Steinmetz v. Kijakazi

Filing 16

MEMORANDUM OPINION (Order to follow as separate docket entry) re 1 Complaint filed by Adrien Steinmetz. Signed by Chief MJ Daryl F. Bloom on January 6, 2025. (kjn)

IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
ADRIEN STEINMETZ,
Plaintiff
v.
CAROLYN COLVIN, Acting
Commissioner of Social Security,1
Defendant

: Civil No. 1:23-CV-2066
:
:
:
:
: (Chief Magistrate Judge Bloom)
:
:
:
:

MEMORANDUM OPINION
I.

Introduction
On December 18, 2019, Adrien Steinmetz filed an application for

supplemental security income pursuant to Title XVI of the Social
Security Act. Following a hearing before an Administrative Law Judge
(“ALJ”), the ALJ found that Steinmetz was not disabled from her alleged
onset date of disability of December 18, 2019, through September 27,
2022, the date of the ALJ’s decision.

1 Carolyn Colvin became the Acting Commissioner of Social Security on

November 30, 2024. Pursuant to Rule 25(d) of the Federal Rules of Civil
Procedure and 42 U.S.C. § 405(g), Carolyn Colvin is substituted as the
defendant in this suit.
1

Steinmetz now appeals that decision, arguing the ALJ’s decision is
not supported by substantial evidence. After a review of the record, we
conclude that the ALJ’s decision is not supported by substantial evidence.
Therefore, we will remand this matter for further consideration by the
Commissioner.
II.

Statement of Facts and of the Case
On December 18, 2019, Steinmetz applied for supplemental

security income, citing an array of physical and mental impairments,
including bulging discs of the cervical spine, cervical and lumbar
radiculopathy, osteoporosis, and anxiety.

(Tr. 13).

According to

Steinmetz’s medical records, her alleged disabilities arose from a motor
vehicle accident on April 19, 2019. (Tr. 357). Steinmetz was 54 years old
at the time of the alleged onset of disability, had at least a high school
education, and had past employment as a certified home health aide and
a house painter. (Tr. 44-47).
On April 29, 2019, more than one week after the accident,
Steinmetz presented to the Lehigh Valley Hospital.

(Tr. 311).

Physician’s Assistant Lisa Wippel noted a CT scan was performed on
2

Steinmetz’s spine, with negative results. (Id.). Steinmetz also received
an x-ray and an examination and was referred for treatment at Complete
Injury Care (“CIC”). (Tr. 558).

Steinmetz treated at CIC 30 times

between May 8 and September 10, 2019. (Tr. 495-558). At her initial
evaluation with CIC on May 8, 2019, Dr. Eric Homa noted that Steinmetz
had lower back pain that she rated as eight out of ten and which radiated
(Id.).

down her upper and lower leg.

Steinmetz reported “major

discomfort or difficulty” with sitting, standing, bending, lifting, walking,
lying down, sleeping, housework, and personal care / dressing. (Tr. 481).
On May 13, 2019, Steinmetz established care with Geisinger Health
System (“GSH”) at their Pottsville location.

(Tr. 307).

Certified

registered nurse practitioner (“CRNP”) Corrine Joy recorded Steinmetz
was experiencing stiffness on the right side of her body but that she felt
the treatment by Dr. Homa was sufficient to address it. (Id.). Steinmetz
also reported she had a past diagnosis of osteoporosis and had failed to
continue treatment after an initial consult with a rheumatologist in 2016
but was now interested in resuming treatment. (Id.).

3

Steinmetz continued to treat at CIC between May 14 and July 18 of
2019. During that time, her pain levels in four specific areas (cervical
pain, thoracic pain, lumbar pain, and headache) slowly but continuously
fell. (Tr. 522, 524, 526, 530, 534, 536, 538, 540, 542, 544, 546, 548, 550,
552, 554). On July 22, Steinmetz had an MRI at Schuylkill Medical
Imaging which showed a broad-based posterior central disc bulging at
C5-C6. (Tr. 493). Steinmetz continued her regular treatments at CIC
until September 16, 2019, where her pain levels at her final session were
recorded as roughly half of what she reported at her intake in May. (Tr.
495).
On November 14, 2019, Steinmetz was seen at GSH Pottsville by
Dr. Christian Shuman, who stated Steinmetz was at a high risk for
fracture due to her osteoporosis. (Tr. 303). Steinmetz received a DEXA
scan at Pottsville Dexa Imaging on November 25. (Tr. 313). The results
showed her lumbar spine had a T-Score of -2.6, and her left femoral neck
had a T-Score of -3.0; the results of that examination explain that
anything below -2.5 indicates a high fracture risk. (Tr. 335).

4

On July 31, 2020, Steinmetz underwent an internal medicine
examination with Dr. Marielle Stone, M.D., related to her disability
application. (Tr. 357). Dr. Stone noted that Steinmetz’s chief complaint
was “constant pain, especially on the right side of her body” and that
additional “areas of constant pain include her lower left leg due to
osteoporosis and neck and low back pain that worsened following the car
accident, but was preexisting.” (Id.). On examination, Dr. Stone noted
that Steinmetz walked with normal gait and was able to walk on heels
and toes without difficulty. (Id.). Dr. Stone also noted that Steinmetz
had tenderness to palpitation “over both scapular spines . . . [the]
paraspinal muscles of the cervical and thoracic spine over the right side
. . . [and the] lumbar spine[.]” (Id.). Dr. Stone found Steinmetz had
“bilateral paraspinal tenderness of the lumbar spine” and that “[s]harp
touch elicits paresthesia in the C6 dermatome of the right upper
extremity. [Steinmetz] has decreased sharp sensation in the L4, L5, and
S1 dermatomes of the right lower extremity.” (Tr. 360). In addition to
the osteoporosis, bulging cervical discs, radiculopathy, chronic low back

5

and right-side pain, Dr. Stone also diagnosed chronic left lower extremity
pain. (Id.).
Following this examination, Dr. Stone opined that Steinmetz could
sit for a maximum of two hours at a time, stand a maximum of one hour
at a time, or walk a maximum of twenty minutes at a time. (Tr. 364).
She further opined that Steinmetz could sit for a maximum of eight
hours, stand for a maximum of five hours, and walk a maximum of two
hours of the course of an eight-hour workday. (Id.). Dr. Stone stated that
Steinmetz did not require help with activities of daily living, and could
drive, cook, clean, do laundry, and shop without issue. (Tr. 358). Dr.
Stone found Steinmetz capable of providing once-a-week childcare and
that she could dress and bathe herself. (Id.).
On August 11, 2020, Dr. Glenda Cardillo, M.D., reviewed the record
and opined that Steinmetz was capable of performing medium work. (Tr.
68). Specifically, Dr. Cardillo found that Steinmetz was subject to some
exertional limitations, opining that she can occasionally lift 50 pounds,
can frequently lift 25 pounds, can stand and/or walk for “about 6 hours
in an 8-hour workday [,]” and sit for the same. (Tr. 66). Dr. Cardillo cited
6

osteoporosis as evidence supporting those conclusions. (Id.). Dr. Cardillo
noted that Steinmetz did not submit a description of daily activities, and
instead repeated Dr. Stone’s findings on that topic. (Id.).
Around this time, Steinmetz filled out a function report, in which
she stated: “anything involving my legs I can only do a few mins at a
time” and that she could walk only “a block or less” without stopping. (Tr.
225). In January of 2021, Steinmetz’s daughter submitted a third-party
function report, alleging that her mother’s “chronic pain lessens her
ability to work, stand, or move about,” that “all movement causes severe
pain,” and that her mother’s condition affects her ability to stand and sit.
(Tr. 238, 240, 243).
On March 31, 2021, Dr. Michael Lombard, M.D., reviewed the
record on reconsideration and found that Steinmetz could perform
medium work. (Tr. 87). Dr. Lombard’s findings were similar to Dr.
Cardillo’s findings, in that Dr. Lombard found that Steinmetz can
occasionally lift 50 pounds, can frequently lift 25 pounds, can stand
and/or walk for “about 6 hours in an 8-hour workday [,]” and can sit for
the same. (Tr. 83-84). He noted that Steinmetz had a normal gait and
7

did not need an assistive device to ambulate. (Tr. 85). Dr. Lombard
stated that Steinmetz did not submit a description of daily activities but
noted Dr. Stone’s findings on that matter. (Id.).
It is against this factual backdrop that the ALJ conducted a hearing
in Steinmetz’s case on July 1, 2022.

(Tr. 33-60).

Steinmetz and a

vocational expert (“VE”) both testified at this hearing. (Id.). Following
this hearing, the ALJ issued a decision denying Steinmetz’s application
for benefits. (Tr. 10-21). In that decision, the ALJ first concluded that,
since Steinmetz’s alleged onset of disability, she had not had any work
that rose to the level of substantial gainful activity. (Tr. 12-13). At Step
2 of the sequential analysis that governs Social Security cases, the ALJ
found that Steinmetz suffered from the following severe impairments:
bulging discs of the cervical spine; cervical and lumbar radiculopathy;
and osteoporosis.

(Tr. 13).

The ALJ further concluded that while

Steinmetz suffered from other impairments such as nasal bone fracture,
rib deformity, and anxiety, these impairments were non-severe. (Id.). At
Step 3 the ALJ determined that these impairments did not meet or equal

8

the severity of a listed impairment under the Commissioner’s
regulations. (Tr. 16).
Between Steps 3 and 4 the ALJ concluded that Steinmetz:
[H]a[d] the residual functional capacity to perform medium
work as defined in 20 CFR 416.967(c), except she must avoid
concentrated exposure to extreme cold, vibration, and
hazards.
(Id.).
In reaching this RFC determination, the ALJ considered the
objective medical record detailed above, the medical opinion evidence,
and Steinmetz’s reported symptoms. (Tr. 20-21). With respect to his
consideration of medical opinion evidence, the ALJ found the opinions of
state agency consulting Drs. Cardillo and Lombard to be:
[P]ersuasive as they are consistent with and supported by the
previously discussed evidence of record, including the benign
physical examination findings as noted by both medical
consultants and the claimant’s providers, a lack of anything
other than routine treatment for her physical impairments
during the relevant time period, and the claimant’s reported
activities of daily living, including taking care of her personal
needs, taking care of her young granddaughter, driving,
painting, drawing coloring, doing household chores such as
laundry and cleaning, doing the dishes, shopping in stores,
managing her finances, and spending time with others both
in person and over the telephone.
9

(Tr. 19).
The ALJ found the opinion of Dr. Stone “somewhat persuasive.”
(Tr. 19). The ALJ concluded that Dr. Stone’s postural or manipulative
limitations were not supported by the evidence nor found by the other
medical evaluators, and so were not persuasive. (Id.). However, the ALJ
specifically opined that Dr. Stone’s opinion on “exertional level is
persuasive[,]” for all the same reasons that he found the opinions of Drs.
Cardillo and Lombard to be persuasive, listed above. (Id.).
With respect to Steinmetz’s symptoms, the ALJ noted that while
Steinmetz’s “medically determinable impairments could reasonably be
expected to cause the alleged symptoms [,]” that her statements
concerning the intensity, persistence, and limiting effects of her
impairments were not entirely consistent with the medical evidence. (Tr.
17). Steinmetz established she was previously employed as a certified
home health aide as well as a house painter. (Tr. 46-47). Steinmetz
testified that her main health problem was constant pain in both legs,
especially the left, and that she also had pain in her back and arms. (Tr.
47). She stated that she gets out of breath a lot, that she needed a break
10

after “ten minutes” of being on her feet, that her pain is primarily “in the
back of my [left] leg [,]” and it was “constant[.]” (Tr. 49, 51, 52). Steinmetz
explained that after standing for ten minutes, pain began to set in, and
that pain worsened if she “stand[s] for a long time[.]” (Tr. 53).
Regarding these allegations, the ALJ noted that Steinmetz engaged
“in a variety of activities,” including household chores like cleaning or
laundry, caring for her personal needs, preparing simple meals, driving,
shopping, managing finances, painting, drawing, coloring, assisting in
the care of her four-year-old granddaughter, and socializing both in
person and over the phone. (Tr. 18.). The ALJ relied on Steinmetz’s
assertion that she did not need a cane or walking device and did not need
assistance from her roommate except for when moving items around
their home. (Id.). While acknowledging Steinmetz had some limitations
and the above facts are not dispositive, the ALJ found that the facts as a
whole “suggest that the claimant can perform work within the above
parameters on a sustained and continuous basis.” (Id.).
Having made these findings, the ALJ found at Step 4 that
Steinmetz could not perform her past work. (Tr. 20). However, at Step
11

5, the ALJ found she could perform other jobs that existed in significant
numbers in the national economy, such as a bus cleaner, warehouse
worker, or hand packer. (Tr. 21). Having reached these conclusions, the
ALJ determined that Steinmetz had not met the showing necessary to
sustain her claim for benefits and denied the claim.
This appeal followed. (Doc. 1). On appeal, Steinmetz challenges
the adequacy of the ALJ’s decision, arguing: (1) the ALJ’s function-byfunction assessment was inadequate and frustrates judicial review; (2)
the ALJ erred by omitting without explanation certain limitations in
medical opinions he relied upon; (3) that the ALJ improperly substituted
his own medical opinion for those on record resulting in an RFC that
exceeds all medically recommended limitations, and; (4) the ALJ erred in
not ordering a mental consultative examination in order to fully and
fairly develop the record. (Doc. 10 at 5).
As discussed in greater detail below, having considered the
arguments of counsel and carefully reviewed the record, we conclude that
the ALJ’s decision should be remanded for further consideration by the
Commissioner in accordance with this decision.
12

III.

Discussion
A.

Substantial Evidence Review – the Role of this Court

This Court’s review of the Commissioner’s decision to deny benefits
is limited to the question of whether the findings of the final decisionmaker 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 means 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, or fails to resolve, a conflict created by countervailing evidence.”

Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993) (quoting Kent v.
Schweiker, 710 F.2d 110, 114 (3d Cir. 1983)) (internal quotations
omitted). However, where there has been an adequately developed
13

factual record, substantial evidence may be “something less than the
weight of the evidence, and the possibility of drawing two inconsistent
conclusions from the evidence does not prevent [the ALJ’s decision] from
being supported by substantial evidence.” Consolo v. Fed. Maritime

Comm’n, 383 U.S. 607, 620 (1966). The court must “scrutinize the record
as a whole” to determine if the decision is supported by substantial
evidence. Leslie v. Barnhart, 304 F. Supp.2d 623, 627 (M.D. Pa. 2003).
The Supreme Court has explained the limited scope of our review,
noting that “[substantial evidence] means—and means only—‘such
relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.’” Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019)
(quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)).
Under this standard, we must look to the existing administrative record
to determine if there is “‘sufficient evidence’ to support the agency’s
factual determinations.” Id. Thus, the question before us is not whether
the claimant is disabled, but rather whether the Commissioner’s finding
that he or she is not disabled is supported by substantial evidence and
was based upon a correct application of the law. See Arnold v. Colvin, No.
14

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 . . . .”).
When conducting this review, we must remain mindful that “we
must not substitute our own judgment for that of the fact finder.” Zirnsak

v. Colvin, 777 F.3d 607, 611 (3d Cir. 2014) (citing Rutherford v. Barnhart,
399 F.3d 546, 552 (3d Cir. 2005)). Thus, we cannot re-weigh the evidence.
Instead, we must determine whether there is substantial evidence to
support the ALJ’s findings. In doing so, we must also determine whether
the ALJ’s decision meets the burden of articulation necessary to enable
judicial review; that is, the ALJ must articulate the reasons for his
decision. Burnett v. Comm'r of Soc. Sec. Admin., 220 F.3d 112, 119 (3d
Cir. 2000). This does not require the ALJ to use “magic” words, but rather
15

the ALJ must discuss the evidence and explain the reasoning behind his
decision with more than just conclusory statements. See Diaz v. Comm'r

of Soc. Sec., 577 F.3d 500, 504 (3d Cir. 2009) (citations omitted).
Ultimately, 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).
B.

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

To receive disability benefits under the Social Security Act, a
claimant must show that he or she is 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)(1)(A); 42 U.S.C. §1382c(a)(3)(A); see also
20 C.F.R. §§404.1505(a), 416.905(a). This requires a claimant to show a
severe physical or mental impairment that precludes [him/her] from
engaging in previous work or “any other substantial gainful work which
exists in the national economy.” 42 U.S.C. §423(d)(2)(A); 42 U.S.C.
§1382c(a)(3)(B); 20 C.F.R. §§404.1505(a), 416.905(a). To receive benefits
16

under Title II of the Social Security Act, a claimant must show that he or
she is under retirement age, contributed to the insurance program, 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, the ALJ follows a five-step
evaluation. 20 C.F.R. §§404.1520(a), 416.920(a). The ALJ must
sequentially determine whether the claimant: (1) is engaged in
substantial gainful activity; (2) has a severe impairment; (3) has a severe
impairment that meets or equals a listed impairment; (4) is able to do his
or her past relevant work; and (5) 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), 416.920(a)(4).
Between Steps 3 and 4, the ALJ must also determine the 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, 220 F.3d at 121 (citations omitted); see also 20
C.F.R. § 404.1545(a)(1). In making this assessment, the ALJ must
consider all the claimant’s medically determinable impairments,
17

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), 416.945(a)(2). Our
review of the ALJ’s determination of the plaintiff’s RFC is deferential,
and that determination will not be set aside if it is supported by
substantial evidence. Burns v. Barnhart, 312 F.3d 113, 129 (3d Cir.
2002).
The claimant bears the burden at Steps 1 through 4 to show a
medically determinable impairment that prevents him or her from
engaging in any past relevant work. Mason, 994 F.2d at 1064. If met, the
burden then shifts to the Commissioner to show at Step 5 that there are
jobs in significant numbers in the national economy that the claimant
can perform consistent with the claimant’s RFC, age, education, and
work experience. 20 C.F.R. §§404.1512(f), 416.912(f); Mason, 994 F.2d at
1064.
With respect to the RFC determination, courts have followed
different paths when considering the impact of medical opinion evidence
on this determination. While some courts emphasize the necessity of
medical opinion evidence to craft a claimant’s RFC, see Biller v. Acting
18

Comm’r of Soc. Sec., 962 F. Supp. 2d 761, 778–79 (W.D. Pa. 2013), other
courts have taken the approach that “[t]here 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). Additionally, in cases that involve no credible medical
opinion evidence, courts have held 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).
Given these differing approaches, we must evaluate the factual
context underlying an ALJ’s decision. Cases that emphasize the
importance of medical opinion support for an RFC assessment typically
arise in the factual setting where well-supported medical sources have
found limitations to support a disability claim, but an ALJ has rejected
the medical opinion based upon an assessment of other evidence. Biller,
962 F. Supp. 2d at 778–79. These cases simply restate the notion that
medical opinions are entitled to careful consideration when making a
disability determination. On the other hand, when no medical opinion
19

supports a disability finding or when an ALJ relies upon other evidence
to fashion an RFC, courts have routinely sustained the ALJ’s exercise of
independent judgment based upon all the facts and evidence. See

Titterington, 174 F. App’x 6; Cummings, 129 F. Supp. 3d at 214–15.
Ultimately, it is our task to determine, considering the entire record,
whether the RFC determination is supported by substantial evidence.

Burns, 312 F.3d 113.
C.

Legal Benchmarks for the ALJ’s Assessment of Medical
Opinions

The plaintiff filed this disability application in December of 2019
after Social Security Regulations regarding the consideration of medical
opinion evidence were amended. Prior to March of 2017, the regulations
established a hierarchy of medical opinions, deeming treating sources to
be the gold standard. However, in March of 2017, the regulations
governing the treatment of medical opinions were amended. Under the
amended regulations, ALJs are to consider several factors to determine
the persuasiveness of a medical opinion: supportability, consistency,
relationship with the claimant, specialization, and other factors tending
to support or contradict a medical opinion. 20 C.F.R. § 404.1520c(c).
20

Supportability and consistency are the two most important factors,
and an ALJ must explain how these factors were considered in his or her
written decision. 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2); Blackman

v. Kijakazi, 615 F. Supp. 3d 308, 316 (E.D. Pa. 2022). Supportability
means “[t]he more relevant the objective medical evidence and
supporting explanations . . . are to support his or her medical opinion(s)
. . . . the more persuasive the medical opinions . . . will be.” 20 C.F.R. §§
404.1520c(c)(1), 416.920c(c)(1). The consistency factor focuses on how
consistent the opinion is “with the evidence from other medical sources
and nonmedical sources.” 20 C.F.R. §§ 404.1520c(c)(2), 416.920c(c)(2).
While there is an undeniable medical aspect to the evaluation of
medical opinions, it is well settled 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). When confronted with several
medical opinions, the ALJ can choose to credit certain opinions over
others but “cannot reject evidence for no reason or for the wrong reason.”

Mason, 994 F.2d at 1066. Further, the ALJ can credit parts of an opinion
21

without giving credit to the whole opinion and may formulate a
claimant’s RFC based on different parts of different medical opinions, so
long as the rationale behind the decision is adequately articulated. See

Durden v. Colvin, 191 F. Supp. 3d 429, 455 (M.D. Pa. 2016). On the other
hand, in cases where no medical opinion credibly supports the claimant’s
allegations, “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 ALJ’s Decision is Not Supported by Substantial Evidence.

As we have noted, the ALJ’s decision must be accompanied by “a
clear and satisfactory explication of the basis on which it rests,” Cotter,
642 F.2d at 704, and the 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).

After consideration, we conclude that the ALJ’s RFC

determination is not supported by an adequate explanation.
As discussed above, an ALJ is not mandated to accept any medical
opinion and is free to evaluate the evidence on record to reach his or her
22

own conclusions, including conclusions supported by no medical opinion
on record. Cummings, 129 F. Supp. 3d at 214–15. But where an ALJ has
found a medical opinion to be persuasive yet does not incorporate all of
that opinion’s limitations into the RFC, that omission must be explained
in the opinion. Durden, 191 F. Supp. 3d 455. An opinion that fails to
explain such an omission is not based on substantial evidence. Cotter v.

Harris, 642 F.2d 700, 704-05 (3d Cir. 1981) (“[W]e need 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. In the
absence of such an indication, the reviewing court cannot tell if
significant probative evidence was not credited or simply ignored.”); see

also Dobrowolsky v. Califano, 606 F.2d 403, 407 (3d Cir. 1979) (“[U]nless
the [ALJ] has analyzed all evidence and has sufficiently explained the
weight he has given to obviously probative exhibits, to say that his
decision is supported by substantial evidence approaches an abdication
of the court’s duty[.]”) (internal quotation marks omitted).
Steinmetz contends that the ALJ’s RFC determination is not
supported by substantial evidence because the ALJ failed to conduct a
23

function-by-function assessment regarding her ability to stand and walk.
Social Security Ruling (“SSR”) 96-8p explains that the ALJ’s “RFC
assessment must first identify the individual’s functional limitations or
restrictions and assess his or her work-related abilities on a function-byfunction basis” and that the “function-by-function assessment [must be]
based upon all of the relevant evidence of an individual’s ability to do
work-related activities.” SSR 96-8p, 1996 WL 362207. The ruling
explains that the “RFC may be expressed in terms of an exertional
category, such as light . . . [h]owever, without the initial function-byfunction assessment . . . it may not be possible to determine whether the
individual is able” to do either past work or other work available in the
national economy. Id. The ruling further explains this is because “a
failure to first make a function-by-function assessment . . . could result
in the adjudicator overlooking some of an individual’s limitations or
restrictions.”

Id.

That ruling also identifies that when discussing

“exertional capacity,” there are seven areas of strength to be considered—
sitting, standing, walking, lifting, carrying, pushing, and pulling. Id.
Further, the ruling instructs that “[e]ach function must be considered
24

separately (e.g., ‘the individual can walk for 5 out of 8 hours and stand
for 6 out of 8 hours.’)” Id. Finally, the SSR explains that even if functions
would be grouped together in a particular occupation, that does not
change the function-by-function requirement of the evaluative process,
as “it is not invariably the case that treating the activities together will
result in the same decisional outcome as treating them separately.” Id.
Here, the ALJ determined that Steinmetz was able to undertake “a
full range of medium work.” (Tr. 20). This is an acceptable expression of
the RFC—so long as the initial assessment considered each limitation in
isolation. SSR 96-8p. The Commissioner argues this requirement is met
here by the ALJ’s reliance on the medical opinions of Drs. Cardillo and
Lombard, who themselves “considered Plaintiff’s ability to stand and
walk and found that she could perform medium work.” (Doc. 14 at 13).
This statement is accurate, but not sufficient to bring the opinion into
compliance with SSR 96-8p, which requires each impairment be
considered individually. SSR 96-8p. Nowhere in the ALJ’s opinion does
he discuss standing or walking, except to acknowledge that Steinmetz
avers she has problems with both. (Tr. 17).
25

Dr. Stone, whose opinion the ALJ found somewhat persuasive,
opined in the most detail on the issues of standing and walking. Dr.
Stone opined that Steinmetz could sit for two hours at a time, stand one
hour at a time, walk 20 minutes at a time, and could sit for eight, stand
for five, and walk for up to three hours in an eight-hour workday. (Tr.
364).

As briefly discussed above, while the ALJ disagreed with Dr.

Stone’s findings related to postural or manipulative activities, he
explicitly found her opinion as to “[t]he exertional level is persuasive as
it is consistent with and supported by the previously discussed evidence
of record . . . .” (Tr. 18). SSR 96-8p makes clear that standing and walking
are part of the exertional level findings. SSR 96-8p. Thus, our reading
of the ALJ’s decision indicates that the ALJ was persuaded by Dr. Stone’s
opinion of Steinmetz’s standing and walking limitations, and yet did not
include the relevant limitations in his RFC nor in his hypotheticals to the
VE discussed below. This could have been simple oversight or considered
omission—without a function-by-function assessment addressing this
limitation, we can only guess why it is absent.

26

This is the sort of

ambiguity that the Third Circuit has warned will require a remand.

Cotter, 642 F.2d 705.
We find a case in this district instructive on this issue. See Barbour

v. Kijakazi, 2021 WL 4478332 (M.D. Pa. Sep. 30, 2021) (Arbuckle, M.J.).
In Barbour, the ALJ assigned “great weight” to a medical opinion which
included limitations on the claimant’s ability to sit, stand, and walk. See

Barbour, 2021 WL 4478332, at *4. However, the ALJ failed to conduct a
function-by-function assessment of those activities and crafted an RFC
wherein the claimant was found to be capable of light work. See id.
Judge Arbuckle concluded that the ALJ’s RFC determination was not
supported by substantial evidence and remanded the matter because the
ALJ failed to include a function-by-function assessment. Id. The same
logic applies here. While the ALJ here found Dr. Stone’s overall opinion
“somewhat” persuasive, he found it to be “persuasive” regarding the
sitting, standing, and walking limitations.

(Tr. 18).

This error is

compounded by the fact that the ALJ limited Steinmetz to medium work,
which requires even more of an ability than the limitation to light work
assessed to be inadequate in Barbour.
27

The ALJ needed to either account for that limitation or explain the
reason he rejected it. See Burnett v. Commissioner of Social Sec. Admin.,
220 F.3d 112, 121 (3d Cir. 2000) (remanding where the ALJ “failed to
mention or refute some of the contradictory medical evidence before him
. . . failure to mention and explain this contradictory evidence was
error.”); see also Mattox v. Kijakazi, 2023 WL 5943135, at *7 (M.D. Pa.
Sep. 12, 2023) (“Despite finding that the consultants’ opinions were
persuasive, the ALJ did not include any standing/walking limitations . .
. [while] the ALJ was not bound . . . to adopt all the limitations, he was
required to explain his basis for [not] doing so.”); Simon v. Kijakazi, 2022
WL 828935, at *9 (M.D. Pa. Mar. 18, 2022) (remanding because a
“limitation contained within . . . an opinion deemed persuasive by the
ALJ, was not addressed or incorporated into the RFC in any meaningful
fashion.”); Evantis v. Berryhill¸ 2018 WL 1465276, at *11 (M.D. Pa. Feb.
28, 2018) (“[T]he ALJ was by no means bound by Dr. Feinstein’s opinion
on [claimant’s] limitations, and was not required to adopt all of the
limitations, [but] she was required to explain her basis for doing so.”);

Hines v. Colvin, 2015 WL 8489970, at *13 (M.D. Pa. Dec. 9, 2015) (“[T]he
28

ALJ did not provide an explanation as to why these limitations, which
were contained within opinions the ALJ gave great weight to and held
were supported by and consistent with the record, were not included in
the RFC . . . substantial evidence does not support the ALJ’s RFC
determination due to the exclusion of these limitations.”).
The omission frustrates the task of judicial review. On this record,
we cannot say if substantial evidence supports the ALJ’s conclusion that
Steinmetz has the residual functional capacity for medium work.

Burnett, 220 F.3d 123 (“Because the ALJ erred in not evaluating all of
the medical evidence, this Court cannot now assess whether the ALJ's
determination that [claimant] has the residual functional capacity to
perform ‘light’ work was supported by substantial evidence[.]”).
Accordingly, a remand is required for further consideration of this issue.
Because we hold that a remand is necessary, we do not reach
consideration of plaintiff’s other alleged errors. While we reach this
conclusion, we note that nothing in this Memorandum Opinion should be
deemed as expressing a judgment on the ultimate outcome of this matter.
Rather, that task is left to the ALJ on remand.
29

IV.

Conclusion
For the foregoing reasons, the decision of the Commissioner will be

REMANDED for further consideration.
An appropriate order follows.

S/ Daryl F. Bloom

Daryl F. Bloom
United States Magistrate Judge

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