Case Name in Social Security Case - Unavailable

1
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
KIMBERLY WHITNEY, 	: 	Civil No. 4:24-CV-1950
:
Plaintiff 	:
:
v. 	: 	(Magistrate Judge Carlson)
:
FRANK BISIGNANO,1 :
Commissioner of Social Security, 	:
:
Defendant. 	:
MEMORANDUM OPINION
I. 	Introduction
This case involves an unusual confluence of events which together in
combination compel remand. The plaintiff, Kimberly Whitney, alleged she was
unable to work due to an array of physical impairments and mental impairments
including depression, borderline personality disorder, anxiety and post-traumatic
stress disorder which she alleged would keep her off-task and absent in excess of
allowable 	employment 	standards. 	(Tr. 	44). 	Two 	State 	agency 	psychological
consultants 	considered 	the 	medical 	record 	with 	regard 	to 	Whitney’s 	mental
1 Frank Bisignano became the Commissioner of Social Security on May 6, 2025.
Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure, Frank Bisignano
should be substituted as the 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).
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 1 of 29

2
impairments and concluded she would be limited to jobs requiring only one- to two-
step tasks. While Whitney underwent a consultative examination of her physical
abilities, no treating or examining source opined on her mental capacity to perform
work-related activity.
The longitudinal medical evidence of Whitney’s mental impairments was not
extensive but at least demonstrated that she had a history of abuse and neglect, two
past 	psychiatric 	hospitalizations, 	a 	history 	of 	self-harm, 	and 	was 	receiving
psychiatric treatment during the relevant period. The ALJ accepted that Whitney’s
mental impairments would at least moderately affect her ability to perform work-
related activity and partially credited the opinions of the State agency experts.
However, the ALJ rejected the expert consensus that Whitney would be limited to
one- to two-step tasks, an aspect of these medical opinions which would have
rendered her unable to perform the jobs the ALJ concluded she could perform. Thus,
the ALJ substituted his own lay opinion of the evidence in concluding that Whitney
would not be limited to one- to two-step tasks, a conclusion which was clearly
outcome determinative and unmoored to any medical opinion; and denied this claim.
On this striking confluence of events, we are reminded of two basic tenets of Social
Security practice. First, it is well settled that the ALJ may not simply substitute “her
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 2 of 29

3
own credibility judgments, speculation or lay opinion,” for the opinions of medical
sources. Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000). Moreover:
ALJs have a duty to develop a full and fair record in social security
cases. See Brown v. Shalala, 44 F.3d 931, 934 (11th Cir.1995); Smith
v. Harris, 644 F.2d 985, 989 (3d Cir.1981). Accordingly, an ALJ must
secure relevant information regarding a claimant's entitlement to social
security benefits.
Ventura v. Shalala, 55 F.3d 900, 902 (3d Cir. 1995).
In the instant case, the ALJ’s decision to ignore an outcome determinative
medical opinion consensus and failure to seek an examining source to support the
decision 	that 	Whitney’s 	mental 	impairments 	were 	not 	disabling, 	was 	error.
Therefore, 	this 	case 	will 	be 	remanded 	for 	further 	consideration 	by 	the
Commissioner.
II. 	Statement of Facts and of the Case
On January 3, 2022, Kimberly Whitney filed applications for disability and
supplemental security income benefits under Titles II and XVI of the Social Security
Act, alleging disability beginning March 4, 2021. (Tr. 17). In this application,
Whitney alleged that she was disabled due to an array of physical and mental
impairments, including borderline personality disorder, chronic fatigue, major
depressive disorder with psychosis, post-traumatic stress disorder (PTSD), mixed
anxiety depressive disorder, polycystic kidney disease, irritable bowel syndrome,
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 3 of 29

4
and restless leg syndrome. (Tr. 63). Whitney was born on January 18, 1985, and was
36 years old, which is defined as a younger individual under the Commissioner’s
regulations, on the alleged disability onset date. (Id.)
With 	respect to her mental 	impairments, Whitney 	submitted 	an 	Adult
Function Report which identified a constellation of impairments including that she
has panic attacks and is paranoid constantly, gets anxiety and is unable to regulate
her emotions, needs reminders for appointments and forgets to eat, can only pay
attention for five to ten minutes and cannot handle stress or changes in routine. (Tr.
337-43). These subjective reports were corroborated by treatment notes from her
initial psychiatric evaluation at Pennsylvania Counseling Services in June 2022,
which noted significant psychological symptomology including poor energy and
motivation, trouble sleeping, lack of appetite, passive suicidal thoughts, daily
anxiety, twice weekly panic attacks, waking at night yelling out, mood reactivity due
to past trauma, chronic feelings of emptiness, self-destructive behaviors, emotional
lability, 	poor 	frustration 	tolerance, 	a 	pattern 	of 	difficulty 	with 	interpersonal
relationships, and a history of self-harm. (Tr. 503-04). She also reported a history of
visual hallucinations of "dead people" previously when she was severely depressed.
(Tr. 504). A past history of psychiatric hospitalization was also reported including
one hospitalization in 2019. (Tr. 504).
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 4 of 29

5
Whitney was diagnosed with recurrent moderate major depressive disorder
(MDD), post-traumatic stress disorder (PTSD) from physical, sexual, and emotional
abuse, borderline personality disorder. (Tr. 504-05). Thus, Whitney’s psychological
impairments and the symptoms she described were reinforced in the objective
medical record. Nonetheless, as often occurs, her mental status examinations were
largely normal in some other spheres, showing normal concentration and thought
content, good insight and judgment, intact memory, and appropriate manner. (Tr.
505, 636, 640, 644, 647, 652, 655). She attended psychiatric care between December
2021 and May 2024 at Pennsylvania Counseling Services where she continued to
report symptoms of her psychological impairments. (Tr. 483-602, 634-712, 886-
1052). However, medication supervision reports in March 2023 and January 2024
indicated her conditions were stable and improving on medication. (Tr. 634-35, 898-
99). Thus, the longitudinal record of her mental impairments demonstrates these
impairments were severe and supports her subjective reports of symptoms, yet
indicates that her conditions were variable, like many psychological impairments,
and periodically improved with treatment.
Given 	this 	equivocal 	clinical 	history, 	two 	non-treating, 	non-examining
sources opined on the limiting effects of Whitney’s mental impairments. In
November 2022, State agency psychological consultant Dr. Marci Cloutier reviewed
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 5 of 29

6
Whitney’s medical record and opined that she would have mild limitations in her
ability to understand, remember, or apply information and moderate limitations in
her ability to interact with others, concentrate, persist, or maintain pace, and adapt
or manage oneself. (Tr. 65). Specifically, Dr. Cloutier opined that Whitney would
be moderately limited in her ability to carry out detailed instructions, maintain
attention and concentration for extended periods, complete a normal workday and
workweek without interruptions from her symptoms, and respond appropriately to
changes in the work setting. (Tr. 69-70). In explaining her RFC limitations, Dr.
Cloutier included a familiar limitation to one-to-two step tasks, stating:
Based on available evidence, clm able to concentrate, persist and
maintain pace to complete tasks. Clm is able to understand and apply
basic information. Clm is able to appropriately interact with others and
cope with mild stressors. Intensity and persistence of reported sx's have
a moderate limiting effect on functioning and is partially consistent
with mer. Clm's impairment would not preclude 1-2 step functions on
a sustained basis.
(Tr. 70).
The opinion of Dr. Cloutier was largely mirrored on reconsideration in May
2023 by State agency psychological consultant Dr. Faisal Roberts. Dr. Roberts
opined that Whitney had the same limitations in the “paragraph B” criteria and the
same moderate limitations in her capacity to carry out detailed instructions, maintain
attention and concentration for extended periods, complete a normal workday and
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 6 of 29

7
workweek without interruptions from her symptoms, and respond appropriately to
changes in the work setting. (Tr. 88-93). In concluding that Whitney could
understand, retain, and follow only simple instructions, Dr. Roberts specifically
clarified that this meant she could perform only one- and two-step tasks, stating:
The claimant’s basic memory processes are intact. The claimant can
understand, retain, and follow simple instructions (i.e., perform one-
and two-step tasks). The claimant can make simple decisions and would
not require special supervision in order to sustain a routine. The
claimant can perform simple, routine, repetitive tasks in a stable
environment. The claimant is capable of performing within a schedule
and at a consistent pace.
(Tr. 93). Indeed, Dr. Roberts took particular care to clarify that his opinion that
Whitney would be limited to simple instructions meant that she could only perform
one- and two-step tasks.
The state agency psychological consultants Dr. Cloutier and Dr. Roberts were
the only experts to opine on Whitney’s mental RFC. Thus, the record was devoid of
any opinion by an expert who had treated or examined Whitney to determine the
limiting effects of her mental impairments. Nonetheless, the consensus of the two
State agency experts was that Whitney would, at most, be able to perform one- to
two-step tasks.
It was against this medical backdrop that Whitney’s disability claim came to
be heard by the ALJ on August 13, 2024. (Tr. 39-62). At the hearing, Whitney
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 7 of 29

8
testified that she was unable to sustain full-time work due to the combined effects of
her physical and mental impairments that would keep her off task and absent in
excess of allowable employment standards. (Tr. 44). She described paranoia and
difficulty interacting with others. (Tr. 56-57). A vocational expert (VE) testified that
an 	individual 	with 	a 	residual 	functional 	capacity 	(RFC) 	identified 	by 	the
administrative law judge (ALJ) could perform the occupations of marker, router, and
routing clerk, all with a reasoning level of two. (Tr. 59-60). The ALJ did not question
the VE about the effect of limiting Whitney to one- to two-step tasks, despite both
medical experts who opined on Whitney’s mental abilities concluding that this was
the most she could perform.
Following this hearing, on August 23, 2024, the ALJ issued a decision
denying Whitney’s application for benefits. (Tr. 14-33). In that decision, the ALJ
first concluded that the plaintiff met the insured status requirements of the Social
Security Act through December 31, 2026, and had not engaged in substantial gainful
activity since March 4, 2021, the alleged onset date. (Tr. 19-20). At Step 2 of the
sequential analysis that governs Social Security cases, the ALJ found that Whitney
had the following severe impairments: obesity, polycystic kidney disease, restless
leg syndrome, depression disorder, borderline personality disorder, anxiety disorder,
and post-traumatic stress disorder (PTSD). (Tr. 20).
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 8 of 29

9
At Step 3, the ALJ determined that these impairments did not meet or
medically equal the severity of any listed impairments. (Tr. 21-23). In considering
whether her mental impairments met the criteria of a listing, the ALJ concluded she
had mild limitations in understanding, remembering, or applying information, and
moderate 	limitations 	in 	interacting 	with 	others, 	concentrating, 	persisting, 	or
maintaining pace, and adapting or managing oneself. (Id.)
Between Steps 3 and 4, the ALJ then fashioned the following residual
functional capacity (RFC) assessment for Whitney:
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) except no
climbing ladders, ropes, or scaffolds, as those are defined in the
DOT/SCO. 	The 	claimant 	can 	do 	occasional 	crawling, 	balancing,
crouching, kneeling, stooping, or climbing ramps or stairs, as those are
defined in the DOT/SCO; and have occasional exposure to non-weather
temperature 	extremes 	of 	heat 	or 	cold, 	wetness 	and 	non-weather
humidity, vibration, or atmospheric conditions, as those are defined in
the DOT/SCO. The claimant can have no exposure to hazards, as those
are defined in the DOT/SCO. She can have frequent interactions with
supervisors, 	coworkers, 	and/or 	the 	public; 	can 	carry 	out 	simple
instructions; cannot perform work requiring a specific production rate
such as assembly line work or work that requires hourly quotas; and
can deal with occasional changes in a routine work setting.
(Tr. 23).
In reaching this RFC determination, the ALJ clearly accounted for some of
the limitations opined by the only two medical experts who opined on Whitney’s
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 9 of 29

10
abilities but overtly rejected the medical consensus that she would be limited to one-
to two-step tasks, the only limitation opined by these experts that would have
rendered the plaintiff unable to perform the occupations identified by the vocational
expert.
On this score, the ALJ found the opinions of Dr. Cloutier and Dr. Roberts
“generally persuasive,” concluding that these opinions were supported by citation to
objective medical evidence and a narrative explanation and were mostly consistent
with the objective findings, treatment history, and activities of daily living. (Tr. 28).
However, as to the one- to two-step limitation opined by both experts, the only
limitation which would have rendered Whitney unable to perform the jobs identified
by the VE, the ALJ explained:
[T]he limitation to one to two-step mentation is not persuasive as this
is contrary to the claimant’s own stated capacity and findings on
objective examination. For example, the longitudinal record shows well
preserved mentation despite varied diagnosis and with only medication
and therapy (Exhibit 1F/6; 2F/47; 3F/2-3, 6-7, 10-11, 14-15, 18-19, 23-
24, 27, 32, 34, 36, 38, 40, 42, 44, 46, 48, 50). The record also
longitudinally consistently notes the claimant has a very good response
to therapy and is making good progress (Exhibit 3F; 8F; 13F).
Moreover, the claimant is independent with activities of daily living
including driving, taking her children to school events, completing
household chores, and managing her son’s benefits (Testimony; Exhibit
6E; 11E).
(Tr. 28). Thus, based upon the ALJ’s own interpretation of the record, he concluded
that a one- to two-step task limitation was inconsistent with the objective findings,
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 10 of 29

11
treatment history, and activities of daily living, but the balance of the opinions of
these experts were entirely consistent with these records.
Having made these findings, the ALJ concluded that Whitney could perform
the jobs of marker (DOT 209.587-034; 165,089 jobs nationally); router (DOT
222.587-038; 22,160 jobs nationally); and routing clerk (DOT 222.687-022; 105,700
jobs nationally). (Tr. 32). Accordingly, the ALJ concluded that the plaintiff did not
meet the stringent standard for disability set by the Act and denied this claim. (Id.)
This appeal followed. (Doc. 1). On appeal, Whitney argues, inter alia, that the
ALJ erred in rejecting the expert consensus that she would be limited to one- to two-
step tasks and for failing to order consultative examination to support his RFC
determination. After a review of the evidence, we agree that the ALJ’s failure to
acknowledge the medical consensus or further develop the record and instead adopt
an RFC which was bereft of medical opinion support resulted in an erroneous
disability 	determination. 	Therefore, 	we 	will 	remand 	this 	case 	for 	further
consideration by the Commissioner.
III. 	Discussion
A. Substantial Evidence Review – the Role of this Court
When reviewing the Commissioner’s final decision denying a claimant’s
application for benefits, this Court’s review is limited to the question of whether the
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 11 of 29

12
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]
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:
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 12 of 29

13
The phrase “substantial evidence” is a “term of art” used throughout
administrative law to describe how courts are to review agency
factfinding. T-Mobile South, LLC v. Roswell, 574 U.S. ––––, ––––,
135 S.Ct. 808, 815, 190 L.Ed.2d 679 (2015). Under the substantial-
evidence standard, a court looks to an existing administrative record
and asks whether it contains “sufficien[t] evidence” to support the
agency's factual determinations. Consolidated Edison Co. v. NLRB,
305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) (emphasis
deleted). And whatever the meaning of “substantial” in other contexts,
the threshold for such evidentiary sufficiency is not high. Substantial
evidence, this Court has said, is “more than a mere scintilla.” Ibid.; see,
e.g., Perales, 402 U.S. at 401, 91 S.Ct. 1420 (internal quotation marks
omitted). It means—and means only—“such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.”
Consolidated Edison, 305 U.S. at 229, 59 S.Ct. 206. See Dickinson v.
Zurko, 527 U.S. 150, 153, 119 S.Ct. 1816, 144 L.Ed.2d 143 (1999)
(comparing the substantial-evidence standard to the deferential clearly-
erroneous standard).
Biestek, 139 S. Ct. at 1154.
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
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
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 13 of 29

14
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 v. Barnhart, 399 F.3d 546, 552 (3d
Cir. 2005)). 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. 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).
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 14 of 29

15
Thus, in practice ours is a twofold task. We must evaluate the substance of the
ALJ’s decision under a deferential standard of review, but we must also give that
decision careful scrutiny to ensure that the rationale for the ALJ’s actions is
sufficiently articulated to permit meaningful judicial review.
This principle applies with particular force to legal challenges, like the claim
made here, based in part upon alleged inadequacies in the articulation of a claimant’s
mental RFC. In Hess v. Comm’r Soc. Sec., 931 F.3d 198, 212 (3d Cir. 2019), the
United States Court of Appeals recently addressed the standards of articulation that
apply in this setting. In Hess the court of appeals considered the question of whether
an RFC which limited a claimant to simple tasks adequately addressed moderate
limitations on concentration, persistence, and pace. In addressing the plaintiff’s
argument that the language used by the ALJ to describe the claimant’s mental
limitations was legally insufficient, the court of appeals rejected a per se rule which
would require the ALJ to adhere to a particular format in conducting this analysis.
Instead, framing this issue as a question of adequate articulation of the ALJ’s
rationale, the court held that: “as long as the ALJ offers a ‘valid explanation,’ a
‘simple tasks’ limitation is permitted after a finding that a claimant has ‘moderate’
difficulties in ‘concentration, persistence, or pace.’ ” Hess v. Comm’r Soc. Sec., 931
F.3d 198, 211 (3d Cir. 2019). On this score, the appellate court indicated that an ALJ
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 15 of 29

16
offers a valid explanation a mental RFC when the ALJ highlights factors such as
“mental status examinations and reports that revealed that [the claimant] could
function effectively; opinion evidence showing that [the claimant] could do simple
work; and [the claimant]’s activities of daily living, . . . . ” Hess v. Comm’r Soc.
Sec., 931 F.3d 198, 214 (3d Cir. 2019).
In our view, the teachings of the Hess decision are straightforward. In
formulating a mental RFC the ALJ does not need to rely upon any particular form
of words. Further, the adequacy of the mental RFC is not gauged in the abstract.
Instead, the evaluation of a claimant’s ability to undertake the mental demands of
the workplace will be viewed in the factual context of the case, and a mental RFC is
sufficient if it is supported by a valid explanation grounded in the evidence.
B. Initial Burdens of Proof, Persuasion, and Articulation for the ALJ
To receive benefits under the Social Security Act by reason of disability, a
claimant must demonstrate an inability to “engage in any substantial gainful activity
by reason of any medically determinable physical or mental impairment which can
be expected to result in death or which has lasted or can be expected to last for a
continuous period of not less than 12 months.” 42 U.S.C. §423(d)(1)(A); see also 20
C.F.R. §404.1505(a). 	To satisfy this requirement, a claimant must have a severe
physical or mental impairment that makes it impossible to do his or her previous
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 16 of 29

17
work or any other substantial gainful activity that exists in the national economy. 42
U.S.C. §423(d)(2)(A); 20 C.F.R. §404.1505(a). To receive benefits under Title II of
the Social Security Act, a claimant must show that he or she contributed to the
insurance program, is under retirement age, and became disabled prior to the date on
which he or she was last insured. 42 U.S.C. §423(a); 20 C.F.R. §404.131(a).
In making this determination at the administrative level, the ALJ follows a
five-step sequential evaluation process. 20 C.F.R. §404.1520(a). Under this process,
the ALJ must sequentially determine: (1) whether the claimant is engaged in
substantial gainful activity; (2) whether the claimant has a severe impairment; (3)
whether the claimant’s impairment meets or equals a listed impairment; (4) whether
the claimant is able to do his or her past relevant work; and (5) whether the claimant
is able to do any other work, considering his or her age, education, work experience
and residual functional capacity (“RFC”). 20 C.F.R. §404.1520(a)(4).
Between Steps 3 and 4, the ALJ must also assess a claimant’s residual
functional capacity (RFC). RFC is defined as “that which an individual is still able
to do despite the limitations caused by his or her impairment(s).” Burnett v. Comm’r
of Soc. Sec., 220 F.3d 112, 121 (3d Cir. 2000) (citations omitted); see also 20 C.F.R.
§§404.1520(e), 404.1545(a)(1). In making this assessment, the ALJ considers all of
the claimant’s medically determinable impairments, including any non-severe
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 17 of 29

18
impairments identified by the ALJ at step two of his or her analysis. 	20 C.F.R.
§404.1545(a)(2).
There is an undeniable medical aspect to an RFC determination, since that
determination entails an assessment of what work the claimant can do given the
physical limitations that the claimant experiences. Yet, when considering the role
and necessity of medical opinion evidence in making this determination, courts have
followed several different paths. Some courts emphasize the importance of medical
opinion support for an RFC determination and have suggested that “[r]arely can a
decision be made regarding a claimant's residual functional capacity without an
assessment from a physician regarding the functional abilities of the claimant.”
Biller v. Acting Comm'r of Soc. Sec., 962 F. Supp. 2d 761, 778–79 (W.D. Pa. 2013)
(quoting Gormont v. Astrue, Civ. No. 11–2145, 2013 WL 791455 at *7 (M.D. Pa.
Mar. 4, 2013)). In other instances, it has been held that: “There is no legal
requirement that a physician have made the particular findings that an ALJ adopts
in the course of determining an RFC.” Titterington v. Barnhart, 174 F. App’x 6, 11
(3d Cir. 2006). Further, courts have held in cases where there is no evidence of any
credible medical opinion supporting a claimant’s allegations of disability that “the
proposition that an ALJ must always base his RFC on a medical opinion from a
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 18 of 29

19
physician is misguided.” Cummings v. Colvin, 129 F. Supp. 3d 209, 214–15 (W.D.
Pa. 2015).
These 	seemingly 	discordant 	legal 	propositions 	can 	be 	reconciled 	by
evaluation of the factual context of these decisions. Those cases which emphasize
the importance of medical opinion support for an RFC assessment typically arise in
the factual setting where a well-supported medical source has identified limitations
that would support a disability claim, but an ALJ has rejected the medical opinion
which supported a disability determination based upon a lay assessment of other
evidence. Biller, 962 F.Supp.2d at 778–79. In this setting, these cases simply restate
the commonplace idea that medical opinions are entitled to careful consideration
when making a disability determination, particularly when those opinions support a
finding of disability. In contrast, when an ALJ is relying upon other evidence, such
as contrasting clinical or opinion evidence or testimony regarding the claimant’s
activities of daily living, to fashion an RFC courts have adopted a more pragmatic
view and have sustained the ALJ’s exercise of independent judgment based upon all
of the facts and evidence. See Titterington v. Barnhart, 174 F. App'x 6, 11 (3d Cir.
2006); Cummings v. Colvin, 129 F. Supp. 3d 209, 214–15 (W.D. Pa. 2015). In either
event, once the ALJ has made this determination, our review of the ALJ's assessment
of the plaintiff's RFC is deferential, and that RFC assessment will not be set aside if
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 19 of 29

20
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
perform that are consistent with the claimant’s age, education, work experience and
RFC. 20 C.F.R. §404.1512(f); Mason, 994 F.2d at 1064.
The ALJ’s disability determination must also meet certain basic substantive
requisites. Most significant among these legal benchmarks is a requirement that the
ALJ adequately explain the legal and factual basis for this disability determination.
Thus, in order to facilitate review of the decision under the substantial evidence
standard, the ALJ's decision must be accompanied by “a clear and satisfactory
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 20 of 29

21
explication of the basis on which it rests.” Cotter v. Harris, 642 F.2d 700, 704 (3d
Cir. 1981). Conflicts in the evidence must be resolved and the ALJ must indicate
which evidence was accepted, which evidence was rejected, and the reasons for
rejecting certain evidence. Id. at 706-07. In addition, “[t]he ALJ must indicate in his
decision which evidence he has rejected and which he is relying on as the basis for
his finding.” Schaudeck v. Comm’r of Soc. Sec., 181 F.3d 429, 433 (3d Cir. 1999).
C. The ALJ’s Duty to Develop the Medical Record.
There is a necessary corollary to these legal standards defining the role of the
ALJ in disability determinations. As the Supreme Court has observed:
Although “[m]any agency systems of adjudication are based to a
significant extent on the judicial model of decisionmaking,” 2 K. Davis
& R. Pierce, Administrative Law Treatise § 9.10, p. 103 (3d ed.1994),
the SSA is “[p]erhaps the best example of an agency” that is not, B.
Schwartz, Administrative Law 469–470 (4th ed.1994). See id., at 470
(“The most important of [the SSA's modifications of the judicial model]
is 	the 	replacement 	of 	normal 	adversary 	procedure 	by 	... 	the
‘investigatory model’ ” (quoting Friendly, Some Kind of Hearing, 123
U. Pa. L.Rev. 1267, 1290 (1975))). Social Security proceedings are
inquisitorial rather than adversarial. It is the ALJ's duty to investigate
the facts and develop the arguments both for and against granting
benefits, see Richardson v. Perales, 402 U.S. 389, 400–401, 91 S.Ct.
1420, 28 L.Ed.2d 842 (1971) . . . .
Sims v. Apfel, 530 U.S. 103, 110–11, 120 S. Ct. 2080, 2085, 147 L. Ed. 2d 80 (2000).
Consequently, it is a fundamental basic tenet of Social Security practice that:
ALJs have a duty to develop a full and fair record in social security
cases. See Brown v. Shalala, 44 F.3d 931, 934 (11th Cir.1995); Smith
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 21 of 29

22
v. Harris, 644 F.2d 985, 989 (3d Cir.1981). Accordingly, an ALJ must
secure relevant information regarding a claimant's entitlement to social
security benefits.
Ventura v. Shalala, 55 F.3d 900, 902 (3d Cir. 1995).
Therefore, an ALJ has a responsibility to assist a claimant in fully and fairly
developing the factual record relating to a disability claim. See Sanchez v. Comm'r
of Soc. Sec., 271 Fed.Appx. 230, 233 (3d Cir. 2008). As part of this duty, “[t]he
decision to order a consultative examination is within the sound discretion of the
ALJ.” Basil v. Colvin, No. CIV.A. 12-315E, 2014 WL 896629, at *2 (W.D. Pa. Mar.
6, 2014) citing Thompson v. Halter, 45 Fed.Appx. 146, 149 (3d Cir. 2002); 20 C.F.R.
§§ 404.1517, 416.917. However, the exercise of this discretion is guided by settled
principles and is linked to an informed assessment of the evidence in each case.
Thus:
An “ALJ's duty to develop the record does not require a consultative
examination unless the claimant establishes that such an examination is
necessary to enable the ALJ to make the disability decision.” Id. Other
circumstances 	necessitating 	a 	consultative 	examination 	include
situations where a claimant's medical records do not contain needed
additional evidence, or when the ALJ needs to resolve a conflict,
inconsistency 	or 	ambiguity 	in 	the 	record. 	See, 	20 	C.F.R. 	§§
404.1519(a), 416.919(a).
Basil v. Colvin, No. CIV.A. 12-315E, 2014 WL 896629, at *2 (W.D. Pa. Mar. 6,
2014). See Rissmiller v. Colvin, No. CV 15-5731, 2016 WL 6107209, at *5 (E.D.
Pa. Oct. 18, 2016). Therefore, a determination of whether a consultative examination
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 22 of 29

23
is needed in a particular case is a discretionary judgment by an ALJ and is a judgment
that should be firmly rooted in an assessment of the evidence as a whole. Ultimately,
the ALJ's duty to develop the record requires a consultative examination when it is
shown that the claimant has established that such an examination is needed to enable
the ALJ to make a fully informed disability decision. See Thompson v. Halter, 45
Fed.Appx. 146, 149 (3d Cir. 2002); Metzger v. Berryhill, No. 3:16-CV-1929, 2017
WL 1483328, at *5–6 (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).
It is against these legal guideposts that we assess the ALJ’s decision in this
case.
D. This Case Will Be Remanded.
After a review of the record, we conclude that the ALJ’s analysis in this case
was flawed in at least two material ways. At the outset, the ALJ rejected a medical
consensus that Whitney would be limited to jobs requiring only one- to two-step
tasks and instead fashioned an RFC based largely upon his own lay interpretation of
the evidence. On this score, no treating or examining source opined on Whitney’s
mental RFC. Instead, the ALJ relied, in part, upon the opinions of two non-treating,
non-examining State consultative examiners in formulating the mental RFC. The
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 23 of 29

24
ALJ found these opinions generally persuasive but rejected their consensus that
Whitney would be limited to jobs requiring only one- to two-step tasks. Instead, the
ALJ fashioned a mental RFC which was divorced from the medical consensus, and
was based upon the ALJ’s lay opinion that, “the longitudinal record shows well
preserved mentation,” and notes that she responded well to therapy. (Tr. 28).
In our view, this is simply not a sufficient explanation, grounded in the
evidence, for rejecting a medical consensus regarding a potentially disabling
limitation where the ALJ credited these expert’s opinions that she would be
moderately limited in her ability to carry out detailed instructions and maintain
attention and concentration for extended periods. Moreover, it is unclear what the
ALJ meant by the record showing “well preserved mentation,” where the record, in
fact, noted two psychiatric hospitalizations, including one in 2019, and significant
psychological 	symptomology 	including 	poor 	energy 	and 	motivation, 	trouble
sleeping, lack of appetite passive suicidal thoughts, daily anxiety, twice weekly
panic attacks, waking at night yelling out, mood reactivity due to past trauma,
chronic feelings of emptiness, self-destructive behaviors, emotional lability, poor
frustration tolerance, a pattern of difficulty with interpersonal relationships, and a
history of self-harm. (Tr. 503-04). Given this backdrop acknowledged by the ALJ,
more was needed by way of explanation to reject this medical source consensus.
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 24 of 29

25
Indeed, the ALJ’s decision to reject every medical opinion in this case in favor
of his own view of the evidence is particularly problematic since:
In 	following 	this 	course 	and 	effectively 	discounting 	all 	medical
opinions, the ALJ gave insufficient credence to the concept that
“[r]arely can a decision be made regarding a claimant's residual
functional capacity without an assessment from a physician regarding
the functional abilities of the claimant.” Biller v. Acting Comm'r of Soc.
Sec., 962 F. Supp. 2d 761, 778–79 (W.D. Pa. 2013) (quoting Gormont
v. Astrue, Civ. No. 11-2145, 2013 WL 791455 at *7 (M.D. Pa. Mar. 4,
2013)).
Diaz v. Berryhill, 388 F. Supp. 3d 382, 398 (M.D. Pa. 2019). Moreover, it is
axiomatic that an ALJ errs in relying upon his own lay opinion to reject clinically
supported medical source opinions. See Cordero v. Kijakazi, 597 F. Supp. 3d 776,
806 (E.D. Pa. 2022). Thus, it is well settled that the ALJ may not simply substitute
“her own credibility judgments, speculation or lay opinion,” for the opinions of
medical sources. Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000).
The rejection of only this aspect of these medical source opinions is
undeniably outcome determinative, since, although the ALJ did not include this
limitation in a hypothetical to the VE at the hearing,2 a rising tide of caselaw has
2 The ALJ’s failure to include a one- to two-step limitation in the hypotheticals posed
to the VE at the hearing is also problematic. Indeed, the Third Circuit has repeatedly
recognized that “hypothetical question posed to a vocational expert ‘must reflect all
of a claimant's impairments,” and requires “great specificity . . . when an ALJ
incorporates a claimant's mental or physical limitations into a hypothetical.”
Ramirez v. Barnhart, 372 F.3d 546, 554–55 (3d Cir. 2004) (quoting Charupcala v.
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 25 of 29

26
concluded that this type of one- to two-step limitation is inconsistent with reasoning
level 2 work; a reasoning level required by all of the occupations identified by the
vocational expert. See Daniel M. v. Kijakazi, No. 2:21-CV-243, 2023 WL 154909,
at *3 (D. Vt. Jan. 11, 2023) (collecting cases). Moreover, in our view, the ALJ’s
decision has the appearance of a results oriented outcome since the ALJ seemingly
rejected the only part of these concurring opinions which would render the plaintiff
unable to perform the occupations identified by the VE.3
Heckler, 829 F.2d 1269, 1276 (3d Cir. 1987); Burns v. Barnhart, 312 F.3d 113, 122
(3d. Cir. 2002).
3 The plaintiff also argues on appeal that the jobs identified by the VE, which were
pulled from the Dictionary of Occupation Titles (DOT) are outdated and are both
performed differently and not as abundantly available as when the DOT was last
updated in the 1970s. Without precedent to support a decision to entirely abandon
the DOT as the primary source used in Social Security disability cases to determine
whether a claimant is disabled or can perform work that exists in the national
economy, it is worth noting that Courts have recently expressed concern over the
relevancy of the DOT, which the Department of Labor discontinued updating in
1991 and, seemingly, replaced with O*NET. See Junod v. Berryhill, No. CV 17-
1498, 2018 WL 5792214, at *4 (W.D. Pa. Nov. 5, 2018) (citing Whitmire v.
Commissioner of Society Security, Civ. No., 2014 WL 582781, *9 (M.D. Pa. Feb.
14, 2014); Cunningham v. Astrue, 360 Fed. Appx. 606, 615-16 (6 th Cir. 2010)).
Nonetheless, overall, courts in our circuit and others have been hesitant to reject the
testimony of Vocational Experts relying upon the DOT in favor of the descriptions
on O*NET, given the fact that “Social Security Ruling 00-4P sets forth that the
relevant inquiry is whether VE testimony is consistent with the DOT.” Devault v.
Astrue, Civ. No. 2:13-cv-0155, 2014WL 3565972, at *6 (W.D. Pa. July 18, 2014).
See Smith v. Comm'r of Soc. Sec., No. CV 19-20682 (RBK), 2020 WL 7396355, at
*7 (D.N.J. Dec. 17, 2020) (the ALJ fulfilled her obligation by inquiring whether
there was any conflict between the vocational expert's testimony and the DOT.
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 26 of 29

27
This cascade of errors on the part of the ALJ was then compounded by the
failure to seek a mental consultative examination. Here, the ALJ found the opinions
of the non-examining, non-treating sources generally persuasive, except to the extent
that their consensus would render the plaintiff unable to perform the occupations
identified by the VE. But the ALJ erred in basing this conclusion upon his lay
interpretation of the longitudinal record regarding her “intact mentation.” Given the
significance of this issue to the disability determination we believe that the ALJ was
required to order a consultative examination if the ALJ believed the consensus of
the State agency experts was not supported by the evidence.
On this score, it is clear that “a determination of whether a consultative
examination is needed in a particular is a discretionary judgment by an ALJ, and is
a judgment that should be firmly rooted in an assessment of the evidence as a whole.”
Moreover, the inconsistency that Plaintiff points to is not an inconsistency with the
DOT. . . . The VE is allowed to rely on the DOT even if it is inconsistent with its
more modern counterpart O*NET); Junod v. Berryhill, No. CV 17-1498, 2018 WL
5792214, at *4 (W.D. Pa. Nov. 5, 2018) (collecting cases). This Court has
acknowledged criticisms regarding the reliability of the “aging DOT” but declined
invitations to “abandon the VE’s testimony regarding the DOT job descriptions in
favor of those found in O’Net . . . in large part, due to the lack of clarity as to whether
the Commissioner consider O’Net a reliable resource.” Whitmire, 2014 WL 582781,
at *10. Thus, we will follow the course we have in the past and decline to remand
on this issue, while acknowledging the plaintiff’s desire to preserve this issue should
there be a sea change in the law on this score. See Pollock v. O’Malley, No. 1:22-
CV-1856, 2024 WL 4803530 (M.D. Pa. Nov. 15, 2024).
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 27 of 29

28
Metzger v. Berryhill, No. 3:16-CV-1929, 2017 WL 1483328, at *6 (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). However, in the
exercise of this discretion, “circumstances necessitating a consultative examination
include situations where a claimant's medical records do not contain needed
additional evidence, or when the ALJ needs to resolve a conflict, inconsistency or
ambiguity in the record.” Basil v. Colvin, No. CIV.A. 12-315E, 2014 WL 896629,
at *2 (W.D. Pa. Mar. 6, 2014). Here, to the extent the ALJ concluded the opinions
of the only experts who opined on Whitney’s mental RFC conflicted with the record
as to her ability to perform one- to two-step tasks, the ALJ should have sought
another opinion to supplement the record and support the RFC determination.
Simply put, the ALJ erred by rejecting the state agency expert consensus that
Whitney would be limited to one- to two-step tasks without further developing the
record by seeking an examining source to opine on her mental RFC and fashioning
an RFC for Whitney which was untethered to any medical opinion. This cascade of
errors committed by the ALJ resulted in an RFC assessment which is unsupported
by substantial evidence. Yet, while we conclude that these errors compel a remand
in this case, nothing in this Memorandum Opinion should be deemed as expressing
a judgment on what the ultimate outcome of any reassessment of this evidence
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 28 of 29

29
should be. Instead, that judgment should remain to province of the ALJ once an
adequate medical record is fully developed.
IV. 	Conclusion
Accordingly, for the foregoing reasons, 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: February 25, 2026
Case 4:24-cv-01950-MCC Document 24 Filed 02/25/26 Page 29 of 29