasks.” Doc. 10 at 10. Edwards contends that the three jobs

cited at step five require a “Reasoning Level 2” which “requires the ability

to carry out ‘detailed’ instructions,” which “an individual limited to only

simple instructions [like Edwards] could not carry out.” Doc. 13 at 20.

Upon review of the relevant case law in the Third Circuit, the Court finds

that while a claimant who is limited to “very short and simple

instructions” or “short and simple instructions” cannot perform jobs

identified at reasoning level two, a claimant who is only limited to “simple

instructions” can. Money v. Barnhart, 91 F. App’x 210, 215 (3d Cir. 2004)

(concluding that jobs at reasoning level two does not contradict the

mandate that work be simple, routine and repetitive); see also Lawrence

v. Saul, 941 F.3d 140, 143 (4th Cir. 2019) (finding no conflict between an

RFC to carry out simple instructions and jobs that require reasoning level

two).

Although the issue Edwards raised is often litigated, her factual

circumstances that inform the issue is rather unique. As other courts in

this district have found, when a claimant is limited to one- to two-step

instructions (i.e., short and simple instructions), the claimant may not be

able to perform a reasoning level two job. See, e.g., Warren v. Dudek, No.

24-635, 2025 WL 1168276, at *7 (M.D. Pa. Apr. 22, 2025) (“Here, the jobs

identified by the ALJ at Step 5 require a reasoning level 2, which could

be inconsistent with a limitation to one-to-two-step tasks.”); Latourette v.

King, No. 24-516, 2025 WL 580597, at *8 (M.D. Pa. Feb. 21, 2025); Reep

v. Bisignano, No. 24-712, 2025 WL 1508453, at *8–9 (M.D. Pa. May 27,

2025). But Edwards is limited to neither short and simple instructions

nor to one- to two-step tasks, which would only qualify her for a reasoning

level one job. Instead, she is limited to simple instructions. Doc. 10 at 10.

That distinction is critical.

The court in Cowher v. O’Malley clarified this distinction. No.

21-178, 2024 WL 3161865, at *7–9 (W.D. Pa. June 24, 2024). In Cowher,

the court explained that “a difference exists between an individual

capable of following ‘simple instructions,’ and an individual only capable

of following ‘very short and simple instructions (i.e., perform one and two

step tasks).’” 2024 WL 3161865, at *7. It concluded that while a limitation

to very short and simple instructions is consistent with jobs at reasoning

level one, courts generally find that a limitation to simple instructions is

consistent with jobs at both reasoning level one and level two. Id.

(collecting cases). Because the ALJ determined that Edwards can

“understand, remember and carry out simple instructions,” Doc. 10 at 10,

not short and simple instructions, the Court finds no conflict at step five

between Edwards’s RFC limitations and the three jobs identified which

require reasoning level two. Substantial evidence, therefore, supports the

ALJ’s decision at step five.

IV. CONCLUSION

Accordingly, the Commissioner’s decision is AFFIRMED.

An appropriate order follows.

Date: October 7, 2025 s/Sean A. Camoni

Sean A. Camoni

United States Magistrate Judge