Foust

UNITED STATES DISTRICT COURT

MIDDLE DISTRICT OF PENNSYLVANIA

RONDI F.,1

Plaintiff, CIVIL NO. 3:23-CV-01670

v. (LATELLA, M.J.)

FRANK BISIGNANO,

Defendant.

MEMORANDUM

This is an action brought under Section 1383(c) of the Social

Security Act and 42 U.S.C. § 405(g), seeking judicial review of the final

decision of the Commissioner of Social Security (hereinafter, “the

Commissioner”) denying Plaintiff Rondi F.’s claims for a period of

disability and disability insurance benefits (“DIB”) under Titles II and

XVI of the Social Security Act. (Doc. 1 at ¶1). The Parties consented to

1 To protect the privacy interests of plaintiffs in social security cases, we

have adopted the recommendation of the Judicial Conference of the

United States that federal courts should refer to plaintiffs in such cases

by their first name and last initial. See Tammy H. v. Frank Bisignano,

Commissioner of Social Security, No. 1:24-cv-00838, Docket No. 19 at

n.1 (M.D. Pa. Aug. 27, 2025).

have a magistrate judge conduct all proceedings in this case, including

entry of a final judgment. (Doc. 7).2 For the reasons expressed herein,

and upon detailed consideration of the arguments raised by the parties

in their respective briefs, the Commissioner’s decision will be vacated

and the matter will be remanded for rehearing.

1. BACKGROUND AND PROCEDURAL HISTORY

On July 27, 2016, Plaintiff Rondi F. (“Mr. F”) filed applications for

Title II and Title XVI benefits, respectively. (Doc. 1 at ¶5). In these

applications, Mr. F. claimed disability beginning July 25, 2015.3 (Id.).

The Social Security Administration initially denied Mr. F.’s claims on

October 21, 2016. (Id. at ¶6). Mr. F. filed a request for a hearing before

an Administrative Law Judge (“ALJ”) on November 8, 2016. (Id. at

¶7). An ALJ conducted the requested hearing on April 9, 2018. (Id.).

2 On June 24 we entered an Order providing the parties with notice of

our intent to continue to exercise the jurisdiction consented to previously

by the parties, absent any objection. (Doc. 21). No such objection was

raised.

3 Plaintiff later amended the alleged onset date to May 1, 2016. (Doc.

11-14 at 6).

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In a written opinion dated December 4, 2018, the ALJ determined

that Mr. F. was not disabled and therefore not entitled to the benefits

sought. (Id. at ¶8). Plaintiff appealed that decision to the Appeals

Council, and subsequently to the District Court. (Doc. 9-11 at 9-28).4

The District Court remanded the case. (Id. at 26-27). Based upon the

District Court remand, the Appeals Council issued an order vacating

the December 4, 2018 decision and instructing the ALJ that upon

remand, he should, inter alia, give further consideration to the treating

source opinion of Dr. Barclay Wilson. (Doc. 11-9 at 44-45).

A second hearing was held on June 23, 2021. Following that

hearing, the ALJ issued a partially favorable decision, finding that

Plaintiff has been disabled beginning January 24, 2020. (Doc. 11-15 at

2-24). Plaintiff also appealed this decision to the District Court. (Doc.

11-15 at 38). The District Court again remanded the matter. (Id.). The

Appeals Council vacated the unfavorable part of the decision and

remanded the matter. (Doc. 11-15 at 42). In its order, the Appeals

4 For clarity, we will cite to the NextGen/ECF document numbers and

pagination.

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Council noted, among other things, that the ALJ failed to adequately

evaluate the treating source opinions of Dr. Wilson and Dr. Lin and

directed the ALJ to give further consideration to those opinions on

remand. (Doc. 11-15 at 42-43).

A third hearing was held on May 25, 2023. (Doc. 11-14 at 37). On

June 20, 2023, the ALJ found:

Based on the application for a period of disability

and disability insurance benefits protectively

filed on July 27, 2016, the claimant was not

disabled under sections 216(i) and 223(d),

respectively, of the Social Security Act through

December 31, 2016, the date last insured.

Based on the application for supplemental

security income protectively filed on July 27,

2016, the claimant has been disabled under

section 1614(a)(3)(A) of the Social Security Act

beginning on January 24, 2020.

The component of the Social Security

Administration responsible for authorizing

supplemental security income will advise the

claimant regarding the non-disability

requirements for these payments, and if eligible,

the amount and the months for which payment

will be made.

(Id. at 27). Plaintiff filed a request for review by the Appeal’s Council

but the Appeals Council did not assume jurisdiction, and so, the ALJ’s

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decision became final on August 20, 2023. (Doc. 1 at ¶13).

Plaintiff initiated this action on October 10, 2023. (Doc. 1). The

Commissioner responded on January 16, 2024, filing his Answer and

providing the requisite transcripts from the disability proceedings.

(Docs. 10, 11). The parties then filed their respective briefs (Docs. 14,

18, 19), with Mr. F. alleging that three errors warrant reversal or

remand. (Doc. 14 at 5).

2. THE ALJ’S DECISION

In a decision dated June 20, 2023, the ALJ determined Mr. F.

“was not disabled prior to January 24, 2020, but became disabled on

that date and has continued to be disabled through the date of this

decision.” (Doc. 11-14 at 26). The ALJ further specified that Mr. F.

“has not been under a disability, within the meaning of the Social

Security Act at any time through December 31, 2016, the date last

insured.” (Doc. 11-14 at 26). The ALJ reached this conclusion after

proceeding through the five-step sequential analysis required by the

Social Security Act. See 20 C.F.R. § 404.1520. The ALJ determined

that Mr. F. met the insured status requirements of the Social Security

Act through December 31, 2016. (Doc. 11-14 at 8).

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At step one, an ALJ must determine whether the claimant is

engaging in substantial gainful activity (“SGA”). 20 C.F.R §

404.1520(a)(4)(i). If a claimant is engaging in SGA, the Regulations

deem them not disabled, regardless of age, education, or work

experience. 20 C.F.R. § 404.1520(b). SGA is defined as work activity—

requiring significant physical or mental activity—resulting in pay or

profit. 20 C.F.R. § 404.1572. In making this determination, the ALJ

must consider only the earnings of the claimant. 20 C.F.R. § 404.1574.

The ALJ determined Mr. F. “has not engaged in [SGA] since May 1,

2016, the alleged onset date.” (Doc. 11-14 at 8). Thus, the ALJ’s

analysis proceeded to step two.

At step two, the ALJ must determine whether the claimant has a

medically determinable impairment that is severe or a combination of

impairments that are severe. 20 C.F.R. § 404.1520(a)(4)(ii). If the ALJ

determines that a claimant does not have an “impairment or

combination of impairments which significantly limits [the claimant’s]

physical or mental ability to do basic work activities, [the ALJ] will find

that [the claimant] does not have a severe impairment and [is],

therefore, not disabled.” 20 C.F.R. § 404.1520(c). If a claimant

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establishes a severe impairment or combination of impairments, the

analysis continues to the third step.

The ALJ found Mr. F. had the following severe impairments:

degenerative disc disease of the lumbar spine; deep vein thrombosis of

the left lower extremity; right leg tibia displaced fracture; pulmonary

emboli; and obesity. (11-4 at 9).

At step three, the ALJ must determine whether the severe

impairment or combination of impairments meets or equals the medical

equivalent of an impairment listed in 20 C.F.R. Part 404, Subpt. P, App.

1 (20 C.F.R. §§ 404.1520(d); 404.1525; 404.1526). If the ALJ determines

that the claimant’s impairments meet these listings, then the claimant

is considered disabled. 20 C.F.R. § 404.1520(a)(4)(iii). The ALJ

determined that none of Mr. F.’s impairments, considered individually

or in combination, met or equaled a Listing. (Doc. 11-14 at 12).

Specifically, the ALJ considered Listings 1.00 et seq., (Musculoskeletal

Disorders); 3.00 et seq. (Respiratory Disorders); 4.00 et seq.

(Cardiovascular System), and SSR-19-2p. (Doc. 11-14 at 12).

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Between steps three and four, the ALJ determines the claimant’s

residual functional capacity (“RFC”), crafted upon consideration of the

medical evidence provided. The ALJ determined that:

since May 1, 2016, [Mr. F.] has the residual

functional capacity to perform light work as

defined in 20 CFR 404.1567(b) and 416.967(b)

with the following limitations: [Mr. F.] could

occasionally perform pushing and/or pulling

motions with the upper and lower extremities,

such as operating levers, hand controls, pedals,

and foot controls. Also [Mr. F.] could occasionally

stoop, crouch, kneel, use ramps and climb stairs;

and perform jobs that do not require balancing,

crawling, or climbing of ladders, ropes, or

scaffolding. Also, [Mr. F.] could tolerate

occasional exposure to vibrations, extreme cold,

high humidity, and atmospheric conditions that

potentially cause respiratory irritation, such as

strong fumes, noxious odors, concentrated dust,

or gases, and work environments with poor

ventilation. Further, [Mr. F.] can perform jobs

that do not require exposure to workplace

hazards, such as unprotected heights and

dangerous, moving machinery.

(Doc. 11-14 at 14).

Having assessed a claimant’s RFC, at step four the ALJ must

determine whether the claimant has the RFC to perform the

requirements of their past relevant work. 20 C.F.R. §

404.1520(a)(4)(iv). A finding that the claimant can still perform past

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relevant work requires a determination that the claimant is not

disabled. 20 C.F.R. § 404.1520(a)(4)(iv). Past relevant work is defined

as work the claimant has done within the past 15 years, that was

substantial gainful activity, and that lasted long enough for the

claimant to learn how to do it. 20 C.F.R. § 404.1560(b). If the claimant

cannot perform past relevant work or has no past relevant work, then

the analysis proceeds to the fifth step.

The ALJ determined Mr. F. is unable to perform past relevant

work. (11-14 at 24). The ALJ noted past relevant work as a motor

vehicle assembler, a packer, and a warehouse worker, but the exertional

requirements of each exceeded Mr. F.’s RFC. (Id.).

At step five of the sequential analysis process, an ALJ considers

the claimant’s age, education, and work experience to see if a claimant

can make the adjustment to other work. 20 C.F.R. § 404.1520(a)(4)(v).

These factors are not considered when evaluating a claimant’s ability to

perform past relevant work. 20 C.F.R. § 404.1560(b)(3). If a claimant

has the ability to make an adjustment to other work, they will not be

considered disabled. 20 C.F.R. § 404.1520(a)(4)(v).

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The ALJ made vocational determinations that prior to the

established disability onset date, Mr. F. was an individual closely

approaching advanced age. (Doc. 11-14 at 24). On January 24, 2020,

Mr. F.’s age category changed to an individual of advanced age. (Id.);

see also 20 C.F.R. § 404.1563. The ALJ also noted that Mr. F. has a

limited education as considered in 20 C.F.R. § 404.1564. (Doc. 11-14 at

25). The ALJ determined that upon consideration of these factors, Mr.

F.’s RFC, and the testimony of a vocational expert, “[p]rior to January

24, 2020, the date the claimant’s age category changed, there were jobs

that existed in significant numbers in the national economy that the

claimant could have performed.” (Doc. 11-14 at 25). The ALJ

specifically identified occupations of cashier, marker, and

inspector/packer. (Doc. 11-14 at 26).

As a result of this analysis, the ALJ determined that Mr. F. was

not disabled prior to January 24, 2020, but became disabled on that

date and has continued to be disabled through the date of the ALJ’s

decision. (Doc. 11-14 at 26). The ALJ further stated that Mr. F. was

not disabled at any time through December 31, 2016, the date last

insured. (Id.).

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3. STANDARD OF REVIEW

In order to receive benefits under Title II or Title XVI of the Social

Security Act, a claimant must demonstrate an “inability to engage in

any substantial gainful activity by reason of any medically

determinable physical or mental impairment which can be expected to

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

continuous period of not less than 12 months.” 42 U.S.C. §§

423(d)(1)(A), 1382c(a)(3)(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 significant numbers in the national

economy. 42 U.S.C. § 423(d)(2)(A); 20 C.F.R. § 404.1505(a).

Additionally, to be eligible to receive benefits under Title II of the Social

Security Act, a claimant must be insured for disability insurance

benefits. 42 U.S.C. § 423(a); 20 C.F.R. § 404.131.

In evaluating whether a claimant is disabled as defined in the

Social Security Act, the Commissioner follows a five-step sequential

evaluation process. 20 C.F.R. § 404.1520(a); 20 C.F.R. § 416.920(a).

Under this process, the Commissioner must determine, in sequence: (1)

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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 past relevant work, considering his or her

residual functional capacity (“RFC”); and (5) whether the claimant is

able to do any other work that exists in significant numbers in the

national economy, considering his or her RFC, age, education, and work

experience. 20 C.F.R. § 404.1520(a); 20 C.F.R. § 416.920(a). The

claimant bears the initial burden of demonstrating a medically

determinable impairment that prevents him or her from doing past

relevant work. 20 C.F.R. § 404.1512(a); 20 C.F.R. § 416.912(a). Once

the claimant has established at step four that he or she cannot do past

relevant work, the burden then shifts to the Commissioner at step five

to show that jobs exist in significant numbers in the national economy

that the claimant could perform that are consistent with his or her

RFC, age, education, and past work experience. 20 C.F.R. §

404.1512(f); 20 C.F.R. § 416.912(f).

In reviewing the Commissioner's final decision denying a

claimant's application for benefits, the Court's review is limited to

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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). 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)

(internal quotations omitted). 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

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determining if the Commissioner's decision is supported by substantial

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

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

before the Court, therefore, is not whether Mr. F. was disabled during

the period of time in question, but whether the Commissioner's finding

that Mr. F. was not disabled is supported by substantial evidence and

was reached based upon a correct application of the relevant

law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1

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

denote a lack of substantial evidence.”); 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

v. Astrue, 901 F. Supp. 2d 533, 536 (M.D. Pa. 2012) (“[T]he court has

plenary review of all legal issues decided by the Commissioner.”).

4. DISCUSSION

Mr. F. asserts that the ALJ committed three errors that warrant

reversal or remand. (Doc. 14 at 5). First, he argues that the ALJ

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rejected the opinions of his treating physicians for erroneous reasons.

(Id. at 7). Second, he claims that the ALJ failed to incorporate all of his

credibly established limitations in the hypothetical that he posed to the

vocational expert. (Id. at 17). Third, he alleges that, because he cannot

perform light work and is limited to sedentary exertion by his

impairments, a finding of disability is directed by the Medical

Vocational Guidelines. (Doc. 14 at 19). We will first consider Plaintiff’s

argument that the ALJ rejected the opinions of his treating physicians.

A. EVALUATION OF OPINIONS OF TREATING PROVIDERS

During the course of this protracted litigation, the Appeals

Council twice remanded prior ALJ decisions with specific instructions to

give further consideration to the opinion of Dr. Barclay Wilson, one of

Plaintiff’s treating physicians. (See. Docs. 11-9 at 43-45; 11-15 at 42-

43). In the second remand order, the Appeals Council also directed the

ALJ to also give further consideration to the treating source opinion of

Dr. Paul Lin. (Doc. 11-15 at 43). The Appeals Council further indicated

that, “[a]s appropriate, the Administrative Law Judge may request the

treating sources provide additional evidence and/or further clarification

of the opinions and medical source statements about what the claimant

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can still do despite the impairments (20 CFR 404.1520b and 416920b).”

(Doc. 11-15 at 43). A review of the record reveals that the opinions of

Plaintiff’s treating physician, Dr. Wilson, were not given proper

consideration.

To evaluate the ALJ’s treatment of these opinions, it is necessary

to understand the requirements for evaluating the opinions of treating

physicians. In March of 2017, the Social Security Regulations

regarding consideration of medical opinion evidence were amended. See

20 C.F.R. 404.1520c(c). However, for claims filed before March 27,

2017, ALJs are required to apply the Social Security Regulations’ pre-

2017 rules to assess the opinion of a treating physician.5 See 20 C.F.R.

§ 416.927; see also Mercado v. Kijazi, 629 F. Supp. 3d 528, 535 (M.D. Pa.

5 The March 27, 2017 amendment to the regulations eliminated the

treating physician rule. See Revisions to Rules Regarding the

Evaluation of Medical Evidence, 82 Fed. Reg. 5844 (Jan. 18, 2017). By

the terms of that amendment, however, the treating physician rule

continues to apply to applications filed before that date, such as in this

case. Foux v. Kijakazi, No. 3:22-CV-01144, 2023 WL 6201379, at *5

(M.D. Pa. Sept. 22, 2023).

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2019). Mr. F. initially filed his application for benefits on July 27, 2016.

Therefore, the pre-2017 rules, referred to as the “treating physician

rule,” apply.

Under the so called “treating physician rule,” the opinion of a

treating source is afforded controlling weight where well-supported by

objective medical evidence and not inconsistent with substantial

evidence in the record. See 20 C.F.R. § 404.1527; Morales v. Apfel, 225

F.3d 310, 316 (3d Cir. 2000). “An ALJ may reject a treating physician’s

opinion outright only on the basis of contradictory medical evidence, but

may afford a treating physician’s opinion more or less weight depending

upon the extent to which supporting explanations are provided.”

Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999) (citing Newhouse v.

Heckler, 753 F.2d 283, 236 (3d Cir. 1999)). However, in the Third

Circuit, “an ALJ may not reject a supported treating medical opinion

with only lay interpretation of medical evidence.” Burns v. Colvin, 165

F. Supp. 3d 579, 588 (M.D. Pa. 2016) (citing Frankenfield v. Bowen, 861

F.2d 405, 408 (3d Cir. 1988)). Merely citing to contradictory medical

evidence, as opposed to contradictory medical opinions, is insufficient.

Ferguson v. Schweiker, 765 F.2d 31, 36-37 (3d Cir. 1985). Under the

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treating physician rule, “the Third Circuit has only affirmed an ALJ

who rejects a treating source medical opinion when there are two or

more medical opinions that the claimant is not disabled.” Burns, 156 F.

Supp. 3d at 588-89 (citing Jones v. Sullivan, 954 F.2d 125, 129 (3d Cir.

1991); Plummer v. Apfel, 186 F.3d 422, 430 (3d Cir. 1999); Brown v.

Astrue, 649 F.3d 193, 194 (3d Cir. 2011).

Where a conflict exists between a treating source and another

medical source, an ALJ accept, reject, or weigh each opinion, so long as

“good reasons” are provided for doing so. 20 C.F.R. § 404.1527(c)(2). It

is the duty of the ALJ to explain the rationale for the weight afforded.

Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999). The purpose of this

is to allow for meaningful judicial review. Burnett v. Comm’r Soc. Sec.

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

A. Substantial Evidence Does Not Support the ALJ’s

Treatment of Dr. Wilson

Mr. F. first claims that the ALJ erroneously assigned Dr. Wilson,

one of his treating physicians, little weight. (Doc. 14 at 11). Citing to

January 6, 2016 and June 20, 2017 MRIs, Mr. F. claims that “objective

imaging evidence, as well as clinical findings of paraspinal muscle

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spasms . . . and restricted lumbar range of motion . . . support[] Dr.

[Wilson’s] limitation to sedentary exertion.” (Doc. 14 at 12). Mr. F. also

proffers the evidence of his right leg fractures and osteopenia and

asserts that those impairments, “in combination with the severe lumbar

degenerative disease, morbid obesity, pulmonary emboli and deep vein

thrombosis significantly limited his ability to walk, stand, l[i]ft and

carry.” (Id. at 13). Mr. F. further asserts that the ALJ’s reliance on Dr.

Lin’s opinion as an indication that he is capable of light work was

misplaced. (Id. at 14). Mr. F. alleges that because Dr. Lin opined that

he was permanently unable to lift more than fifteen pounds, he would

not be able to perform light work and instead would be limited to

sedentary work. (Id). Accordingly, the ALJ’s citation to Dr. Lin’s

opinion as being in conflict with Dr. Wilson’s opinion was erroneous.

(Id.).6 Plaintiff alleges that if the ALJ had properly credited Dr.

Wilson’s opinion, he would have found Plaintiff disabled. (Id. at 10).

6 Mr. F. also suggests that the ALJ improperly discounted Dr. Wilson’s

opinion because, in the ALJ’s view, Dr. Wilson did not indicate that the

limitations continued past December 31, 2016. (Doc. 14 at 13).

(footnote continued on next page)

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The Commissioner responds to this argument by asserting that

the ALJ “meticulously explained why he assigned this opinion little

weight.” (Doc. 18 at 15). The Commissioner cited to the ALJ’s opinion,

which noted that Dr. Wilson’s treatment notes and observations did not

support his opinions regarding the significant sitting, standing, and

walking limitations that would preclude all full-time work. (Id.). The

Commissioner acknowledged the positive findings assessed by Dr.

Wilson, but stated that those findings and the imaging of Mr. F.’s back

and legs supported a finding that he was restricted to light work, not a

finding that he unable to perform all work. (Id.). Additionally, the

Commissioner pointed out that the ALJ noted that Dr. Wilson’s opinion

was inconsistent with Dr. Lin’s conclusion that Plaintiff was able to

perform light work. (Id. at 16). Finally, the Commissioner cited the

ALJ’s finding that the record lacked evidentiary support for Dr.

However, as the Commissioner pointed out, the ALJ indicated –

notwithstanding his concern regarding the timeframe considered by Dr.

Wilson – that he “considered the opinion for the entire time at issue,

May 1, 2016 to January 23, 2020.” (Doc. 11-14 at 21). Thus, this

argument raised by Mr. F. is without merit.

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Wilson’s opinion that Mr. F. would miss three days of work per month.

(Id.). The Commissioner asserts that Mr. F. is requesting that the

Court reweigh the evidence, which is inappropriate. (Id. at 17). Rather,

the Commissioner maintains that substantial evidence supports the

ALJ’s conclusion with respect to Dr. Wilson’s opinions. (Id. at 18).

We turn now to Dr. Wilson’s opinions and the ALJ’s assessment of

the same. Dr. Wilson issued a Medical Opinion on February 27, 2018.

(Doc. 11-7 at 120-22). He opined that Mr. F.’s maximum ability to lift

and carry on an occasional or frequent basis was less than 10 pounds;

his maximum ability to stand and walk was less than 2 hours per 8

hour work day; his maximum ability to sit was less than 2 hours per 8

hour work day; and that he could only sit or stand for 10 minutes before

needing to change positions. (Id. at 120). He opined that he could climb

stairs occasionally, but could never twist, stoop, crouch, or climb

ladders. (Id. at 121). Further, he indicated that Mr. F.’s ability to

reach, and push and pull were limited by his impairments, but his

ability to handle (gross manipulation), finger (fine manipulation), and

feel were not affected. (Id.). Dr. Wilson also opined that Mr. F. should

avoid all exposure to hazards and avoid moderate exposure to extreme

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cold, but had no limitations with respect to extreme heat, wetness,

humidity, noise, and fumes. (Id.). Finaly, he indicated that Mr. F.

would be absent “about three times a month.” (Id. at 122).

Dr. Wilson authored a second opinion on January 9, 2019, directed

to the Pennsylvania Department of Public Welfare. (Doc. 11-13 at 144).

On this two-page form, Dr. Wilson indicated that Mr. F. is

“permanently disabled.” (Id. at 146). This form was not detailed, but

did include a section for Dr. Wilson to indicate the primary and

secondary diagnoses. (Id. at 146.) The writing is difficult to decipher.

(Id.). However, it appears as though one of the two primary diagnoses

indicated by Dr. Wilson was pulmonary thrombosis. (Id). The second

primary diagnosis is not legible. (Id). The secondary diagnoses are

sleepiness and depression. (Id.).

The ALJ gave Dr. Wilson’s February 27, 2018 opinion little

weight. (Doc. 11-14 at 21). The ALJ stated:

Relative to the entire time at issue for this

remand, the doctor’s opinion is not consistent

with the longitudinal record, nor do his own

examinations/records support the outlined

limitations. First, the limitations outlined by Dr.

Wilson, specifically the sit, stand, and walk

limitations, eliminate all full-time work, but

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when the claimant saw him, the clinical

examination do not support the same. To

illustrate, the positive physical findings in 2016

from his examinations noted a tender lumbar

spine and restricted lumbar range of motion

(Exhibit C6F/1). In 2017, Dr. Wilson noted a

tender lumbar spine and tender left knee (Exhibit

C6F). In 2018, Dr. Wilson’s examinations noted a

tender and swollen right leg; a tender lumbar

spine and muscle spasms with limited lumbar

range of motion; left lower leg edema; edema of

both legs; fingers swollen in his right hand; and a

tender and swollen right knee (Exhibit C11F).

Lastly, in 2019, his examinations noted a tender

right ankle; an abscess on his right leg; and a

tender lumbar spine (Exhibit C11F). While these

findings, and the lumbar MRIs from 2016, 2017,

and 2019; the right lower extremity MRI; the

chest x-rays and the left lower extremity deep

vein thrombosis diagnostic testing support

limiting the claimant to light work, with

push/pull, postural and environmental

limitations, they do not support the limitations

outlined by Dr. Wilson which eliminates all work

(Exhibits C2F, C4F, C6F, C7F, C11F, C16F,

C19F). Second, Dr. Wilson as the primary care

physician referred the claimant to Dr. Lin for an

orthopedic consultation. Dr. Lin, an orthopedic

surgeon, indicates the claimant is capable of light

work, which does not correlate with the

limitations outlined by Dr. Wilson (Exhibits

C6F/21, C7F). Third, there is nothing in the

record to support that the claimant would miss

three days of work a month, and the doctor does

not outline a reason for this indication. Thus, it

appears as if Dr. Wilson’s outlined restrictions

are based on the claimant’s self-reported

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limitations, rather than diagnostic and clinical

examination findings. For these reasons, his

opinion is given little weight.

(Doc. 11-14 at 17-18). Likewise, the ALJ gave Dr. Wilson’s January 9,

2019 opinion little weight. With respect to that opinion, the ALJ stated:

Dr. Wilson indicates the claimant is permanently

disabled. A statement by a medical source that a

claimant is “disabled”, is an issue reserved to the

Commissioner (20 CFR 404.1527(d) or 416.927).

Here, Dr. Wilson does not outline what the

claimant is capable of doing. Notably, this is a

check the box form with the only additional

information provided relative to the claimant’s

physical capabilities being a section where the

claimant outlines what he subjectively believes

his limitations are. Moreover, the examination

from Dr. Blakeslee, from January 3, 2019, which

is the closest to the date the doctor authored his

opinion, notes normal cervical range of motion; no

cervical tenderness; no spasm of the bilateral

paraspinal muscles; no clubbing, cyanosis, or

edema of the extremities; and a bilateral negative

straight leg raise test (Exhibit C11F/29). For

these reasons, the opinion is given little weight.

(Doc. 11-14 at 22).

It is clear from the ALJ’s opinion that the primary reason for

discounting Dr. Wilson’s opinions was the ALJ’s own lay interpretation

of the medical evidence. (See Doc. 11-14 at 17-18) (citing as his first

reason for affording little weight to Dr. Wilson’s opinion medical

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findings that the ALJ states do not support the degree of limitations

assessed by Dr. Wilson); (see also Doc. 11-14 at 22) (noting that Dr.

Wilson’s opinion that Mr. F. is permanently disabled is not supported

by certain specific medical findings from an examination conducted by a

different physician).

The only medical opinion cited by the ALJ in support of his

decision to afford little weight to Dr. Wilson’s opinion, was that of Dr.

Lin. (Doc. 11-14 at 17-18). The ALJ stated, “Dr. Lin, an orthopedic

surgeon, indicates the claimant is capable of light work, which does not

correlate with the limitations outlined by Dr. Wilson.” (Id.). That

rationale, however, is complicated by the fact that Dr. Lin’s opinions

contain an internal conflict. In his notes from a January 22, 2018 visit

with Mr. F., Dr. Lin states that he did not believe Mr. F. was capable of

doing “vigorous physical work,” but that he was “employable at the light

physical demand level.” (Doc. 11-7 at 145). However, in his notes from

that same date, Dr. Lin opined that Mr. F. could not lift more than 15

pounds. (Id. at 147). Light work, as defined by the Social Security

Regulations, requires an ability to lift and carry up to 20 pounds. See

20 C.F.R. § 404.1567; SSR83-10. Thus, an assessed limitation of an

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ability to only lift up to 15 pounds is inconsistent with employment at

the light work level. Because of this conflict, it is unclear whether Dr.

Lin actually understood Mr. F. to be capable of light work. Given this

clear conflict, the ALJ could have, as suggested by the Appeals Council,

requested further clarification from Dr. Lin. (See Doc. 11-15 at 43).

However, absent clarification, we cannot say that Dr. Lin’s January 22,

2018 opinion constitutes a “contradictory medical opinion” sufficient to

disregard the opinion of Dr. Wilson, another treating physician. See

Ferguson, 765 F.2d at 37.

Because the ALJ based his decision to afford little weight to Dr.

Wilson, a treating physician, upon his own law interpretation of medical

records and only a single medical opinion, which, we cannot say was

contradictory to Dr. Wilson’s assessed limitations given the unresolved

conflict contained therein, we are unable to say that substantial

evidence supports the ALJ’s treatment of Dr. Wilson’s opinion.

Had the ALJ given controlling weight to Dr. Wilson’s opinion and

adopted the limitations assessed by Dr. Wilson in his RFC, Mr. F. would

have been found disabled. (See Doc. 11-8 at 551) (vocational expert

testifying that an individual limited to less than ten pounds lifting and

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carrying, less than two hours total standing and walking during an

eight-hour day, and less than two hours total sitting during an eight-

hour shift would not be able to do any work); see also (Doc. 11-10 at 641)

(vocational expert testifying that there would be no circumstances

where an individual would be able to miss approximately three days of

work per month). Accordingly, we cannot conclude that this error was

harmless.

Because remand is appropriate based upon these grounds, we

decline to address Plaintiff’s other allegations of error. A remand may

produce different results as to those issues, making discussion of them

moot. See Burns, 156 F.Supp.3d at 598.

5. REMEDY

The Court has authority to affirm, modify or reverse the

Commissioner's decision “with or without remanding the case for

rehearing.” 42 U.S.C. § 405(g); Melkonyan v. Sullivan, 501 U.S. 89, 100-

01 (1991). However, the Third Circuit has advised that benefits should

only be awarded where “the administrative record of the case has been

fully developed and when substantial evidence in the record as a whole

indicates that the claimant is disabled and entitled to benefits.”

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Morales v. Apfel, 225 F.3d 310, 320 (3d Cir. 2000). See generally Fla.

Power & Light Co. v. Lorion, 470 U.S. 729, 744 (1985) (“[T]he proper

course, except in rare circumstances, is to remand to the agency for

additional investigation or explanation.”). Because the Court concludes

that the ALJ’s treatment of Dr. Wilson, a treating physician, was not

supported by substantial evidence, further development of the record is

required. Accordingly, the decision of the Commissioner will be vacated

and the case will be remanded.

6. CONCLUSION

Based on the foregoing and pursuant to sentence four of 42 U.S.C.

§ 405(g), the Commissioner’s decision will be vacated and the case will

be remanded to the Commissioner to fully develop the record, conduct

a new administrative hearing, and appropriately evaluate the evidence.

An appropriate Order is filed simultaneously with this

Memorandum.

Dated: November 17, 2025 s/ Leo A. Latella

LEO A. LATELLA

United States Magistrate Judge

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