BACH v. COMMISSIONER OF SOCIAL SECURITY

Filing 27

OPINION Filed. Signed by Judge Robert Kirsch on 10/24/2024. (jal, )

NOT FOR PUBLICATION
UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY

CHARLES B.,
Plaintiff,
V.

COMMISSIONER OF SOCIAL SECURFTY,

Civil Action No. 16-3230 (RK)

OPINION

Defendant.

KIRSCH, District Judge
THIS MATTER comes before the Court on Plaintiff Charles B.'s ("Charles")1 appeal from
the Commissioner of the Social Security Administration's (the "Commissioner") final decision,
which denied Charles's request for disability insurance benefits. (ECF No. 1.) The Court has
jurisdiction to review this appeal under 42 U.S.C. § 405(g) and reaches its decision without oral
argument pursuant to Local Civil Rule 78.1. For the reasons below, the Court AFFIRMS the
Commissioner's decision.
I.

BACKGROUND
In this appeal, the Court must answer the following question: Does substantial evidence

support Administrative Law Judge Karen Shelton's ("Judge Shelton") determination of Charles's
residual functional capacity?

1 The Court identifies Plaintiff by first name and last initial only. See D.N.J. Standing Order 2021-10.

A. PROCEDURAL POSTURE
1. Initial ALJ Decision
Charles applied for disability insurance benefits on September 8, 2010, alleging an onset
date of February 28, 2010. (Administrative Record ("AR") at 654.)2 The Social Security
Administration (the "Administration") denied the request initially. Thereafter, Charles requested
a hearing before an Administrative Law Judge ("ALJ"), which was held on October 24, 2011.

(ECF Nos. 18 at 5; 21 at 2.) On October 31, 2011, an ALT issued a decision finding Plaintiff not
disabled, as defined in the Social Security Act during the relevant period. (AR at 111-26.) On May
23, 2013, the Appeals Council—the agency's final decisionmaker—vacated the October 31, 2011
decision and remanded it to an ALJ for a new hearing because the ALJ failed to consider parts of
the medical opinions in the Record. {Id. at 127-30.)
2. Second ALJ Decision
A new hearing was held before a different ALJ on June 24, 2014 (ECF Nos. 18 at 6; 21 at

2), after which the ALJ found Plaintiff not disabled on September 3, 2014 (AR at 189-209). On
April 1, 2016, the Appeals Council denied Charles's request to review the ALJ's September 3,
2014 decision. (Id. at 215-22.) Charles then filed this action in the District Court for the District
of New Jersey. (ECF No. 1.) On November 4, 2016, the Commissioner filed a Motion to Remand
the action pursuant to the sixth sentence of 42 U.S.C. § 405(g), because the decision, in part, was
based on a medical opinion about a different person. (ECF No. 4.) Accordingly, the Honorable
Judge Brian R. Martinotti remanded the matter to the Commissioner on December 21, 2016. (ECF
No. 5.)

2 The Administrative Record ("Record" or "AR") is available at ECF No. 10. This Opinion will reference
only page numbers in the Record without the corresponding ECF numbers.

3. Second Benefits Application & Third ALJ Decision
During this time, Charles filed a second disability insurance benefits application, alleging
disability as of September 4, 2014. (AR at 171.) This second claim was denied in the first instance
and upon reconsideration. (Id. at 176-77, 185.) On May 3, 2017, the Appeals Council remanded
both the 2010 and 2016 disability claims to an ALJ, noting the District Court's remand order. (Id.

at 133.) Further, the Appeals Council directed the ALJ to consolidate the 2010 and 2016 disability
claims, create a single record, and issue a decision on the consolidated claims. (Id.) On September
17, 2018, Charles attended his third hearing before an ALJ. {Id. at 448-57.) After which, a third
ALJ issued a written decision finding Charles not disabled on December 4, 2018. (Id. at 140-55.)
On January 27, 2020, the Appeals Council remanded the case to an ALJ for several reasons,

including for: (i) failing to consolidate Charles's 2010 and 2016 claims; (ii) further examination
of Charles's sleep apnea, insomnia and obesity; (iii) failure to adequately consider Charles's
subjective claims of pain; and (iv) failure to reconcile Charles's exertional limitation of occasional
reaching with the jobs identified for Charles by the vocational expert ("VE"), which require
constant reaching. {Id. at 163-67.)
4. Fourth and Fifth ALJ Decisions
As a result of the January 2020 remand, Charles testified at his fourth hearing before an
ALJ on December 16, 2020. (M at 93-109.) The ALJ issued a written decision finding him not
disabled on January 15, 2021. {Id. at 240-56.) The Appeals Council again remanded the case to
an ALJ for failing to adequately evaluate Charles's sleep apnea and reported symptoms of pain.

(Id. at 268-9.)3 On remand, the case was assigned to another ALJ, Judge Shelton, who held
hearings on January 30, 2023 and April 25, 2023. (Id. at 43-92, 270.) Plaintiff, represented by
counsel, testified at these hearings, as did an impartial VE. (Id. at 43-92.) On June 5, 2023,Judge
Shelton issued a written opinion finding that Charles was not disabled. (Id. at 9-32.) The Appeals
Council denied Charles's request to review Judge Shelton's decision, making the decision final.
(Id. at 1-5.) This case was reopened in the instant Court on January 16, 2024. (ECF No. 7.) On
January 17, 2024, the instant case was transferred to the undersigned. (ECF No. 8.) The

Administrative Record was filed on February 5, 2024 (ECF No. 10), Charles filed his moving brief
challenging Judge Shelton's decision on May 1, 2024 (ECF No. 18), the Commissioner filed an

opposition brief on May 3 1, 2024 (ECF No. 21), and Charles filed his reply on June 28, 2024 (ECF
No. 26).
B. JUDGE SHELTON?S DECISION4
In her June 5, 2023 opinion, Judge Shelton found that Charles was not disabled under the
prevailing Administration regulations. (See generally AR at 10-32.) To reach this decision, Judge
Shelton applied the five-step process for determining whether an individual is disabled as set forth

3 As stated above, prior to Judge Shelton's issuing her written ALT opinion, the instant matter was remanded

by the Appeals Council five separate times, resulting in four separate ALT opinions and hearings written by
three different ALJs, all of which found Charles not disabled. (AR at 43-92, 111-26, 128, 133, 140-55,
163, 189-209,240-56, 268-9, 448-57; ECF Nos. 4, 18 at 5; 21 at 2.) However, the RFC determinations
made by the prior ALJs ruling in the instant matter have no bearing on Judge Shelton's determination of
disability. See Morales v. Apfel, 225 F.3d 310, at 316 (3d Cir. 2000) (holding that a reviewing court is
"bound to the Commissioner's findings of fact if they are supported by substantial evidence in the record");
see also Correa v. Comm'r ofSoc. See., No. 20-00367, 2022 WL 17622967, at *6 (D.N.J. Dec. 13, 2022)

("[0]ur review does not hinge on whether the ALJ arrived at an RFC determination different than the initial
decision, rather, as discussed below, this Court must evaluate whether the ALJ based her RFC detennination
on substantial evidence.").
4 The Court notes that Judge Shelton's opinion is twenty-four single-spaced pages long, and the

Administrative Record is over 2200 pages long. Charles's appeal mainly challenges Judge Shelton's RFC
determination as a precursor to Step Four, particularly her evaluation of Dr. Wilen and Dr. Kwock's medical
opinions. (ECFNos. 18 at 27-35, 37-38; 26 at 1-5, 6-9.) Therefore, the Court limits the statement of facts
to focus on these medical opinions and any other necessary facts to put these opinions into context.

in 20 C.F.R. § 404.1520(a). {Id. at 10-12.) At Step One, Judge Shelton found that Charles had not
engaged in substantial gainful activity since the alleged onset date, February 28, 2010. (Jd. at 12
(citing 20 C.F.R. § 404.1571 et seq.').') At Step Two, Judge Shelton found that Charles suffered
from several severe impairments, including: degenerative disc disease-cervical spine and lumbar
spine with radiculopathy, status post-right triceps tendon rupture repair, right rotator cuff tear, left
shoulder partial tear, degenerative joint disease, and obesity. (Id. at 12-16 (citing 20 C.F.R.
404.1520(c)).) At Step Three, Judge Shelton determined that Charles did not have "an
impainnent or combination of impairments" that qualified under the Administration's listed
impairments. {Id. at 16-17 (citing 20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526).) As aprecursor
to Step Four, Judge Shelton concluded that Charles had the residual functional capacity ("RFC")
to:
[P]erform sedentary work as defined in 20 CFR 404.1567(a) except: Occasionally climb
ramps and stairs. No climbing ladders, ropes or scaffold. Frequently balance. Occasionally
stoop, kneel, crouch and crawl. Only occasionally overhead reach. Frequent reaching in
other directions. Frequent handling and fingering. No unprotected heights or hazardous
machinery. Simple routine tasks in a routine environment with few changes, simple work
decisions, and can work 2 hours before needing a standard 15-minute break.

(Id. at 17-30.) At Step Four, Judge Shelton found that Charles "is unable to perform any
past relevant work." (Id. at 30 (citing 20 C.F.R. § 404.1565).) Finally, at Step Five, Judge Shelton
heard testimony from a vocational expert and concluded that "there are jobs that exist in significant
numbers in the national economy" that Charles could perform. (Id. at 30-31 (citing 20 C.F.R. §§
404.1569, 404.1569a).) The impartial expert testified that representative jobs Charles could
perform, consistent with Judge Shelton's RFC, included an order clerk, charge account clerk, and
document preparer. {Id. at 31.)
This appeal concerns Judge Shelton's RFC determination and whether she properly

considered the opinion evidence from Charles's treating and non-treating physicians such that
substantial evidence supports her RFC determination. (ECF Nos. 18 at 27-39; 26 at 1-9.)
As part of the ALJ's RFC determination, Judge Shelton first reviewed Charles's selfreported symptoms and claimed functional limitations. (AR at 17-18.) The ALJ considered
Charles's treatment history—which related to his degenerative disc disease of the cervical spine
and lumbar spine with radiculopathy, status post-right triceps tendon rupture repair, right rotator
cuff tear, left shoulder partial tear, degenerative joint disease, and obesity—and determined that
Charles's impairments could be expected to produce the symptoms he alleged, but the extent of
Charles's "alleged limitations is not entirely consistent with the record." (M at 18-25.) Judge
Shelton proceeded to perform a thirteen-page analysis of Charles's medical record from March
2009 through December 2017. As described below, Judge Shelton explicated how her RFC
determination found support in the medical records she reviewed. (M at 18-29.)
Judge Shelton considered Charles's surgical and treatment history. (M at 19.) Charles
underwent right triceps tendon repair surgery in March 2009; however, the surgery occurred prior
to the alleged onset date and without complication. {Id. at 936-97.) During the relevant period, the
record reveals one emergency room visit for low back pain in September 2011, from which he was
discharged the same day. (Id. at 1593-95.) Charles's treatment history involved a multi-pronged
approach of physical therapy, injections, chiropractic manipulation, pain management medication,
and exercise strengthening programs. However, Judge Shelton characterized this treatment

5 (Id. at 1416-17, 1420-21, 1424-25,1429,1433, 1436, 1464-65, 1468-69,1472-73,1476-77,1480-81,
1484-85,1488-89, 1492-93, 1496-97, 1500-01, 1504, 1507-08,1510-11,1513-14,1517-18, 1520-22,
1524-25,1527-28, 1531-32, 1535, 1539, 1543, 1547, 1552, 1568-91,1648, 1650-51, 1654,1656-57,
1660, 1662-63, 1666, 1668-69, 1673, 1675-76, 1679, 1681-82,1685-88, 1691, 1693-94, 1697, 16991700,1703-06,1709-12, 1715-17, 1720-22, 1730-32, 1735-37,1740-42,1745-47, 1750-52, 1755-57,
1760-62, 1765-67, 1770-72, 1775-77,1780-82, 1785-87, 1790-92,1795-97,1800-01,1805-07, 1810-

history as conservative, noting that Charles did not undergo surgery during the relevant time
period. (Id. at 19.)
Medical records evidenced diminished dermatomal sensation to pinprick at C5-C7 and L3-

L5 {id. at 20 (citing 1355, 1359, 1560,1564,1605)); decreased range of motion in the spine, right
elbow, right shoulder, left elbow, decreased extremity strength, spinal spasm and weaknesses ;
and positive Spurling's tests.7 Besides the cited abnormal findings mentioned above, Judge Shelton
notes that Charles's medical records "document exam findings of normal strength, intact,
sensation, and/or no noted motor, strength, sensory, arm/hand use, or gait deficit or abnormality"
as further evidenced by the record failing to "reveal any noted pain behaviors upon exam" like
"shifting in a chair while seated, having to stand/walk after sitting for a short period, having to
sit/lie down after standing/walking for a short period." (Id. at 21.) Collectively, Judge Shelton
found Charles's medical records to reveal that Charles "was alert, fully oriented," and without
"any noted assistive device use, atrophy, edema, swelling, joint instability/laxity, fasciculations,
pronator drift, dysmetria, dysdiadochokinesia, titubation, nystagmus, contracture, cogwheeling,
involuntary moments/tremors, or deformity." (Id.)
Other exam findings in the Record document normal cervical range of motion, normal

11,1815-17,1820-22,1825-26,1829-30, 1833-34,1837-38, 1841-42,1862,1864-66, 1869-1881.)
6 (id. (citing 1103, 1106-09, 1100, 112-13, 116, 118-19, 1121, 22, 1124-26;1409, 1411-12,1415-16,
1419-20, 1423-24,1427-28,1431-32,1435-36, 1438^4, 1460, 1463-64, 1467-68, 1471-72, 1475-76,
1479-80, 1483-84, 1487-88, 1491-92, 1495-96, 1499-1500, 1503-04, 1507,1510, 1513, 1517, 1520,
1524, 1527, 1530-31, 1534-35, 1538-39, 1542, 1546^1.7, 1550-51, 1647-^8, 1653-54, 1659-60,166566, 1672-73, 1678-79, 1684-85, 1690-91, 1696-97, 1702-03, 1708-09, 1714-15, 1719-20, 1724-25,
1729-30, 1734-35, 1739^0,1744-45,1749-50, 1754-55,1759-60, 1764-65,1769-70,1774-75, 177980, 1784-85, 1789-90, 1794-95, 1799-80, 1804-05, 1809-10, 1814-15, 1819-20, 1824-25, 1828-29,
1832-33, 1836-37, 1840^1).)
7 (id. (citing 1099,1648, 1654,1660,1666,1673,1679, 1685,1691,1697,1703,1709) or straight leg raises
(id. at 1409, 1416, 1420, 1460, 1468, 1472, 1476,1480, 1484,1488,1492,1496,1499, 1504,1510,1513,
1535,1539,1542,1547,1551, 1666, 1673, 1679,1685,1691, 1697, 1703,1709, 1715,1720, 1725,1730,
1770,1775,1780,1785,1790, 1795,1800,1805,1810,1815, 1820,1825,1829,1833,1837, 1841).)

power and coordination in legs, no recent evidence of atrophy (i.e. the last examination citing
atrophy was in early 2013), adequate strength in the right arm, and normal power in the left arm.
{Id. at 20-21 (citing 1089, 1364-65. 1374, 1446-48, 2044-47).) Judge Shelton characterizes the
reported decreased extremity strength as "generally [] only slightly decreased at 4/5, except for 3,5 or 3/5 as to the right upper extremity upon some exams during the course of post-right triceps
tendon repair surgery recovery in 2009," and the decreased reflex "was only a slight decrease at

1/2." (Id. at 21 (citing 1099, 1112, 1114, 1373).) Judge Shelton also notes that these medical
records document only a one-time finding of "decreased right fifth finger and right lower extremity
sensation and an abnormal gait." (Id. at 1099.)
Next, Judge Shelton reviewed the diagnostic imaging and testing in the record. (Id. at 2223.) Charles received cervical spine x-rays in April 2010, May 2013, and October 2015, which
showed spasms, and degenerative joint disease, but no fractures or dislocations. (M at 22 (citing

1370,1556, 1600).) Cervical spine MRIs in May 2010 and October 2013 showed, among other
things, bulges, disc protrusions, or hemiations at levels from C3 to C-7 (id. at 22 (citing 1077,
1553-54)), but otherwise "failed to reveal any noted spinal cord compression, nerve root
impingement, thecal sac compromise, fracture, or dislocation." (id. (citing 1077, 1383-94)).
As for Charles's lumbar spine, he underwent x-rays in April 2010, November 2010, June
2013, and October 2015, which showed spasms and degenerative joint disease or osteoarthdtis,
but no fractures or dislocations. (Id. (citing 1354,1370, 1559, 1600).) Lumbar spine MRIs in April
2010, September 2013, and May 2017 revealed disc hemiations at L4-5 and bulges at L5-S1, but
otherwise failed to reveal "any noted nerve root impingement, fracture, or dislocation." (Id. at 22

(citing 1078, 1557-58, 1602).)
Regarding Charles's spinal impairments, Judge Shelton reviewed several MRIs and

electromyography and nerve conduction studies ofradiculopathy ("EMGs") that evidenced C5-C6
and C6-C7 radiculopathy and L4-L5 and L5-S1 radiculopathy. (M at 1356, 1360,1561,1565,
1605, 1609.) Judge Shelton notes that these EMGS did not document "brachial plexopathy or
myopathy." (Id. (citing 1355-1362, 1379-1406, 1560-68, 1605-14).)
Judge Shelton reviewed Charles's subjective claims of pain and symptoms. Charles alleges
that he is unable to work because of the injuries he sustained to his back, right arm, and left arm
while working as a police officer. {Id. at 12.) Further, he testified that he could drive but only in
short increments, he did not do any household chores, and he was "unable to perform a desk job
at the police department due to an inability to sit for long periods of time." (Id. at 13.) A typical
day for Charles consisted of seeing his children off to school, laying down to rest, and watching
television, but his medicine made him fall asleep several times during the day. {Id.} His neck and
back pain inhibited him from lifting anything more than ten to fifteen pounds with both arms, and
his shoulder injuries made it difficult to reach overhead or in front of him. (Id) Further, he testified
that he was unable to bend down. Charles claimed that he could walk for one or two blocks, stand
for fifteen to twenty minutes, and sit for thirty minutes at a time. (M)
Judge Shelton found that the extent of Charles's claimed symptoms were inconsistent with
the concurrent record evidence or were otherwise addressed through her RFC determination. {Id.
at 23.) While Charles self-reported having the symptoms above, he also testified to driving his
children, grocery shopping, managing his finances, "not requiring reminders to take care of
personal needs or go places," and preparing simple meals, and attending his own doctor's
appointments. {Id. at 23.) Treatment records did not state that Charles required assistance getting
on and off the exam table, he removed his socks and shoes independently, and "was able to squat,
walk on his toes, and walk on his heels." (Id. at 20 (citing 2043-2049).)

Regarding the opinion evidence in the record, Judge Shelton reviewed the medical opinions
from Charles's treating and non-treating physicians. She gave no weight to the state agency
medical consultants, Drs. Leong and Rizwan, who found Charles had no severe physical
impairments, because these medical consultants did not have the opportunity to review the
evidence presented at Charles's hearing, and because a finding of no severe impairments is
contrary to the record. (Id. (citing 169-77, 180-86).) As to Drs. Chitoor Govindaraj and Dyana
Aldea, two consultative examinators, who found Charles "cleared for occupation with no
restriction," (id. (citing 1363-67, 2043^1-9)), Judge Shelton found these two opinions inconsistent
with objective medical evidence in the record of Charles's shoulder tears, and thus accorded these
opinions "limited weight." (M)
Following Charles's right triceps surgery in 2009, Dr. Ruggiero, Charles's surgeon and a
treating physician, recommended to the New York City Police Department Medical Board that
Charles receive disability retirement benefits because he would unable to return to normal police
activities. (Id. at 1039.)8 Drs. Nicholas DePalma, Stephen Borkow, and Marjorie Scheiber, were
the members of the New York City Police Department Medical Board that reviewed Dr.
Ruggiero's recommendation and Charles's application for Accident Disability Retirement. (Id. at
1129-33.) Drs. DePalma, Borkow, and Scheiber agreed with Dr. Ruggiero's assessment and found
Charles was precluded from performing his full duties as a New York city police officer. (Id.)
Judge Shelton considered these medical opinions, finding the notion that Charles had work-related
limitations on account of his right triceps injury to be consistent with the record; however, "these

8 The court notes that Charles's right tendon triceps injury and surgery occurred in 2009, prior to the alleged
onset date., However, Charles continued to suffer from pain and issues related to this injury during the
relevant period. {Id. at 18.)

10

opinions [were] vague, conclusory, not a specific function-by function assessment," and came to
a conclusion of disability which is a "matter reserved to the Commissioner." (Id, at 27.) For these
reasons, Judge Shelton accorded the opinions ofDrs. DePalma, Borkow, Scheiber, and Ruggiero
limited weight.
Finally, of particular relevance to this appeal, the ALJ evaluated the opinions of Drs.
Napolitano, John Kwock, Daniel Wilen, and Mark Pames. (Id. at 25, 28-29.) Dr. Napolitano
conducted a single physical exam and opined that Charles could do light work, but limited to
"occasional overhead reaching, frequent reaching in other directions, frequent handling and
fingering, and no unprotected heights or mechanical parts." (Id. at 27 (citing 1446-48).) Judge
Shelton found Dr. Napolitano's identified limitations as generally consistent with record evidence

of Charles's left and right shoulder tears (evidenced by the 2011 and 2017 MRIs showing said
tears), exam findings of decreased upper extremity sensation, and positive Spurling testing.
However, Judge Shelton found Dr. Napolitano's designation of light work inconsistent with the
record, as evidenced by these same abnormal findings. (M) As such, Judge Shelton accorded Dr.
Napolitano's opinion only partial weight. (M)
Dr. Kwock was an impartial medical expert who testified at Charles's ALT hearing on
December 16, 2020. Judge Shelton accorded his opinion partial weight. (Id. at 25.) While Dr.
Kwock testified that Charles "could perform work at the light exertional level, with frequent
push[mg]/pull[ing]; occasional overhead reaching;" frequent use of his feet, frequent climbing
except only occasionally climbing ladders, balancing, kneeling; "occasional stooping, crouch, and

9 (Id. (citing 1099,1648, 1654,1660,1666,1673,1679, 1685,1691,1697,1703,1709) or straight leg raises
(id. at 1409,1416, 1420, 1460,1468,1472,1476,1480, 1484,1488,1492, 1496, 1499, 1504,1510, 1513,
1535, 1539,1542,1547, 1551, 1666,1673,1679,1685,1691, 1697,1703,1709,1715,1720, 1725,1730,
1770,1775,1780,1785, 1790, 1795,1800,1805,1810, 1815, 1820, 1825, 1829,1833,1837, 1841).)

11

crawling; and occasional working at unprotected heights and in proximity to heaving or moving
machinery," Judge Shelton found Dr. Kwock's opinion regarding Charles's foot use limitation and
ability to do light work inconsistent with the record. (M) As to the "exertional, postural, reaching,
and hazard exposure limitations" of Dr. Kwock's opinion, Judge Shelton found these "generally
consistent with the record." {Id.)
Dr. Wilen was Charles's treating physician from 2010-2017. (M at 20-21 (citing 13791406, 1405-1444, 1457- 1560, 1615-1843).) Judge Shelton summarized Dr. Wilen's opinions,
noting that in September 2011 and May 2014, he opined that Charles could stand or walk for less
than two hours and sit for less than four hours, and he could lift and/or carry ten pounds
occasionally and five pounds frequently. {Id. at 28 (citing 1406-07, 1457-58).) Further Dr. Wilen
found that Charles would be out sick on average of two days or more per month, would require
frequent breaks during the workday, takes medicine that would interfere with his ability to
concentrate in a work setting, and "would be "unable to complete eight hours of work due to pain."
(M) As such, in his "Social Security Disability Report[s]," Dr. Wilen found Charles "totally
disabled." (Id. (citing 1404-05; 1408-10; 1459-61).) Judge Shelton found Dr. Wilen's opinions
as to Charles's exertional limitations generally consistent with the overall record. {Id. at 28.) Dr.
Wilen's limitation to carrying less than ten pounds was consistent with Charles's history of right
triceps repair, and his MRIs showing tears in both shoulders. {Id.) Further, Dr. Wilen's limitation
to sedentary work is consistent with Charles's MRI findings of degenerative spinal disorders. {Id.

at 28 (citing 1370, 1556, 1600).)
However, Judge Shelton found the extent of Dr. Wilen's limitations inconsistent with the
record. (Id.) While the record notes Charles experienced tiredness and fatigue as a side effect of
his medication, the record does not document any deficits in terms of "alertness, orientation or

12

motor function upon exam." (M) As such, Dr. Wilen's finding that Charles would be unable to
concentrate at work on account of his medication is not consistent with the Record. (Id.) Further,
while the Record documents L4 nerve root abutment, it fails to reveal "a specific spinal diagnostic
imaging finding of nerve root impingement." (Id. (citing 2602).) Lastly, Dr. Wilen claims Charles
can stand or walk for two hours and sit for four hours, but his treatment notes do not state that
Charles is unable to "stand/walk for [two] hours or sit for at least six hours." (Id. at 29.) As to Dr.
Wilen's belief that Charles was totally disabled, Judge Shelton found such a statement "vague,
conclusory, not a specific function-by-function assessment," and a matter reserved for the ALJ to
determine. (M) For these reasons, Judge Shelton accorded Dr. Wilen's opinions less weight.
Regarding Dr. Fames, Judge Shelton noted that Dr. Pames completed a medical source
opinion form on July 5, 2018, after the date last insured. (Id. at 28 (citing 1844^5).)10 Dr. Parnes
opined that Charles was totally disabled as he could only stand or walk for less than two hours and
sit for less than four hours of an eight-hour workday, and lift and/or carry ten pounds occasionally

and five pounds frequently. {Id. (citing 1381-82; 1406-07; 1457-58).) Judge Shelton found the
exertional limitations in this opinion generally consistent with the Record, but the extent to which
Dr. Fames limited Charles inconsistent with the evidence as a whole. (Id. at 29.) Judge Shelton
noted Charles's reported decrease in reflex and extremity strength was only slight (i.e. reflex was
1/2 and strength was 4/5). (Id. (citing 1862, 1864-66, 1869-81).) Dr. Parnes did not document
Charles using an ambulatory assistive device, "contracture, cogwheeling, foot drop, wrist, drop, or
pain behaviors upon exam, such as, [] shifting in a chair while seated [or] having to stand/walk
after sitting for a short period...." (Id. (citing 923-1615; 1646-1833; 1862-81, 2042^1.9.) Lastly,

10 Judge Shelton noted that Dr. Fames's opinion states that he treated Charles since 2010, but the treatment

records provided by Dr. Fames first document him treating Charles in March 2017. {Id. (citing 1843-83.)

13

Dr. Fames's limitation that Charles can only carry up to ten pounds infrequently is contradicted
by Charles's own testimony that he can lift up to fifteen pounds using both hands. (Id. at 29.) Given
these inconsistencies, Judge Shelton accorded Dr. Fames's opinions less weight.

II. LEGAL STANDARD
A. STANDARD OF REVIEW
The Court reviews the "final decision of the Commissioner of Social Security" to determine
whether the Commissioner's findings are supported by "substantial evidence." 42 U.S.C. § 405(g).
In the event that the Appeals Council denies a claimant's request for review, "the ALJ's decision
is the Commissioner's final decision." Matthews v. Apfel, 239 F.3d 589, 592 (3d Cir. 2001)
(citation omitted). Substantial evidence is "more than a mere scintilla but may be somewhat less
than a preponderance of the evidence." Zimsak v. Colvin, 777 F.3d 607, 610 (3d Ctr. 2014)
(quoting Rutherford v. Barnhart, 399 P.3d 546, 552 (3d Cir. 2005)). Put differently, "[i]t means
such relevant evidence as a reasonable mind might accept as adequate to support a
conclusion." Morales v. Apfel, 225 F.3d 310, 316 (3d Cir. 2000) (quoting Plummer v. Apfel,
186 F.3d 422, 427 (3d Cir. 1999)). This evidentiary threshold is "not high." Biestek v. Berryhill,

587 U.S. 97, 103 (2019).
The scope of the Court's review of the ALT's decision is "quite limited." Rutherford, 399
F.3d at 552. On review, the Court may not "re-weigh the evidence or impose [its] own factual
determinations." Chandler v. Comm'r of Soc. See., 667 F.3d 356, 359 (3d Cir. 2011) (citing
Richardson v. Perales, 402 U.S. 389,401 (1971)). "Where the ALJ's findings of fact are supported
by substantial evidence, we are bound by those findings, even if we would have decided the factual
inquiry differently." Fargnoli v. Massanari, 247 F.3d 34, 38 (3d Cir. 2001) (citing Hartranft v.
Apfel, 181 F.3d 358, 360 (3d Cir. 1999)). The Court must "review the record as a whole to

14

determine whether substantial evidence supports a factual finding." Zimsak, 777 F.3d at 610
(citing Schaudeck v. Comm'r ofSoc. Sec. Admin., 181 F.3d 429, 431 (3d Cir. 1999)). "Since it is
apparent that the ALJ cannot reject evidence for no reason or for the wrong reason, an explanation
from the ALJ of the reason why probative evidence has been rejected is required so that a
reviewing court can determine whether the reasons for rejection were improper." Cotter v. Harris,

642 F.2d 700, 706-07 (3d Cir. 1981) (citation omitted).
B. ESTABLISHING ELIGIBILITY FOR DISABILITY INSURANCE BENEFITS
A claimant may establish disability under the Social Security Act by proving they are
unable 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)(l)(A).
The ALJ applies a well-established "five-step sequential evaluation process," which requires
considering whether the claimant:

(1) is engaged in substantial gainful activity; (2) suffers from an
impairment or combination of impairments that is "severe"; (3)
suffers from an impairment or combination of impairments that
meets or equals a listed impairment; (4) is able to perform his or her
past relevant work; and (5) is able to perform work existing in
significant numbers in the national economy."
McCrea v. Comm'r of Soc. See., 370 F.3d 357, 360 (3d Cir. 2004) (citing 20 C.F.R.
§§ 404.1520(a)-(f), 416.920(a)-(f)). The claimant bears the burden at the first four steps, at
which point it shifts to the Commissioner at Step Five. Hess v. Comm'r Soc. See., 931 F.3d 198,

201 (3d Cir. 2019).

III. DISCUSSION
Charles contends that Judge Shelton erred in Grafting his RFC because it is not supported
by substantial evidence. (ECF Nos. 18 at 27-38; 26 at 1-9.) Charles presents three central

15

arguments in support of this claim. First, Judge Shelton improperly weighed Dr. Wilen's opinions
and inadequately discussed Dr. Wilen's specialty as an orthopedic surgeon, his extensive treatment
relationship with Charles, and the objective medical evidence supporting his opinions. Second,
Judge Shelton failed to explain why she rejected Dr. Kwock's limitation of Charles to occasional
lateral reaching, and instead, found Dr. Napolitano's limitation of Charles to frequent lateral
reaching as consistent with the record. Third, Judge Shelton improperly rejected medical opinion
evidence in the record and inserted her own lay opinion when determining Charles could perform
sedentary work.

In a comprehensive twenty-three-page, single-spaced decision, Judge Shelton reviewed the
evidentiary record to determine Charles's RFC. (AR at 8-32.) While Judge Shelton afforded little
weight to the opinions of physicians deciding Plaintiff had no limitations whatsoever, she also
discredited others who opined that Plaintiff was totally disabled such that he was precluded from
performing sedentary work. (Id. at 25-29.) Instead, based on the record, Judge Shelton determined
that Plaintiff retained the ability to perform sedentary work (the least exerdonally demanding type
of work), except he can never climb ladders, ropes, scaffolds, be exposed to unprotected heights
or hazardous machinery, he can occasionally climb ramps, stairs, stoop, kneel, crouch, crawl, reach
overhead, and he can frequently balance, reach in other directions, handle, and finger.
Additionally, Charles is limited to "simple routine tasks in a routine environment with few
changes, simple work decisions," and can work for two hours before needing a standard fifteenminute break. {Id. at 17-30.) Judge Shelton formulated this RFC based on a review of the
competing medical opinion evidence, Charles's treatment records, objective medical diagnostic
tests, and Charles's own testimony and statements as to his pain. {Id. at 9-32.) As discussed below,
the Court finds substantial evidence supports Judge Shelton's RFC determination. For the

16

following reasons, Charles's challenges to his RFC determination are unavailing.
A. DR. WlLEN'S OPINION

Charles argues that Judge Shelton erred in discounting Dr. Wilen's opinions, which stated
that Charles was incapable of performing sedentary work and was totally disabled. (ECF Nos. 18
at 27-35, 26 at 1-6.) Specifically, Charles contends that Judge Shelton violated 20 C.F.R. §
404.1527(c)(2) by improperly evaluating Dr. Wilen's medical specialization, the nature and extent
of Dr. Wilen's treating relationship with Charles, and mis characterizing objective medical
evidence in the record that supports Dr. Wilen's opinions. Charles maintains that had Judge
Shelton adequately considered these factors, she necessarily would have found Dr. Wilen's
opinions merited "controlling weight." (ECF No. 26 at 1.) However, the Court finds Judge Shelton
did not violate the regulations in her analysis of Dr. Wilen's opinions and substantial evidence
supports Judge Shelton assigning less weight to said opinions.
For disability applications filed on or prior to March 17, 2017, such as this one, the ALT's
consideration of medical opinion evidence is governed by regulations at 20 C.F.R. §§ 404.1527,
416.927. An ALJ will "weigh" medical opinions when evaluating the RFC but is never bound by

such opinions. See 20 C.FR. § 404.1527 (d) (2) (the "final responsibility for deciding [the RFC] is
reserved to the Commissioner.") These Regulations further explain that treating-source medical
opinions can be afforded "controlling weight" if they are "well-supported by medically acceptable
clinical and laboratory diagnostic techniques," and not "inconsistent with the other substantial
evidence" in the record. 20 C.F.R. § 404.1527(c)(2); see also Plummer, 186 F.3d at 429. When a
treating-source's opinion is not assigned controlling weight, the ALJ is directed to consider factors
such as the treating physician's specialty, the opinion's consistency with the record, the support
and explanation provided by the source, the nature and extent of the treatment relationship, and

17

any other relevant factors. See 20 C.F.R. § 404.1527(c)(2)-(6). The ALJ must adequately articulate
her "supporting explanations" for affording a treating physician's opinion less weight. Brownawell
v. Comm'r ofSoc. See., 554 F.3d 352, 355 (3d Cir. 2008) (citing Plummer, 186 F.3d 422, 429 (3d

Cir. 1999)).
When an ALJ evaluates a medical opinion, the ALJ is not required "to use particular
language or adhere to a particular format in conducting [her] analysis." Jones v. Bamhart, 364
F.3d 501, 505 (3d Cir. 2004) (citing Bumett v. Comm'r ofSoc. Sec. Admin., 220 F.3d 112,11920 (3d Cir. 2000)). Instead, the Court must "ensure that there is sufficient development of the
record and explanation of findings to permit meaningful review." Id. This requirement governs the
Court's review of each Step of the ALJ's analysis, including her RFC determination. An ALJ's
finding of a claimant's RFC must "be accompanied by a clear and satisfactory explication of the
basis on which it rests." Fargnoli, 247 F.3d at 41 (quoting Cotter, 642 F.2d at 704 (the Court
"need[s] from the ALJ not only an expression of the evidence s/he considered which supports the
result, but also some indication of the evidence which was rejected.")); see also Bumett, 220 F.3d

at 121 ("Although the ALJ may weigh the credibility of the evidence, [s/]he must give some
indication of the evidence which [s/]he rejects and [the] reason(s) for discounting such evidence."

(citing Plummer, 186 F.3d at 429)).
The Court "examine[s] the ALJ's conclusions as to a claimant's RFC with 'the deference
required of the substantial evidence standard of review.'" Martin v. Comm'r of Soc. See.,

547F.App'x 153, 160 (3d Cir. 2013) (quoting Burns v. Bamhart, 312F.3d 113, 129 (3d Cir.
2002)). Substantial evidence does not require highly detailed explanations, "[t]o the contrary, a
reviewing court must 'uphold' even 'a decision of less than ideal clarity if the agency's path may
reasonably be discerned/" Garland v. Ming Dai, 593 U.S. 357, 369 (2021) (citation omitted); see

18

also Cotter, 650 F.2d at 482 (T]he ALJ is not required to supply a comprehensive explanation for
the rejection of evidence; in most cases, a sentence or short paragraph would probably suffice.")
As an initial matter, the Court finds substantial evidence supports Judge Shelton's
determination that Dr. Wilen's opinions should be afforded limited weight rather than controlling
weight. The ALJ's analysis of Dr. Wilen's opinions is as follows:
Treating provider, Dr. Daniel Wilen, M.D. issued several opinions.
Specifically, on September 1, 2011 and May 13, 2014, Dr. Wilen completed
opinion forms in which he opined that the claimant could stand/walk for less
than two hours, sit for less than four hours, and lift and/or carry more than
five pounds and less than ten pounds occasionally and less than five pounds
frequently ([AR at 1381-82,1457-58]). Further, he also opined in these forms
that the claimant would be out sick an average of two or more days per month,
required frequent breaks/rest during the workday, was unable to complete
eight hours of work due to pain, requires medications that interfere with his
ability to function in a work setting, would have difficulty concentrating on
his work, and is "disabled" (Id.). Moreover, in "Social Security Disability
Report[s]" dated September 18, 2011 and May 16, 2014, Dr. Wilen reiterated
his contemporaneous objective findings, and concluded that the claimant was
"totally disabled" ([Id. at 1404-05, 1408-09, 1459-61]).
Dr. Wilen issued his opinions while treating the claimant, presumably
meaning that objective findings and subjective allegations from
contemporaneous exams were the support for his opinions. Further, the
existence of exertional limitations is generally consistent with the overall
evidence of record. This includes, for example, a history of right triceps repair

([id. at 936-37]), shoulder MRI findings of tearing in the left shoulder in 2011
and the right shoulder in 2017([^. at 1368, 1614]), and spinal MRI findings
consistent with degenerative changes in 2010, 2013 and 2017, as detailed at
length above {[id., at 1077-78, 1553-54, 1557-58, 1602]). However, the
extent of limitation Dr. Wilen suggests is inconsistent with the record. For
example, the record documents a remote history of right triceps surgery in
2009([id. Sit 936-37]), without any noted spinal surgery or any other extremity
surgery in the relevant period ([id. at 923-1615, 1646-1843, 1862-81, 204349]). Further, despite obesity, symptoms, and alleged medication side effects,
as noted above, the record failed to reveal, within the relevant period, deficits
in terms of alertness, orientation or motor function upon exam, ambulatory
assistive device use upon exam, or a repeated pattern of emergency room
presentations^'^.]). Moreover, while the record documents L4 nerve root
abutment ([id. at 1601-02]), the record fails to reveal, in the relevant period,
a specific spinal diagnostic imaging finding of nerve root impingement (id.).
In addition, the opinions that he is "totally disabled" are vague, conclusory,

19

not a specific funcdon-by-function assessment, and on a matter reserved to

the Commissioner.
Therefore, in light of the above, the undersigned accords only less weight to
Dr. Wilen's opinions.

(AR at 28.) Where the deferential substantial evidence standard means an "ALJ is not
required to supply a comprehensive explanation for the rejection of evidence; in most cases, a
sentence or short paragraph would probably suffice," Judge Shelton's explanation above for
finding the extent of limitations articulated by Dr. Wilen inconsistent with the record more than
satisfies this standard. Cotter, 650 F.2d at 482; Martin, 547 F. App'x at 160 (quoting Bums, 312
F.3d at 129).
While Judge Shelton found support in the record for the existence of exertional imitations
outlined in Dr. Wilen's opinions, (AR at 28 (citing 1368, 1614)), Judge Shelton explained that "the
extent of limitation Dr. Wilen suggests," "is inconsistent with the record." {Id. at 28.) To support
this determination, Judge Shelton noted that after Charles's right triceps surgery in 2009,
subsequent exams revealed "good" ranges of right elbow motion, decreased pain, and increased
strength after starting a strengthening process. (Id. at 20,28 (citing 1063-65).) Judge Shelton noted
that Charles required no other spinal or extremity surgery during the relevant period. (Id. (citing
923-1615, 1646-1843, 1862-81, 2043-49).) Further, despite Charles's obesity and symptoms of
drowsiness and lethargy, the record did not reveal that Charles suffered any deficiency "in terms
of alertness, orientation or motor function upon exam." (Id.} There is no evidence in the record
documenting use of an ambulatory device, and the record indicates Charles made only one
emergency room visit during the relevant period, in which Charles was discharged the same day
for back pain. {Id.) Lastly, while the record documents L4 nerve root abutment, there is no evidence
showing "a specific spinal diagnostic imaging finding of nerve root impingement." {Id. (citing

20

1601-02).) Based on all these reasons, Judge Shelton found the extent of limitations articulated by
Dr. Wilen, precluding Charles from performing any work, as inconsistent with the Record, thus
prompting her to afford his opinions less weight.
Further, in a factually analogous case, the District Court in Kimberly D. v. Comm'r ofSoc.
Sec. found the ALJ's terse rationale for affording a treating physician's opinion less weight which consisted of a single sentence stating that the opinion "was inconsistent with objective
medical evidence, conclusory, and contrary to the doctor's own evaluations," - as sufficient when

considered in light of the entire ALJ opinion that included a detailed "review of [p]laintiffs
medical history." Kimberly D. v. Comm'r of Soc. See., No. 21-8718, 2022 WL 3926073, at *6
(D.N.J. Aug. 31, 2022) It is evident that Judge Shelton's rational for affording less weight to Dr.
Wilen's opinion is for more substantive and extensive than the ALT's opinion that was affirmed in
Kimberly D. v. Comm'rofSoc. Sec. (M)
While Charles claims there is no evidence in the record that contradicts Dr. Wilen's
opinions that Charles is incapable of performing sedentary work, he fails to account for the six
opinions in the record that found Charles capable of performing light work. (AR at 17.) The Court
notes that the sedentary level of exertion requires "periods of standing or walking" that generally
"total no more than about 2 hours of an 8-hour workday, and sitting should generally total
approximately 6 hours of an 8-hour workday," as compared to light work which "requires standing
or walking, off and on, for a total of approximately 6 hours of an 8-hour work day." SSR 83-10,

1983 WL 31251 at *5. Judge Shelton actually found Plaintiff more limited exertionally than half
of the opining doctors in the record by limiting Plaintiff to sedentary work. {Id.); see Morales, 225
F.3d at 317 ("Where ... the opinion of a treating physician conflicts with that of a non-treating,
non-examining physician, the ALJ may choose whom to credit."). Thus, a full reading of the

21

written decision lends credence to her findings regarding Dr. Wilen's opinion. Sejeck v. Berryhill,
No. 18-16734, 2019 WL 7207506, at *7 (D.N.J. Dec. 27, 2019) ("[W]hile an ALJ must consider
the opinions of treating physicians, [t]he law is clear . . . that the opinion of a treating physician
does not bind the ALJ where it is not well supported or there is contradictory evidence." (alteration
in original) (internal quotation marks and citation omitted)).
In addition, Judge Shelton reviewed in detail the orthopedic medical records from
Healthcare Associates in America, that formed the bases for Dr. Wilen's opinions. She noted the
existence of abnormal findings (i.e. positive Spurling tests, decreased ranges of movement in the
spine and upper extremities, and decreased extremity strength), but found that these reports of
decreased extremity strength were slight, and such records document only a "one-time exam
finding" of an abnormal gait, and decreased sensation in the right finger and arm. (AR at 21.) This
detailed review of Dr. Wilen's treatment notes undergirded her evaluation of Dr. Wilen's opinions,
thereby satisfying the Court that the ALJ did not "reject [Dr. Wilen's] evidence for no reason or
for the wrong reason." Plummer, 186 F.3d at 429 (quoting Mason v. Shalala, 994 F.2d 1058,1066
(3d Cir. 1993)). Rather, substantial evidence supports Judge Shelton's decision to give less weight
to Dr. Wilen's medical assessment. See id. (citing Stewart v. Sec'y ofH.E.W., 714 F.2d 287, 290

(3d Cir. 1983)).
Equally unavailing is Charles's contention that the ALJ failed to adequately consider Dr.
Wilen's specialty, extensive treatment relationship, and objective medical evidence supporting

u Charles also argues that Judge Shelton ignores the fact that Dr. Wilen's opinion is consistent with Dr.
Fames's opinion as evidence that she erred in her RFC determination. (ECF No. 18 at 37.) However, Judge

Shelton explained why she gave less weight to both Drs. Wilen and Fames's opinions. (AR at 28-29.)
Simply because Charles can point to one opinion that is consistent with Dr. Wilen's, does not evidence
error on Judge Shelton's part, and the Court notes that half the opinions in the record contradict Dr. Wilen's
opinions. {Id. at 25-27.)

22

such opinions, as required under Section 404.1527(c)(2). As a preliminary matter, "[a]n ALJ need
not explicitly discuss each factor [under 20 C.F.R. § 404.1527] in [her] decision." O'Neill v.
Comm'r of Soc. See., No. 18-0698, 2019 WL 413539, at *6 (D.N.J. Jan. 31, 2019); Samah v.
Comm'r of Soc. See., No. 17-08592, 2018 WL 6178862, at *5 (D.N.J. Nov. 27, 2018) (same)
(collecting cases). "Instead, an ALJ need only 'explain his evaluation of the medical evidence for
the district court to meaningfully review whether his [or her] reasoning accords with the
regulation's standards.'" Samah, 2018 WL 6178862, at *5 (quoting Laverde v. Colvin, No. 141242, 2015 WL 5559984, at *6 n.3 (W.D. Pa. Sept. 21, 2015)); see also Sutherland v. Comm'r

Soc. See., 785 F. App'x 921, 928 (3d Cir. 2019) ("Although the ALJ did not specifically identify
each factor [under 20 C.F.R. § 404.1527(c)], all relevant factors were considered throughout the
lengthy, detailed opinion.") (citations omitted). Judge Shelton did just that in this case.
Although Judge Shelton did not explicitly refer to Dr. Wilen as a "board certified
orthopedic surgeon," she specifically considered Dr. Wilen's "orthopedic medical records" from
March 2009 to November 2017. (AR at 20-21.) As such, the ALJ opinion sufficiently indicates
that Judge Shelton was aware of Dr. Wilen's orthopedic specialty when she considered his
treatment records in evaluating his opinions. See Moore v. Comm'rofSoc. See., No. 20-1550, 2021
WL 5604988, at *3 n. 6 (W.D. Pa. Nov. 30, 2021) (despite ALJ not explicitly referencing each
factor of section 404.1527, "it is clear from the decision, read as a whole, that the ALJ considered
Plaintiffs treating history with Dr. Sharma including its length, Dr. Sharma's specialty, and the
degree to which other evidence in the record supported Dr. Shanna's opinion. And while explicit
mention of the relevant factors might have aided this Court's review, ALJs are not required to use
any 'particular language' or 'format' where their decisions demonstrate consideration of the
'appropriate factors' and permit 'meaningful review.'") (quoting Jones, 364 F.3d at 504-05).

23

Next, Charles argues that Judge Shelton should have articulated in greater detail the length
and nature of Dr. Wilen's treatment relationship with him. (ECF No. 18 at 31-32.) However, Judge
Shelton specifically acknowledged that Dr. Wilen was a "treating provider." (AR at 28.) She
further explained that "Dr. Wilen issued his opinions while treating Plaintiff, presumably meaning
that objective findings and subjective allegations from contemporaneous exams were the support
for his opinions" and extensively reviewed Dr. Wilen's treatment records. (Id. at 20-21 (citing

923-1615, 1646-1843, 1862-81, 2043-49).) While Charles argues that Judge Shelton failed to
mention various diagnostic tests that Dr. Wilen ordered for Charles in her evaluation of Dr. Wilen's
opinions, Judge Shelton discussed these diagnostic tests in her review of the medical record
evidence. (Id. at 22-23 (citing 1368, 1553-55, 1557-58, 1560-65).)Judge Shelton also cited to
Dr. Wilen's orthopedic treatment notes, which included the length of time Dr. Wilen treated
Charles, when explaining that his exertional limitations for Charles were not supported by these
treatment notes. {Id. at 29 (citing 923-1615, 1646-1843, 1862-81, 2043-49).)
This explanation demonstrates that Judge Shelton sufficiently considered the "appropriate
factors" (i.e. the nature of Dr. Wilen's treatment relationship) to permit "meaningful review" by
this Court. Jones, 364 F.3d at 504-05. A more specific or explicit discussion of these factors is not
required by the regulations. See Diaz v. Comm'r of Soc. See., 577 F. 3d 500, 504 (3d Cir. 2009)
(stating that an ALJ "need not employ particular 'magic' words" or "adhere to a particular format"
rather, the decision need only contain a sufficient discussion of the evidence and explanation of
the ALJ's reasoning to enable "meaningful judicial review"); see also Gary-Maryon v. Colvin, No.
14-1318, 2015 WL 2090226, at *2 (W.D. Pa. May 5, 2015) ("The ALJ . . . recited and considered
Plaintiffs treatment history, thus implicitly considering the nature and extent of the treating

24

relationship."). Accordingly, the ALJ opinion sufficiently discusses Dr. Wilen's treatment
relationship with Charles.
Finally, Charles maintains that Judge Shelton mischaracterized the objective medical findings
of "muscle spasm, muscle weakness, and decreased range of motion" in Dr. Wilen's treatment notes

as subjective evidence. (ECF Nos. 18 at 34; 26 at 1-2.) In doing so, Judge Shelton diminished the
supportability of Dr. Wilen's opinions, as supportability is measured by the degree to which an opinion
is grounded in objective medical evidence. (Id. at 35.) In her opinion, Judge Shelton wrote that Dr.
Wilen's treatment notes "generally document exam findings of subjective spinal, trapezius, buttock,
upper extremity, or lower extremity tenderness with spinal spasm or spinal weakness, decreased ranges

of spinal, right elbow, right shoulder, or left shoulder motion, and decreased extremity strength." (AR
at 20) (emphasis added). The Court finds Judge Shelton appropriately characterized the findings of
tenderness as subjective, because "[presumably, [claimant's physician] would detect the tenderness,
because plaintiff would report feeling pain upon palpation. As a result, the physical findings of
tenderness ultimately depended upon plaintiff s subjective reports." Antoniolo v. Colvin, 208 F.Supp.
3d 487, 597 (D. Del 2016) (quotations omitted). Accordingly, Judge Shelton did not mischaracterize
the objective evidence of muscle spasms, decreased extremity strength, and limited range of motion as
subjective, but accurately considered the subjective evidence of pain and tenderness caused by these
objective findings.
B. ALJ RELIANCE ON LAY OPINION
Charles next argues that Judge Shelton improperly relied on "her own lay re-interpretation
of the evidence cobbled from non-physicians who have not reviewed the complete record." (ECF
No. 18 at 35) (citing Brownawell, 554 F.3d). Charles points to the fact that Judge Shelton "cites
no reliable medical opinion" in support of her RFC determination as evidence of this claim. (M)

25

Charles also attacks Judge Shelton's references to the absence of evidence in the Record as
irrelevant when such absent evidence is unrelated to Charles' impairments. (Id. at 36; ECF No. 26
at 2-3.) Essentially, Charles claims that substantial evidence supports the limitations outlined by
Charles's treating physicians (i.e. limitations that preclude even sedentary work) and asks this
court to re-weigh the evidence in favor of that RFC determination. (Id. at 35-37.) The Court must
decline this invitation for the following reasons.
First, an ALJ is not required to point to every medical fact in the record that directly
supports its ultimate RFC determination. See Chandler, 667 F.3 d at 362 (holding ALJ did not err
when it extrapolated from the medical opinions in the record in Grafting its own RFC determination
as the ALJ "is not precluded from reaching RFC determinations without outside medical expert
review of each fact incorporated into the decision.") Additionally, "it is the ALJ—not treating or
examining physicians or state agency physicians—who makes the ultimate disability and RFC
determinations." See Roger D. v. Kijakazi, 20-1806, 2021 WL 4191434, at *5 (D.N.J. Sept. 15,

2021) (citing Chandler, 667 F.3d at 361); Mays v. Bamhart, 78 F. App'x 808, 813 (3d Cir. 2015)
("[T]he ALJ is responsible for making a [RFC] determination."). As previously stated, where "the
opinion of a treating physician conflicts with that of a non-treating, non-examining physician, the
ALJ may choose whom to credit," but cannot reject evidence for no reason or the wrong reason.
Morales, 225 P.Sdat 317. As discussed above in Section III.A, Judge Shelton's opinion—that
reviewed over eight years of medical records, opinions from twelve different medical sources,
Charles's hearing testimony and subjective complaints, and analysis explaining why Dr. Wilen's
opinion was given its corresponding weight by citing to several pieces of record evidence—clearly

26

satisfies the substantial evidence standard. (AR at 9-32.); see also Cotter, 650 F.2d at 482; Martin,
547 F. App'x at 160 (quoting Burns, 312 F.3d at 129).
Further, Charles's claim that Judge Shelton could not cite to a single medical opinion to
support her RFC determination ignores the fact that she discounted several opinions that found
Charles could perform light work. (ECF No. 21 at 26; AR at 17.) The Court notes that sedentary
work is a more limiting exertional category than light work. See 20 C.F.R. § 404.1567(b) ("If
someone can do light work, we determine that he or she can also do sedentary work, unless there
are additional limiting factors such as loss of fine dexterity or inability to sit for long periods of
time.") For example, Dr. Kwock specifically testified that Charles could stand or walk for six hours
or sit for six hours of an eight-hour. workday. (Id. at 97.) While Judge Shelton rejected Dr. Kwock' s
opinion to the extent it found Charles capable of light work, said opinion still supports Judge
Shelton's more limited designation of sedentary work. See SSR 83-10, 1983 WL 31251, at *5.
Accordingly, despite Judge Shelton finding these opinions — to the extent they found Charles
capable of light work - inconsistent with the Record, such opinions still lend support to her
limitation of sedentary work. (AR at 25-27.)
Continuing to challenge Judge Shelton's RFC determination, Charles argues that she
improperly relied on the absence of evidence and surgical interventions during the relevant period
to support her RFC determination. However, Judge Sherton is permitted to point to the "absence
of muscle fasciculations, pronator drift, dysmetria, dysdiadochokinesia, tibulation, nystagmus,
contracture, cogwheeling, involuntary/tremors or deformity" as evidence that the extent of
Charles's limitations were not as significant as Dr. Wilen described. (ECF Nos. 18 at 37; 26 at 2.);
see Lane v. Comm'r of Soc. See., 100 F. App'x 90, 95 (3d Cir. 2004) (noting that the ALJ is

27

"entitled to rely not only on what the record says, but also on what it does not say.") (citation
omitted.) As such, Judge Shelton appropriately considered that the record did not contain positive
findings that indicate the existence of musculoskeletal or neurological impairments.

C. DR. KWOCK'S OPINION
Lastly, Charles argues that the ALJ erred in its evaluation of Dr. Kwock's opinion testimony.
Charles claims that Judge Shelton improperly ignored Dr. Kwock's statement that Charles is limited
to occasional lateral reaching. (ECF No. 18 at 37.)
As previously noted, it is the ALJ—not a testifying medical expert—who makes the ultimate
RFC determination. See Chandler, 667 F. 3 d at 361. Even when an ALJ gives a medical opinion
significant weight, there is no requirement that the ALJ adopt every limitation articulated by that source
opinion in the RFC assessment. See WUkinson v. Comm'r ofSoc. See., 558 F. App'x 254, 256 (3d Cir.
2014) ("[N]o rule or regulation compels an ALJ to incorporate into an RFC every finding made by a
medical source simply because the ALJ gives the source's opinion as a whole 'significant' weight.")
Accordingly, the fact that Judge Shelton gave "partial weight" to Dr. Kwock's opinion does not require

Charles claims that the absence in the record of "fasciculations, pronator drift, dysmetria,
dysdiadochokinesia, titubation, nystagmus, contracture, cogwheeling, involuntary moments/tremors"
severe only to show whether someone has Parldnson's Disease, and thus, should have no significance on
Judge Shelton's determination because Charles does not claim to have Parkinson's Disease. (ECF No. 26
at 3.) However, these medical findings can be an indication of Parldnson's Disease as well as

musculoskeletal or neurological impairments of the kind Charles exhibits. (AR at 22, 28.) Further, Charles
claims that his lack of surgery during the relevant period cannot be used as a "proxy for a finding of nondisability." (ECF No. 26 at 3.) Judge Shelton references the absence of surgery as one of several factors
that contributed to how she weighed Dr. Wilen's opinions and Charles's RFC determination, and may
consider a lack of surgery as part of her calculus when characterizing Charles's treatment plan as
conservative. See Roger D., 2021 WL 4191434 at * 10 ("courts in this circuit have characterized medication
management and injections as conservative treatment) (citing Sudler v. Comm'r ofSoc. See., 827 F. App'x

241, 245-46 (3d Cir. 2020) (characterizing injections as "relatively routine and conservative treatment");
Jimenez v. Colvin, No. 15-3762, 2016 WL 2742864, at *4 (D.N.J. May 11,2016) (noting that "the treatment
was conservative: medication, including trigger point injections, and physical therapy"); Herman v. Colvin,

No. 12-6640,2013 WL 6909915, at *8 (D.N.J. Dec. 31, 2013) ("The ALJ also emphasized the conservative
methods by which Plaintiff was treated. The record evidences treatment of pain medications, injections,
and chiropractic treatment.").

28

her to adopt every exertional limitation outlined in his opinion into her RFC determination. (AR at
25.); see also Wilkinson, 558 F. App'x at 256 (permitting the ALJ to rely "on multiple sources in
reaching her conclusion" as to a claimant's RFC) Judge Shelton adequately considered Dr. Kwock's
opinion and explained why she felt it merited "partial weight." (AR at 25.) In reference to the exertional
limitations in Dr. Kwock's opinion, Judge Shelton found them generally consistent with the record but
gave no indication that she adopted Dr. Kwok's exertional limitations wholesale. {Id. at 26.)
While Judge Shelton did not explicitly discuss the portion of Dr. Kwok's testimony that limited
Charles to occasional lateral reaching on account of his right elbow injury, she did not "simply ignore"
this limitation. (AR at 25-27.) Judge Shelton provided ample explanation for why she limited Charles
to frequent lateral reaching in her discussion of Dr. Napolitano's opinion. (Jd. at 27.) The Court reviews
an ALJ opinion as a whole. See Jones, 364 F.3d at 503 (an ALJ' s decision should be "read as a whole")
Judge Shelton explained that Dr. Napolitano's limitation to "occasional overhead reaching, frequent
lateral reaching in other directions, frequent handling, and fingering . .." was consistent with the record
because it accounted for the fact that Charles's suffered from some upper extremity issues (i.e. right
and left shoulder tears, decreased upper extremity sensation, and positive Spurling tests,), but otherwise
showed a "broad range of normal findings." {Id. (citing 1444-46).)
This explanation sufficiently enables the Court to determine why Judge Shelton found Charles
limited to "frequent reaching in other directions," which is all that is required to satisfy the deferential
substantial evidence standard. See Burnett, 220 F.3d at 121; see also Cotter, 650 F.2d at 482 (stating
that an ALJ must provide "some explanation" for "probative evidence which would have suggested a
contrary disposition," and "a sentence or short paragraph would probably suffice") Although Charles
points to Dr. Kwock's opinion—limiting Charles to occasional lateral reaching—as contrary evidence,

the Court "will uphold the ALJ's decision even if there is contrary evidence that would justify the

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opposite conclusion, as long as the 'substantial evidence' standard is satisfied." Johnson v. Comm'rof

Soc. See., 497 F. App'x 199, 201 (3d Cir. 2012) (citing Simmonds v. Heckler, 807 F.2d 54, 58 (3d Cir.
1986)). Charles further questions the medical bases of Dr. Napolitano's opinion. (ECF No. 26 at 8.)
However, as previously noted, it is Judge Shelton—not a treating or examining physician or a medical
expert—who makes the ultimate RFC determinations. See Chandler, 667 F.3d at 361. Moreover, as
explained above, Judge Shelton cited to medical evidence in the record to support her finding that
Charles is limited to frequent lateral reaching. (AR at 27 (citing 1026, 1099, 1368, 1446, 1614,1648,

1654,1660,1666,1669,1673, 1685, 1703, 1709).)14

13 See e.g. Roger D., 2021 WL 4191434, at *9 (citing Johnson, 497 F. App'x at 201 (citing Simmonds, 807
F.2d at 58); see also Chandler, 667 F.3d at 359 ("Courts are not permitted to re-weigh the evidence or
impose their own factual determinations [under the substantial evidence standard]."); Ration v. Comm'r of
Soc. Sec.Admin., 131 F. App'x 877, 880 (3dCir. 2005) ("When 'presented with the not uncommon situation
of conflicting medical evidence .... [t]he trier of fact has the duty to resolve that conflict.'") (quoting
Richardson, 402 U.S. at 399 (alteration in original)); Davison v. Comm'r ofSoc. See., No. 18-15840, 2020

WL 3638414, at *8 (D.N.J. July 6, 2020) ("The ALJ cited to multiple other reports and surveyed a
significant amount of evidence. He was not required to discuss or describe every page of the record. He did
not, as [the claimant] seems to suggest, cherry pick a handful of positive statements out of a universe of
negative statements."); Lewis v. Comm'rofSoc. See., No. 15-6275, 2017 WL 6329703, at *8 (D.N.J. Dec.

11, 2017) ("Though the Plaintiff accuses the ALJ of cherry-picking evidence, it actually appears that the
Plaintiff is the one guilty of cherry-picking since the bulk of the medical record seems to indicate minimal
issues with executive function and mental capabilities."). The Court therefore declines Charles's invitation
to impose his own factual determinations and re-weigh the evidence. See Chandler, 667 F.3d at 359;

Zirnsak, 777 F.3d at 611 (stating that a reviewing court "must not substitute [its] own judgment for that of
the fact finder")
14 Because the Court finds substantial evidence supports the ALJ's RFC determination, the Court need not
address Charles's final argument that reversal for the award of benefits, not remand, is warranted in the

instant matter. (ECF Nos. 18 at 39; 26 at 9.)

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CONCLUSION
Having reviewed the record as a whole, the Court affirms the decisions of Judge Shelton
and the Administration's Appeals Council. The Court will issue an order consistent with this

Opinion.

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^

I ^
ROBERT KlRSCH "
UNITED STATES DISTRICT JUDGE

Dated: October 24, 2024

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