# Bohr

> District Court, M.D. Pennsylvania · July 15, 2026

URL: https://www.frixlaw.com/law-library/cases/11409152

## Case

- **Full name:** Brian Robert Bohr v. Frank Bisignano, Commissioner of Social Security
- **Court:** District Court, M.D. Pennsylvania
- **Decided:** July 15, 2026
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

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## Opinion text

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

1
“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.

2
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).

3
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..

4
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).

5
(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

6
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

7
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,

8
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)

9
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.

10
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

11
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

12
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).

13
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).

14
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

15
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

16
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.

17
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

18
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

19
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.

20
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

21
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.

22
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

23
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)

24
(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

25
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

26
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

27
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

28
“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

29
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

30
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

31
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

32
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:
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). In our view, this assessment by the ALJ complies with the requirements
under Hess and is supported by substantial evidence.
As to the plaintiff’s physical impairments, the plaintiff argues the ALJ failed
to include limitations for a variety of symptoms and impairments he argues were
supported by the record including shoulder and thoracic pain, peripheral neuropathy,

33
and fatigue.
At the outset, the ALJ considered the evidence of Bohr’s cervical and thoracic

spine degenerative disc disease, but concluded that this impairment was nonsevere
since, “treatment has provided a significant amount of pain relief/improvement.”
(Tr. 17). Moreover, the RFC fashioned in this case fully accounted for these

limitations. As the ALJ explained, “any effects from the claimant’s cervical and
thoracic spine-related conditions . . . are accounted for in the less than full range of
light exertional residual functional capacity below.” (Id.) To the extent the plaintiff
argues more limitations were required to account for this impairment, in the form of

upper extremity limitations, neither the treatment records nor any medical opinion
source supports the view that reaching limitations were necessary. Instead, it appears
the plaintiff continued to perform activities which required the use of his upper

extremities such as hanging off of his [ ] roof trying to fix a shingle,” (tr. 1019), and
remodeling his bathroom. (Tr. 1232).
The ALJ also discussed the plaintiff’s fatigue and hypersomnia but also
concluded it was nonsevere since it was controlled by medical

technology/monitoring. Substantial evidence supports this conclusion since, while
the record notes chronic fatigue and excessive sleepiness, after an October 2021
consultation where it was noted his CPAP had been recalled and needed to be

34
evaluated to ensure appropriate pressure, no further notes of hypersomnia, cataplexy,
or narcolepsy were noted and there is no evidence further testing was conducted.

(Tr. 469). In fact, 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 plaintiff’s neuropathy, the ALJ also
acknowledged this diagnosis and treatment, (tr. 22), and explained, “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.”

(Tr. 24). Given the thorough and comprehensive summary of the plaintiff’s
impairments and comprehensive RFC assessment which addressed the limitations
resulting therefrom, under the deferential standard of review which governs Social

Security appeals there was no error here.
The plaintiff also challenges the ALJ’s evaluation of the medical opinion
evidence, arguing that there was little basis or support for the limitations set forth in
the RFC where the ALJ assigned only partial weight to the state agency opinion and

no treating or consultative source opined on his limitations. But this argument clearly
fails under the new paradigm which governs the evaluation of medical opinion
evidence. Indeed, as previously explained, “[t]he ALJ – not treating or examining

35
physicians or State agency consultants – must make the ultimate disability and RFC
determinations.” Chandler, 667 F.3d at 361. Therefore, “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. Moreover:
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).
Thus, there was no error here where the ALJ partially credited all the medical
opinions and fashioned an RFC based on different parts of each opinion. On the
contrary, this is precisely what ALJs are empowered to do in evaluating multiple
medical source statements in the context of the plaintiff’s longitudinal medical
records, the plaintiff’s own statements about his disability, and other evidence in the
record. Indeed, in this setting, where there is no apparent treating source statement
supporting a disability claim, an ALJ may rely upon other evidence, such as clinical
evidence, non-examining and non-treating source opinions, and testimony regarding

36
the claimant's activities of daily living, to fashion an RFC.3 When an ALJ is put to
crafting an RFC in the absence of treating source statements, courts often adopt a

pragmatic view, which sustains 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); (“There is no legal requirement that a physician have made the

particular findings that an ALJ adopts in the course of determining an RFC.
Surveying the medical evidence to craft an RFC is part of the ALJ's duties.”);

3 The plaintiff also makes a passing, relatively undeveloped argument that the ALJ
erred in failing to order a consultative examination in this case. But:

The decision to order a consultative examination is within the sound
discretion of the ALJ unless the claimant establishes that such an
examination is necessary to enable the ALJ to make the disability
decision.” Miller v. Berryhill, No. 17-cv-1452, 2019 WL 3776662, at
*18 (M.D. Pa. Aug. 12, 2019) (citing Thompson v. Halter, 45 F. App'x.
146, 149 (3d Cir. 2002)). “[W]here the medical evidence in the record
is inconclusive, a consultative examination is often required for proper
resolution of a disability claim.” Brown v. Saul, No. 18-cv-01619, 2020
WL 6731732, at *10 (M.D. Pa. Oct. 23, 2020) (report and
recommendation adopted by 2020 WL 6729164 (M.D. Pa. Nov. 16,
2020)) (citing Hawkins v. Chater, 113 F.3d 1162, 1166 (10th Cir.
1997)).

Chalfant v. Comm’r of Soc. Sec., No. 4:20-CV-1719, 2022 WL 838118, at *5 (M.D.
Pa. Mar. 21, 2022). Here, while the plaintiff argues that the evidence of record should
have been viewed in a different light, he has not made a showing that the record was
somehow inconclusive or unable to be resolved without further examining source
opinions. Therefore, this argument fails.

37
Cummings v. Colvin, 129 F. Supp. 3d 209, 214–15 (W.D. Pa. 2015). Our review of
the ALJ's assessment of the plaintiff's RFC then is deferential, and that RFC

assessment should not be set aside if it is supported by substantial evidence. Burns
v. Barnhart, 312 F.3d 113, 129 (3d Cir. 2002); see also 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).
In this case, in the absence of any treating source opinions supporting Bohr’s
claim, the ALJ carefully assessed his treatment history. (Tr. 21-24). That treatment

history addressed all of Bohr’s impairments, both severe and non-severe, but
contained multiple entries which undermined his claim of disability, including
examinations showing no motor, gait, sensory, or reflex deficits, improvement with

treatment, and activities of daily living which were inconsistent with his alleged
debilitation limitations, including his ability to work on a roof and install drywall.
(Tr. 23-24). These medical records, therefore, provided sufficient evidentiary
support for the ALJ's RFC determination, which limited Bohr to a reduced range of

light work. This light work RFC with certain mental and environmental limitations
was also supported, in part, by the opinions of the non-treating, non-examining State
agency sources, which this court, and the court of appeals, have held can be credited

38
even in the absence of any treating source medical opinions. See Blatt v. Colvin, No.
116CV00128CCCGBC, 2017 WL 2791059, at *17 (M.D. Pa. Mar. 17, 2017), report

and recommendation adopted sub nom. Blatt v. Berryhill, No. 1:16-CV-128, 2017
WL 2778554 (M.D. Pa. June 27, 2017) (citing Chandler v. Comm’r of Soc. Sec.,
667 F.3d 356, 361 (3d Cir. 2011)).

Furthermore, even assuming the RFC fashioned by the ALJ was less
restrictive than the medical records compel, any error alleged by the plaintiff would
be harmless in the face of the vocational expert testimony that identified jobs 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, even if the
plaintiff needed to alternate between sitting and standing due to low back pain and

both lower extremity numbness. (Tr. 69-72). Thus, even if the ALJ had concluded
the plaintiff’s severe and nonsevere impairments had limited him to sedentary work,
a level which fell below the level any medical expert opined, the ALJ still would
have found him capable of performing jobs which existed in the national economy.

Finally, an overarching theme in the plaintiff’s challenge to this unfavorable
decision is that the ALJ’s credibility determination of the plaintiff’s alleged
symptoms and limitations was flawed. On this score, the plaintiff argues that the

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ALJ failed to address why the plaintiff would quit work “for no reason” based upon
his work history which showed a commitment to his field. (Doc. 10, at 13). But we

note that nothing in the ALJ’s decision implies the plaintiff left work for no reason.
In fact, the ALJ credited the plaintiff’s symptoms and limitations to the extent they
were supported by the clinical record and concluded the plaintiff could not return to

his past heavy exertion work, but that he could perform a limited range of light work
despite these limitations.4 Moreover, it is clear that:
Although a claimant's work history is one of many factors the ALJ
considers in assessing an individual's subjective complaints, 20 C.F.R.
§ 404.1529(c)(3), the ALJ is not required to equate a long work history
with credibility. See Christl v. Astrue, 2008 WL 4425817, *12
(W.D.Pa. Sept.30, 2008). Thus, a claimant's work history alone is not
dispositive of the question of ... credibility.

Patton v. Astrue, No. CIV.A.08-205J, 2009 WL 2876715, at *3 (W.D. Pa. Sept. 8,
2009). Rather “[w]ork history ‘is only one of many factors an ALJ may consider in
assessing a claimant's subjective complaints.’” Sanborn v. Colvin, No. CIV.A. 13-
224, 2014 WL 3900878, at *16 (E.D. Pa. Aug. 11, 2014), aff'd sub nom. Sanborn v.
Comm'r of Soc. Sec., 613 F. App'x 171 (3d Cir. 2015). Thus, in the instant case,
given the substantial body of clinical, opinion, and anecdotal evidence supporting

4 Further, the plaintiff’s testimony at the hearing about why he left work was vague
and confusing. When asked why he was laid off he stated only that 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).

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the ALJ's decision, the ALJ was not obliged to reach a contrary conclusion based
solely upon Bohr’s work history.5

In sum, we are sympathetic to the plaintiff whose difficult and essential job
left him with both physical and mental aftereffects which have limited his ability to
perform his duties. But, at bottom, it appears that the plaintiff is requesting that this

court re-weigh the evidence. This we may not do. See Chandler, 667 F.3d at 359
(citing Richardson v. Perales, 402 U.S. 389, 401 (1971) (“Courts are not permitted
to re-weigh the evidence or impose their own factual determinations”); see also
Gonzalez v. Astrue, 537 F.Supp.2d 644, 657 (D. Del. 2008) (“In determining

whether substantial evidence supports the Commissioner’s findings, the Court may
not undertake a de novo review of the Commissioner’s decision and may not re-
weigh the evidence of the record”) (internal citations omitted)). Rather, our task is

5 Moreover, cases which have remanded on the issue of work history have typically
done so in the face of a long and consistent work history. See e.g. Corley v. Barnhart,
102 F.Appx. 752, 755 (3d Cir. 2004); Dobrowolsky v. Califano, 606 F.2d 403, 409
(3d Cir.1979) (noting that testimony by a claimant who had 29 years of continuous
work, 15 with the same employer, as to his capabilities was entitled to substantial
credibility); Witkowski v. Colvin, 999 F.Supp.2d 764, 766 (M.D. Pa. 2014)
(remanding where the ALJ failed to account for a claimant's 24 years of continuous
work, 15 with the same employer, when assessing his credibility). We do not
discount the importance and difficulty of the work Bohr performed as an EMT and
paramedic. Nonetheless, since the plaintiff alleges he became disabled at a relatively
young age, he does not demonstrate the sort of lengthy work history which would
be entitled to substantial credibility under these standards.

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simply to determine 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. Finding that this deferential standard of review is met here, we conclude that
a remand is not appropriate.
In closing, the ALJ’s assessment of the evidence in this case complied with
the dictates of the law and was supported by substantial evidence. This is all that the

law requires, and all that a claimant can demand in a disability proceeding. Thus,
notwithstanding the argument that this evidence might have been viewed in a way
which would have also supported a different finding, we are obliged to affirm this

ruling once we find that it is “supported by substantial evidence, ‘even [where] this
court acting de novo might have reached a different conclusion.’” Monsour Med.
Ctr. v. Heckler, 806 F.2d 1185, 1190–91 (3d Cir. 1986) (quoting Hunter Douglas,
Inc. v. NLRB, 804 F.2d 808, 812 (3d Cir. 1986)). Accordingly, under the deferential

standard of review that applies to appeals of Social Security disability
determinations, we find that substantial evidence supported the ALJ’s evaluation of
this case and will affirm that decision.

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IV. Conclusion
Accordingly, for the foregoing reasons, the final decision of the

Commissioner denying this claim will be AFFIRMED.
An appropriate order follows.
s/ Martin C. Carlson
Martin C. Carlson
United States Magistrate Judge
DATED: July 14, 2026

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/11409152. Public record. Not legal advice.