Lee v. O'Malley

Filing 17

MEMORANDUM (Order to follow as separate docket entry) re: 1 Complaint filed by Rashim Lee. Signed by Magistrate Judge Martin C Carlson on 3/10/25. (rw)

IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
RASHIM LEE,

:
:
Plaintiff
:
:
v.
:
:
LELAND DUDEK,
:
1
Acting Commissioner of Social Security, :
:
Defendant.
:

Civil No. 3:24-CV-00893
(Magistrate Judge Carlson)

MEMORANDUM OPINION
I.

Introduction
Case law has long placed a duty of articulation upon Administrative Law

Judges when deciding Social Security disability claims. Thus, the ALJ's decision
must be accompanied by “a clear and satisfactory explication of the basis on which
it rests.” Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981). Conflicts in the evidence
must be resolved and the ALJ must indicate which evidence was accepted, which
evidence was rejected, and the reasons for rejecting certain evidence. Id. at 706-

Leland Dudek became the Acting Commissioner of Social Security on February 16,
2025. Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure, Leland Dudek
should be substituted for the previously named defendant in this suit. No further
action need be taken to continue this suit by reason of the last sentence of section
205(g) of the Social Security Act, 42 U.S.C. § 405(g).

1

1

707. In addition, “[t]he ALJ must indicate in his decision which evidence he has
rejected and which he is relying on as the basis for his finding.” Schaudeck v.
Comm’r of Soc. Sec., 181 F. 3d 429, 433 (3d Cir. 1999). A necessary corollary to
this duty of articulation is the concept that when a conflict in the evidence exists, the
ALJ may choose whom to credit but “cannot reject evidence for no reason or for the
wrong reason.” Mason v. Shalala, 994 F.2d 1058, 1066 (3d Cir. 1993). At a
minimum this obligation to articulate the basis of a disability determination means
that the ALJ’s ruling must correctly state the facts as they relate to the claimant’s
disabilities. Accordingly, when an ALJ’s decision rests upon a material
misapprehension concerning the facts, a remand is often necessary.
So it is here.
Rashim Lee was a fifty year old worker who applied for disability benefits
based upon the combined effects of a series of severe impairments, including
osteoarthritis; rotator cuff tear; cubital tunnel syndrome; diabetes; and neuropathy.
(Tr. 20). Lee’s treating physician reported that these impairments confined him to a
limited range of sedentary work. (Tr. 968-69). This view was shared by an
examining, consulting physician who also agreed that Lee could do no more than a
limited range of sedentary work. (Tr. 690-99). Thus, every physician who actually
treated or examined Lee agreed that he was limited to sedentary work due to his
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physical impairments. Moreover, the first state agency expert to consider Lee’s case
also found that he could only perform sedentary work, and therefore could not return
to his past relevant work. (Tr. 61-65). The only contrary view that deviated from this
medical consensus was the opinion of a second non-examining state agency source,
who found on reconsideration that Lee could perform light work. (Tr. 82-86).
Thus, the preponderance of the medical opinion evidence—including one
state agency expert opinion—clearly stated that Lee could only perform a limited
range of sedentary work. Notwithstanding this evidence, the ALJ found that Lee
could perform light work. (Tr. 21). In reaching this result the ALJ concluded—
incorrectly—that both state agency experts determined that Lee could perform light
work. (Tr. 23). The ALJ then relied upon this inaccurate recital regarding the medical
opinion evidence to support his residual functional capacity assessment, and his
finding that Lee was not disabled. (Tr. 26-27).
This conclusion rests on a misstatement of fact. The ALJ erroneously
characterized the medical opinion as being in equipoise with two medical opinions
supporting a light work RFC and two other opinions restricting Lee to sedentary
work. In fact, the preponderance of the medical opinion evidence from three of the
four medical sources agreed that Lee could only perform sedentary work. Since the
ALJ’s decision was grounded upon this potentially material factual error concerning
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the medical opinion evidence, we find that this decision’s evaluation of the medical
opinion evidence is based upon “the wrong reason.” Id. Accordingly, we will remand
this case for further consideration and evaluation of the medical opinion evidence.
II.

Statement of Facts and of the Case
In November of 2021, Rashim Lee filed an application for a period of

disability and disability insurance benefits along with an application for
supplemental security income pursuant to Titles II and XVI of the Social Security
Act. on November 10, 2021. In both applications, Lee alleged an onset of disability
beginning January 2, 2020. (Tr. 17). According to Lee he had become disabled due
to the combined effects of the following severe impairments: osteoarthritis; rotator
cuff tear; cubital tunnel syndrome; diabetes; and neuropathy. (Tr. 20). Lee was born
on December 17, 1971, and was 50 years old, which under the Commissioner’s
regulations made him an individual closely approaching advanced age, on the
amended alleged disability onset date. (Tr. 25).
Lee’s disability application was supported by nearly 700 pages of clinical
records and medical opinions. (Tr. 355-1026). In particular, the record contained
four medical opinions, three of which found that Lee could do no more than
sedentary work.

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One of these opinions came from a treating physician, Dr. Mark Goedecker,
who provided physical assessment of Lee on February 9, 2023. (Tr. 968-69). In this
assessment Dr. Goedecker stated that Lee’s impairments would constantly interfere
with his ability to work; indicated that he would need at least four unscheduled
breaks during the workday; found that he could only lift ten or twenty pounds
occasionally; determined that Lee would be limited in reaching and fingering; and
reported that Lee would miss more than four days of work each month. (Id.) Thus,
at best, based upon his treating relationship with the plaintiff, Dr. Goedecker opined
that Lee could do no more than a confined scope of sedentary work.
Dr. Goedecker’s conclusions were echoed by a consulting examining
physician, Dr. Ahmed Kneifati, who conducted an examination of Lee on March 9,
2022. (Tr. 690-99). Based upon his examination, Dr. Kneifati found that Lee could
only occasionally lift of carry up to ten pounds; was limited in his right hand reaching
and feeling; and was subject to multiple postural and environmental limitations. (Tr.
694-97). Dr. Kneifati’s findings also clearly restricted Lee to no more than a limited
range of sedentary work.
This conclusion was also shared by the first state agency expert to examine
Lee’s case, Dr. Gerald Levandoski. (Tr. 56-66). On March 30, 2022, Dr. Levandoski
issued an opinion in Lee’s case. (Id.) Dr. Levandoski found that Lee could only
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occasionally life up to ten pounds. (Tr. 61). He also found that Lee would be subject
to an array of limitations in terms of reaching, fingering, stooping, balancing,
kneeling and crouching. (Tr. 61-2). Moreover, according to Dr. Levandoski Lee
would need to avoid extreme cold, vibrations and machinery hazards. (Tr. 63). Dr.
Levandoski specifically found that Lee was confined to sedentary work due to his
impairments. (Tr. 65).
Thus, the record reveals a broad medical consensus among treating,
examining, and state agency expert sources that Lee could do no more than a limited
range of sedentary work, a potentially significant finding given Lee’s status as a
worker closely approaching advanced age. The only outlier among these medical
opinions was a second non-examining state agency source, Dr. Angela Walker, who
opined on December 13, 2022, that Lee could perform light work. (Tr. 86).
It was against this clinical backdrop that an ALJ conducted a hearing
regarding Lee’s disability application on June 28, 2023, at which Lee and a
vocational expert testified. (Tr. 34-54). Following this hearing, on August 2, 2023,
the ALJ issued a decision denying Lee’s application for benefits. (Tr. 14-31). In that
decision, the ALJ first concluded that Lee met the insured status requirements of the
Social Security Act through December 31, 2023 and had not engaged in substantial
gainful activity since January 2, 2020, the alleged onset date. (Tr. 19-20). At Step 2
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of the sequential analysis that governs Social Security cases, the ALJ found that Lee
suffered from the following severe impairments: osteoarthritis; rotator cuff tear;
cubital tunnel syndrome; diabetes; and neuropathy. (Tr. 20). At Step 3 the ALJ
determined that Lee did not have an impairment or combination of impairments that
met or medically equaled the severity of one of the listed impairments. (Id.)
The ALJ then fashioned the following RFC for the plaintiff:
After careful consideration of the entire record, the undersigned finds
that the claimant has the residual functional capacity to perform light
work as defined in 20 CFR 404.1567(b) and 416.967(b) and he can
frequently handle, finger, and feel with his right upper extremity; and
occasionally reach, push, and pull with his right upper extremity. He
can occasionally crawl and never climb ladders, ropes, or scaffolds. He
should avoid concentrated exposure to extreme cold and vibrations and
even moderate exposure to dangerous machinery or unprotected
heights.
(Tr. 21).
In reaching this conclusion, which deviated from three out of the four medical
opinions in this case, the ALJ first concluded that the opinions of Doctors Kneifati
and Goedecker—the only physicians who had actually treated, examined, or seen
Lee—were unpersuasive. (Tr. 23-24). The ALJ then misstated and overstated the
state agency expert medical opinion evidence. According to the ALJ:
The record includes a March 2022 prior administrative medical finding
from a state agency medical consultant, Gerald Levandoski, MD. Dr.
Levandoski stated the claimant could perform light work; stand and/or
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walk two hours in an eight-hour workday; occasionally balance, stoop,
kneel, crouch, and climb ramps and stairs; never crawl and climb
ladders, ropes, or scaffolds; frequently handle and occasionally reach
overhead with his right upper extremity; limited far acuity and near
acuity in the right eye; and avoid concentrated exposure to extreme
cold, vibration, and hazards (2A/6-9; 4A/6-9). The record includes a
December 2022 prior administrative medical finding from a state
agency medical consultant, Angela Teresa Walker, MD. Dr. Walker
noted the claimant could perform light work; occasionally push, pull,
and operate hand controls with his right upper extremity; occasionally
crawl; never crawl and climb ladders, ropes, or scaffolds; frequently
handle, finger, or feel and occasionally reach with his right upper
extremity; avoid concentrated exposure to extreme cold and vibration;
and avoid moderate exposure to hazards (6A/5-7; 8A/6-9). Insofar as
they state the claimant can perform light work; frequently handle,
finger, and feel with his right upper extremity; and occasionally reach,
push, and pull with his right upper extremity; occasionally crawl; never
climb ladders, ropes, or scaffolds; should avoid concentrated exposure
to extreme cold and vibrations; even moderate exposure to dangerous
machinery or unprotected heights; these statements are supported by
the longitudinal treatment notes, which generally show the claimant is
in no acute distress with good range of motion, normal and symmetric
hands, capillary refill in less than two seconds, symmetric pulses, intact
cranial nerves, no atrophy, no focal deficit, no clubbing, no cyanosis,
and no edema (2F; 5F; 6F; 10F; 14F; 16F; 17F; 19F; 20F; 21F). These
statements are also consistent with the claimant’s activities of daily
living, which shows he helps care for his dog and can prepare simple
meals and shop in stores (3E; 9E). Further, Dr. Levandoski and Dr.
Walker are highly qualified experts who had the opportunity to review
the claimant’s records.
(Tr. 23) (emphasis added).
This description clearly misstated Dr. Levandoski’s opinion. Contrary to the
ALJ’s assertion, Dr. Levandoski never opined that Lee could perform light work.
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Instead, the doctor flatly stated that Lee was limited to sedentary work, thus
concurring in the opinions of the treating and examining sources. Moreover, the
ALJ’s factual misstatement erroneously altered the quantum of evidence in a way
which plainly prejudiced Lee. Instead of accurately describing the opinion evidence
as a broad consensus among treating, examining, and state agency sources restricting
Lee to sedentary work, with one outlying opinion, the ALJ suggested that the opinion
evidence was somehow evenly balanced between two experts who opined that Lee
could perform light work and two other experts who limited him to sedentary work.
Having erred in this fashion, the ALJ then chose to adopt a light work RFC for Lee,
even though the preponderance of the medical opinion evidence when accurately
understood, found that he could not perform light work. The ALJ then relied upon
this inaccurate recital regarding the medical opinion evidence to support his residual
functional capacity assessment, and his finding that Lee was not disabled. (Tr. 2627).
This appeal followed. (Doc. 1). On appeal, Lee challenges the ALJ’s
evaluation of this medical opinion evidence. Since we find that this medical opinion
evidence evaluation rests upon a material factual error, we agree that the ALJ’s
responsibility of adequately articulating the basis for a medical opinion evaluation

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has not been met in this this case. Therefore, we will remand this case for further
consideration and evaluation of the medical opinion evidence.
III.

Discussion
A.

Substantial Evidence Review – the Role of this Court

When reviewing the Commissioner’s final decision denying a claimant’s
application for benefits, this Court’s review is limited to the question of whether the
findings of the final decision-maker are supported by substantial evidence in the
record. See 42 U.S.C. §405(g); Johnson v. Comm’r of Soc. Sec., 529 F.3d 198, 200
(3d Cir. 2008); Ficca v. Astrue, 901 F. Supp.2d 533, 536 (M.D.Pa. 2012).
Substantial evidence “does not mean a large or considerable amount of evidence, but
rather such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.” Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial
evidence is less than a preponderance of the evidence but more than a mere scintilla.
Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of evidence is not
substantial evidence if the ALJ ignores countervailing evidence or fails to resolve a
conflict created by the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir.
1993). But in an adequately developed factual record, substantial evidence may be
“something less than the weight of the evidence, and the possibility of drawing two
inconsistent conclusions from the evidence does not prevent [the ALJ’s decision]
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from being supported by substantial evidence.” Consolo v. Fed. Maritime Comm’n,
383 U.S. 607, 620 (1966). “In determining if the Commissioner’s decision is
supported by substantial evidence the court must scrutinize the record as a whole.”
Leslie v. Barnhart, 304 F. Supp.2d 623, 627 (M.D.Pa. 2003).
The Supreme Court has underscored for us the limited scope of our review in
this field, noting that:
The phrase “substantial evidence” is a “term of art” used throughout
administrative law to describe how courts are to review agency
factfinding. T-Mobile South, LLC v. Roswell, 574 U.S. ––––, ––––,
135 S.Ct. 808, 815, 190 L.Ed.2d 679 (2015). Under the substantialevidence standard, a court looks to an existing administrative record
and asks whether it contains “sufficien[t] evidence” to support the
agency's factual determinations. Consolidated Edison Co. v. NLRB,
305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) (emphasis
deleted). And whatever the meaning of “substantial” in other contexts,
the threshold for such evidentiary sufficiency is not high. Substantial
evidence, this Court has said, is “more than a mere scintilla.” Ibid.; see,
e.g., Perales, 402 U.S. at 401, 91 S.Ct. 1420 (internal quotation marks
omitted). It means—and means only—“such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.”
Consolidated Edison, 305 U.S. at 229, 59 S.Ct. 206. See Dickinson v.
Zurko, 527 U.S. 150, 153, 119 S.Ct. 1816, 144 L.Ed.2d 143 (1999)
(comparing the substantial-evidence standard to the deferential clearlyerroneous standard).
Biestek, 139 S. Ct. at1154.
The question before this Court, therefore, is not whether the claimant is
disabled, but rather whether the Commissioner’s finding that she is not disabled is

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supported by substantial evidence and was reached based upon a correct application
of the relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205,
at *1 (M.D.Pa. Mar. 11, 2014) (“[I]t has been held that an ALJ’s errors of law denote
a lack of substantial evidence.”) (alterations omitted); Burton v. Schweiker, 512 F.
Supp. 913, 914 (W.D. Pa. 1981) (“The Secretary’s determination as to the status of
a claim requires the correct application of the law to the facts.”); see also Wright v.
Sullivan, 900 F.2d 675, 678 (3d Cir. 1990) (noting that the scope of review on legal
matters is plenary); Ficca, 901 F. Supp.2d at 536 (“[T]he court has plenary review
of all legal issues . . . .”).
Several fundamental legal propositions which flow from this deferential
standard of review. First, when conducting this review “we are mindful that we must
not substitute our own judgment for that of the fact finder.” Zirnsak v. Colvin, 777
F.3d 607, 611 (3d Cir. 2014) (citing Rutherford, 399 F.3d at 552). Thus, we are
enjoined to refrain from trying to re-weigh the evidence. Rather our task is to simply
determine whether substantial evidence supported the ALJ’s findings. However, we
must also ascertain whether the ALJ’s decision meets the burden of articulation
demanded by the courts to enable informed judicial review. Simply put, “this Court
requires the ALJ to set forth the reasons for his decision.” Burnett v. Comm'r of Soc.

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Sec. Admin., 220 F.3d 112, 119 (3d Cir. 2000). As the Court of Appeals has noted
on this score:
In Burnett, we held that an ALJ must clearly set forth the reasons for
his decision. 220 F.3d at 119. Conclusory statements . . . are
insufficient. The ALJ must provide a “discussion of the evidence” and
an “explanation of reasoning” for his conclusion sufficient to enable
meaningful judicial review. Id. at 120; see Jones v. Barnhart, 364 F.3d
501, 505 & n. 3 (3d Cir.2004). The ALJ, of course, need not employ
particular “magic” words: “Burnett does not require the ALJ to use
particular language or adhere to a particular format in conducting his
analysis.” Jones, 364 F.3d at 505.
Diaz v. Comm'r of Soc. Sec., 577 F.3d 500, 504 (3d Cir. 2009).
Thus, in practice ours is a twofold task. We must evaluate the substance of the
ALJ’s decision under a deferential standard of review, but we must also give that
decision careful scrutiny to ensure that the rationale for the ALJ’s actions is
sufficiently articulated to permit meaningful judicial review.
B.

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

To receive benefits under the Social Security Act by reason of disability, a
claimant must demonstrate an inability to “engage in any substantial gainful activity
by reason of any medically determinable physical or mental impairment which can
be expected to result in death or which has lasted or can be expected to last for a
continuous period of not less than 12 months.” 42 U.S.C. §423(d)(1)(A); 42 U.S.C.
§1382c(a)(3)(A); see also 20 C.F.R. §§404.1505(a), 416.905(a). To satisfy this
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requirement, a claimant must have a severe physical or mental impairment that
makes it impossible to do his or her previous work or any other substantial gainful
activity that exists in the national economy. 42 U.S.C. §423(d)(2)(A); 42 U.S.C.
§1382c(a)(3)(B); 20 C.F.R. §§404.1505(a), 416.905(a). To receive benefits under
Title II of the Social Security Act, a claimant must show that he or she contributed
to the insurance program, is under retirement age, and became disabled prior to the
date on which he or she was last insured. 42 U.S.C. §423(a); 20 C.F.R. §404.131(a).
In making this determination at the administrative level, the ALJ follows a
five-step sequential evaluation process.

20 C.F.R. §§404.1520(a), 416.920(a).

Under this process, the ALJ must sequentially determine: (1) whether the claimant
is engaged in substantial gainful activity; (2) whether the claimant has a severe
impairment; (3) whether the claimant’s impairment meets or equals a listed
impairment; (4) whether the claimant is able to do his or her past relevant work; and
(5) whether the claimant is able to do any other work, considering his or her age,
education, work experience and residual functional capacity (“RFC”). 20 C.F.R.
§§404.1520(a)(4), 416.920(a)(4).
Between Steps 3 and 4, the ALJ must also assess a claimant’s residual
functional capacity (RFC). RFC is defined as “that which an individual is still able
to do despite the limitations caused by his or her impairment(s).” Burnett v. Comm’r
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of Soc. Sec., 220 F.3d 112, 121 (3d Cir. 2000) (citations omitted); see also 20 C.F.R.
§§404.1520(e), 404.1545(a)(1), 416.920(e), 416.945(a)(1).

In making this

assessment, the ALJ considers all of the claimant’s medically determinable
impairments, including any non-severe impairments identified by the ALJ at step
two of his or her analysis. 20 C.F.R. §§404.1545(a)(2), 416.945(a)(2).
Once the ALJ has made this determination, our review of the ALJ's
assessment of the plaintiff's RFC is deferential, and that RFC assessment will not be
set aside if it is supported by substantial evidence. Burns v. Barnhart, 312 F.3d 113,
129 (3d Cir. 2002); see also Metzger v. Berryhill, No. 3:16-CV-1929, 2017 WL
1483328, at *5 (M.D. Pa. Mar. 29, 2017), report and recommendation adopted sub
nom. Metzgar v. Colvin, No. 3:16-CV-1929, 2017 WL 1479426 (M.D. Pa. Apr. 21,
2017); Rathbun v. Berryhill, No. 3:17-CV-00301, 2018 WL 1514383, at *6 (M.D.
Pa. Mar. 12, 2018), report and recommendation adopted, No. 3:17-CV-301, 2018
WL 1479366 (M.D. Pa. Mar. 27, 2018).
At Steps 1 through 4, the claimant bears the initial burden of demonstrating
the existence of a medically determinable impairment that prevents him or her in
engaging in any of his or her past relevant work. Mason, 994 F.2d at 1064. Once this
burden has been met by the claimant, it shifts to the Commissioner at Step 5 to show
that jobs exist in significant number in the national economy that the claimant could
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perform that are consistent with the claimant’s age, education, work experience and
RFC. 20 C.F.R. §§404.1512(f), 416.912(f); Mason, 994 F.2d at 1064.
There is an undeniable medical aspect to an RFC determination, since that
determination entails an assessment of what work the claimant can do given the
physical limitations that the claimant experiences. Yet, when considering the role
and necessity of medical opinion evidence in making this determination, courts have
followed several different paths. Some courts emphasize the importance of medical
opinion support for an RFC determination and state that “[r]arely can a decision be
made regarding a claimant's residual functional capacity without an assessment from
a physician regarding the functional abilities of the claimant.” Biller, 962 F.Supp.2d
at 778–79 (quoting Gormont v. Astrue, Civ. No. 11–2145, 2013 WL 791455 at *7
(M.D. Pa. Mar. 4, 2013)). In other instances, it has been held that “[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). Further, courts have held in cases where there is no evidence of any
credible medical opinion supporting a claimant’s allegations of disability that “the
proposition that an ALJ must always base his RFC on a medical opinion from a
physician is misguided.” Cummings v. Colvin, 129 F.Supp.3d 209, 214–15 (W.D.
Pa. 2015).
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These seemingly discordant legal propositions can be reconciled by
evaluation of the factual context of these decisions. Those cases which emphasize
the importance of medical opinion support for an RFC assessment typically arise in
the factual setting, like that presented here, where well-supported medical sources
have opined regarding limitations which would support a disability claim, but an
ALJ has rejected the medical opinion which supported a disability determination
based upon a lay assessment of other evidence. Biller, 962 F.Supp.2d at 778–79. In
this setting, these cases simply restate the commonplace idea that medical opinions
are entitled to careful consideration when making a disability determination,
particularly when those opinions support a finding of disability. In contrast, when
no medical opinion supports a disability finding or when an ALJ is relying upon
other evidence, such as contrasting clinical or opinion evidence or testimony
regarding the claimant’s activities of daily living, to fashion an RFC courts have
adopted a more pragmatic view and have sustained the ALJ’s exercise of
independent judgment based upon all of the facts and evidence. See Titterington,
174 F. App'x 6; Cummings, 129 F.Supp.3d at 214–15. In either event, once the ALJ
has made this determination, our review of the ALJ's assessment of the plaintiff's
RFC is deferential, and that RFC assessment will not be set aside if it is supported

17

by substantial evidence. Burns v. Barnhart, 312 F.3d 113; see also Metzger v.
Berryhill, 2017 WL 1483328, at *5; Rathbun v. Berryhill, 2018 WL 1514383, at *6.
The ALJ’s disability determination must also meet certain basic substantive
requisites. Most significant among these legal benchmarks is a requirement that the
ALJ adequately explain the legal and factual basis for this disability determination.
Thus, in order to facilitate review of the decision under the substantial evidence
standard, the ALJ's decision must be accompanied by “a clear and satisfactory
explication of the basis on which it rests.” Cotter v. Harris, 642 F.2d 700, 704 (3d
Cir. 1981). Conflicts in the evidence must be resolved and the ALJ must indicate
which evidence was accepted, which evidence was rejected, and the reasons for
rejecting certain evidence. Id. at 706-707. In addition, “[t]he ALJ must indicate in
his decision which evidence he has rejected and which he is relying on as the basis
for his finding.” Schaudeck v. Comm’r of Soc. Sec., 181 F. 3d 429, 433 (3d Cir.
1999).
C.

Legal Benchmarks for the ALJ’s Assessment of Medical Opinions

Lee filed his disability application following a paradigm shift in the manner
in which medical opinions were evaluated when assessing Social Security claims.
Prior to March 2017, ALJs were required to follow regulations that defined medical
opinions narrowly and created a hierarchy of medical source opinions with treating
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sources at the apex of this hierarchy. However, in March of 2017, the
Commissioner’s regulations governing medical opinions changed in a number of
fundamental ways. The range of opinions that ALJs were enjoined to consider were
broadened substantially, and the approach to evaluating opinions was changed from
a hierarchical form of review to a more holistic analysis. As one court has aptly
observed:
The regulations regarding the evaluation of medical evidence have been
amended for claims filed after March 27, 2017, and several of the prior
Social Security Rulings, including SSR 96-2p, have been rescinded.
According to the new regulations, the Commissioner “will no longer
give any specific evidentiary weight to medical opinions; this includes
giving controlling weight to any medical opinion.” Revisions to Rules
Regarding the Evaluation of Medical Evidence (“Revisions to Rules”),
2017 WL 168819, 82 Fed. Reg. 5844, at 5867–68 (Jan. 18, 2017), see
20 C.F.R. §§ 404.1520c(a), 416.920c(a). Instead, the Commissioner
must consider all medical opinions and “evaluate their persuasiveness”
based on the following five factors: supportability; consistency;
relationship with the claimant; specialization; and “other factors.” 20
C.F.R. §§ 404.1520c(a)-(c), 416.920c(a)-(c).
Although the new regulations eliminate the perceived hierarchy of
medical sources, deference to specific medical opinions, and assigning
“weight” to a medical opinion, the ALJ must still “articulate how [he
or she] considered the medical opinions” and “how persuasive [he or
she] find[s] all of the medical opinions.” Id. at §§ 404.1520c(a) and
(b)(1), 416.920c(a) and (b)(1). The two “most important factors for
determining the persuasiveness of medical opinions are consistency and
supportability,” which are the “same factors” that formed the
foundation of the treating source rule. Revisions to Rules, 82 Fed. Reg.
5844-01 at 5853.
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An ALJ is specifically required to “explain how [he or she] considered
the supportability and consistency factors” for a medical opinion. 20
C.F.R. §§ 404.1520c (b)(2), 416.920c(b)(2). With respect to
“supportability,” the new regulations provide that “[t]he more relevant
the objective medical evidence and supporting explanations presented
by a medical source are to support his or her medical opinion(s) or prior
administrative medical finding(s), the more persuasive the medical
opinions or prior administrative medical finding(s) will be.” Id. at §§
404.1520c(c)(1), 416.920c(c)(1). The regulations provide that with
respect to “consistency,” “[t]he more consistent a medical opinion(s) or
prior administrative medical finding(s) is with the evidence from other
medical sources and nonmedical sources in the claim, the more
persuasive the medical opinion(s) or prior administrative medical
finding(s) will be.” Id. at §§ 404.1520c(c)(2), 416.920c(c)(2).
Under the new regulations an ALJ must consider, but need not
explicitly discuss, the three remaining factors in determining the
persuasiveness of a medical source's opinion. Id. at §§ 404.1520c(b)(2),
416.920c(b)(2). However, where the ALJ has found two or more
medical opinions to be equally well supported and consistent with the
record, but not exactly the same, the ALJ must articulate how he or she
considered those factors contained in paragraphs (c)(3) through (c)(5).
Id. at §§ 404.1520c(b)(3), 416.920c(b)(3).
Andrew G. v. Comm'r of Soc. Sec., No. 3:19-CV-0942 (ML), 2020 WL 5848776, at
*5 (N.D.N.Y. Oct. 1, 2020).
Oftentimes, as in this case, an ALJ must evaluate various medical opinions.
Judicial review of this aspect of ALJ decision-making is still guided by several
settled legal tenets. First, when presented with a disputed factual record, it is well
established that “[t]he ALJ – not treating or examining physicians or State agency
consultants – must make the ultimate disability and RFC determinations.” Chandler
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v. Comm’r of Soc. Sec., 667 F.3d 356, 361 (3d Cir. 2011). Thus, when evaluating
medical opinions “ the ALJ may choose whom to credit but ‘cannot reject evidence
for no reason or for the wrong reason.’” Morales v. Apfel, 225 F.3d 310, 317 (3d
Cir. 2000) (quoting Mason, 994 F.2d at 1066). Therefore, provided that the decision
is accompanied by an adequate, articulated rationale, it is the province and the duty
of the ALJ to choose which medical opinions and evidence deserve greater weight.
Further, in making this assessment of medical evidence:
An ALJ is [also] entitled generally to credit parts of an opinion without
crediting the entire opinion. See Thackara v. Colvin, No. 1:14–CV–
00158–GBC, 2015 WL 1295956, at *5 (M.D. Pa. Mar. 23, 2015);
Turner v. Colvin, 964 F. Supp. 2d 21, 29 (D.D.C. 2013) (agreeing that
“SSR 96–2p does not prohibit the ALJ from crediting some parts of a
treating source's opinion and rejecting other portions”); Connors v.
Astrue, No. 10–CV–197–PB, 2011 WL 2359055, at *9 (D.N.H. June
10, 2011). It follows that an ALJ can give partial credit to all medical
opinions and can formulate an RFC based on different parts from the
different medical opinions. See e.g., Thackara v. Colvin, No. 1:14–CV–
00158–GBC, 2015 WL 1295956, at *5 (M.D. Pa. Mar. 23, 2015).
Durden v. Colvin, 191 F.Supp.3d 429, 455 (M.D. Pa. 2016).
Finally, with respect to assessing competing medical opinion evidence, it is
clear beyond peradventure that:
When a conflict in the evidence exists, the ALJ may choose whom to
credit but “cannot reject evidence for no reason or for the wrong
reason.” Mason v. Shalala, 994 F.2d 1058, 1066 (3d Cir.1993). The
ALJ must consider all the evidence and give some reason for

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discounting the evidence she rejects. See Stewart v. Secretary of
H.E.W., 714 F.2d 287, 290 (3d Cir.1983).
Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999).
It is against these legal benchmarks that we assess the instant appeal.
D.

This Case Should Be Remanded for Further Consideration of the
Medical Opinion Evidence.

This case presents a striking circumstance. It is clear that the ALJ’s medical
opinion evidence evaluation rests upon a false premise, the notion that both state
agency experts agreed that Lee could perform light work.
This was error. The opinion evidence was not evenly divided as the ALJ
suggested in this decision. Rather, that opinion evidence revealed a broad consensus
among treating, examining, and state agency sources restricting Lee to sedentary
work, with only one outlying opinion. Because this error misstated the opinion
evidence in a fundamental, and fundamentally prejudicial way, a remand is
necessary here. This is not a novel conclusion on our part. Quite the contrary, it is
entirely in accord with our past practice when presented with ALJ decisions which
are based upon a misapprehension regarding the medical expert opinions. See e.g.,
Dunn v. Kijakazi, No. 1:21-CV-91, 2022 WL 17584231, at *11 (M.D. Pa. Dec. 12,
2022); Perfinski v. Saul, No. 1:20-CV-78, 2021 WL 1060360, at *8 (M.D. Pa. Mar.
19, 2021).
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Moreover, in the absence of some further explanation and articulation of its
rationale, the ALJ’s decision cannot be reconciled with the revised medical opinion
regulations that the ALJ was obliged to follow. Those regulations eschew any
hierarchical ranking of opinions, but call upon ALJ’s to evaluate medical opinions
against the following benchmarks:
(1) Supportability. The more relevant the objective medical evidence

and supporting explanations presented by a medical source are to
support his or her medical opinion(s) or prior administrative medical
finding(s), the more persuasive the medical opinions or prior
administrative medical finding(s) will be.
(2) Consistency. The more consistent a medical opinion(s) or prior
administrative medical finding(s) is with the evidence from other
medical sources and nonmedical sources in the claim, the more
persuasive the medical opinion(s) or prior administrative medical
finding(s) will be.
(3) Relationship with the claimant. This factor combines consideration
of the issues in paragraphs (c)(3)(i) through (v) of this section.
(i) Length of the treatment relationship. The length of time a
medical source has treated you may help demonstrate whether
the medical source has a longitudinal understanding of your
impairment(s).
(ii) Frequency of examinations. The frequency of your visits
with the medical source may help demonstrate whether the
medical source has a longitudinal understanding of your
impairment(s).
(iii) Purpose of the treatment relationship. The purpose for
treatment you received from the medical source may help
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demonstrate the level of knowledge the medical source has of
your impairment(s).
(iv) Extent of the treatment relationship. The kinds and extent
of examinations and testing the medical source has performed
or ordered from specialists or independent laboratories may
help demonstrate the level of knowledge the medical source has
of your impairment(s).
(v) Examining relationship. A medical source may have a better
understanding of your impairment(s) if he or she examines you
than if the medical source only reviews evidence in your folder.
20 C.F.R. § 404.1520c.
In this case, once the medical opinions are correctly described it is apparent
that there was a consensus among the treating and examining sources that Lee was
confined to a limited range of sedentary work. This consensus was also shared by
the first state agency expert who review this case, Dr. Levandoski. Thus, when we
consider the consistency of the medical opinions—one of the key factors which must
now be assessed—it is evident that the greater weight of consistent opinion evidence
favors a finding that Lee could only perform sedentary work. Moreover, these
opinions represented not only the preponderance of the medical opinion evidence,
two of the opinions were issued by treating or examining sources who had greater
opportunities to assess Lee’s limitations. In light of this significant medical evidence
which undermined the ALJ’s RFC determination, and the fact that this RFC seems
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to rest upon a basic misunderstanding regarding the true state of the medical
opinions, a remand is necessary in this case.
In sum, under the regulations governing evaluation of medical opinion
evidence, more is needed by way of explanation in this case. Since the ALJ’s burden
of articulation is not met in the instant case, this matter must be remanded for further
consideration by the Commissioner. Yet, while we reach this result, we note that
nothing in this Memorandum Opinion should be deemed as expressing a judgment
on what the ultimate outcome of any reassessment of this evidence should be. Rather,
the task should remain the duty and province of the ALJ on remand.
IV.

Conclusion
Accordingly, for the foregoing reasons, IT IS ORDERED that the plaintiff’s

request for a new administrative hearing is GRANTED, the final decision of the
Commissioner denying these claims is vacated, and this case is remanded to the
Commissioner to conduct a new administrative hearing.
An appropriate order follows.
/s/ Martin C. Carlson
Martin C. Carlson
United States Magistrate Judge
DATED: March 10, 2025

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