Case Name in Social Security Case - Unavailable

IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
LISSETTE SOTO, 	: Civil No. 1:25-CV-365
:
Plaintiff, 	:
:
v. 	:
: (Chief Magistrate Judge Bloom)
FRANK BISIGNANO, 	:
Commissioner of Social Security,1 	:
:
Defendant. 	:
MEMORANDUM OPINION
I. 	Introduction
Lissette Soto filed an application under Titles II and XVI of the
Social Security Act for disability benefits and supplemental security
income on April 6, 2022. 	Following a hearing before an Administrative
Law Judge (“ALJ”), the ALJ found that Soto was not disabled from her
alleged onset of disability, April 4, 2022, through the date of the ALJ’s
decision, April 19, 2024.2
1 	Frank 	Bisignano 	became 	the 	Commissioner 	of 	Social 	Security 	on
May 7, 2025. Pursuant to Rule 25(d) of the Federal Rules of Civil
Procedure 	and 	42 	U.S.C. 	§ 	405(g), 	Bisignano 	is 	substituted 	as 	the
defendant in this suit.
2 Tr. 31.
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Soto now appeals this decision, arguing that the ALJ’s decision is
not supported by substantial evidence. After a review of the record, and
mindful of the fact that substantial evidence “means only—‘such relevant
evidence as a reasonable mind might accept as adequate to support a
conclusion,’” 3 we conclude that substantial evidence supports the ALJ’s
findings in this case. 	Therefore, we will affirm the decision of the
Commissioner denying this claim.
II. 	Statement of Facts and of the Case
Lissette Soto filed for disability benefits and supplemental security
income, alleging disability due to a host of physical and mental health
impairments, including arthritis, a left hip replacement, thyroid disease,
acquired 	deformity 	of 	a 	limb, 	and 	bilateral 	hand 	numbness 	and
weakness. 4 	Soto was 47 years old at the time of her alleged onset of
disability, had a high school education, and had past work as a machine
packager. 5
3
Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019).
4 Tr. 98.
5 Tr. 31-32.
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The administrative record in this case reveals that Soto suffered
from a host of physical impairments. 6 	Prior to her alleged onset date, in
June of 2021, Soto complained of hip pain following a left hip replacement
surgery in 2019.7 	An examination revealed a stiff gait favoring her left
hip, tenderness, groin pain, and 4/5 strength in her left hip. 8 	Soto was
not interested in physical therapy, and her provider noted that she may
not have been completing all of her home exercises daily. 9 	Soto received
an MRI of her lumbar spine in August of 2021, which showed minor
spondylosis at L4-5 and L5-S1.10
In February of 2022, Soto presented to an orthopedic urgent care
for 	lower 	back 	and 	left 	shoulder 	pain. 11 	She 	further 	reported
experiencing numbness of her bilateral hands for several years. 12 	On
examination, Soto had increased pain in her shoulder with range of
6 Because Soto’s appeal focuses only on her physical health impairments,
we 	will 	forego 	a 	discussion 	of 	the 	records 	of 	her 	mental 	health
impairments.
7 Tr. 441.
8 Tr. 442.
9 Tr. 443.
10 Tr. 477.
11 Tr. 785.
12
Id.
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motion, no significant tenderness, symmetric grip strength, a negative
straight leg raise, an antalgic gait, and guarded movements.13 	Imaging
of her cervical and lumbar spine showed slight narrowing at C5-C6.14
Soto subsequently received trigger point injections in her left shoulder. 15
Soto treated at the neurosurgery clinic at Penn State Hershey
Medical Center in March of 2022 for her upper extremity pain. 16 	On
examination, Soto had a normal gait, 5/5 strength in her lower and upper
extremities, and pain with abduction of her left shoulder. 17 	It was
recommended that she receive an MRI and undergo physical therapy. 18
Soto also met with interventional pain management around this time,
where she reported that her shoulder pain had improved somewhat, and
the trigger point injections were beneficial. 19 	A physical examination
revealed mild to moderate tenderness, normal range of motion with pain
13 Tr. 787.
14
Id.
15 Tr. 390.
16 Tr. 427.
17 Tr. 428.
18
Id.
19 Tr. 381.
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at end ranges, and positive Hawkins and Neer’s signs.20 Later in March,
Soto complained of right hip pain and presented with an antalgic gait
favoring her right leg. 21 On examination, she had pain and crepitus with
range of motion, her leg lengths were approximately equal, and she had
4/5 strength in both hips. 22 	An x-ray at this visit showed moderate to
severe osteoarthritis of her right hip.23 	She received injections in April,
as she was reluctant to have surgery.24
Soto also underwent a cervical spine MRI in June of 2022, which
showed multilevel degenerative changes. 25 	She followed up with the
neurosurgery clinic at Penn State, at which time the provider reviewed
the recent imaging and diagnosed her with cervical spinal stenosis and
radiculopathy. 26 	It was noted that she had “a good chance of improving
20 Tr. 383.
21 Tr. 465-66.
22 Tr. 466.
23
Id.
24 Tr. 466-69.
25 Tr. 410.
26 Tr. 412.
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with nonsurgical treatment options,” and the provider recommended
physical therapy as a next step.27
Soto treated for her right hip pain in July of 2022, at which time
she 	reported 	increased 	pain 	and 	difficulty 	with 	prolonged 	activity,
specifically 	with 	walking. 28 	At 	this 	time, 	she 	was 	working 	as 	a
housekeeper. 29 	It was noted that Soto had been using a cane or walker
for ambulation, and that she tried injections and physical therapy, both
of which were unsuccessful. 30 	An examination revealed an antalgic gait,
restricted hip motion, pain and crepitus with range of motion, and 4/5 hip
strength. 31 	Her provider recommended a total replacement of her right
hip, which she received in August.32
At her first postoperative visit in September of 2022, the provider
noted Soto was doing well, taking her narcotic pain medications, and
using a cane or walker for ambulation.33 	She was advised to continue
27 Tr. 412-13.
28 Tr. 470.
29
Id.
30
Id.
31 Tr. 471.
32 Tr. 471, 492.
33 Tr. 494.
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physical therapy. 34 	An x-ray interpretation at this visit showed that the
surgical components were located and “well positioned” and that Soto’s
“[l]eg lengths are approximately equal.” 35 	Soto’s initial physical therapy
evaluation indicated that she experienced significant pain and spasms
post-surgery. 36 	Her problem areas included decreased range of motion
and right lower extremity strength, gait dysfunction, constant pain, and
decreased tolerance for rising from a seated position and walking up and
down stairs. 37
During this time Soto also treated with Dr. Deborah Bernal, M.D.
for her low back and neck pain. 38 Dr. Bernal noted that Soto used a cane
and a walker since her right hip surgery and was complaining of muscle
cramps in her legs. 39 	It was noted that Dr. Bernal provided Soto with
instructions regarding her cane height. 40 	At a surgery follow up in
October, 	Soto 	ambulated 	well 	with 	a 	cane 	and 	limped 	without 	it,
34 Tr. 495.
35
Id.
36 Tr. 502.
37
Id.
38 Tr. 512.
39 Tr. 515.
40 Tr. 512.
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experienced muscle spasms, and exhibited 5/5 strength in her hips and
knees.41 	Physical therapy notes from around this time indicated that
Soto’s 	gait 	with 	a 	cane 	was 	steadily 	improving, 	but 	she 	reported
increased right knee pain.42 In November, Soto’s physical therapist noted
an improvement of a minimal antalgic gait pattern without an assistive
device, as well as minimal assistance needed from her upper extremities
to complete the exercises.43
Soto complained of continued right knee pain and ankle pain in
November, at which time it was noted that she “may have gone back to
work a little early and is now having an inflammatory flareup.” 44 	She
exhibited an antalgic gait without an assistive device.45 	At her third
surgery follow up, Soto reported experiencing spasms in her right leg and
using a cane.46 	Her provider noted she had a valgus deformity and
arthritis in her knees, and he recommended injections, which Soto
41 Tr. 531.
42 Tr. 571.
43 Tr. 535.
44 Tr. 707.
45 Tr. 706.
46 Tr. 708.
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declined. 47 	At a physical therapy appointment in December, Soto’s
primary complaint was her knee pain, with her therapist noting she
walked with an antalgic gait pattern using a cane.48
In January of 2023, Soto was seen at Family First Health for a
follow 	up 	of 	her 	hypothyroidism, 	at 	which 	time 	a 	musculoskeletal
examination noted that Soto was ambulating without assistance.49 	Soto
also followed up with Dr. Bernal around this time, who ordered an x-ray
to evaluate Soto’s leg length difference and advised her to wear a sole in
her left shoe for support at all times while walking. 50 	An x-ray revealed
mild valgus angulation of Soto’s right leg, and that her left leg was
shorter 	than 	her 	right. 51 	In 	March, 	at 	a 	post-surgery 	follow 	up
appointment, it was noted that Soto had good motion of the hip and good
strength, 	tenderness 	throughout 	her 	lumbar 	region 	and 	pain 	with
straight leg raise testing, and that she had a valgus deformity of her right
47
Id.
48 Tr. 720.
49 Tr. 808.
50 Tr. 744-45.
51 Tr. 754.
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knee.52 	The provider noted that Soto was doing well with respect to her
hip, and that she declined any intervention for her ongoing lumbar and
right leg pain. 53
In April, Soto was treated at Wellspan Orthopedics, at which time
she reported bilateral hip pain that was worse on her right side.54 	On
examination, she “ambulate[d] slowly and deliberately, but with no
distinct gait abnormality[]” and did not use an assistive device.55 	After
obtaining x-rays, the provider indicated that Soto may have had “an
extrinsic source of discomfort which most likely would be the lumbosacral
spine.” 56 	At her annual post-surgery follow up in August of 2023, Soto
complained of increased hip pain bilaterally, and reported she received
an injection two months prior. 57 	On examination, Soto exhibited good
range of motion, no instability, 5/5 strength, and was “[a]mbulating well
52 Tr. 829.
53
Id.
54 Tr. 775.
55 Tr. 777.
56 Tr. 778.
57 Tr. 826.
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with no limp and no devices[,] [and] able to sit comfortably in a chair and
rise without assistance.”58
At an urgent care visit in September, Soto reported increased low
back pain. 59 The treatment notes indicated that Soto’s providers believed
the issue to be her back rather than her hips, although the urgent care
provider noted “[s]he has yet to see spine provider from what I can see.”60
The provider ordered an MRI and a neurosurgery consult, given that
Soto’s 	“symptoms 	are 	complex 	and 	overlapping.”61 	In 	October, 	a
physiatry treatment note indicated that Soto was supposed to “[u]se the
heel lift at all times[,]” and provided instructions on cane height. 62
It is against the backdrop of this record that an ALJ held a hearing
on Soto’s disability application on December 13, 2023. 63 	Soto and a
Vocational Expert (“VE”) both appeared and testified at this hearing. 64
Following this hearing, on April 19, 2024, the ALJ issued a decision
58 Tr. 827.
59 Tr. 832.
60
Id.
61
Id.
62 Tr. 873.
63 Tr. 60-74.
64
Id.
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denying 	Soto’s 	application 	for 	disability 	benefits. 65 	The 	ALJ 	first
concluded that Soto had not engaged in substantial gainful activity since
her alleged onset of disability, April 4, 2022.66 At Step 2 of the sequential
analysis that governs disability claims, the ALJ found that Soto suffered
from 	the 	following 	severe 	physical 	impairments: 	degenerative 	disc
disease, degenerative joint disease, and obesity.67 	At Step 3, the ALJ
concluded that none of these impairments met or equaled the severity of
a listed impairment under the Commissioner’s regulations.68
Between Steps 3 and 4, the ALJ then concluded that Soto:
[H]a[d] the residual functional capacity to perform light work
as 	defined 	in 	20 	CFR 	404.1567(b) 	and 	416.967(b) 	except
occasional postural movements except frequent balancing and
stooping; avoid concentrated exposure to vibration, dangerous
machinery, and unprotected heights; and work that is limited
to simple and routine tasks, involving only simple, work-
related decisions. 69
In 	reaching 	this 	RFC 	determination, 	the 	ALJ 	considered 	the
objective medical record detailed above, the medical opinion evidence,
65 Tr. 15-38.
66 Tr. 20.
67 Tr. 21.
68 Tr. 21-24.
69 Tr. 24.
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and Soto’s reported symptoms. 	With respect to the medical opinion
evidence, 	the 	ALJ 	considered 	the 	opinions 	of 	the 	state 	agency
consultants, Drs. Nugent and Tedesco.70 	Dr. Nugent opined that Soto
could perform a range of light work with occasional postural limitations,
except she could never climb ladders, ropes, or scaffolds, and that she
must avoid concentrated exposure to extreme cold and heat, humidity,
vibration, fumes, and hazards. 71 	On reconsideration, Dr. Tedesco found
that Soto could perform light work with occasional postural limitations,
except that she could frequently balance and stoop, and that she should
avoid concentrated exposure to vibrations and hazards.72
The 	ALJ 	found 	Dr. 	Nugent’s 	opinion 	generally 	persuasive,
reasoning that the opinion was generally consistent with the medical
record, but that more recent treatment records from April of 2023
indicated Soto could frequently balance and stoop.73 	The ALJ found Dr.
Tedesco’s opinion persuasive, in that the findings were consistent with
70 Tr. 29-30.
71 Tr. 103-06.
72 Tr. 123-25.
73 Tr. 29.
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the overall record, again noting that the more recent records indicated
that Soto ambulated without assistance and was advised to use a shoe
insert. 74 	The ALJ further stated that with respect to the environmental
limitations, he found Dr. Tedesco’s opinion more persuasive than Dr.
Nugent’s. 75
With 	respect 	to 	Soto’s 	symptoms, 	the 	ALJ 	found 	that 	Soto’s
statements concerning the intensity, persistence, and limiting effects of
her 	impairments 	were 	not 	entirely 	consistent 	with 	the 	medical
evidence. 76 	Soto testified that she was working part time as a cleaner,
roughly one hour per day, at the time of the hearing. 77 	She reported
working so few hours because of her hip pain, including the pain resulting
from her unequal leg lengths.78 	Soto testified that she used a cane “[a]ll
74
Id.
75 Tr. 30. As we will discuss in more detail in our analysis, it is clear from
the 	decision 	as 	a 	whole, 	and 	particularly 	from 	the 	ALJ’s 	RFC
determination, 	that 	the 	ALJ 	found 	Dr. 	Tedesco’s 	postural 	and
environmental 	limitations 	more 	persuasive 	and 	consistent 	with 	the
record than Dr. Nugent’s despite what appears to be a typographical
error in the decision.
76 Tr. 24-29.
77 Tr. 63-64.
78 Tr. 64.
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the time[,]” and that she experienced leg pain and spasms in her right
leg. 79 At the time of the hearing, she was receiving injections for her back
pain. 80 	She reported she was afraid to have any more surgeries because
“everything 	just 	changed 	with 	them 	doing 	my 	hip.” 81 	She 	further
testified 	that 	her 	two 	older 	daughters 	helped 	her 	with 	shopping,
transportation, and caring for her younger daughter. 82
The ALJ ultimately found Soto’s testimony to be inconsistent with
the objective clinical findings.83 The ALJ recounted the objective medical
evidence, which included unremarkable and abnormal findings as to her
gait, as well as her testimony that she used a cane all the time.84 	The
ALJ discussed the treatment notes indicating that Soto used a cane for
ambulation after her right hip surgery, but that subsequent treatment
notes 	reflected 	a 	normal 	gait 	and 	that 	she 	ambulated 	without
assistance.85 	Further, the ALJ recognized the January 2023 findings
79 Tr. 65-66.
80 Tr. 67.
81 Tr. 68.
82 Tr. 69.
83 Tr. 24-29.
84 Tr. 25-28.
85
Id.
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that Soto’s legs were unequal in length, but further noted that her
provider’s 	treatment 	recommendation 	was 	to 	use 	a 	shoe 	lift. 86
Ultimately, the ALJ found that Soto was not as limited as she alleged.
Having made these findings, the ALJ found at Step 4 that Soto
could not perform her past relevant work but found at Step 5 that she
could perform the occupations of a cashier II, storage facility rental clerk,
and furniture rental consultant.87 	Accordingly, the ALJ found that Soto
had not met the stringent standard prescribed for disability benefits and
denied her claim. 88
This appeal followed. 	On appeal, Soto argues that the ALJ’s
decision is not supported by substantial evidence because the ALJ failed
to appreciate the significance of her hip replacements and the unequal
length of her legs, found the state agency consulting opinions persuasive,
and failed to account for her need to use a cane. 	Further, the plaintiff
contends that she is entitled to a remand under sentence six of Section
405(g). This case is fully briefed and is therefore ripe for resolution. For
86 Tr. 26-27, 31.
87 Tr. 31-32.
88 Tr. 33.
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the 	reasons 	set 	forth 	below, 	we 	will 	affirm 	the 	decision 	of 	the
Commissioner.
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 decision-
maker are supported by substantial evidence in the record.89 	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.” 90 	Substantial evidence means less
than a preponderance of the evidence but more than a mere scintilla.91
A single piece of evidence is not substantial evidence if the ALJ
“ignores, 	or 	fails 	to 	resolve, 	a 	conflict 	created 	by 	countervailing
89
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).
90
Pierce v. Underwood, 487 U.S. 552, 565 (1988).
91
Richardson v. Perales, 402 U.S. 389, 401 (1971).
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evidence.”92 	However, where there has been an adequately developed
factual record, substantial evidence may be “something less than the
weight of the evidence, and the possibility of drawing two inconsistent
conclusions from the evidence does not prevent [the ALJ’s decision] from
being supported by substantial evidence.” 93 	The court must “scrutinize
the record as a whole” to determine if the decision is supported by
substantial evidence. 94
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.’”95 	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.”96 	Thus, the
92
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).
93 Consolo v. Fed. Maritime Comm’n, 383 U.S. 607, 620 (1966).
94
Leslie v. Barnhart, 304 F. Supp.2d 623, 627 (M.D. Pa. 2003).
95
Biestek, 139 S. Ct. at 1154 (quoting
Consolidated Edison Co. v. NLRB,
305 U.S. 197, 229 (1938)).
96 Id.
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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. 97
When conducting this review, we must remain mindful that “we
must not substitute our own judgment for that of the fact finder.” 98 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.99 	This does not require the ALJ
97
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 . . . .”).
98
Zirnsak v. Colvin, 777 F.3d 607, 611 (3d Cir. 2014) (citing
Rutherford
v. Barnhart, 399 F.3d 546, 552 (3d Cir. 2005)).
99
Burnett v. Comm’r of Soc. Sec. Admin., 220 F.3d 112, 119 (3d Cir. 2000).
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to use “magic” words, but rather the ALJ must discuss the evidence and
explain the reasoning behind his or her decision with more than just
conclusory 	statements. 100 	Ultimately, 	the 	ALJ’s 	decision 	must 	be
accompanied by “a clear and satisfactory explication of the basis on which
it rests.” 101
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.” 102 	This requires a claimant to show a severe physical
or mental impairment that precludes him or her from engaging in
previous work or “any other substantial gainful work which exists in the
100
See Diaz v. Comm’r of Soc. Sec., 577 F.3d 500, 504 (3d Cir. 2009)
(citations omitted).
101
Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981).
102 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).
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national economy.” 103 	To receive benefits 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.104
In 	making 	this 	determination, 	the 	ALJ 	follows 	a 	five-step
evaluation. 105 	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”).106
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
103 	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).
104 42 U.S.C. §423(a); 20 C.F.R. §404.131(a).
105 20 C.F.R. §§404.1520(a), 416.920(a).
10620 C.F.R. §§404.1520(a)(4), 416.920(a)(4).
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impairment(s).”107 In making this assessment, the ALJ must consider all
the claimant’s medically determinable impairments, including any non-
severe impairments identified by the ALJ at step two of his or her
analysis. 108 	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. 109
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. 110 	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. 111
107
Burnett, 220 F.3d at 121 (citations omitted);
see also 20 C.F.R. §
404.1545(a)(1).
108 20 C.F.R. §§404.1545(a)(2), 416.945(a)(2).
109
Burns v. Barnhart, 312 F.3d 113, 129 (3d Cir. 2002).
110
Mason, 994 F.2d at 1064.
111 20 C.F.R. §§404.1512(f), 416.912(f);
Mason, 994 F.2d at 1064.
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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, 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.” 112 	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.” 113
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
112
Titterington v. Barnhart, 174 F. App’x 6, 11 (3d Cir. 2006);
see also
Biller v. Acting Comm’r of Soc. Sec., 962 F. Supp. 2d 761, 778–79 (W.D.
Pa. 2013).
113
Cummings v. Colvin, 129 F. Supp. 3d 209, 214–15 (W.D. Pa. 2015).
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24
the medical opinion based upon an assessment of other evidence. 114
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 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.115 	Ultimately, it is our task to
determine, 	considering 	the 	entire 	record, 	whether 	the 	RFC
determination is supported by substantial evidence. 116
C. Legal Benchmarks for the ALJ’s Assessment of Medical Opinions
For applications filed after March of 2017, the regulations require
ALJs 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. 117 	Supportability and consistency are the
114
Biller, 962 F. Supp. 2d at 778–79.
115
See Titterington, 174 F. App’x 6;
Cummings, 129 F. Supp. 3d at 214–
15.
116
Burns, 312 F.3d 113.
117 20 C.F.R. § 404.1520c(c).
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two most important factors, and an ALJ must explain how these factors
were considered in his or her written decision. 118 	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.”119 	The consistency
factor focuses on how consistent the opinion is “with the evidence from
other medical sources and nonmedical sources.”120
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.” 121 	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.” 122 Further, the ALJ can credit parts of an opinion without giving
118 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).
119 20 C.F.R. §§ 404.1520c(c)(1), 416.920c(c)(1).
120 20 C.F.R. §§ 404.1520c(c)(2), 416.920c(c)(2).
121
Chandler v. Comm’r of Soc. Sec., 667 F.3d 356, 361 (3d Cir. 2011).
122
Mason, 994 F.2d at 1066.
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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. 123 	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.” 124
D. Legal 	Benchmarks 	for 	the 	ALJ’s 	Assessment 	of 	a 	Claimant’s
Alleged Symptoms
When evaluating lay testimony regarding a claimant’s reported
degree 	of 	pain 	and 	disability, 	the 	ALJ 	must 	make 	credibility
determinations. 125 	Our review of those determinations is deferential. 126
However, it is incumbent upon the ALJ to “specifically identify and
explain what evidence he found not credible and why he found it not
credible.” 127 	An ALJ should give great weight to a claimant’s testimony
123
See Durden v. Colvin, 191 F. Supp. 3d 429, 455 (M.D. Pa. 2016).
124
Cummings, 129 F. Supp. 3d at 214–15.
125
See Diaz v. Comm’r, 577 F.3d 500, 506 (3d Cir. 2009).
126
Id.
127
Zirnsak v. Colvin, 777 F.3d 607, 612 (3d Cir. 2014) (citations omitted).
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“only when it is supported by competent medical evidence.” 128 	As the
Third Circuit has noted, while “statements of the individual concerning
his or her symptoms must be carefully considered, the ALJ is not required
to credit them.”129
The Social Security Rulings and Regulations provide a framework
for evaluating the severity of a claimant’s reported symptoms.130 	Thus,
the ALJ must follow a two-step process: first, the ALJ must determine
whether a medically determinable impairment could cause the symptoms
alleged; 	and 	second, 	the 	ALJ 	must 	evaluate 	the 	alleged 	symptoms
considering the entire administrative record.131
Symptoms such as pain or fatigue will be considered to affect a
claimant’s ability to perform work activities only if medical signs or
laboratory findings establish the presence of a medically determinable
impairment that could reasonably be expected to produce the alleged
128
	McKean v. Colvin, 150 F. Supp. 3d 406, 415–16 (M.D. Pa. 2015)
(citations omitted).
129
Chandler v. Comm’r of Soc. Sec., 667 F.3d 356, 363 (3d. Cir. 2011)
(referencing 20 C.F.R. §404.1529(a) (“statements about your pain or other
symptoms will not alone establish that you are disabled”).
130 20 C.F.R. §§ 404.1529, 416.929; SSR 16–3p.
131 SSR 16-3p.
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symptoms. 132 	During the second step of this assessment, the ALJ must
determine whether the claimant’s statements regarding the intensity,
persistence, or limiting effects of his or her symptoms are substantiated
considering the entire case record. 133 This includes, but is not limited to,
medical 	signs 	and 	laboratory 	findings; 	diagnoses; 	medical 	opinions
provided by treating or examining sources and other medical sources; and
information regarding the claimant’s symptoms and how they affect his
or her ability to work. 134
The Social Security Administration recognizes that individuals
may be limited by their symptoms to a greater or lesser extent than other
individuals with the same medical impairments, signs, and laboratory
findings. 135 	Thus, to assist in the evaluation of a claimant’s subjective
symptoms, the Social Security Regulations set forth seven factors that
may be relevant to the assessment of the claimant’s alleged symptoms. 136
These 	factors 	include: 	the 	claimant’s 	daily 	activities; 	the 	“location,
132 20 C.F.R. §§ 404.1529(b), 416.929(b); SSR 16–3p.
133 20 C.F.R. § 404.1529(c), 416.929(c); SSR 16–3p.
134
Id.
135 SSR 16-3p.
136 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3).
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duration, frequency, and intensity” of the claimant’s pain or symptoms;
the type, dosage, and effectiveness of medications; treatment other than
medications; 	and 	other 	factors 	regarding 	the 	claimant’s 	functional
limitations. 137
E. The ALJ’s Decision is Supported by Substantial Evidence.
Our review of the ALJ’s decision denying an application for benefits
is significantly deferential. Our task is simply to determine whether the
ALJ’s decision is supported by substantial evidence in the record; that is
“only— ‘such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.’”138 	Judged against this deferential
standard of review, we conclude that substantial evidence supported the
ALJ’s decision in this case.
Soto first contends that the ALJ failed to appreciate the significance
of her hip replacements and the unequal length of her legs and failed to
consider this as a separate impairment. 139 	To the extent the plaintiff is
asserting that her unequal leg length should have been found to be its
137
Id.
138
Biestek, 139 S. Ct. at 1154.
139 Doc. 28 at 22-25.
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own severe impairment at Step 2, this argument is unavailing. 	At Step
2, the ALJ determines whether a claimant has a medically severe
impairment 	or 	combination 	of 	impairments. 140 	An 	impairment 	is
considered severe if it “significantly limits an individual’s physical or
mental abilities to do basic work activities,” or if it is “something beyond
‘a slight abnormality which would have no more than a minimal effect on
an 	individual’s 	ability 	to 	work.’” 141 	This 	Step 	2 inquiry 	is
a de minimis screening device used to cast out meritless claims.142 	The
claimant 	bears 	the 	burden 	to 	show 	that 	an 	impairment 	should 	be
considered severe.143
Here, while the ALJ did not explicitly find the plaintiff’s unequal
leg length to be a severe impairment, it is clear that the ALJ discussed
the medical findings and the impact of this impairment on the plaintiff’s
functional ability. 	For example, the ALJ discussed the plaintiff’s hip
140
Bowen v. Yuckert, 482 U.S. 137, 140-41 (1987).
141 20 C.F.R. 404.1520(c);
McCrea v. Comm'r of Soc. Sec., 370 F.3d 357,
360 (3d Cir. 2004) (citations omitted).
142
McCrea, 370 F.3d at 360;
Newell v. Comm'r of Soc. Sec., 347 F.3d 541,
546 (3d Cir. 2003).
143
Bowen, 482 U.S. at 146;
Stancavage v. Saul, 469 F. Supp. 3d 311, 331
(M.D. Pa. 2020).
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replacement 	surgeries 	in 	the 	context 	of 	Listing 	1.17, 	although 	he
ultimately found the plaintiff did not meet this listing. 144 	He further
considered the plaintiff’s testimony regarding her unequal leg length and
her need to use a cane to support herself. 145 He also thoroughly recounted
the medical records pertaining to the plaintiff’s surgeries and subsequent
medical 	treatment. 146 	Finally, 	he 	considered 	the 	medical 	opinion
evidence, which considered the records of the plaintiff’s hip surgeries and
unequal leg length. 147 	Ultimately, the ALJ found that despite her
limitations, 	Soto 	could 	perform 	light 	work 	with 	occasional 	postural
limitations, except she could frequently balance and stoop.148 	Thus, any
exclusion of these impairments at Step 2 was harmless, as the ALJ
clearly 	considered 	these 	impairments 	and 	how 	they 	impacted 	the
plaintiff’s ability to function.
Moreover, and fundamentally, the plaintiff fails to identify how she
is more limited than the ALJ found. Indeed, it is the plaintiff’s burden to
144 Tr. 22.
145 Tr. 24-25.
146 Tr. 24-28.
147 Tr. 29-30.
148 Tr. 24.
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prove she is unable to work, and her brief fails to identify additional
limitations based on these impairments. Instead, she simply argues that
the ALJ mischaracterized her doctor’s recommendation that she wear a
shoe lift, and that the ALJ failed to appreciate the significance of the
plaintiff’s symptoms.149 	These arguments are unavailing and fail to
identify 	limitations 	that 	the 	ALJ 	allegedly 	failed 	to 	account 	for.
Accordingly, we find the ALJ’s Step 2 determination is supported by
substantial evidence.
Soto next contends that the ALJ erred in finding the two consulting
opinions persuasive.150 	She first points to inconsistent language in the
ALJ’s decision, in which the ALJ states that “the undersigned notes that
Dr. Tedesco’s findings are more persuasive than Dr. Nugent’s findings
because the postural and environmental limitations in
	Dr. Nugent’s
149 While the plaintiff strenuously argues that the ALJ erroneously relied
on what she characterizes as the lone treatment note from April 2023
that the plaintiff ambulated without assistance, there are several other
treatment notes in the record indicating that the plaintiff ambulated
without assistance after surgery, including her one-year surgical follow-
up appointment in August of 2023.
	See Tr. 826-27;
see also Tr. 535, 801,
808.
150 Doc. 28 at 25-29.
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findings are more consistent with the record as a whole.” 151 	Read alone,
this statement would appear to suggest that the ALJ found Dr. Tedesco’s
opinion more persuasive even though Dr. Nugent’s findings were more
consistent with the record. 	However, “[i]n the context of social security
cases, errors in ALJ decisions have been excused as mere scrivener’s
errors when the ALJ’s intent was apparent.”152
Here, in our view, it is clear that the ALJ found Dr. Tedesco’s
opinion, and particularly the postural and environmental limitations, to
be more consistent with the record. 	For example, in discussing Dr.
Tedesco’s opinion, the ALJ explicitly reasoned that the more recent April
2023 records and imaging were consistent with Dr. Tedesco’s postural
limitations to frequent balancing and stooping. 153 The ALJ also explicitly
found 	that 	these 	notes 	supported 	Dr. 	Tedesco’s 	environmental
limitations to avoid concentrated exposure to vibration, machinery, and
151 Tr. 30 (emphasis added).
152
Amy A. v. Kijakazi, 2021 WL 5864063, at *5 (D.N.J. Dec. 10, 2021)
(quoting
Hudon v. Astrue, 2011 WL 4382145, at *4 (D.N.H. Sept. 20,
2011)) (internal quotation marks omitted).
153 Tr. 29.
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34
heights. 154 	The ALJ explicitly included Dr. Tedesco’s findings in the RFC
assessment. 155 	Accordingly, we conclude that the ALJ’s typographical
error is harmless, as the ALJ’s intent in finding Dr. Tedesco’s opinion
more persuasive and more consistent with the record is apparent from
the decision as a whole. Thus, a remand is not required.
Soto also argues that finding these opinions persuasive was error
because these opinions found that Soto’s leg lengths were approximately
equal, and as such, were not consistent with the medical evidence
showing her unequal leg lengths. 156 	But the plaintiff’s reliance on the
wording in Dr. Nugent’s opinion is entirely misplaced. While she appears
to contend that it was Dr. Nugent’s opinion that Soto’s leg lengths were
“approximately equal,” 157 it is clear from Dr. Nugent’s findings that this
was not his own opinion but rather a recitation of Soto’s own medical
records from her providers. 158 	Indeed, Dr. Nugent’s opinion recites the
medical 	records 	he 	reviewed, 	which 	included 	a 	September 	2022
154 Tr. 29-30.
155 Tr. 24.
156 Doc. 28 at 29.
157
Id.
158
See Tr. 100.
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examination and x-ray interpretation in which the provider noted Soto’s
length 	lengths 	were 	approximately 	equal. 159 	The 	language 	in 	Dr.
Nugent’s opinion is taken verbatim from the treatment notes from Soto’s
post-operative visit in September of 2022.160 Dr. Tedesco’s opinion, which
was rendered later, specifically considered the January 2023 imaging
showing that Soto’s right leg was longer than her left, as well as the April
2023 	assessment 	where 	Soto 	ambulated 	without 	assistance. 161
Accordingly, 	the 	plaintiff’s 	contention 	that 	the 	ALJ 	relied 	on 	two
consulting opinions that were inconsistent with the record and that did
not adequately consider all of her impairments is entirely unavailing.
Finally, Soto contends that the ALJ erred in assessing her reported
need to use a cane for ambulation. She appears to rely on her subjective
testimony that she needed a cane to ambulate at all times, coupled with
her argument that “there is almost nothing that suggests that any
physician does not think a cane is necessary.”162 	In some cases, the
159
Id.
160
See Tr. 494.
161 Tr. 120.
162 Doc. 28 at 31.
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36
claimant’s use of a cane may be outcome-determinative. 	However, the
burden lies with the claimant initially to show that the cane is medically
required by providing “medical documentation establishing the need for
a hand-held assistive device to aid in walking or standing, and describing
the 	circumstances 	for 	which 	it 	is 	needed[.]”163 	If 	the 	claimant
demonstrates such a medical necessity, then the ALJ must directly
“address the evidence concerning Plaintiff's use of” an assistive device. 164
The failure to do so may require a remand.165
Here, the ALJ found that Soto’s use of a cane was not medically
necessary. 166 	He considered her subjective testimony that she used a
cane at all times but reasoned that there was no medical evidence that
documented her need for a cane for continuous use. 167 	The ALJ found
that while the records showed Soto used a cane after her hip surgery,
more recent treatment records demonstrated that she ambulated without
163
Howze v. Barnhart, 53 F. App’x 318, 222 (3d Cir. 2002) (citing SSR 96-
9p).
164
Steward v. Comm’r of Soc. Sec., 2009 WL 1783533, at *5 (W.D. Pa.
June 23, 2009).
165
Id.
166 Tr. 28.
167
Id.
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37
an assistive device.168 	Indeed, the medical records indicate that in April
2023 and in August of 2023 at her annual surgery follow up, Soto was
ambulating without a cane.169 	Accordingly, we cannot conclude that the
ALJ erred in finding Soto’s use of a cane not medically necessary. Rather,
the 	ALJ 	considered 	Soto’s 	testimony 	against 	the 	objective 	medical
evidence and found that Soto was not as limited as she alleged. There is
no basis for a remand.
Given that the ALJ considered all the evidence and adequately
explained the decision for including or discounting certain limitations as
established 	by 	the 	evidence, 	we 	find 	no 	error 	with 	the 	decision.
Therefore, under the deferential standard of review that applies to
appeals of Social Security disability determinations, we conclude that
substantial evidence supported the ALJ’s evaluation of this case.
168
Id.
169 Tr. 777 (“The patient ambulates slowly and deliberately, but with no
distinct gait abnormality. She is not using assistive device.”); Tr. 826-27
(“Ambulating well with no limp and no devices.”).
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F. The Plaintiff is Not Entitled to a Remand under Sentence Six.
Soto additionally contends that this case should be remanded for
further consideration of the functional capacity evaluation rendered by
Dr. Bernal. However, after consideration, we conclude that this evidence
does not entitle the plaintiff to a remand.
Under sentence six of 42 U.S.C. § 405(g), this court “may at any
time order additional evidence to be taken before the Commissioner of
Social Security, but only upon a showing that there is new evidence which
is material and that there is good cause for the failure to incorporate such
evidence into the record in a prior proceeding[.]”170 Accordingly, to obtain
a remand based on new evidence, a plaintiff must demonstrate that the
evidence is “new” and “material.” 171 	Evidence is not new if it is “merely
cumulative of what is already in the record,”172 or if it was “in existence
or 	available 	to 	the 	claimant 	at 	the 	time 	of 	the 	administrative
proceeding.” 173 	To be material, the evidence must be “relevant and
170 42 U.S.C. § 405(g).
171 Szubak v. Sec’y of Health and Human Servs., 745 F.2d 831, 833 (3d
Cir. 1984).
172
Id.
173
Sullivan v. Finkelstein, 496 U.S. 617, 626 (1990).
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39
probative.” 174 	Further, the claimant must demonstrate “good cause” for
why the evidence was not incorporate into the record.175 	Finally, there
must be a “reasonable probability that the additional evidence would
change the outcome of the decision.”176 	This evidence may be considered
to determine if a remand is required under sentence six; however, it may
not be considered in assessing whether the ALJ’s decision was supported
by substantial evidence. 177
Soto contends that the functional capacity evaluation by Dr. Bernal,
which she apparently underwent in December of 2023 but did not receive
a report of until February or April of 2024, entitles her to a remand and
to have this evidence considered. 178 	However, we conclude that this
evidence is not new, and further, that the plaintiff fails to show good
cause for not presenting this evidence to the ALJ.
174
Id.
175
Id.
176 20 C.F.R. § 404.970(a)(5); 20 C.F.R. § 416.1470(a)(5) (effective January
17, 2017);
Walters v. Saul, 452 F. Supp. 3d 164, 183 (M.D. Pa. 2020).
177
Szubak, 745 F.2d 831, 833 (3d Cir. 1984);
Walters v. Saul, 452 F. Supp.
3d 164, 183 (M.D. Pa. 2020).
178 Doc. 28 at 32-37.
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First, this evidence is not “new.” 	While it is true that Soto did not
obtain the report of the functional capacity evaluation until after the
administrative hearing, the examination was either ordered or conducted
by a provider that Soto treated with since at least March of 2022.179 Thus,
while Soto did not have this functional capacity evaluation in-hand at the
time of the administrative hearing, we cannot conclude that this evidence
was not available to her since she could have secured an examination and
report from Dr. Bernal during the relevant period.180
In a similar vein, the plaintiff has not shown good cause for failing
to present the evidence to the ALJ. 	As we have explained, the plaintiff
treated with Dr. Bernal since before her alleged onset of disability.
Accordingly, she could have requested a functional capacity evaluation
at any time prior to the administrative hearing. 	Further, the plaintiff’s
179
See Tr. 523 (March 25, 2022 office visit with Dr. Bernal).
180
See e.g.,
Black v. Colvin, 2015 WL 1275926, at *6 (W.D. Pa. Mar. 19,
2015) 	(finding 	that 	the 	plaintiff’s 	evidence 	from 	her 	primary 	care
physician was not “new” because she could have secured it from her
physician prior to the ALJ’s decision, and thus it was “available” to her);
Fraser 	v. 	Astrue, 	2009 	WL 	948341, 	at 	*2 	(E.D. 	Pa. 	Apr. 	8, 	2009)
(determining that the letter from the plaintiff’s treating physician was
not “new” because the treating doctor “could have provided a letter of this
nature to plaintiff prior to the hearing in front of the ALJ.”).
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41
counsel at the administrative hearing represented that he received the
report prior to the ALJ’s decision in this matter, although it is not
entirely clear when exactly he received the report. 181 	But “it is a well-
established principle that mere failure to obtain evidence before the ALJ
made a determination when it could have been obtained does not amount
to ‘good cause.’”182 Accordingly, “the fact that [the report] did not exist at
the time of the hearing before the ALJ does not show that [the plaintiff]
had good cause for not obtaining an examination and report in sufficient
time to present such to the ALJ.” 183
In sum, we conclude that the plaintiff’s evidence is not new, and
further, that she fails to show good cause for not presenting this evidence
to the ALJ. Accordingly, a remand under sentence six is not appropriate.
181
See Doc. 28-2.
182
Simonson v. Berryhill, 2017 WL 5632691, at *4 (M.D. Pa. Nov. 22,
2017) (
citing Scatorchia v. Comm’r of Soc. Sec., 137 F. App’x 468, 472 (3d
Cir. 2005)).
183
Byers v. Bisignano, 2026 WL 267454, at *3 (M.D. Pa. Feb. 2, 2026).
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42
IV. 	Conclusion
For the foregoing reasons, the decision of the Commissioner in this
case will be affirmed, and the plaintiff’s appeal denied.
An appropriate order follows.
Submitted this 17th day of March 2026.
s/ Daryl F. Bloom
Daryl F. Bloom
Chief United States Magistrate Judge
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