Matos

IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF PENNSYLVANIA

MOLLY ANNE MATOS, : Civil No. 4:24-CV-675

:

Plaintiff :

:

v. : (Magistrate Judge Carlson)

:

FRANK BISIGNANO,1 :

Commissioner of Social Security, :

:

Defendant. :

MEMORANDUM OPINION

I. Introduction

A claimant’s ability to perform the mental demands of the workplace are often

essential to the disability determination. Therefore, when an individual’s ability to

perform simple and complex tasks are at issue in a Social Security appeal, it is

incumbent upon the Administrative Law Judge (ALJ) hearing this disability claim

to provide a logical bridge between the evidence and the ALJ’s legal conclusions

and factual findings, a logical nexus which addresses the claimant’s mental

limitations in these areas and explains how they do not preclude employment. These

1 Frank Bisignano became the Commissioner of Social Security on May 6, 2025.

Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure, Frank Bisignano

should be substituted as the defendant in this suit. No further action need be taken to

continue this suit by reason of the last sentence of section 205(g) of the Social

Security Act, 42 U.S.C. § 405(g).

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legal conclusions and factual findings are typically supported and guided by the

opinions of medical experts. On this score, although it is ultimately the ALJ who

makes the RFC determination, and determines which medical opinions and evidence

deserve greater weight, it is also well-settled that, when evaluating medical opinions,

an ALJ should refrain from substituting his own lay opinion in place of a medical

opinion. See Morales v. Apfel, 225 F.3d 310, 319 (3d Cir. 2000). Moreover, “the

ALJ may choose whom to credit but ‘cannot reject evidence for no reason or for the

wrong reason,’” Id. at 317 (quoting Mason v. Shalala, 994 F.2d 1058, 1066 (3d Cir.

1993)). Thus, in a case such as this where an ALJ has eschewed the opinions of

medical experts in favor of his own interpretation of the record without a valid

explanation, a remand is necessary.

We are reminded of these familiar principles in the instant case. In this case,

the ALJ found that the plaintiff, Molly Matos, was not disabled and was capable of

performing routine two or three step tasks or instructions despite the state agency

medical experts whom the ALJ credited opining she was, at most, capable of

performing one- to two-step tasks. Indeed, while the ALJ found the two state agency

experts, who stated throughout their opinions Matos was limited to one- to two-step

tasks, persuasive the ALJ actually found that “the claimant is slightly more limited”

than these opinions stated. Yet the ALJ did not address why he failed to adopt this

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limitation. Instead after stating that Matos was more limited than the state agency

experts—who limited her to one to two steps tasks—opined the ALJ then

inexplicably concluded Matos was capable of performing more complex two to three

step tasks. In our view, the ALJ’s internally inconsistent analysis both “reject[s]

evidence for no reason,” Morales at 317, and does not provide a complete logical

bridge for the decision denying benefits to the plaintiff. This was error. Therefore,

we will order this case remanded for further consideration by the Commissioner.

II. Statement of Facts and of the Case

A. Introduction

On October 29, 2021, Molly Matos filed a Title II application for a period of

disability and disability insurance benefits, alleging disability beginning August 19,

2021. (Tr. 17). In this application Matos alleged that she was disabled due to an array

of physical and mental impairments, including neuropathy, migraines, anxiety,

depression, PTSD, tremors, high blood pressure, bulging discs, and arthritis in her

back. (Tr. 64). Matos was born on August 4, 1992, and was twenty-nine years old at

the time of the alleged onset of her disability, making her a younger worker under

the Commissioner’s regulations. (Id.) She had at least a high school education and

prior employment as a preschool teacher, administrative clerk, and in the service

industry. (Tr. 55-56).

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B. Matos’ Mental Impairments and the Expert Opinions Regarding Her

Limitations.

The longitudinal medical record of Matos’ mental impairments reveals that

she experienced a traumatic childhood and young adulthood, resulting in depression

with two suicide attempts, anxiety, PTSD, and an eating disorder requiring inpatient

psychiatric treatment. (Tr. 1020, 1030-33). She also underwent a partial

hospitalization program for depression and PTSD during the relevant period. (Tr.

796-902).

Matos’ mental impairments caused her to experience anxiety, panic attacks,

depression, mood instability, and difficulty concentrating. (Tr. 1030). As

consultative examiner, Dr. John Kajic, summarized on February 14, 2022:

She reports difficulty falling asleep with frequent wakening and a loss

of appetite on most days. She says she has lost about 20 lb since 08/21.

Depressive symptomatology includes dysphoric mood, crying spells,

hopelessness, loss of usual interests, irritability, fatigue and loss of

energy, diminished self-esteem, concentration difficulties, diminished

sense of pleasure, and social withdrawal. Suicidal and homicidal

ideation, plan, intent, or means are denied at this time. Anxiety-related

symptomatology: Excessive apprehension and worry, easily fatigued,

irritability, fear of being judged or negatively evaluated in social

settings, difficulty concentrating, and avoidance of social settings.

Phobic responses around crowds and enclosed spaces. Trauma

experienced from being physically and/or sexually abused as an adult

woman and history of domestic violence; she was beat with a rifle. She

has flashbacks, hyperstartle response, nightmares, hypervigilance,

avoidance, intrusive thoughts, angry outbursts, detachment from

others, and sleep disturbances. She reports experiencing panic attacks

at least two to three times a week primarily from flashbacks. She gets

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palpitations, nausea, and passes out, sweating, dizziness, breathing

difficulties, trembling, and chest pain. Manic symptomatology is

denied. When asked about thought disorder, she says, “At night, I feel

as if I can see things outside my window when I’m driving, and I hear

noises when I’m trying to sleep.” Paranoid ideations are denied.

Obsessions and compulsions: The claimant reports she chronically

bites the inside of her cheeks and lips until she bleeds. She picks the

skin around her fingers off when she is anxious.

(Tr. 564). Thus, without question, the psychological symptoms Matos experienced

were significant and severe during the relevant period. Nonetheless, her mental

status examinations were frequently normal, and her intellectual functioning

reported as average, (e.g. Tr. 66, 78, 367, 418, 483, 504, 564, 762, 804, 934) despite

showing signs of depression (Tr. 483-84, 804-05). Indeed, the ALJ acknowledged

that Matos’ emotional impairments caused her limitations in several of the

“paragraph B” criteria, including that she was moderately limited in understanding,

remembering, or applying information and concentrating, persisting, and

maintaining pace. As the ALJ summarized when considering her limitations in the

four “paragraph B” areas of mental functioning:

In understanding, remembering or applying information, the claimant

had a moderate limitation. The claimant alleges she has difficulty

understanding and following instructions (11E). However, the claimant

notes she can drive and shop by computer (11E). This implies she can

understand, remember, and apply information. Longitudinal treatment

notes generally show the claimant is fully oriented with normal speech,

normal thought process, normal thought content, intact memory, intact

associations, intact fund of knowledge, fair insight, and fair judgment

(3F; 4F; 5F; 6F; 7F; 8F; 12F; 13F; 16F; 17F; 19F; 23F; 24F; 26F; 27F).

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

claimant alleges she isolated herself, does not leave the house, and

cannot be in crowds (Hearing Testimony; 11E). Regardless, the

claimant states she lives with her husband and three children and

attends church (11E). This implies she can interact with others.

Progress notes mostly show the claimant is fully oriented, alert,

pleasant, and cooperative with appropriate affect, normal speech,

normal thought process, normal thought content, normal perceptions,

normal behavior, fair insight, and fair judgment (3F; 4F; 5F; 6F; 7F;

8F; 12F; 13F; 16F; 17F; 19F; 23F; 24F; 26F; 27F).

With regard to concentrating, persisting or maintaining pace, the

claimant had a moderate limitation. The claimant insists she has

difficulty concentrating and completing tasks (Hearing Testimony;

11E). Nonetheless, the claimant notes she can drive and shop by

computer (11E). This implies she can concentrate, persist, and maintain

pace. Treatment notes largely show the claimant is fully oriented and

alert with normal thought process, normal thought content, normal

perceptions, intact associations, good attention span, intact

concentration, fair insight, and fair judgment (3F; 4F; 5F; 6F; 7F; 8F;

12F; 13F; 16F; 17F; 19F; 23F; 24F; 26F; 27F).

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

moderate limitation. The claimant maintains she gets panic attacks

(Hearing Testimony; 11E). However, the claimant reports she helps

feed her children and can drive and shop by computer (11E). This

implies she can adapt and manage herself. Longitudinal treatment notes

generally show the claimant is fully oriented, alert, pleasant, and

cooperative with appropriate affect, normal speech, normal thought

process, normal thought content, normal perceptions, intact memory,

intact associations, good attention span, intact concentration, normal

behavior, intact fund of knowledge, fair insight, and fair judgment (3F;

4F; 5F; 6F; 7F; 8F; 12F; 13F; 16F; 17F; 19F; 23F; 24F; 26F; 27F).

(Tr. 21-22).

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The ALJ’s conclusion that Matos had moderate limitations in all four areas of

mental functioning was supported by the medical opinion evidence including two

state agency psychological consultants, her treating provider, and a consultative

examiner.

On February 25, 2022, State agency psychological consultant Dr. John

Gavazzi opined that Matos had mild limitations in her ability to understand,

remember, or apply information, and moderate limitations in her ability to interact

with others, concentrate, persist, or maintain pace, and adapt or manage oneself. (Tr.

68). As to her sustained concentration and persistence limitations, Dr. Gavazzi

opined that: “The claimant can make simple decisions. The claimant would be able

to maintain regular attendance and be punctual. The claimant can carry out very short

and simple instructions. The claimant can perform one- and two-step tasks.” (Tr.

73). Then again, in the additional explanation portion, Dr. Gavazzi stated, “The

claimant can perform one- or two-step, routine tasks in a stable environment.” (Tr.

74).

On reconsideration, state agency psychological consultant Dr. Molly Cowan

also opined that Matos had moderate limitations in her ability to concentrate, persist,

or maintain pace and echoed Dr. Gavazzi’s conclusion that “The claimant can

perform one- and two-step tasks” both by way of narrative to account for these

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moderate limitations and in the overall MRFC explanation section stating again that

“[t]he claimant can perform one- or two-step, routine tasks in a stable environment.

(Tr. 79, 84, 85).

On September 9, 2022, Matos’ treating provider, CRNP Christine Buckley,

also provided an opinion on Matos’ mental RFC that was even more restrictive than

those of the state agency experts. CRNP Buckley opined Matos would have extreme

limitations in her ability to concentrate, persist, or maintain pace, and marked

limitations in all other areas of mental functioning. (Tr. 939). She noted that Matos

would be unable to understand and remember even very short and simple

instructions, maintain attention for two-hour segments, and make simple work-

related decisions. (Tr. 938).

After conducting a mental status consultative examination of the plaintiff, Dr.

John Kajic completed a mental RFC assessment in which he also concluded Matos

had moderate impairments in understanding, remembering, and carrying out

complex instructions but no limitations in understanding, remembering, and carrying

out simple instructions. (Tr. 567).

Thus, both state agency medical experts clearly opined Matos would be

limited to performing one- or two-step tasks, her treating provider opined she would

essentially be unable to understand and remember even short and simple

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instructions, and the consultative examiner agreed she had moderate impairments in

these arenas.

C. The ALJ Hearing and Decision

It was against this medical backdrop that Matos’ disability claim came to be

heard by the ALJ on March 15, 2023, at which Matos and a Vocational Expert (VE)

testified. (Tr. 37-62). The ALJ presented a hypothetical to the VE that included a

limitation to two- to three-step tasks or instructions, but did not question the VE

about whether a one- to two-step limitation would preclude her from performing the

jobs the VE identified. (Tr. 57-62).2

Following this hearing, on May 15, 2023, the ALJ issued a decision denying

Matos’ application for benefits. (Tr. 14-31). In that decision, the ALJ first concluded

that the plaintiff last met the insured status requirements of the Social Security Act

on March 31, 2023, and had not engaged in substantial gainful activity from the

alleged onset date of August 19, 2021, through her date last insured of March 31,

2023. (Tr. 19). At Step 2 of the sequential analysis that governs Social Security

cases, the ALJ found that Matos had the following severe impairments: degenerative

2 Curiously, the ALJ did question the VE about several other mental limitations

which were not ultimately included in the RFC, including only frequently

maintaining concentration, persistence, or pace, needing unscheduled breaks, and

being absent for about twenty percent of the work time and the VE concluded these

limitations would preclude all competitive employment. (Tr. 58-59).

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disc disease of the cervical and lumbar spine, obesity, right carpal tunnel syndrome,

traumatic brain injury, headaches, depression, bipolar disorder, anxiety, and post-

traumatic stress disorder. (Tr. 20). At Step 3, the ALJ determined that these

impairments did not meet or medically equal the severity of any listed impairments.

(Tr. 20).

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

(“RFC”), considering the plaintiff’s limitations from her impairments, stating that:

After careful consideration of the entire record, the undersigned finds

that, through the date last insured, the claimant had the residual

functional capacity to perform light work as defined in 20 CFR

404.1567(b) and she could have occasionally balanced, stooped,

kneeled, crouched, crawled, climbed ramps and stairs, or used foot

controls bilaterally; and never have climbed ladders ropes scaffolds.

She could have frequently reached, handled, fingered, felt, pushed, or

pulled bilaterally; and could have occasionally overhead reached with

the left upper extremity. She could have tolerated occasional exposure

to cold temperature extremes; humidity; or concentrated dust, fumes,

or gases. She could have never worked at unprotected heights or contact

dangerous moving machinery. She had the mental capacity to maintain

concentration, persistence, or pace for two-hour segments sufficient to

perform routine two to three step tasks or instructions; could have

frequently interacted with public, supervisors, or coworkers; and could

have performed work that involves no more than frequent changes in

work situations in a routine work setting.

(Tr. 22)(emphasis added).

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In formulating the RFC, the ALJ considered the medical opinions of the four

experts who opined on Matos’ mental RFC. The ALJ found the opinions of Dr.

Gavazzi and Dr. Cowan persuasive, explaining:

These statements are supported by the progress notes through the date

last insured, which mostly show the claimant is fully oriented, alert,

pleasant, and cooperative with appropriate affect, normal speech,

normal thought process, normal thought content, normal perceptions,

intact memory, intact associations, good attention span, intact

concentration, normal behavior, intact fund of knowledge, fair insight,

and fair judgment (3F; 4F; 5F; 6F; 7F; 8F; 12F; 13F; 16F; 17F; 19F;

23F; 24F; 26F; 27F). These statements are also consistent with the

claimant’s lack of recent inpatient mental health treatment. Further, Dr.

Gavazzi and Dr. Cowan are highly qualified experts who had the

opportunity to review the claimant’s records.

(Tr. 28). The ALJ went on to credit the statements of these experts, but find they

were not quite restrictive enough, stating: “Thus, the undersigned finds Dr.

Gavazzi’s and Dr. Cowan’s statements are persuasive. However, based on the

medical evidence of record, the undersigned finds the claimant is slightly more

limited as she moderate limitations understanding, remembering, or applying

information.” (Id.)

Inexplicably, despite concluding that the opinions of both state agency mental

consultants finding Matos was capable of following and remembering, at most, one-

to two-step instructions persuasive, and holding that Matos would be even “more

limited” than those opinions required, the ALJ ultimately concluded Matos could

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perform routine two- to three-step tasks or instructions, a limitation that was not

presented by any of the medical experts and required more of the plaintiff than the

opinions of the state agency experts.3

Having made these findings, the ALJ concluded that Matos could not return

to her past work but could perform other light exertional work in the national

economy. (Tr. 30-31). Accordingly, the ALJ concluded that the plaintiff did not meet

the stringent standard for disability set by the Act and denied this claim. (Id.)

This appeal followed. (Doc. 1). On appeal, Matos contends, inter alia, that the

ALJ erred in failing to address the opinions of the state agency psychologists,

supported by the opinions of the other medical experts, that she be limited to one- to

two-step instructions. After a review of the evidence, we agree that the ALJ’s

omission of this limitation, and adoption of a less restrictive limitation of two- to

three-step instructions was divorced from any medical opinion and unexplained in

the ALJ’s analysis, leaving the factual, legal and logical bridge between the evidence

and the ALJ’s findings lacking. Therefore, we will remand this case for further

consideration by the Commissioner.

3 The ALJ also found the opinion of consultative examiner Dr. Kajic that she had

moderate limitations in understanding, remembering, and carrying out instructions

persuasive but found the more restrictive opinion of Matos’ treating provider, CRNP

Buckley, unpersuasive.

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III. Discussion

A. Substantial Evidence Review – the Role of this Court

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

application for benefits, this Court’s review is limited to the question of whether the

findings of the final decision-maker are supported by substantial evidence in the

record. See 42 U.S.C. §405(g); Johnson v. Comm’r of Soc. Sec., 529 F.3d 198, 200

(3d Cir. 2008); Ficca v. Astrue, 901 F. Supp.2d 533, 536 (M.D. Pa. 2012).

Substantial evidence “does not mean a large or considerable amount of evidence, but

rather such relevant evidence as a reasonable mind might accept as adequate to

support a conclusion.” Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial

evidence is less than a preponderance of the evidence but more than a mere scintilla.

Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of evidence is not

substantial evidence if the ALJ ignores countervailing evidence or fails to resolve a

conflict created by the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir.

1993). But in an adequately developed factual record, substantial evidence may be

“something less than the weight of the evidence, and the possibility of drawing two

inconsistent conclusions from the evidence does not prevent [the ALJ’s decision]

from being supported by substantial evidence.” Consolo v. Fed. Maritime Comm’n,

383 U.S. 607, 620 (1966). “In determining if the Commissioner’s decision is

13

supported by substantial evidence the court must scrutinize the record as a whole.”

Leslie v. Barnhart, 304 F. Supp.2d 623, 627 (M.D. Pa. 2003).

The Supreme Court has underscored for us the limited scope of our review in

this field, noting that:

The phrase “substantial evidence” is a “term of art” used throughout

administrative law to describe how courts are to review agency

factfinding. T-Mobile South, LLC v. Roswell, 574 U.S. ––––, ––––,

135 S.Ct. 808, 815, 190 L.Ed.2d 679 (2015). Under the substantial-

evidence standard, a court looks to an existing administrative record

and asks whether it contains “sufficien[t] evidence” to support the

agency's factual determinations. Consolidated Edison Co. v. NLRB,

305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) (emphasis

deleted). And whatever the meaning of “substantial” in other contexts,

the threshold for such evidentiary sufficiency is not high. Substantial

evidence, this Court has said, is “more than a mere scintilla.” Ibid.; see,

e.g., Perales, 402 U.S. at 401, 91 S.Ct. 1420 (internal quotation marks

omitted). It means—and means only—“such relevant evidence as a

reasonable mind might accept as adequate to support a conclusion.”

Consolidated Edison, 305 U.S. at 229, 59 S.Ct. 206. See Dickinson v.

Zurko, 527 U.S. 150, 153, 119 S.Ct. 1816, 144 L.Ed.2d 143 (1999)

(comparing the substantial-evidence standard to the deferential clearly-

erroneous standard).

Biestek, 139 S. Ct. at 1154.

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

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

supported by substantial evidence and was reached based upon a correct application

of the relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205,

at *1 (M.D. Pa. Mar. 11, 2014) (“[I]t has been held that an ALJ’s errors of law denote

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a lack of substantial evidence”) (alterations omitted); Burton v. Schweiker, 512 F.

Supp. 913, 914 (W.D. Pa. 1981) (“The Secretary’s determination as to the status of

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

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

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

of all legal issues . . . .”).

Several fundamental legal propositions which flow from this deferential

standard of review. First, when conducting this review “we are mindful that we must

not substitute our own judgment for that of the fact finder.” Zirnsak v. Colvin, 777

F.3d 607, 611 (3d Cir. 2014) (citing Rutherford v. Barnhart, 399 F.3d 546, 552 (3d

Cir. 2005)). Thus, we are enjoined to refrain from trying to re-weigh the evidence.

Rather our task is to simply determine whether substantial evidence supported the

ALJ’s findings. However, we must also ascertain whether the ALJ’s decision meets

the burden of articulation demanded by the courts to enable informed judicial

review. Simply put, “this Court requires the ALJ to set forth the reasons for his

decision.” Burnett v. Comm'r of Soc. Sec. Admin., 220 F.3d 112, 119 (3d Cir. 2000).

As the Court of Appeals has noted on this score:

In Burnett, we held that an ALJ must clearly set forth the reasons for

his decision. 220 F.3d at 119. Conclusory statements . . . are

insufficient. The ALJ must provide a “discussion of the evidence” and

an “explanation of reasoning” for his conclusion sufficient to enable

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meaningful judicial review. Id. at 120; see Jones v. Barnhart, 364 F.3d

501, 505 & n. 3 (3d Cir.2004). The ALJ, of course, need not employ

particular “magic” words: “Burnett does not require the ALJ to use

particular language or adhere to a particular format in conducting his

analysis.” Jones, 364 F.3d at 505.

Diaz v. Comm'r of Soc. Sec., 577 F.3d 500, 504 (3d Cir. 2009).

Thus, in practice ours is a twofold task. We must evaluate the substance of the

ALJ’s decision under a deferential standard of review, but we must also give that

decision careful scrutiny to ensure that the rationale for the ALJ’s actions is

sufficiently articulated to permit meaningful judicial review.

This principle applies with particular force to legal challenges, like the claim

made here, based upon alleged inadequacies in the articulation of a claimant’s

mental RFC. In Hess v. Comm’r Soc. Sec., 931 F.3d 198, 212 (3d Cir. 2019), the

United States Court of Appeals recently addressed the standards of articulation that

apply in this setting. In Hess the court of appeals considered the question of whether

an RFC which limited a claimant to simple tasks adequately addressed moderate

limitations on concentration, persistence, and pace. In addressing the plaintiff’s

argument that the language used by the ALJ to describe the claimant’s mental

limitations was legally insufficient, the court of appeals rejected a per se rule which

would require the ALJ to adhere to a particular format in conducting this analysis.

Instead, framing this issue as a question of adequate articulation of the ALJ’s

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rationale, the court held that: “as long as the ALJ offers a ‘valid explanation,’ a

‘simple tasks’ limitation is permitted after a finding that a claimant has ‘moderate’

difficulties in ‘concentration, persistence, or pace.’ ” Hess v. Comm’r Soc. Sec., 931

F.3d 198, 211 (3d Cir. 2019). On this score, the appellate court indicated that an ALJ

offers a valid explanation a mental RFC when the ALJ highlights factors such as

“mental status examinations and reports that revealed that [the claimant] could

function effectively; opinion evidence showing that [the claimant] could do simple

work; and [the claimant]’s activities of daily living, . . . . ” Hess v. Comm’r Soc.

Sec., 931 F.3d 198, 214 (3d Cir. 2019).

In our view, the teachings of the Hess decision are straightforward. In

formulating a mental RFC the ALJ does not need to rely upon any particular form

of words. Further, the adequacy of the mental RFC is not gauged in the abstract.

Instead, the evaluation of a claimant’s ability to undertake the mental demands of

the workplace will be viewed in the factual context of the case, and a mental RFC is

sufficient if it is supported by a valid explanation grounded in the evidence.

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

To receive benefits under the Social Security Act by reason of disability, a

claimant must demonstrate an inability to “engage in any substantial gainful activity

by reason of any medically determinable physical or mental impairment which can

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

continuous period of not less than 12 months.” 42 U.S.C. §423(d)(1)(A); see also 20

C.F.R. §404.1505(a). To satisfy this requirement, a claimant must have a severe

physical or mental impairment that makes it impossible to do his or her previous

work or any other substantial gainful activity that exists in the national economy. 42

U.S.C. §423(d)(2)(A); 20 C.F.R. §404.1505(a). To receive benefits under Title II of

the Social Security Act, a claimant must show that he or she contributed to the

insurance program, is under retirement age, and became disabled prior to the date on

which he or she was last insured. 42 U.S.C. §423(a); 20 C.F.R. §404.131(a).

In making this determination at the administrative level, the ALJ follows a

five-step sequential evaluation process. 20 C.F.R. §404.1520(a). Under this process,

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

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

whether the claimant’s impairment meets or equals a listed impairment; (4) whether

the claimant is able to do his or her past relevant work; and (5) whether the claimant

is able to do any other work, considering his or her age, education, work experience

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

Between Steps 3 and 4, the ALJ must also assess a claimant’s residual

functional capacity (RFC). RFC is defined as “that which an individual is still able

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to do despite the limitations caused by his or her impairment(s).” Burnett v. Comm’r

of Soc. Sec., 220 F.3d 112, 121 (3d Cir. 2000) (citations omitted); see also 20 C.F.R.

§§404.1520(e), 404.1545(a)(1). In making this assessment, the ALJ considers all of

the claimant’s medically determinable impairments, including any non-severe

impairments identified by the ALJ at step two of his or her analysis. 20 C.F.R.

§404.1545(a)(2).

There is an undeniable medical aspect to an RFC determination, since that

determination entails an assessment of what work the claimant can do given the

physical limitations that the claimant experiences. Yet, when considering the role

and necessity of medical opinion evidence in making this determination, courts have

followed several different paths. Some courts emphasize the importance of medical

opinion support for an RFC determination and have suggested that “[r]arely can a

decision be made regarding a claimant's residual functional capacity without an

assessment from a physician regarding the functional abilities of the claimant.”

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

(quoting Gormont v. Astrue, Civ. No. 11–2145, 2013 WL 791455 at *7 (M.D. Pa.

Mar. 4, 2013)). In other instances, it has been held that: “There is no legal

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

in the course of determining an RFC.” Titterington v. Barnhart, 174 F. App’x 6, 11

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(3d Cir. 2006). Further, courts have held in cases where there is no evidence of any

credible medical opinion supporting a claimant’s allegations of disability that “the

proposition that an ALJ must always base his RFC on a medical opinion from a

physician is misguided.” Cummings v. Colvin, 129 F. Supp. 3d 209, 214–15 (W.D.

Pa. 2015).

These seemingly discordant legal propositions can be reconciled by

evaluation of the factual context of these decisions. Those cases which emphasize

the importance of medical opinion support for an RFC assessment typically arise in

the factual setting where a well-supported medical source has identified limitations

that would support a disability claim, but an ALJ has rejected the medical opinion

which supported a disability determination based upon a lay assessment of other

evidence. Biller, 962 F.Supp.2d at 778–79. In this setting, these cases simply restate

the commonplace idea that medical opinions are entitled to careful consideration

when making a disability determination, particularly when those opinions support a

finding of disability. In contrast, when an ALJ is relying upon other evidence, such

as contrasting clinical or opinion evidence or testimony regarding the claimant’s

activities of daily living, to fashion an RFC courts have adopted a more pragmatic

view and have sustained the ALJ’s exercise of independent judgment based upon all

of the facts and evidence. See Titterington v. Barnhart, 174 F. App'x 6, 11 (3d Cir.

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

event, once the ALJ has made this determination, our review of the ALJ's assessment

of the plaintiff's RFC is deferential, and that RFC assessment will not be set aside if

it is supported by substantial evidence. Burns v. Barnhart, 312 F.3d 113, 129 (3d

Cir. 2002); see also Metzger v. Berryhill, No. 3:16-CV-1929, 2017 WL 1483328, at

*5 (M.D. Pa. Mar. 29, 2017), report and recommendation adopted sub nom. Metzgar

v. Colvin, No. 3:16-CV-1929, 2017 WL 1479426 (M.D. Pa. Apr. 21, 2017); Rathbun

v. Berryhill, No. 3:17-CV-00301, 2018 WL 1514383, at *6 (M.D. Pa. Mar. 12,

2018), report and recommendation adopted, No. 3:17-CV-301, 2018 WL 1479366

(M.D. Pa. Mar. 27, 2018).

At Steps 1 through 4, the claimant bears the initial burden of demonstrating

the existence of a medically determinable impairment that prevents him or her in

engaging in any of his or her past relevant work. Mason, 994 F.2d at 1064. Once this

burden has been met by the claimant, it shifts to the Commissioner at Step 5 to show

that jobs exist in significant number in the national economy that the claimant could

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

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

The ALJ’s disability determination must also meet certain basic substantive

requisites. Most significant among these legal benchmarks is a requirement that the

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ALJ adequately explain the legal and factual basis for this disability determination.

Thus, in order to facilitate review of the decision under the substantial evidence

standard, the ALJ's decision must be accompanied by “a clear and satisfactory

explication of the basis on which it rests.” Cotter v. Harris, 642 F.2d 700, 704 (3d

Cir. 1981). Conflicts in the evidence must be resolved and the ALJ must indicate

which evidence was accepted, which evidence was rejected, and the reasons for

rejecting certain evidence. Id. at 706-07. In addition, “[t]he ALJ must indicate in his

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

his finding.” Schaudeck v. Comm’r of Soc. Sec., 181 F.3d 429, 433 (3d Cir. 1999).

C. Legal Benchmarks for the ALJ’s Assessment of Medical Opinions

The plaintiff filed this disability application following a paradigm shift in the

manner in which medical opinions were evaluated when assessing Social Security

claims. Prior to March 2017, ALJs were required to follow regulations which defined

medical opinions narrowly and created a hierarchy of medical source opinions with

treating sources at the apex of this hierarchy. However, in March of 2017, the

Commissioner’s regulations governing medical opinions changed in a number of

fundamental ways. The range of opinions that ALJs were enjoined to consider were

broadened substantially, and the approach to evaluating opinions was changed from

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a hierarchical form of review to a more holistic analysis. As one court as aptly

observed:

The regulations regarding the evaluation of medical evidence have been

amended for claims filed after March 27, 2017, and several of the prior

Social Security Rulings, including SSR 96-2p, have been rescinded.

According to the new regulations, the Commissioner “will no longer

give any specific evidentiary weight to medical opinions; this includes

giving controlling weight to any medical opinion.” Revisions to Rules

Regarding the Evaluation of Medical Evidence (“Revisions to Rules”),

2017 WL 168819, 82 Fed. Reg. 5844, at 5867–68 (Jan. 18, 2017), see

20 C.F.R. §§ 404.1520c(a), 416.920c(a). Instead, the Commissioner

must consider all medical opinions and “evaluate their persuasiveness”

based on the following five factors: supportability; consistency;

relationship with the claimant; specialization; and “other factors.” 20

C.F.R. §§ 404.1520c(a)-(c), 416.920c(a)-(c).

Although the new regulations eliminate the perceived hierarchy of

medical sources, deference to specific medical opinions, and assigning

“weight” to a medical opinion, the ALJ must still “articulate how [he

or she] considered the medical opinions” and “how persuasive [he or

she] find[s] all of the medical opinions.” Id. at §§ 404.1520c(a) and

(b)(1), 416.920c(a) and (b)(1). The two “most important factors for

determining the persuasiveness of medical opinions are consistency and

supportability,” which are the “same factors” that formed the

foundation of the treating source rule. Revisions to Rules, 82 Fed. Reg.

5844-01 at 5853.

An ALJ is specifically required to “explain how [he or she] considered

the supportability and consistency factors” for a medical opinion. 20

C.F.R. §§ 404.1520c (b)(2), 416.920c(b)(2). With respect to

“supportability,” the new regulations provide that “[t]he more relevant

the objective medical evidence and supporting explanations presented

by a medical source are to support his or her medical opinion(s) or prior

administrative medical finding(s), the more persuasive the medical

opinions or prior administrative medical finding(s) will be.” Id. at §§

404.1520c(c)(1), 416.920c(c)(1). The regulations provide that with

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respect to “consistency,” “[t]he more consistent a medical opinion(s) or

prior administrative medical finding(s) is with the evidence from other

medical sources and nonmedical sources in the claim, the more

persuasive the medical opinion(s) or prior administrative medical

finding(s) will be.” Id. at §§ 404.1520c(c)(2), 416.920c(c)(2).

Under the new regulations an ALJ must consider, but need not

explicitly discuss, the three remaining factors in determining the

persuasiveness of a medical source's opinion. Id. at §§ 404.1520c(b)(2),

416.920c(b)(2). However, where the ALJ has found two or more

medical opinions to be equally well supported and consistent with the

record, but not exactly the same, the ALJ must articulate how he or she

considered those factors contained in paragraphs (c)(3) through (c)(5).

Id. at §§ 404.1520c(b)(3), 416.920c(b)(3).

Andrew G. v. Comm'r of Soc. Sec., No. 3:19-CV-0942 (ML), 2020 WL 5848776, at

*5 (N.D.N.Y. Oct. 1, 2020).

Oftentimes, as in this case, an ALJ must evaluate various medical opinions.

Judicial review of this aspect of ALJ decision-making is still guided by several

settled legal tenets. First, when presented with a disputed factual record, it is well-

established that “[t]he ALJ – not treating or examining physicians or State agency

consultants – must make the ultimate disability and RFC determinations.” Chandler

v. Comm’r of Soc. Sec., 667 F.3d 356, 361 (3d Cir. 2011). Thus, when evaluating

medical opinions “the ALJ may choose whom to credit but ‘cannot reject evidence

for no reason or for the wrong reason.’” Morales v. Apfel, 225 F.3d 310, 317 (3d

Cir. 2000) (quoting Mason, 994 F.2d at 1066). Therefore, provided that the decision

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is accompanied by an adequate, articulated rationale, it is the province and the duty

of the ALJ to choose which medical opinions and evidence deserve greater weight.

Further, in making this assessment of medical evidence:

An ALJ is [also] entitled generally to credit parts of an opinion without

crediting the entire opinion. See Thackara v. Colvin, No. 1:14–CV–

00158–GBC, 2015 WL 1295956, at *5 (M.D. Pa. Mar. 23, 2015);

Turner v. Colvin, 964 F. Supp. 2d 21, 29 (D.D.C. 2013) (agreeing that

“SSR 96–2p does not prohibit the ALJ from crediting some parts of a

treating source's opinion and rejecting other portions”); Connors v.

Astrue, No. 10–CV–197–PB, 2011 WL 2359055, at *9 (D.N.H. June

10, 2011). It follows that an ALJ can give partial credit to all medical

opinions and can formulate an RFC based on different parts from the

different medical opinions. See e.g., Thackara v. Colvin, No. 1:14–CV–

00158–GBC, 2015 WL 1295956, at *5 (M.D. Pa. Mar. 23, 2015).

Durden v. Colvin, 191 F.Supp.3d 429, 455 (M.D. Pa. 2016). Finally, where there is

no evidence of any credible medical opinion supporting a claimant’s allegations of

disability “the proposition that an ALJ must always base his RFC on a medical

opinion from a physician is misguided.” Cummings, 129 F.Supp.3d at 214–15.

D. This Case Will Be Remanded.

After a review of the record, we conclude that the ALJ’s adoption of a two- to

three-step limitation in complete contravention to the medical opinions he found

persuasive, which concluded Matos was limited to following one-to-two step

instructions, was error. At the outset, in reviewing this ALJ’s decision we find

ourselves at the intersection between two well-settled paradigms in the Social

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Security field. First, our highly deferential standard of review empowers “[t]he ALJ

– not treating or examining physicians or State agency consultants – [to] make the

ultimate disability and RFC determinations.” Chandler, 667 F.3d at 361. Thus, our

decision in this case in no way undercuts the legal tenet that an ALJ is not required

to adopt every limitation opined by the experts but “can formulate an RFC based on

different parts from the different medical opinions.” Durden, 191 F.Supp.3d at 455.

However, at base, an ALJ must draft a reviewable opinion that is grounded in the

evidence and provides the court with an adequately articulated rationale for the

limitations adopted. Here, the internal inconsistencies in the ALJ’s evaluation of the

medical opinion evidence and the adoption of a two-to-three step instruction

limitation in the RFC despite the evidence he credited stating the claimant should be

limited to one-to-two step instructions defy logic and are not explained in the ALJ’s

decision.

Indeed, as previously discussed, two state agency medical experts opined that

Matos would be moderately limited in her ability to understand and remember

detailed instructions, explaining, “The claimant can make simple decisions. The

claimant would be able to maintain regular attendance and be punctual. The claimant

can carry out very short and simple instructions. The claimant can perform one- and

two-step tasks.” (Tr. 73, 85). Both experts reiterated this one-to-two step task

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limitation in both the narratives within the worksheet section and the final narrative

explanation of the RFC assessment. The ALJ found these opinions persuasive, but

concluded, based on the medical evidence of record, that Matos would be even more

limited than these experts opined. Nonetheless, the ALJ adopted an RFC requiring

Matos to perform two-to-three step tasks, a mental RFC that was less restrictive than

the opinions the ALJ concluded were not limiting enough. This assessment was

untethered from any of the opinion evidence and was inconsistent with the ALJ’s

determination that Matos was more severely impaired than the state agency experts

had found, since the ALJ failed to explain in body of the RFC assessment why Matos

was not subject to the limitations opined by the experts but instead could perform

two- to three-step tasks.

The ALJ’s RFC assessment on this score runs afoul of several well-settled

legal tenets. First, as enumerated above, an ALJ's decision must be accompanied by

“a clear and satisfactory explication of the basis on which it rests.” Cotter, 642 F.2d

at 704. Furthermore, the ALJ must also “indicate in his decision which evidence he

has rejected and which he is relying on as the basis for his finding.” Schaudeck, 181

F.3d at 433. Moreover, it is well-settled that an ALJ should refrain from substituting

his own lay opinion in place of a medical opinion. Morales 225 F.3d at 319. These

mandates apply here in the context of the ALJ’s assessment of medical opinion

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evidence. Thus, although it is the province of the ALJ to decide which parts of the

medical opinion evidence to credit, and an ALJ is not required to adopt every

limitation opined by the experts whose opinions he found persuasive, an ALJ also

“cannot reject evidence for no reason or for the wrong reason.” Morales, 225 F.3d

at 317. This view is equally supported under the new mental RFC paradigm

developed in Hess, which does not require the ALJ to adhere to a particular format

in conducting the mental RFC analysis, but still requires a valid explanation

grounded in the evidence.

In the instant case, although the ALJ explained the longitudinal medical

record showing relatively normal mental status examinations and Matos’ ability to

perform some activities of daily living was not entirely consistent with her

statements regarding the severity of her mental impairments, the ALJ found the

opinions of the state agency psychological consultants, which clearly indicated

Matos should be limited to one- to two-step instructions, persuasive. The ALJ even

concluded these opinions were not restrictive enough, stating she was “more limited”

than these experts opined. The ALJ then crafted a mental RFC to account for these

limitations, but instead of limiting Matos to one- to two-step instructions,

inexplicably and seemingly based upon no evidence in the record, concluded she

could perform two or three step tasks. This unsupported RFC limitation is neither

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explained by nor grounded in the evidence and leaves the Court to conclude the ALJ

unilaterally rejected all medical opinions in favor of his own subjective impressions.

This was error. See Durden v. Colvin, 191 F. Supp. 3d 429, 455 (M.D. Pa. 2016)

(citing Thanh Tam Vo v. Colvin, No. 1:14–CV–00541–GBC, 2015 WL 5514981, at

*4 (M.D. Pa. Sept. 15, 2015)) (remanding where ALJ completely rejected all

medical opinions, even the one that supported the ALJ's RFC).

Moreover, this error was not harmless where the two of the three jobs

identified by the ALJ require Matos to perform work at an SVP 2 level. Since the

ALJ did not question the vocational expert about whether a limitation to one-to-two

step tasks would preclude her from work at that reasoning level,4 we are without the

benefit of a vocational expert’s testimony regarding whether a limitation to one- to

two-step tasks would preclude Matos from the SVP 2 level occupations identified in

the ALJ’s decision. We do note, however, that other courts have found that

Reasoning Levels 2 and 3 are not consistent with “simple, one-to-two step tasks.”

See Daniel M. v. Kijakazi, No. 2:21-CV-243, 2023 WL 154909, at *3 (D. Vt. Jan.

11, 2023) (collecting cases).

4 The ALJ did question the ALJ about other mental limitations, all of which would

have precluded Matos from competitive employment. Indeed, the omission of any

mention of this one-to-two step task limitation despite the ALJ explicitly assigning

a two-to-three step limitation, is striking.

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Finally, even assuming a one-to-two step task limitation would not preclude

the plaintiff from performing the remaining job identified by the ALJ, garment

packer (DOT 920.687-018) (SVP-1), there are only 12,000 jobs nationally, a number

which relevant caselaw would say is, at most, borderline when it comes to whether

it constitutes a significant number in the national economy.

While the regulations do not set any precise metrics for assessing what may

be a significant number of jobs, the Third Circuit has provided us with benchmarks

regarding what constitutes a substantial number of jobs in the national economy,

finding that, “the testimony from the vocational expert that 20,000 jobs were

available in the national economy is sufficient to support a finding that work exists

in significant numbers.” Young v. Astrue, 519 F. App'x 769, 772 (3d Cir. 2013).

Conversely, when the number of jobs identified in the national economy totals less

than 10,000 positions, or the number of regional jobs falls below 100, courts have

frequently found that the Commissioner's burden of proving at Step 5 that jobs

existed in significant numbers in the national economy has not been met. See e.g.,

Beltran v. Astrue, 700 F.3d 386, 389 (9th Cir. 2012) (135 jobs in the regional

economy held not significant); Ellis v. Kijakazi, 553 F. Supp. 3d 628, 635 (E.D. Wis.

2021) (remanding where only 14,500 jobs identified in the national economy);

Ochoa v. Colvin, No. 1:12-CV-00604-SKO, 2013 WL 4816130, at *8 (E.D.Cal.

30

Sept. 6, 2013) (80 jobs in Sacramento were not significant); Valencia v. Astrue, No.

C 11-06223 LB, 2013 U.S. Dist. LEXIS 41758, 2013 WL 1209353, at *18 (N.D.Cal.

Mar. 25, 2013) (114 regional jobs in San Francisco Bay area and 14,082 national

jobs were not significant); Lenon v. Apfel, 191 F. Supp. 2d 968, 979 (W.D. Tenn.

2001) (117 jobs in the regional economy held not significant); Jimenez v. Shalala,

879 F. Supp. 1069, 1076 (D. Colo. 1995) (200–250 jobs in regional economy held

not significant). Given the flaws in this decision and the lack of any VE testimony

regarding what jobs Matos could perform had the ALJ included a one-to-two step

task limitation, we are that this error was not harmless.

Simply put, more was needed here by way of explanation on the part of the

ALJ to support the decision Matos could perform two to three step tasks. Since the

ALJ’s burden of articulation is not met in the instant case, this matter must be

remanded for further consideration by the Commissioner. Yet, while we reach this

result, we note that nothing in this Memorandum Opinion should be deemed as

expressing a judgment on what the ultimate outcome of any reassessment of this

evidence should be. Rather, the task should remain the duty and province of the ALJ

on remand.

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IV. Conclusion

Accordingly, for the foregoing reasons, the plaintiff’s request for a new

administrative hearing is GRANTED, the final decision of the Commissioner

denying these claims is vacated, and this case is remanded to the Commissioner to

conduct a new administrative hearing.

An appropriate order follows.

s/ Martin C. Carlson

Martin C. Carlson

United States Magistrate Judge

DATED: October 10, 2025

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