Opinion

Bohr

Court: District Court, M.D. Pennsylvania
Filed: Jul 15, 2026
Cited by: 0 cases
Authority: More cited than 42.1%

The opinion

IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF PENNSYLVANIA

BRIAN ROBERT BOHR, : Civil No. 1:24-CV-00290

Plaintiff, :

v. : (Magistrate Judge Carlson)

FRANK BISIGNANO, :

Commissioner of Social Security :

Defendant. :

MEMORANDUM OPINION

I. Introduction

The plaintiff in this case, Brian Bohr, challenges the decision of a Social

Security Administrative Law Judge (ALJ) which found that he had not met the

exacting standards for disability under the Social Security Act. In particular, on

appeal Bohr insists that the ALJ failed to include limitations in the residual

functional capacity (RFC) to account for each of his severe and nonsevere

impairments. He also challenges the ALJ’s treatment of the medical opinion

evidence, arguing the RFC was unsupported since the ALJ only partially credited

the non-examining source opinions and no treating source opined on his limitations.

In considering these arguments, we are enjoined to apply a deferential

standard of review, a standard of review which simply asks whether there is

“substantial evidence” supporting the ALJ’s determination. With respect to this legal

guidepost, as the Supreme Court has explained:

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 v. Berryhill, 139 S. Ct. 1148, 1154 (2019).

In the instant case, after an independent review of the record, and mindful of

the fact that substantial evidence “means only—‘such relevant evidence as a

reasonable mind might accept as adequate to support a conclusion,’” id., we find that

substantial evidence supported the ALJ’s findings. Therefore, for the reasons set

forth below, we will affirm the decision of the Commissioner.

II. Statement of Facts and of the Case

A. Bohr’s Medical History

On November 30, 2021, Brian Bohr applied for a period of disability and

disability insurance benefits under the Social Security Act, alleging disability

beginning June 13, 2019.1 (Tr. 14). According to Bohr, he was totally disabled due

to a series of medical conditions, including PTSD, anxiety, ADD, chronic back pain,

spinal stenosis, COPD, high blood pressure, irregular heartbeat, depression, and

neuropathy. (Tr. 108). Bohr was born was born on August 10, 1977, and was 41

years old, which is defined as a younger individual by the Commissioner’s

regulations, at the time of this alleged onset of his disability. (Id.) He had a high

school education and had previously worked as an EMT and paramedic. (Tr. 44-45).

Bohr’s mental and physical health problems are interrelated and, in many

ways, also stem from his previous work as an EMT and paramedic. He testified that

he was laid off from his previous work due to his health issues, stating he “kept

getting sick,” later clarifying that he was missing work due to chronic pain from

issues with his cervical, thoracic, and lumbar spine. (Tr. 40, 62-63). At the hearing,

1 Bohr previously filed an application for a period of disability and disability

insurance benefits that was denied when an ALJ issued an unfavorable decision on

August 4, 2020. (Tr. 79-99). Nonetheless, the ALJ considered his application to be

reopened, and the alleged onset date remained the date in his original application,

June 13, 2019. (Tr. 14).

he testified that he is unable to be on his feet and that lifting of any kind aggravates

his back and causes excruciating pain. (Tr. 49). He also testified that he can only

walk for five minutes and sit for a half hour and that he can only lift ten pounds. (Tr.

49, 51). As to Bohr’s mental impairments, he testified that he experiences

nightmares and flashbacks of very horrific calls he responded to in his past work and

also that his chronic pain has led to an exacerbation of his mental health, culminating

in a two-week psychiatric inpatient admission in Fall 2022. (Tr. 40).

The medical record reflects that the plaintiff’s impairments caused limitations

in his ability to function physically and mentally. Nonetheless, the clinical evidence

is relatively meager and shows periods of exacerbation of the plaintiff’s symptoms,

but also physical examination findings of normal strength, reflexes, sensation, and

gait. As to the plaintiff’s physical impairments including back pain, spinal stenosis,

neuropathy, and COPD, the ALJ aptly summarized the clinical record:2

The claimant’s treatment records document a diagnosis of neuropathy

in March of 2019, based upon an EMG testing, with reported initial

good control with use of Gabapentin that became less beneficial and the

2 It appears the plaintiff does not challenge the ALJ’s summary and consideration of

the longitudinal medical evidence, in fact, seemingly arguing that the ALJ

adequately touched on the symptomology of each of the plaintiff’s impairments but

did not incorporate all of these symptoms into the RFC. Moreover, the plaintiff has

not provided his own summary of the medical evidence. Thus, while we have

conducted our own independent review of the clinical record, our summary cites

heavily to the ALJ’s decision to the extent that these ALJ findings were supported

by substantial evidence..

claimant has indicated a burning sensation of his feet (Exhibits B5F/69,

143; B8F/16). However, examinations show normal sensation (Exhibits

B2F/1, 14; B4F/3; B5F/34, 70; B10F/8, 18).

A March 13, 2021 MRI of the claimant’s lumbar spine showed

multilevel degenerative disc disease with stable, small left subarticular

recess and left neural foramen disc protrusions at L4-5 and L5-S1

(Exhibit B5F/339). The claimant engaged in treatment, including

injection therapy but received little relief and on May 26, 2021,

underwent a consultation with an orthopedic surgeon who

recommended a lumbar laminectomy (Exhibits B3F/7-12; B5F). On

August 19, 2021, the claimant underwent lumbar surgery (Exhibit

B3F/6). During the two (2) week follow up appointment, the claimant

was documented as doing well and reported improvement of the lower

extremity symptomology and lower back pain (B3/14). Upon

examination, there were no motor or sensory deficits, strength and

reflexes were normal, straight leg raise testing was negative, and a

normal, non-antalgic gait (Exhibit B3F/14). The claimant reported

improvement during a subsequent appointment (Exhibit B3F/17). On

October 22, 2021, the claimant’s physical examination results

demonstrated full extremity strength, normal reflexes and sensation,

and an intact gait (Exhibit B4F/3). However, on November 30, 2021,

the claimant was treated at the ER for significant lumbar spine pain for

three (3) days (Exhibit B5F/27, 31). He continues to utilize medical

marijuana for pain (Exhibit B8F/15). The claimant’s most recent

examination in September of 2022 showed positive tenderness to

palpation of the spine and positive facet loading maneuvers, but full

strength bilaterally, negative straight leg raise testing, and a stable gait

(Exhibit B10F/4, 8). Further, there is no prescription for an assistive

device or opinion of record that the same is medically necessary; the

only indication of use of a cane was following the claimant’s surgery

for a brief period during healing (Exhibit B5F/36).

The claimant also carries a diagnosis of COPD and is prescribed

inhalant medication; however, his respiratory examinations are

generally unremarkable (Exhibits B3F/3, 4; B5F/13, 14).

(Tr. 22-23). Thus, with regard to the plaintiff’s back impairments, the clinical record

indicates that the plaintiff experienced some relief following his 2021 lumbar

laminectomy. In fact, at the ER visit noted by the ALJ, the plaintiff stated that he

experienced relief from his lumbar pain from the laminectomy but that he continued

to experience pain in the thoracic area. (Tr. 498). Further clinical notes also indicate

that he experienced intermittent episodes of neck pain radiating down his arms as far

back as 2019. (Tr. 539, 582, 613, 636, 657). Nonetheless, as noted at the hearing,

these episodes were often associated with increased physical activity on the part of

the plaintiff. For example, in April 2021 he reported to the emergency department

after his back pain was exacerbated “when he was hanging off of his main roof trying

to fix a shingle.” (Tr. 1019). Also, in December 2022, he reported he had hurt his

left shoulder placing drywall while remodeling his bathroom. (Tr. 1049, 1232).

The plaintiff also highlights his chronic fatigue, which is supported by notes

showing diagnoses of chronic fatigue and that he stated he always felt tired and was

falling asleep at inappropriate times. (Tr. 511, 514, 519, 520, 524, 536, 564). But the

etiology of the fatigue is not borne out in the record nor are the limiting effects of

this symptom clear. For example, in October 2021, he had a neurological

consultation for excessive sleepiness and significant daytime hypersomnolence

where it was noted Bohr had a need for excessive naps and sleep attacks and

symptoms consistent with cataplexy. (Tr. 467). It was noted that his CPAP machine

had been recalled and that tests were needed to ensure appropriate pressure on the

CPAP machine, but testing was also recommended to rule out narcolepsy. (Tr. 469).

Nonetheless, it does not appear that any additional testing was performed, our

independent review of the record revealed no additional clinical indication of

narcolepsy, cataplexy, or excessive sleepiness later in the record, and examination

notes frequently stated he was negative for fatigue. (Tr. 403, 420, 499, 522, 526,

533, 540, 547, 555, 568, 574, 577, 583, 590, 597, 601, 608, 614, 620, 625, 628, 637,

640, 651, 658, 668, 676, 689, 695, 709, 950, 1020, 1051, 1060, 1079, 1101).

As to the Bohr’s mental impairments of PTSD, depression, and anxiety, the

ALJ explained:

With regard to the claimant’s mental health conditions, he has been

treated on an outpatient basis for major depressive disorder, a

generalized anxiety disorder, ADHD, and PTSD with medication

management through his primary care physician and some outpatient

counseling (Exhibits B5F/62; B6F; B7F; B14F). During his treatment,

the claimant reported difficulty managing stress, nightmares and

flashbacks, anxiousness, and depression; with the exception of mood

instability and only fair insight and judgment, mental status

examinations are generally unremarkable, showing the claimant is alert

and oriented, thoughts are organized, and memory and cognition are

intact (Exhibits B6F; B7F). Additionally, at times, the claimant has

reported that the prescribed medication is beneficial, including ceasing

of the claimant’s nightmares (Exhibits B6F/6; B7F/4, 10).

On October 26, 2022, the claimant was voluntarily hospitalized for

suicidal ideation without a plan, reporting ongoing pain and depression

relating to his physical conditions and inability to work, losing his pet

of fourteen (14) years, and feeling like a burden to his family (Exhibit

B13F/6, 17). The claimant was noted to have ceased prescribed

medication(s) and was discharged on November 9, 2022 with a new

medication regimen (Exhibit B12F/1-2).

The claimant’s most recent outpatient counseling records show he is

engaging in treatment to learn effective ways to cope with situational

stressors and the guilt associated with not being a financial provider for

his family (Exhibit B14F).

(Tr. 23).

Thus, the clinical record does support some degree of limitation to account for

the plaintiff’s mental impairments but also notes relatively stable mental status

examination findings and improvement with therapy and treatment.

B. The Medical Opinion Evidence

Given this equivocal clinical history, the plaintiff’s records were assessed by

two State agency medical consultants and two psychological consultants. No treating

or examining source opined on the plaintiff’s ability to perform work-related

activity. As to the plaintiff’s physical abilities, on July 13, 2022, State agency

medical consultant Dr. John Gerome Bertolino opined that the plaintiff was capable

of performing light work. (Tr. 116). Specifically, Dr. Bertolino concluded Bohr

could sit, stand, and walk for six hours total in an eight-hour workday, could

occasionally lift and/or carry twenty pounds and could frequently lift and/or carry

ten pounds, but could only frequently climb ramps/stairs, ladders/ropes/scaffolds,

stoop, kneel, crouch, or crawl. (Tr. 112-13). According to Dr. Bertolino, Bohr would

also have certain environmental limitations, including avoiding concentrated

exposure to extreme cold, extreme heat, humidity, noise, vibration, and hazards due

to his lower respiratory disease. (Id.)

On reconsideration, on November 2, 2022, Dr. Ruth Myers Arnold also

concluded the plaintiff could perform a reduced range of light work, finding that he

could only stand/walk for a total of four hours but could sit for a total of six hours in

an eight-hour workday, could occasionally lift and/or carry twenty pounds and

frequently lift and/or carry ten pounds, and could only occasionally climb

ramps/stairs, never climb ladders/ropes/scaffolds but could frequently perform other

postural activities such as balance, stoop, kneel, crouch, and crawl. (Tr. 122-23). Dr.

Arnold referenced the plaintiff’s chronic pain, laminectomy, cervical neck pain,

neuropathic pain in the setting of class I obesity, and history of vertigo but noted he

required no ambulatory assistive device, demonstrated normal gait, drove a motor

vehicle, and that his sensation was intact. (Tr. 123). She further opined that the

plaintiff should avoid concentrated exposure to extreme cold, extreme heat,

humidity, vibration, and fumes, odors, dusts, gasses, and poor ventilation and should

avoid all exposure to hazards, noting his COPD and asthma as well as his orthopedic

and neuropathic conditions. (Tr. 123-24)

With regard to the plaintiff’s ability to mentally function in the workplace, on

June 16, 2022, State agency psychological consultant Dr. Edward Jonas opined on

the plaintiff’s mental RFC, concluding that Bohr had no limitations in his ability to

understand, remember, or apply information, mild limitations in his ability to interact

with others, concentrate, persist, or maintain pace, and moderate limitations in his

ability to adapt or manage oneself. (Tr. 111). Specifically, Dr. Jonas opined that Bohr

would be moderately limited in his ability to respond appropriately to changes in the

work setting, and had somewhat limited stress tolerance, but stated that he could

make simple decisions, appeared able to accept instruction and carry out directives,

and that the functional limitations resulting from his mental health impairments did

not preclude him from meeting the basic mental demands of simple routine tasks on

a sustained basis. (Tr. 115). The opinion of Dr. Roger Fretz on reconsideration

reflected the same limitations as those opined by Dr. Jonas. (Tr. 121, 125). Dr. Fretz

further explained that the updated treatment records showed Bohr continued to be

cooperative and responsive to ongoing mental health treatment with no evidence of

a thought disorder or severe dysfunction in any domain. (Tr. 126).

It was against this medical background that Bohr’s case came to be

considered by the ALJ.

C. The ALJ Hearing and Decision.

A hearing was conducted in this case on March 7, 2023, at which Bohr and a

vocational expert testified. (Tr. 34-78). In his testimony, Bohr highlighted ongoing

issues with his cervical, thoracic, and lumbar spine with the pain exacerbating his

mental health symptoms. (Tr. 40). And, while plaintiff’s counsel noted that his

overexertion can lead to pain, he also indicated that Bohr retained an ability to at

least perform some physical activity and activities of daily living. For example, he

noted instances where the plaintiff shoveled snow, fixed flashing, and helped his

father repair drywall, although he stated he ended up hospitalized after each instance.

(Tr. 41). Nonetheless, the plaintiff also testified he can do laundry, drive, do minimal

cooking, and occasionally grocery shop. (Tr. 52).

The ALJ also examined a vocational expert at the hearing who testified that

jobs existed in the national economy that the plaintiff could perform at both the light

and sedentary exertional levels with the same postural, environmental, and

psychological limitations crafted by the ALJ to account for the plaintiff’s

impairments. (Tr. 69-71). Moreover, the vocational expert (VE) testified that, if the

plaintiff needed to alternate between sitting and standing every thirty minutes due to

low back pain and both lower extremity numbness, the jobs would remain but be

reduced by fifty percent. (Tr. 72). As for off-task and absenteeism, the VE testified

to a ten percent off-task tolerance in unskilled work, and a tolerance of a person

being absent no more than two days per month. (Tr. 73-74). Further, needing an

additional unscheduled 30-minute break every day and having to elevate legs while

sitting would be work preclusive. (Tr. 75).

Following this hearing, on April 3, 2023, the ALJ issued a decision in Bohr’s

case. (Tr. 11-33). In that decision, the ALJ first concluded that Bohr had not engaged

in substantial gainful activity since June 13, 2019, the alleged onset date. (Tr. 16).

At Step 2 of the sequential analysis that governs Social Security cases, the ALJ found

that Bohr had the following severe impairments: lumbar spinal stenosis, chronic

obstructive pulmonary disease (COPD), neuropathy, major depressive disorder,

generalized anxiety disorder, Attention Deficit Hyperactivity Disorder (ADHD), and

Post-Traumatic Stress Disorder (PTSD). (Tr. 17). The ALJ also considered the

plaintiff’s obstructive sleep apnea/hypersomnia and cervical and thoracic

degenerative disc disease but considered these impairments to be nonsevere.

Specifically, the ALJ noted that the plaintiff’s OSA/hypersomnia were controlled

with medication management and use of medical technology/monitoring and that

treatment provided a significant amount of pain relief/improvement to his cervical

and thoracic degenerative disc disease. (Tr. 17). The ALJ also noted that, “any

effects from the claimant’s cervical and thoracic spine-related conditions and obesity

are accounted for in the less than full range of light exertional residual functional

capacity below.” (Tr. 17-18).

At Step 3, the ALJ determined that Bohr did not have an impairment or

combination of impairments that met or medically equaled the severity of one of the

disability listing impairments. (Tr. 18-21). The ALJ considered the plaintiff’s mental

impairments at this step, and concluded he had a mild limitation in understanding,

remembering, or applying information, no limitation in interacting with others, and

moderate limitations in concentrating, persisting, or maintaining pace and adapting

or managing oneself. (Id.)

Between Steps 3 and 4, the ALJ then fashioned a highly restrictive residual

functional capacity (“RFC”) for the plaintiff which considered all of his impairments

as reflected in the medical record, and found that:

After careful consideration of the entire record, the undersigned finds

that the claimant has the residual functional capacity to perform light

work as defined in 20 CFR 404.1567(b) except he can occasionally

climb ramps and stairs. He should avoid climbing ladders or scaffolds

or be exposed to unprotected heights or industrial machinery. He can

tolerate occasional exposure to extremes in temperature, humidity,

vibration, and environmental irritants, such as dusts, odors, fumes, and

gases. The claimant is able to understand, retain, and carry out detailed,

but not complex instructions and use judgment to make simple, work-

related decisions in an environment involving only occasional

workplace change.

(Tr. 21).

In reaching this conclusion the ALJ thoroughly discussed Bohr’s spinal

disorders, pain, neuropathy, COPD, and mental health conditions and, after

summarizing the medical evidence, explained how each of these impairments was

accounted for in the RFC. Specifically, the ALJ stated:

In consideration of the effects of the claimant’s physical conditions, the

claimant was limited to light work and to account for any restrictions

from his neuropathy, ensure his safety, and limit exacerbation of

symptoms, exposure to climbing of ladders and scaffolds and

workplace hazards was precluded and exposure to extremes in

temperature, humidity and vibration was limited. Further, as a result of

the effects of his respiratory condition, the claimant was limited to no

more than occasional exposure to pulmonary irritants. As detailed

above, the claimant's longitudinal examinations showed no motor, gait,

sensory, or reflex deficits in the spine or lower extremities that would

support a conclusion that the claimant was not capable of safely lifting,

carrying, pushing, or pulling at the light level of exertion.

As a result of ongoing mental health symptoms, to account for the

claimant’s deficits in concentration, insight, and judgment and

difficulty managing stress, he was found capable of understanding,

retaining, and carrying out detailed, but not complex instructions and

using judgment to make simple, work-related decisions in an

environment involving only occasional work-place change. In

assessing health mental limitations, the undersigned relied upon

evidence including the claimant's symptom reports, mental status

examination findings, and history of treatment outlined in the

discussion of the record above. Specifically, in finding the limitation to

performing detailed but not complex work involving simple decisions

and little change, the undersigned considered the claimant's limitations

in maintaining concentration, persistence, and pace, and adapting and

managing himself as outlined in Finding of Fact four (4) above.

(Tr. 24).

As to any other symptoms or limiting effects alleged by the plaintiff, the ALJ

concluded they simply were not supported by the clinical record, stating:

The facts of record do not dispute the claimant has physical and mental

conditions that cause difficulty. What the evidence of record

demonstrates is that the claimant’s symptoms may not have existed at

the level of severity asserted by the claimant and/or may have had other

mitigating factors against their negative impact on the claimant’s ability

to engage in work activity. The undersigned finds that the record lacks

sufficient clinical evidence to support limitations beyond the stated

residual functional capacity. The claimant does have medical

impairments; however, the residual functional capacity contemplates

and includes limitations to address these complaints to the extent these

limitations are supported by the evidence of record.

(Id.)

Further, the ALJ determined that Bohr’s reported activities of daily living did

not support the extreme level of impairment which he described, noting:

It is also important to note that the claimant reported independence in

self-care and activities of daily living, such as helping to care for pets,

preparing simple meals, putting away laundry, running the vacuum,

driving a vehicle, managing finances, shopping for groceries, and

spending time with family (Exhibit B6E; Hearing Testimony). The

claimant’s treatment records show that he reported to the ER in April

of 2021 after exacerbating his spine-related condition while working on

a roof (Exhibit B10F/15, 18). Additionally, at the time of the hearing,

the claimant reported his most recent injury occurred in November of

2022, when assisting his father to install drywall (Hearing Testimony).

(Tr. 23).

As to the medical opinion evidence, the ALJ credited parts of each of the State

agency medical and psychological consultant opinions but ultimately crafted an RFC

which reflected different parts of each opinion. For example, as to the opinions of

the State agency psychological consultants, the ALJ found them to be of limited

persuasive value, rejecting the experts’ opinions that he could perform only simple,

routine tasks as inconsistent with the paucity of memory or cognitive deficits noted

in the record, but concluded that the evidence was consistent with the determination

that the claimant as capable of detailed but not complex tasks involving simple

decisions and only occasional change. (Tr. 25). Thus, the ALJ adopted a more

comprehensive mental RFC than what was recommended by these psychological

consultants, noting the deterioration in the plaintiff’s mental condition without

medication, causing voluntary hospitalization, as well as his continued pain and

fatigue which limits his ability to concentrate and engage in more complex tasks.

(Id.) Nonetheless, the ALJ cited to the plaintiff’s ability to perform self-care and

activities of daily living, indicating no further limitations were necessary. (Id.)

The ALJ also partially credited the assessments of the State agency medical

consultants, finding the opinion of Dr. Bertolino that Bohr should be limited to light

exertional work with limitations in climbing, exposure to hazards, and pulmonary

irritants was partially supported by the initial level evidence showing a history of

neuropathy, lumbar-spine related issues, and COPD, but that the reconsideration and

hearing level evidence showing full strength bilaterally, stable gait, and negative

straight leg raise testing and his ability to remain independent in self-care, perform

activities of daily living and engage in manual labor was not consistent with the other

postural limitations opined by Dr. Bertolino. (Tr. 25). The ALJ then concluded the

opinion of Dr. Arnold held little persuasive value, since the medical evidence of

record did not support a determination that Bohr was significantly exertionally

limited considering the improvement in his lumbar spine related condition following

surgery, his ability to engage in physical activity such as roofing and installing

sheetrock, and his most recent physical examination showed full strength bilaterally,

negative straight leg raise testing, and a stable gait. (Tr. 25-26).

Having made these findings, the ALJ concluded that Bohr could not perform

his past relevant work but that there were other jobs that existed in significant

numbers in the national economy that he could perform. (Tr. 26-28). Accordingly,

the ALJ concluded that Bohr had not met the stringent standard of disability set by

law and denied this claim. (Id.)

This appeal followed. (Doc. 1). On appeal, Bohr argues the ALJ erred in

failing to consider all the limitations from both his severe and nonsevere

impairments and also erred in his evaluation of the medical opinion evidence in

formulating an RFC without fully crediting a medical opinion. These issues are fully

briefed by the parties and are, therefore, ripe for resolution.

Upon consideration, we find that substantial evidence supported the ALJ’s

findings that these impairments were not fully disabling. Accordingly, we will affirm

the decision of the Commissioner.

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

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 recently 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 v. Berryhill, 139 S. Ct. 1148, 1154 (2019).

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

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 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, 399 F.3d at 552). 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

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

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

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

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

(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.

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

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

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

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

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. The Commissioner’s Decision Will Be Affirmed.

In the instant case, the plaintiff alleges the RFC was not supported by

substantial evidence because it failed to account for all the limitations established

from his severe and nonsevere impairments and was not based upon a medical

opinion. In considering Bohr’s arguments, we are mindful that we are not free to

substitute our independent assessment of the evidence for the ALJ’s determinations.

Rather, we must simply ascertain whether the ALJ’s decision is supported by

substantial evidence, a quantum of proof which is less than a preponderance of the

evidence but more than a mere scintilla, Richardson, 402 U.S. at 401, and “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, 487

U.S. at 565. Judged against these deferential standards of review, we find that

substantial evidence supported the RFC assessment in this case. Therefore, we will

affirm this decision.

The plaintiff first argues that the RFC fashioned by the ALJ did not account

for limitations from each of his severe and nonsevere impairments. At the outset, we

note that it is longstanding precedent that in crafting the RFC, the ALJ is not required

to include every impairment alleged by the claimant. Rutherford, 399 F.3d at 554.

The ALJ is only required to include all of a claimant's “credibly established”

limitations. Id. (quoting Plummer, 186 F.3d at 431). In our view, ALJ’s decision

accounted for each of the credibly established symptoms and limitations the plaintiff

highlights.

As to Bohr’s mental impairments, the plaintiff argues the ALJ should have

included off-task time and absenteeism in the RFC to account for the plaintiff’s

hospitalization for suicidal ideation. But the ALJ addressed this impairment and

adequately explained why no further limitations were required in the RFC. Indeed,

under the Third Circuit’s holding in Hess, 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.” 931 F.3d 198, 214 (3d Cir.

2019). Here, the ALJ adequately considered evidence of the plaintiff’s mental

impairments, including his inpatient hospitalization for suicidal thoughts, but

concluded that his symptoms reports, mental status examination findings, and

activities of daily living did not support further limitations from his mental

impairments.

As the ALJ explained, the claimant was voluntarily hospitalized for suicidal

ideation without a plan in October 2022 due to ongoing pain and losing his pet of

fourteen years but was also noted to have ceased prescribed medications and was

discharged with a new medication regimen. (Tr. 23). Outpatient counseling records

since that time show he was making progress and responding well to treatment. (Tr.

1226-49). Moreover, the ALJ concluded Bohr’s activities of daily living were

inconsistent with the assertion that his mental health conditions were totally

disabling, as he was able to help care for pets, prepare simple meals, put away

laundry, manage finances, and spend time with family. (Tr. 23). More

fundamentally, there is simply no evidence in the record that the plaintiff’s mental

impairments, while severe, would cause significant off-task time or absenteeism.

Instead, the ALJ adequately accounted for the plaintiff’s alleged mental health

symptoms in the RFC as follows: